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.

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.

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.