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Background Vaping of cannabinoid-based products and informal acquisition of vaping products were associated with the outbreak of E-cigarette or vaping associated lung injury (EVALI) in the USA. Current prevalence of cannabinoid-based vaping within the UK is not known and literature regarding the acquisition of vaping products is limited. Aim To estimate the prevalence of nicotine-based, nicotine-free and cannabinoid-based product vaping within the UK and to determine where vaping products are acquired. Design and methods A voluntary online survey of individuals aged 16 and over within the UK was conducted using a convenience sample. Data were collected on respondent demographics, smoking/vaping history and acquisition of e-liquids/products. Results A total of 2478 responses were included. Median age 45 years (interquartile range 35–57). Prevalence of current vaping of nicotine-based e-liquids, nicotine-free e-liquids and cannabinoid-based products was 14.4%, 11.2% and 5.49%, respectively. Current nicotine-based and nicotine-free vaping was most prevalent in 25–34 years olds (22.4% and 19.2% of respondents). Current cannabinoid-based vaping was most prevalent in 16–24 years olds. The most common 'ever' used cannabinoid-based products were cannabidiol oil/cannabigerol oil and cannabis leaves (4.8%). Specialist vaping stores were the most common source of 'ever' acquisition for all products. 36.8% and 40.5% of respondents who had ever vaped nicotine-based and nicotine-free e-liquids reported prior acquisition from informal sources. Conclusion This survey reported a higher prevalence of current cannabinoid-based vaping within the UK (5.5%) than previously reported in the USA (2.0%). In addition to the informal acquisition of vaping products as demonstrated within the survey, these results highlight potential underestimation of the risk of EVALI within the UK. [ABSTRACT FROM AUTHOR]

Background Isotonitazene is a novel opioid that was first reported in Europe in 2019. There have been no reports of the detection of isotonitazene in patients presenting to the emergency department with acute drug toxicity. Aim There was an increase in presentations to our emergency department with acute opioid toxicity in August 2021. We aim to describe this outbreak and provide detail on two cases in which isotonitazene was quantified in serum samples. Methods Serum samples were available for comprehensive toxicological analysis for two presentations. Written consent was obtained and the samples were analysed through a Thermo XRS ultrahigh-performance liquid chromatography system, interfaced to a Thermo Q Exactive high-resolution accurate mass spectrometer, operating in heated positive ion electrospray mode. Acquired data were processed using Toxfinder software (Thermo) against a regularly updated in-house database. Results There was an increase in acute opioid presentations to our emergency department from a median of 10 per month to 36 in August 2021. Twenty were treated with naloxone, and 23 were admitted to the hospital for observation and treatment. Serum sample analysis from two patients with acute opioid toxicity responsive to naloxone detected the presence of isotonitazene (0.18 and 0.81 ng/ml). Conclusion We report a cluster of acute opioid toxicity presentations to our Emergency Department with detection of isotonitazene in two cases. Analytical screening is important in determining the presence of novel psychoactive substances (NPS) and to help inform the public health of the implications of NPS use, particularly during clusters of acute recreational drug toxicity presentations. [ABSTRACT FROM AUTHOR]

Background: Analysis of anonymous pooled urine samples from street urinals has been used to demonstrate time-trends in the detection of classical recreational drugs and novel psychoactive substances (NPS). Aim: This study aimed to expand this to undertake a geographical trend analysis of classical recreational drugs/NPS across UK. Methods: Samples of anonymous pooled urine were collected from street urinals that had been in place for one night in April 2014 in nine cities across the UK. Collected samples were then analysed for the presence of recreational drugs, NPS anabolic steroids using high-performance liquid chromatography coupled to high-resolution accurate mass full-scan mass spectrometry and gas chromatography coupled to electron impact ionization mass spectrometry operating in selected ion monitoring and full-scan modes. Results: Ten classical recreational drugs, nine NPS and four anabolic steroids were detected across the nine cities; the range of detection was from 1 in Leeds to 14 in London. The most common classical drugs were cocaine (9 cities) and 3,4-methylenedioxy- methamphetamine (8 cities); the most common NPS was 4-methylmethcathinone (5 cities). In addition there was variation in the detection of NPS, with methylhexaneamine detected only in Bristol and London, piperazines (3-trifluoromethylphenylpiperazine and 1-benzylpiperazine) and pentedrone only detected in Birmingham and the cathinone methylone only detected in London. Conclusions: There is variability in the detection of classical recreational drugs, NPS and anabolic steroids across UK, likely reflecting variation in their use. This technique can be used to supplement drug use surveys to determine geographical and time trends in the use of these substances. This is important to ensure appropriate targeting of drug-related interventions. [ABSTRACT FROM AUTHOR]

Background: The epidemiology on recreational drug use is based on self-reported user surveys. The scope of this is limited as users are often not aware of exactly what drug(s) they are using. Waste water (sewage plant) analysis has been used to identify 'regional' recreational drug use but is limited by a lack of understanding of the metabolism and stability of novel recreational drugs. Aims: The feasibility of collecting pooled urine samples from a sub-population attending a night-club using a portal urinal to confirm the classical and novel recreational drugs being used. Design and Methods: Urine samples were collected from a nightclub over one weekend for analysis by various chromatographic techniques involving mass spectrometry. Results: Classical recreational drugs and novel psychoactive substance, including mephedrone, 3-trifluoromethylphenylpiperazine and 2-aminoindane were found. Parent drug/metabolites were also detected for amphetamine, cocaine, ketamine, MDMA, mephedrone and 3-trifluoromethylphenylpiperazine. Conclusion: Anonymous pooled urine samples from within a nightclub can be used to confirm the actual drugs being used by some individuals within this sub-population. Metabolite detection indicates drugs were being used and not simply discarded into the urinal. This methodology could be used to monitor recreational drug trend in other environments, e.g. schools, geographical regions/areas and compare drug use over time. [ABSTRACT FROM AUTHOR]

Background Approximately 10% of patients with chronic obstructive pulmonary disease (COPD) have co-existing diabetes mellitus, conferring an adverse prognosis. Metformin is a valuable first-line treatment for diabetes. However, its rare association with lactic acidosis limits its use among patients at risk of hypoxia. This may deter some practitioners from prescribing it to patients with significant co-existing COPD. It is unknown whether the benefits of metformin outweigh its risks in this context. We therefore sought to determine the effects of metformin on survival and length of stay in a high-risk cohort of diabetic patients hospitalised for COPD exacerbations. Methods The medical records of diabetic patients hospitalised for COPD were reviewed retrospectively. Length of hospital stay and all-cause mortality were compared according to the presence or absence of metformin therapy. Results 130 patients were included, of whom 51 (39%) were prescribed metformin. Patients on metformin had a shorter hospital stay (median 7 vs 9 days respectively; p=0.004). Survival at 90 days was significantly better in the metformin group than in the non-metformin group (94% vs 78% respectively; p=0.015; Abstract P259 figure 1 inset). This persisted over the longer term, with overall median (95% CI) survival of 5.2 years (4.3 to 6.1) in the metformin group and 2.2 years (1.0 to 3.3) in the non-metformin group (HR 0.57; 95% CI 0.35 to 0.94; Abstract P259 figure 1). This difference remained significant in a multivariate model, adjusting for potential confounding effects of age, weight, acute illness severity (APACHE-II score) and comorbidity burden. Among patients prescribed metformin, vs those not, the median (IQR) plasma lactate concentration was 1.45 mmol/l (1.10-2.05) vs 1.10 mmol/l (0.80-1.50), respectively (p=0.012). Conclusion Diabetic patients hospitalised for COPD exacerbations who were prescribed metformin were discharged earlier and survived longer than those not prescribed metformin. Lactate concentration was higher among patients on metformin, although the difference was small. Our results suggest that the drug's benefits may outweigh its rare association with lactic acidosis. Whether this reflects beneficial effects on diabetes- or COPD-related endpoints; other associated conditions; or the effect of unmeasured confounders, is unknown. We are now investigating this within the context of a randomised controlled trial (ISRCTN66148745). [ABSTRACT FROM AUTHOR]

Background: Recent work in the UK estimated the prevalence of current cannabinoid-based vaping to be higher than in the USA, a factor previously associated with e-cigarette or vaping-associated lung injury (EVALI). Research in the USA has demonstrated that attendances to emergency departments relating to e-cigarettes began to rise before the EVALI outbreak, suggesting that vapers also experience milder forms of vaping-related illness., Aim: Quantify symptom prevalence and healthcare utilization amongst current UK vapers., Design: Voluntary online survey of individuals aged 16 and over within the UK., Methods: Anonymized data were collected on demographics, vaping/smoking status and vaping substances used. Current vapers were asked about the presence of 10 prevalent symptoms from previous US EVALI case series, healthcare attendances and diagnoses given. Risk-ratios were calculated to compare the likelihood of symptoms and attendances between substances., Results: A total of 2477 complete responses were analysed. In all, 397 respondents were current vapers. Symptom prevalence within the previous 12 months ranged from 3.8% to 30.5% (bloody sputum, cough). Healthcare attendances per symptomatic respondent ranged from 0.1 to 1.4 (bloody sputum, shortness of breath). Current vapers of cannabinoid-based products (alone/in combination) had the most attendances per symptomatic respondent for 9/10 symptoms and were more likely to report symptoms aside from 'cough' (nicotine-free e-liquids [risk ratio = 1.7]). Clinicians reportedly never diagnosed vaping-related illness., Conclusions: UK vapers experience symptoms previously reported in EVALI cases for which they also seek healthcare. Users of cannabinoid-based products were more likely to report symptoms and accounted for a higher healthcare burden. UK vapers may also experience vaping-related illness that does not meet EVALI case criteria., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Association of Physicians.)

Background: Vaping of cannabinoid-based products and informal acquisition of vaping products were associated with the outbreak of E-cigarette or vaping associated lung injury (EVALI) in the USA. Current prevalence of cannabinoid-based vaping within the UK is not known and literature regarding the acquisition of vaping products is limited., Aim: To estimate the prevalence of nicotine-based, nicotine-free and cannabinoid-based product vaping within the UK and to determine where vaping products are acquired., Design and Methods: A voluntary online survey of individuals aged 16 and over within the UK was conducted using a convenience sample. Data were collected on respondent demographics, smoking/vaping history and acquisition of e-liquids/products., Results: A total of 2478 responses were included. Median age 45 years (interquartile range 35-57). Prevalence of current vaping of nicotine-based e-liquids, nicotine-free e-liquids and cannabinoid-based products was 14.4%, 11.2% and 5.49%, respectively. Current nicotine-based and nicotine-free vaping was most prevalent in 25-34 years olds (22.4% and 19.2% of respondents). Current cannabinoid-based vaping was most prevalent in 16-24 years olds. The most common 'ever' used cannabinoid-based products were cannabidiol oil/cannabigerol oil and cannabis leaves (4.8%). Specialist vaping stores were the most common source of 'ever' acquisition for all products. 36.8% and 40.5% of respondents who had ever vaped nicotine-based and nicotine-free e-liquids reported prior acquisition from informal sources., Conclusion: This survey reported a higher prevalence of current cannabinoid-based vaping within the UK (5.5%) than previously reported in the USA (2.0%). In addition to the informal acquisition of vaping products as demonstrated within the survey, these results highlight potential underestimation of the risk of EVALI within the UK., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Isotonitazene is a novel opioid that was first reported in Europe in 2019. There have been no reports of the detection of isotonitazene in patients presenting to the emergency department with acute drug toxicity., Aim: There was an increase in presentations to our emergency department with acute opioid toxicity in August 2021. We aim to describe this outbreak and provide detail on two cases in which isotonitazene was quantified in serum samples., Methods: Serum samples were available for comprehensive toxicological analysis for two presentations. Written consent was obtained and the samples were analysed through a Thermo XRS ultrahigh-performance liquid chromatography system, interfaced to a Thermo Q Exactive high-resolution accurate mass spectrometer, operating in heated positive ion electrospray mode. Acquired data were processed using Toxfinder software (Thermo) against a regularly updated in-house database., Results: There was an increase in acute opioid presentations to our emergency department from a median of 10 per month to 36 in August 2021. Twenty were treated with naloxone, and 23 were admitted to the hospital for observation and treatment. Serum sample analysis from two patients with acute opioid toxicity responsive to naloxone detected the presence of isotonitazene (0.18 and 0.81 ng/ml)., Conclusion: We report a cluster of acute opioid toxicity presentations to our Emergency Department with detection of isotonitazene in two cases. Analytical screening is important in determining the presence of novel psychoactive substances (NPS) and to help inform the public health of the implications of NPS use, particularly during clusters of acute recreational drug toxicity presentations., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Current data on the epidemiology of recreational drug use is largely based on population and self-population surveys of drug use. In addition, increasingly, particularly for novel psychoactive substances, data collected from web monitoring systems is used to collect information on early trends in the use of NPS and the drugs available to users. All of these indicators rely on users self-report of the drug(s) that they are using, or more accurately the drugs that they perceive they are using. Numerous recent studies have demonstrated significant variation in the content of both classical recreational drugs and novel psychoactive substances. The technique of waste-water analysis has allowed estimation of population level use of a number of established recreational drugs such as cocaine and MDMA. However this technique is limited for novel psychoactive substances because of limitations in the knowledge of the stability and metabolism of these compounds. Our group has developed a technique that involves the collection and analysis of pooled-urine from standalone portable urinals and demonstrated that this technique can be used to detect the use of both classical, established recreational drugs and novel psychoactive substances. We discuss this technique in this paper and the ways in which this can be further developed to allow detection of use of new NPS and trends in use of these substances over time and across geographical regions.

Aim: Analysis of urine samples collected across a city centre, for the detection of novel psychoactive substances (NPS)., Design: Cross-sectional study of anonymized urine samples used for the analysis of classical recreational drugs, NPS and metabolites., Methods: Pooled urine samples collected from portable stand-alone four-person urinals across a city centre were analysed using full-scan accurate-mass high-resolution liquid chromatography coupled to tandem mass spectrometry. Data were processed against compound databases containing >1700 drug compounds and metabolites., Results: Seven established recreational drugs (3,4-methylenedioxyamphetamine, cocaine, cannabis, ketamine, 3,4-methylenedioxy-N-methylamphetamine, methamphetamine and amphetamine) and six potential NPS [hordenine (all 12 urinals), cathine (11), methylhexaneamine (9), 4-methylmethcathinone (6), methiopropamine and metabolites (2) and methoxetamine and metabolites (1)] were detected. Methylhexaneamine, methiopropamine and hordenine are currently uncontrolled in the UK, whereas methoxetamine is currently subject to a Temporary Class Drug Order. Metabolites of the anabolic steroid nandrolone were found in two urinals and trenbolone metabolites and clenbuterol in one urinal., Conclusion: Analysis of pooled urine samples collected anonymously from stand-alone urinals in a large inner city can detect the use of recreational drugs, NPS and anabolic steroids. Metabolite detection indicates actual drug use, metabolism and elimination rather than simply discarded drugs in the urinals. This technique by confirming the actual drug(s) used has the potential to be additive to currently used datasets/key indicators providing more robust information for healthcare authorities, legislative and law enforcement on the drugs actually being used.