MDAI (5,6-methylenedioxy-2-aminoindane; 6,7-dihydro-5H-cyclopenta[f][1,3]benzodioxol-6-amine; 'sparkle'; 'mindy') toxicity: a brief overview and update

OBJECTIVES

MDAI (5,6-methylenedioxy-2-aminoindane; 6,7-dihydro-5H-cyclopenta[f][1,3]benzodioxol-6-amine; 'sparkle'; 'mindy') is a psychoactive substance, sold primarily over the Internet and in 'head' shops as a 'legal high'. Synthesised and used as a research chemical in the 1990s, MDAI has structural similarities to MDMA (3,4-methylenedioxy-N-methylamphetamine) and shares its behavioural properties. Recreational use of MDAI appears to have started in Europe around 2007, with a noticeable increase after 2009 in the UK and other countries. Calls to National Poisons Information Services started in 2010, although there were few presentations to emergency departments by patients complaining of undesirable physical and psychiatric effects after taking MDAI. Recreational use of this drug has been reported only occasionally by online user fora. There is little scientifically based literature on the pharmacological, physiological, psychopharmacological, toxicological and epidemiological characteristics of this drug.

METHODS

Recent literature (including 'grey') was searched to update what is known about MDAI, especially on its toxicity.

RESULTS

The resultant information is presented, including on the first three UK deaths involving MDAI use in 2011 and 2012. 'Serotonin syndrome' appears to be a possible factor in these fatalities.

CONCLUSION

It is vital that any other cases, including non-fatal overdoses, are documented so that a scientific evidence base can be established for them.

2-DPMP (desoxypipradrol, 2-benzhydrylpiperidine, 2-phenylmethylpiperidine) and D2PM (diphenyl-2-pyrrolidin-2-yl-methanol, diphenylprolinol): A preliminary review

2-DPMP (desoxypipradrol, 2-benzhydrylpiperidine, 2-phenylmethylpiperidine) and D2PM (diphenyl-2-pyrrolidin-2-yl-methanol, diphenylprolinol) are psychoactive substances, sold primarily over the Internet and in 'head' shops as 'legal highs', 'research chemicals' or 'plant food'. Originally developed in the 1950s for the treatment of narcolepsy and ADHD, 2-DPMP's use soon became very limited. Recreational use of 2-DPMP and D2PM appears to have started in March 2007, but only developed slowly. However, in the UK their popularity grew in 2009, increasing rapidly during summer 2010. At this time, there were many presentations to UK Emergency Departments by patients complaining of undesirable physical and psychiatric effects after taking 2-DPMP. In spring 2011 there were similar presentations for D2PM. Recreational use of these drugs has been reported only occasionally in on-line user fora. There is little scientifically-based literature on the pharmacological, physiological, psychopharmacological, toxicological and epidemiological characteristics of these drugs. Here we describe what is known about them, especially on their toxicity, including what we believe to be the first three deaths involving the use of 2-DPMP in August 2010. There are no international controls imposed on 2-DPMP or D2PM. However, a ban on their UK importation was imposed in November 2011 and they became Class C drugs on 13 June 2012. It is critical that any other cases, including non-fatal overdoses, are documented so that a scientific evidence-base can be established for them.

Overview of literature and information on "khat-related" mortality: a call for recognition of the issue and further research

During the past 20 years or so, more has become known about the properties of khat, its pharmacology, physiological and psychological effects on humans. However, at the same time its reputation of social and recreational use in traditional contexts has hindered the dissemination of knowledge about its detrimental effects in terms of mortality. This paper focuses on this particular deficit and adds to the knowledge-base by reviewing the scant literature that does exist on mortality associated with the trade and use of khat. We sought all peer-reviewed papers relating to deaths associated with khat. From an initial list of 111, we identified 15 items meeting our selection criteria. Examination of these revealed 61 further relevant items. These were supplemented with published reports, newspaper and other media reports. A conceptual framework was then developed for classifying mortality associated with each stage of the plant's journey from its cultivation, transportation, consumption, to its effects on the human body. The model is demonstrated with concrete examples drawn from the above sources. These highlight a number of issues for which more substantive statistical data are needed, including population-based studies of the physiological and psychological determinants of khat-related fatalities. Khat-consuming communities, and health professionals charged with their care should be more aware of the physiological and psychological effects of khat, together with the risks for morbidity and mortality associated with its use. There is also a need for information to be collected at international and national levels on other causes of death associated with khat cultivation, transportation, and trade. Both these dimensions need to be understood.

Deaths of opiate/opioid misusers involving dihydrocodeine, UK, 1997-2007

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Dihydrocodeine (DHC) is an opioid analgesic sometimes prescribed as an alternative to other medications (e.g. methadone and buprenorphine) for opioid misuse. Its effectiveness is, however, still controversial. DHC prescription rates seem to be related to levels of DHC fatalities, possibly in relation to levels of disregard of the availability of supervised or interval dispensing of opioids, but no large-scale analysis of DHC fatalities has been carried out. We analysed here involvement of DHC in fatalities that occurred between 1997 and 2007 among individuals with a history of opiate/opioid misuse reported to the National Programme on Substance Abuse Deaths (np-SAD).

WHAT THIS STUDY ADDS

DHC, either alone or in combination, was identified in 584 fatalities. Typical cases identified were males in their early thirties. In accidental overdoses, DHC, which had been prescribed to 45% of the victims, was typically identified in combination with other drugs, such as heroin/morphine, methadone and hypnotics/sedatives. Both paracetamol and antidepressants were more typically identified in combination with DHC in suicides. Opiate/opioid misusers should be educated about risks associated with polydrug intake and prescribers should carefully consider a pharmacological intervention alternative to DHC (e.g. methadone, buprenorphine) when managing and treating opiate addiction.

AIMS

Although its effectiveness is somewhat controversial, it appears that dihydrocodeine (DHC) is still prescribed in the UK as an alternative to both methadone and buprenorphine for the treatment of opiate addiction.

METHODS

Data covering the period 1997-2007 voluntarily supplied by coroners were analysed. All cases pertaining to victims with a clear history of opiate/opioid misuse and in which DHC, either on its own or in combination, was identified at post-mortem toxicology and/or implicated in death, were extracted from the database.

RESULTS

Dihydrocodeine, either alone or in combination, was identified in 584 fatalities meeting the selection criteria. In 44% of cases it was directly implicated in the cause of death. These cases represented about 6.8% of all opiate/opioid-related deaths during this period. Typical DHC cases identified were White males in their early thirties. Accidental deaths (96%) were likely to involve DHC in combination with other psychoactives, mainly heroin/morphine, hypnotics/sedatives and methadone. Both paracetamol and antidepressants were found in proportionately more suicide cases than in accidental overdoses. DHC had been prescribed to the decedent in at least 45% of cases.

CONCLUSIONS

Opiate/opioid misusers should be educated about risks associated with polydrug intake. More in particular, co-administration of DHC with heroin, methadone and benzodiazepines may increase the risk of accidental fatal overdose. Prescribers should carefully consider pharmacological intervention alternative to DHC (e.g. methadone, buprenorphine) when managing and treating opiate addiction. More resources are required to do prospective research in this area.

Mephedrone (4-methylmethcathinone; 'meow meow'): chemical, pharmacological and clinical issues

BACKGROUND

Recently, those substances deriving from the active ingredient of the Khat plant, cathinone, have been rising in popularity. Indeed, 4-methylmethcathinone (mephedrone; 'meow meow' and others) has been seen by some as a cheaper alternative to other classified recreational drugs.

AIMS

We aimed here at providing a state-of-the-art review on mephedrone history and prevalence of misuse, chemistry, pharmacology, legal status, product market appearance, clinical/management and related fatalities.

METHODS

Because of the limited evidence, some of the information here presented has been obtained from user reports/drug user-orientated web sites. The most common routes for mephedrone recreational use include insufflation and oral ingestion. It elicits stimulant and empathogenic effects similar to amphetamine, methylamphetamine, cocaine and MDMA. Due to its sympathomimetic actions, mephedrone may be associated with a number of both physical and psychopathological side effects. Recent preliminary analysis of recent UK data carried out in 48 related cases have provided positive results for the presence of mephedrone at postmortem.

DISCUSSION AND CONCLUSIONS

Within the UK, diffusion of mephedrone may have been associated with an unprecedented combination of a particularly aggressive online marketing policy and a decreasing availability/purity of both ecstasy and cocaine. Mephedrone has been recently classified in both the UK and in a number of other countries as a measure to control its availability. Following this, a few other research psychoactives have recently entered the online market as yet unregulated substances that may substitute for mephedrone. Only international collaborative efforts may be able to tackle the phenomenon of the regular offer of novel psychoactive drugs.

Review of Deaths Related to Analgesic- and Cough Suppressant-opioids; England and Wales 1996-2002

OBJECTIVE

The data on England and Wales voluntarily supplied by Coroners to the National Programme on Substance Abuse Deaths for the August 1996-December 2002 time frame were analyzed.

METHODS

All cases in which at least one analgesic- and cough suppressant-opioid other than heroin/morphine, methadone or buprenorphine was identified were extracted from the database. We hypothesized that: a) populations of addicts and non-addicts presented differences in patterns of drugs involved; and b) within the population of addicts and non-addicts, intentional and non-intentional deaths presented different patterns of substance consumption.

RESULTS

A total of 2024 deaths related to selected opioids, either alone or in combination, were included in the analysis. Typically, non-addicts were older than 45 and died as a result of intentional poisoning whilst majority of addicts were young, males and victims of accidental deaths. In about 93% of cases the selected opioids were reported in combination with another substance. Most frequently identified narcotics were propoxyphene, codeine and dihydrocodeine. Co-proxamol, Co-codamol and Co-dydramol were typically prescribed for non-addicts, whilst dihydrocodeine was mostly given to addicts. In non-addicts, alcohol was mostly represented in accidental deaths and antidepressants were typically represented in intentional deaths. Conversely, illicit drugs and hypnotics/sedatives were typically reported in addicts' accidental deaths.

CONCLUSIONS

The present report constitutes the largest available collection of analgesic- and cough suppressant-opioid mortality data in the UK. Users should be educated about risks associated with polydrug misuse.

A survey of staff attitudes to smoking-related policy and intervention in psychiatric and general health care settings

BACKGROUND

Although the move to smoke-free hospital settings is generally a popular initiative, it may be a more challenging and controversial issue in mental health care. A survey was carried out to investigate differences in attitudes between clinical staff in psychiatric and general medical settings to smoke-free policy and intervention.

METHOD

The sample comprised 2574 NHS staff working in two Acute Hospital Trusts and one Mental Health Trust in England. Attitudes were examined on two factors: health care settings as smoke-free environments and the role of staff in stop smoking intervention.

RESULTS

The findings indicated that attitudes on the two factors were only moderately correlated. Psychiatric staff expressed significantly less favourable attitudes than general staff to smoke-free health care settings and also to the role of staff in stop smoking intervention. The largest difference between the settings concerned the implementation of smoking bans. While approximately 1 in 10 staff in the general setting disagreed with a smoking ban in their wards or clinics, nearly one in three psychiatric staff was against such a ban in their setting.

CONCLUSIONS

Staff attitudes need to be carefully considered, particularly in psychiatric settings, in attempts to implement smoke-free policies in health care settings.

Drugs on the web; the Psychonaut 2002 EU project

PURPOSE

Only a few formal assessments of websites with drug-related contents have been carried out. We aimed here at fostering collection and analysis of data from web pages related to information on consumption, manufacture and sales of psychoactive substances.

GENERAL METHODS

An 8-language, two-engine, assessment of the information available in a purposeful sample of 1633 unique websites was carried out.

FINDINGS

A pro-drug and a harm reduction approach were evident, respectively, in 18% and 10% of websites accessed. About 1 in 10 websites offered either psychoactive compounds for sale or detailed data on drugs' synthesis/extraction procedures. Information on a number of psychoactive substances and on unusual drugs' combinations not found in the Medline was elicited.

CONCLUSIONS

This represents the first review which is both comprehensive and multilingual of the online available information on psychoactive compounds. Health professionals may need to be aware of the web being a new drug resource for information and possibly purchase.

Ecstasy (MDMA, MDA, MDEA, MBDB) consumption, seizures, related offences, prices, dosage levels and deaths in the UK (1994-2003)

In the last decade, a global trend of escalating ecstasy (MDMA, MDA, MDEA, MBDB) use was observed. Mentions on medical death certificates, last year's ecstasy use, number of drug offenders, seizures, prices and dosage levels figures were used for this descriptive and correlational study. Figures (1994-2003) were taken from the UK General Mortality Registers, from the Home Office Statistical Bulletins, from the British Crime Survey and from those reported to both the National Crime Intelligence and Forensic Science Services. A total of 394 ecstasy deaths mentions were here identified from the UK; in 42% of cases ecstasy was the sole drug mentioned. Overall, number of fatalities showed a year-per-year increase and positively correlated with: prevalence of last year's use (p < 0.01); number of offenders (p < 0.01) and number of seizures (p < 0.01) but negatively correlated with ecstasy price (p < 0.05). Price negatively correlated with: prevalence of last year's use (p < 0.001) and number of seizures (p < 0.01); but positively correlated with average MDMA dosage per tablet (p < 0.01). MDA, MDEA and MBDB accounted for a significant proportion of tablets only up to 1997, but not afterwards. Increasing production with a concomitant decrease in ecstasy price may have facilitated an increase in consumption levels and this, in turn, may have determined an increase in number of ecstasy deaths mentions. Only medical death certificates and not coroners' reports at the end of their inquests were here analysed; no data were available in respect of other drugs use and toxicology results.

Buprenorphine mortality, seizures and prescription data in the UK, 1980-2002

Buprenorphine safety in overdose has been debated recently, but no mortality data related to this compound from the UK have been published. To gather together all of the buprenorphine mortality figures, a number of different sources have been checked. To inform on buprenorphine safety issues, accessible information related to its availability indicators (i.e. prescriptions; seizures) data for the 1980-2002 time frame have been sought. In the UK, during this period, buprenorphine was mentioned in 43 fatalities. Typically, victims were males in the 25-44 age group. In 12 cases (28% of total), a verdict of suicide was given. Buprenorphine was detected on its own in seven cases; more frequently, it was found together with benzodiazepines and other opiates. Large quantities of buprenorphine were prescribed both in England in 1985-1989 and in 1991-1992 in Scotland, where seizures reached their highest levels. Buprenorphine prescriptions seemed to peak again after 1999, when high dose buprenorphine formulations entered the UK market. No positive correlation was found between the number of buprenorphine deaths over the years and either buprenorphine dispensings/prescriptions or seizures. However, an increase in buprenorphine-related deaths since 1999 was identified and this may be an issue which should be carefully monitored over the next few years.

The effects of methadone and its role in fatalities

Methadone is a synthetic opioid, used both as an analgesic in severe pain relief and now mainly in the treatment of opiate dependence. Such use of the drug has increased as its advantages have become widely recognized. There are undesirable outcomes from its greater use, including a substantial market in diverted methadone and a high number of deaths where the drug has been implicated. It is important to understand how and why methadone causes death so that such fatalities can be minimized, and to disseminate such information. This paper presents an overview of the chief effects of methadone on the human body, considering its metabolism, drug interactions and tolerance. The principal mechanisms by which methadone causes death are discussed: respiratory depression, aspiration of vomit, pulmonary oedema, bronchopneumonia, cardiac problems and renal failure. Many such deaths are preventable, if drug interactions and polydrug use are avoided, its longer period of metabolism and individuals' tolerance levels are considered. It is hoped that this paper will (a) help guide health professionals in their management and treatment of patients participating in methadone treatment programmes, and (b) provide some basic information for those dealing with individuals who have consumed methadone.

Antidepressant-related deaths and antidepressant prescriptions in England and Wales, 1998-2000

BACKGROUND

Deaths from antidepressants continue to account for a substantial proportion of drug-related deaths.

AIMS

To investigate the relative toxicity of the major classes of antidepressant drugs, with the specific objective of assessing this in relation to the cause of death; and to analyse the deaths where there were multiple mentions of antidepressant drugs or other psychoactive drugs with antidepressants.

METHOD

Mortality data were collected from the National Programme of Substance Abuse Deaths, and antidepressant prescription data were collected.

RESULTS

Most deaths from antidepressant drugs were suicides (80%). Tricyclic antidepressants (TCAs) accounted for more drug mentions than did other antidepressant drugs (12 per million prescriptions). Selective serotonin reuptake inhibitors (SSRIs) were associated with a significantly lower risk of toxicity, but 93% of deaths from SSRIs occurred in combination with other drugs, especially TCAs (24.5%). In 'combination' deaths patients were significantly more likely to have had a history of drug misuse.

CONCLUSIONS

The efficacy and safety of augmentation therapy with TCAs in SSRI-resistant patients should be monitored carefully, and patients prescribed antidepressants should be screened for drug use/misuse.

Cause and manner of death in drug-related fatality: an analysis of drug-related deaths recorded by coroners in England and Wales in 2000

This study investigated causes and manner of drug-related fatalities recorded in 2000 in the United Kingdom, measuring the 'masked' manner of death in cases typically recorded as overdose. A retrospective cohort study was used of 1037 cases of accidental drug-related fatalities reported by coroners in England and Wales to the National Programme of Substance Abuse Deaths. Whilst 802 cases were identified as direct acute overdose, representing 77% of the total accidental deaths, 23% of 'overdose' fatalities were caused by asphyxiation (7%), drug-related medical conditions (7%), non-drug-related conditions (4%), traumatic accidents (3%) and infections (2%). Younger people show higher risk of overdose and asphyxiation; older people show higher risk from pre-existing medical conditions. This study not only confirmed the high risk of overdose associated with heroin and polydrug use, but it also identified other high fatality risk factors for heroin/morphine users such as contracting an acute infection leading to septicaemia or endocarditis, or contracting a chronic infection such as HIV, HBV or HCV. In contrast, stimulants particularly featured in traumatic accidents, with amphetamine use most associated with cardio-vascular fatality. These findings highlight the 'masked' manner of death in cases commonly recorded as overdose and demonstrate the need for a more-detailed and systematic method of recording drug-related deaths in order to inform drug education and harm reduction strategies.

Death rates from ecstasy (MDMA, MDA) and polydrug use in England and Wales 1996-2002

The present study reports on all deaths related to taking ecstasy (alone, or in a polydrug combination) occurring in England and Wales in the time frame August 1996-April 2002. Data presented here are based on all information recorded in the National Programme on Substance Abuse Deaths (np-SAD) database. The np-SAD regularly receives all information on drug related deaths in addicts and non addicts from coroners. A total of 202 ecstasy-related fatalities occurred in the chosen time-frame, showing a steady increase in the number of deaths each year. The ratio male:female was 4:1 and 3 of 4 victims were younger than 29. In 17% of cases ecstasy was the sole drug implicated in death and in the remaining cases a number of other drugs (mostly alcohol, cocaine, amphetamines and opiates) have been found. According to toxicology results, MDMA accounted for 86% of cases and MDA for 13% of cases; single deaths were associated with MDEA and PMA. This is the largest sample of ecstasy related deaths so far; possible explanations are given for the observed steady increase in ecstasy-related deaths and a tentative 'rationale' for this polypharmacy combination is then proposed.

Treating an opiate-dependent inpatient population: a one-year follow-up study of treatment completers and noncompleters

INTRODUCTION

The aim of this study was to compare the characteristics of patients who completed (completers) inpatient treatment of drug dependence with those who failed to complete this programme (noncompleters).

METHOD

Participants were assessed at admission using the Substance Abuse Assessment Questionnaire (SAAQ) to obtain information about the sociodemographic background, history of drug and alcohol use, physical health, mental health, offending behaviour, and interpersonal relationships. Follow-up interviews were carried out 3, 6, 9, and 12 months after discharge using the SAAQ-Follow-up. To form the three comparison groups, participants were divided on the basis of completion of detoxification and receipt of aftercare.

RESULTS AND CONCLUSIONS

Significantly better treatment outcome was observed amongst those who completed detoxification and went on to spend at least 6 weeks in a recovery and/or residential rehabilitation unit. In contrast, there were no significant differences between noncompleters and completers who had no aftercare on the majority of measures of drug use during follow-up.

Drug use, self report and urinalysis

Stimulated by the ever present demand to consider the financial implications in management decisions, this study examines the use of urinalysis and self-report in the treatment of drug users, to question if urinalysis, rather than being a routine investigation, could be used with greater discrimination without jeopardising its effectiveness. It concludes that urinalysis remains of importance, as an adjunct to self-report, in providing information and in the treatment of drug users. Suggestions are made as to how it might be used more selectively in treatment based on a clinical knowledge of individual patients and their progress in treatment. However further research is needed to support and define this more clearly.

Evaluation of the opioid addiction test in an out-patient drug dependency unit

BACKGROUND

The opioid addiction test is based on the measurement of pupil dilatation in opioid-dependent people in response to conjunctivally applied naloxone hydrochloride. A positive response (pupil dilatation) indicates that the subject is dependent on opioids.

AIMS

To evaluate the test in an out-patient setting and to identify factors affecting its outcome.

METHOD

Pupil size was measured using binocular pupillometry in 100 new patients attending an out-patient clinic for assessment and treatment of opioid use. Measurement was repeated 40 minutes after the unilateral instillation of naloxone drops into the conjunctival sac.

RESULTS

We performed 127 tests, of which 103 (81.1%) were positive. Males, and those not on methadone at the time of the test, were more likely to have a negative test result.

CONCLUSIONS

The opioid addiction test proved to be a very useful tool for the rapid diagnosis of opioid dependence in the out-patient clinic. Specialist pupillometric equipment increases the number of patients correctly identified as opioid-dependent on the first visit, but is not essential.

Management of substance misusers on the general hospital ward

Since a high prevalence of physical morbidity is associated with substance misuse, drug misusers are frequently admitted to general hospitals. Medical staff often perceive drug misusers as a particularly difficult patient group, feeling that they lack the knowledge and skill to deal with them adequately without specialist support. We review the common physical complications of substance misuse likely to be encountered in a general hospital, and provide comprehensive guidelines for the assessment and management of drug dependence in this setting.

The role of nicotine in tobacco smoking: implications for tobacco control policy

This paper outlines some of the evidence that tobacco smoking is maintained by addiction to nicotine. Smokers often perceive that tobacco helps them cope with stress and aids their mental alertness. Nicotine withdrawal symptoms are one important factor preventing many smoker from quitting (only about 3% succeed with each unaided quit attempt). A number of policies are suggested to reduce the health consequences of smoking more quickly than at present. These include (a) banning all tobacco advertising and prosecuting retailers who sell illegally to children, in order to reduce the number of young people becoming addicted, (b) increasing the real price of tobacco in order to encourage more people to try to stop smoking, (c) providing specialist smokers' clinics in every large general hospital in order to assist highly motivated but addicted smokers to quit and (d) increasing the rate at which tobacco manufacturers must reduce permissible tar and carbon monoxide yields, such that in 20 years time only nicotine delivery products which are free of tar and carbon monoxide will be allowed.

Substance use of medical students: a nationwide survey

Medical students from 13 medical schools in England, Scotland and Wales were asked about their use of tobacco, alcohol and other drugs. Data from 1,278 students (68% response rate) are presented here. 10% of the respondents were current smokers, 10% ex-smokers. In a typical week 17% of the respondents exceeded the recommended limits for sensible drinking. Other drugs besides tobacco or alcohol had been used by 37% of the respondents. Most of the students who had used drugs had done so on no more than 10 occasions. 9% were current users. Although the majority of medical students neither smoke nor drink heavily nor take drugs, a significant minority either persist in or develop potentially harmful substance use behaviour during their studies. The scope for preventive efforts is considerable.

Cannabis and psychotic illness

In-patients with psychotic symptoms and cannabis-positive urine analysis were assessed by PSE within one week of admission and again at one and six months. Concurrently admitted psychotic patients with drug-free urine analysis were controls. At one week the two groups differed significantly on only five PSE items: changed perception, thought insertion, non-verbal auditory hallucinations, delusions of control, and delusions of grandiose ability. One item (delayed sleep) differed at one month, and none at six months. The symptom cluster at one week is consistent with acute cannabis intoxication. Subjects and controls were mostly single, poorly educated, unemployed people with histories of psychotic disorders, and given major tranquillisers on admission. Compared with controls, subjects were younger, less likely to have psychiatric histories, more often male, Afro-Caribbeans with a history of convictions and compulsory admissions. The commonest diagnosis was schizophrenia. Use of the label 'cannabis-induced psychosis' may obscure a diagnosis of paranoid schizophrenia. A short-lived psychotic episode does occur in clear consciousness after cannabis intoxication, but chronic cannabis-induced psychosis was not found.

Systems analysis of a drug dependency service in London: St George's Hospital

Elements of a systems approach to analysing service delivery are outlined. A specific example--St George's Hospital Addiction Behaviour Department--is detailed. Dynamics of the system--from the client's perspective and the workers viewpoint--demonstrate some of the ways in which emotional conflict surrounding the task is handled. The conclusions focus on what might constitute adaptive resolution of systems dilemmas as well as highlighting the public-health concerns relating to AIDS which, we argue, compromise the primary task of an addiction service at the present time.

Cannabis use in a large sample of acute psychiatric admissions

A sample of 908 patients drawn from two London Psychiatric Hospitals is described in terms of age, sex, self-reported drug and alcohol history, drug urinalysis results and initial psychiatric diagnosis. Some (34.5%) of respondents admitted to using cannabis at least once in their lifetime and 13% of those tested had urines positive for cannabis on admission. Cannabis use is commoner in young males. These is a higher likelihood that an initial diagnosis of 'psychosis' will be made at admission if patients either report use of cannabis or present a urine sample positive for cannabis.

An international survey of the educational activities of schools of nursing on psychoactive drugs

A survey of the educational activities of schools of nursing on psychoactive drugs in 99 countries was carried out. All the schools that replied gave specific teaching and many also included the rational use of these drugs. The amount of time devoted to this teaching and the methods used varied greatly. Most schools felt that this topic needed more emphasis and many agreed that guidelines on teaching methods and approaches, as well as broad teaching aims and objectives, would be useful.

Undergraduate medical school training in psychoactive drugs and rational prescribing in the United Kingdom

The present study examines the extent and form of teaching on psychoactive drugs and the rational prescribing of them given to undergraduate medical students in the United Kingdom. All the 21 schools which replied taught on psychoactive drugs. The average was 15.4 hours of formal teaching (lectures, seminars, tutorials). The teaching on psychoactive drugs compares favourably with the average of 4.2 hours teaching given on alcohol related problems and 3.5 hours on drug dependence. It emerged that there was a great deal of variation in the amount of teaching on psychoactive drugs and many schools felt their teaching on rational prescribing was inadequate. There is a need to promote better co-ordination between medical school departments and to identify the key concepts which all medical schools teach. These steps would help to ensure improved teaching on psychoactive drugs and rational prescribing.

Types of opiate addiction and notification to the home office

Hospitalised drug addicts were categorised according to the time lapse between onset of their opiate abuse and their first notification to the Home Office. Late notification correlated with a lower level of dependence, a more intermittent pattern of misuse, and a greater likelihood of alcohol abuse. It is postulated that there may be two types of addiction which lie along a continuum.

Naloxone applied to conjunctiva as a test for physical opiate dependence

Significant pupillary dilatation in response to conjunctivally applied naloxone was demonstrated with polaroid photography in 46 opiate addicts on maintenance methadone prescription. No pupillary response was seen to an identical procedure in 17 non-addict subjects who had been given an opiate premedication before elective surgery. This pupillary response to naloxone could be used as a test to identify the physically dependent opiate user.

An international survey of the educational activities of schools of pharmacy on psychoactive drugs

A survey of the educational activities of schools of pharmacy on psychoactive drugs in 92 countries was carried out. All the schools which replied felt that there was a need for specific education on psychoactive drugs, and the majority felt that the rational use of such drugs should also be taught. Both the amount of teaching given and the methods used varied. This was particularly true for related subjects such as alternatives to psychoactive drug use. Almost a third of schools considered that they did not devote adequate time to psychoactive drugs and their rational use, and many would be grateful for specific educational guidelines in this area.

Analysis of epidemiological data on agonist-antagonist analgesics

Epidemiological information on the abuse of opioid agonist-antagonists is scanty. Most of the available information relates to pentazocine, the 'oldest' of this class of drugs, and it appears that a sporadic episode of its intravenous abuse in several cities in the United States, is subsiding: reformulation of pentazocine tablets to contain naloxone may have contributed to the decline in this abuse. Apart from a few reports of buprenorphine abuse, there are only occasional accounts of abuse of other drugs in this class. However, the lack of data does not necessarily mean that abuse does not occur and it is essential that epidemiologically sound investigations should be made to explore the existence and extent of any such problem. The interpretation of epidemiological data relating to agonist-antagonist abuse is discussed.

In-patient treatment for drug abuse

During 1984 there were 253 admissions to the in-patient drug dependence treatment unit at Tooting Bec Hospital. Of the 198 patients responsible for these admissions, 60% were male and 43% were over the age of 30 years. There were 151 patients admitted for opiate detoxification, and 75% completed the withdrawal schedule. However, only 15 out of 25 patients admitted for benzodiazepine withdrawals were found to be physically dependent. Other reasons for admission included stabilisation of the dose of opiate (24%) and the treatment of physical complications of addiction.

Monitoring changing patterns of drug dependence in accident and emergency departments

A survey was made of drug dependent individuals attending the Accident and Emergency Departments in Greater London in July 1982 and the results were compared with those of an identical survey in July 1975. There was a significant reduction in the number of incidents involving drug dependent patients, the majority of whom attended hospital after a drug overdose; the proportion of suicidal attempts increased significantly in 1982. Barbiturates were taken less frequently in 1982, but heroin and anxiolytics were taken more often. Possible reactions to these findings are discussed and the continuing role of the Accident and Emergency Departments in monitoring changing patterns of drug abuse in emphasised.

The use of a drug utilisation index to monitor psychotropic drug use in hospitals

A pilot study was undertaken to monitor the use of psychotropic drugs in a psychiatric hospital unit and a comparable acute medical unit together with their out-patient clinics, during a 2 month period. Both units served the same catchment area. Using the DDD (defined daily dose) for each class of drug, an index was calculated as an indicator of usage. An index figure of less than one indicated that each patient received on average less than the DDD, whereas an index greater than one showed that each patient received an average daily dose greater than the DDD. Other patient information collected included age, sex, length of time on drug, length of admission and the number of different psychotropic drugs received during admission.

Depression in solvent abusers

Previous studies mention that some solvent abusers have a depressed mood. This study sets out to determine in a formal way whether solvent abusers are more depressed than a comparison group of non-solvent abusers. Forty-seven consecutive admissions (all with delinquent histories) to the secure unit of a regional assessment centre for adolescent boys, who fulfilled certain criteria, were assessed. They completed the General Health 28 item questionnaire (GHQ-28) and the Great Ormond Street (GOS) mood questionnaire. Thereafter, they were administered a semi-structured interview covering the following areas--solvent abuse data, educational data, demographic and family data, criminal history and other drug use data. Results showed that significantly more solvent abusers were depressed than non-solvent abusers as defined by GOS-mood scores of 25 or more (P less than 0.05). Also, mean GHQ-28 total scores (P less than 0.02), GHQ-28 depression subscale scores (P less than 0.02), and GOS-mood scores (P less than 0.05) were significantly higher in the solvent abuse group. In conclusion, solvent abusers are more depressed than a comparison non-solvent abusing group.

Asthma in opiate addicts

A case-note study of 2276 opiate addicts revealed that 112(5%) had a history of asthma and that in 31(1.4%) cases there appeared to be a definite temporal relationship between heroin abuse and the onset of asthma. This rarely-reported complication of heroin dependence has a higher incidence among female addicts (3.3%) than among male addicts (0.7%).