Ammonia release from heated 'street' cannabis leaf and its potential toxic effects on cannabis users.

AIMS: To use selected ion flow tube mass spectrometry (SIFT-MS) to analyse the molecular species emitted by heated 'street' cannabis plant material, especially targeting ammonia. MATERIALS AND METHODS: Samples of 'street' cannabis leaf, held under a UK Home Office licence, were prepared by finely chopping and mixing the material. The samples were then heated in commercially available devices. The air containing the released gaseous compounds was sampled into the SIFT-MS instrument for analysis. Smoke from standard 3% National Institute on Drug Abuse (NIDA) cannabis cigarettes was also analysed. FINDINGS: For 'street' cannabis, ammonia was present in the air samples from the devices at levels approaching 200 parts per million (p.p.m.). This is compared with peak levels of 10 p.p.m. using NIDA samples of known provenance and tetrahydrocannabinol content (3%). Several other compounds were present at lower levels, including acetaldehyde, methanol, acetone, acetic acid and uncharacterized terpenes. CONCLUSIONS: Awareness of the risks of inhaling the smoke directly from burning cannabis has led to the development of a number of alternative methods of delivery, which are claimed to be safer than direct smoking. Ammonia at toxic levels is produced from heating 'street' cannabis in these commercially available devices. Thus, the use of these devices to deliver 'street' cannabis is now open to question and further research is needed to investigate their safety.

Awareness of the need for safe storage of methadone at home is not improved by the use of protocols on recording information giving.

BACKGROUND: Methadone is a synthetic, narcotic analgesic used in the treatment of drug misuse. Tragedies involving children being poisoned by the accidental ingestion of methadone are no longer a rare occurrence. Following an audit of the effectiveness of the provision and recall of information to patients attending an NHS Methadone Clinic a protocol was introduced to ensure that staff documented the provision of such information and patients gave a written confirmation that they had received the information. METHODS: The study was undertaken in the setting of an NHS methadone clinic with the aim of re- auditing the storage of methadone at home following the introduction of the new protocols. 174 patients completed an anonymous questionnaire regarding where they store methadone at home and whether they recall being given advice about safe storage. Community pharmacists were contacted by telephone to assess the level of advice given to methadone patients regarding safety. RESULTS: Only 49 (28.2%) patients recalled being given advice about safe storage, 24 (13.8%) recalled that information was provided by clinic staff. 170 (97.7%) patients regard methadone as being dangerous. (28.2%). Methadone is most commonly stored in a cupboard (37.9%). All methadone is dispensed in a bottle with a child resistant cap on it. All patients reported they stored their methadone in the original bottle provided by the pharmacist. CONCLUSION: Recall of information on safety issues is very poor. Provision of written as well as verbal information is needed. The use of printed safety information cards which patients can take away for future reference may be of use. It is the responsibility of health professionals to ensure they provide information and advice to methadone users on the safe storage of their methadone at home.

Elevated urinary aluminium in current and past users of illicit heroin.

The use of illicit heroin is associated with aberrant neurology of unknown aetiology and various psychiatric illnesses. Aluminium, which is a proven neurotoxin, is present in significant amounts in illicit heroin and may also be volatilized and inhaled following the vaporization of heroin off aluminium foil ('Chasing the Dragon'). The purpose of this study was to establish if the use of illicit heroin was associated with an increase in the body burden of aluminium. We have used graphite furnace atomic absorption spectrometry to measure the aluminium and iron contents of the urine of current and past users of illicit heroin and used these data to estimate body burdens of aluminium. Urinary excretion of aluminium is the most effective non-invasive indicator of the body burden of aluminium and was found to be significantly (P < 0.001) higher in users of illicit heroin, range 14-3382 nmol/mmol creatinine (mean +/- SD; 222 +/- 491 nmol/mmol creatinine), than in a normal non-drug abusing control population, range 23-74 nmol/mmol creatinine (mean +/- SD; 43 +/- 19 nmol/mmol creatinine). Exposure to aluminium from the use of illicit heroin may be of particular significance because the urinary excretion of iron, another major contaminant of illicit heroin, in users (mean +/- SD; 53 +/- 63 nmol/mmol creatinine) was not significantly different (P > 0.05) from the control population (mean +/- SD; 38 +/- 18 nmol/mmol creatinine). We have shown for the first time that the use of illicit heroin may be a significant contributor to the body burden of aluminium. Further research will be required to determine if adventitious aluminium has a role in heroin use-related neuropathology and neurology.

The influence of age and gender on drug use in the United Kingdom--a review.

The aim of this study is to review UK epidemiological research in light of studies on the influence of age and gender on drug use in young people. Literature for this review came from English language publications using a structured search strategy. Within the UK, drug use is commoner in young males than other population groups. When integrated social development models are employed, drug use is seen to be determined by the complex interaction of factors such as age, parental monitoring, and peer group associations. Suggested research directions include combining structural equation modeling with large-scale, UK-based longitudinal social development model studies to develop prevention and intervention efforts that are sensitive to the role of individual, social, and cultural factors.

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.

Quantification of breath carbon disulphide and acetone following a single dose of disulfiram (Antabuse) using selected ion flow tube mass spectrometry (SIFT-MS).

Selected ion flow tube mass spectrometry (SIFT-MS) has been used to measure simultaneously the concentrations of both carbon disulphide and acetone in exhaled breath following the ingestion of a single dose of disulfiram (Antabuse). Carbon disulphide is a product of the metabolism of disulfiram and is excreted mainly through the lungs. Acetone is a product of normal metabolism and appears in the breath of all individuals. These breath analyses were performed in single exhalations and the results were available in real time. The levels of breath acetone and carbon disulphide were compared with levels obtained from a control subject who had not ingested disulfiram. Breath carbon disulphide was seen to increase from 15 p.p.b. to 618 p.p.b. over a 28-hour period, in the single individual tested, following ingestion of disulfiram, while acetone levels increased from 300 p.p.b. (normal) to over 4000 p.p.b. (greatly elevated). No such increases were seen in the breath of the control subject over the same period. An obvious positive correlation between breath carbon disulphide and acetone concentrations following disulfiram ingestion is seen and discussed.

The increase of breath ammonia induced by niacin ingestion quantified by selected ion flow tube mass spectrometry.

The ingestion of relatively large doses of the vitamin niacin by healthy volunteers results in a reddening of the skin, a skin 'flush'. Thus, we have carried out a study of the breath metabolites of two healthy volunteers following (i) the ingestion of 200 mg of immediate-release niacin, (ii) as (i) but preceded by the ingestion of 325 mg of aspirin that diminishes the skin 'flush', (iii) ingestion of 500 mg of slow-release niacin. On-line breath analysis was carried out using selected ion flow tube mass spectrometry, SIFT-MS. The interesting new observation is that the breath ammonia levels of both volunteers clearly increased following (i) and (ii), and an obvious skin flush did occur following (i) but not following (ii). The slow-release niacin (iii) did not result in a flush and the breath ammonia levels increased more slowly and did not reach the higher levels produced by (i) and (ii). The results of these experiments demonstrate that breath ammonia levels are dependent on the blood/plasma levels of niacin, but are not directly related to the flushing phenomenon, and that the observed increases in blood/breath ammonia levels are consistent with current knowledge of the metabolic pathways of niacin. The parallel measurements of breath isoprene are presented, which demonstrate the quality of breath analyses that can be achieved using SIFT-MS.

Aluminum in tobacco and cannabis and smoking-related disease.

PURPOSE: The study aimed to confirm the very high content of aluminum in tobacco and cannabis and to provide for the first time evidence that such aluminum could be biologically available. METHODS: Complete digestion of tobacco and cannabis was achieved using a 50:50 mixture of 14 M HNO3 and 0.1 M NaF. Total Al in digests was measured by graphite furnace atomic absorption spectrometry. A bespoke cigarette smoking apparatus was used to determine if aluminum in active or passive tobacco/cannabis smoke would be trapped by a surrogate lung fluid. RESULTS: The aluminum content of tobacco and cannabis was confirmed to be high, as much as 0.37% and 0.4% by weight respectively. Aluminum in tobacco and cannabis smoke, whether actively (drawn) or passively inhaled, was shown to accumulate significantly in surrogate lung fluids, thus demonstrating its potential biological availability. CONCLUSIONS: Active and passive smoking of tobacco or cannabis will increase the body burden of aluminum and thereby contribute to respiratory, neurological and other smoking-related disease.

Generation of volatile compounds on mouth exposure to urea and sucrose: implications for exhaled breath analysis.

The increase in ammonia and ethanol in the exhaled breath stream following mouthwashes by aqueous solutions of urea and sugar (sucrose), respectively, has been investigated by analysing exhaled breath in real time using selected ion flow tube mass spectrometry, SIFT-MS. It is shown that the measured levels of these compounds in the stream of exhaled breath can be much greater than the endogenous levels originating at the alveolar boundary. Thus, it is concluded that without careful preparation, mouth production of these compounds, and other compounds as yet unidentified, can seriously compromise the quantification of truly endogenous trace compounds present in blood and in the alveolar breath, as required for clinical diagnosis, and can probably introduce additional compounds into the breath stream that could seriously mislead breath analysis. The concentrations of both the urea and sucrose solutions used to enhance the ammonia and ethanol levels were larger than normally present in food and drinks and so in most situations such severe enhancements will not occur.

Safe storage of methadone in the home--an audit of the effectiveness of safety information giving.

BACKGROUND: Accidental poisoning by methadone occurs, particularly as a result of children ingesting a parent's methadone. Health care professionals have a responsibility to provide information and guidance to methadone users on safe storage of methadone. The objective of the study was to audit the effectiveness of information giving on the safety of methadone consumption, dose measurement and storage, and the effectiveness of sources of advice available for patients. METHODS: The study was undertaken prior to the introduction of a scheme for the supervised consumption of methadone, in the setting of an NHS Methadone clinic serving a district population of 490,000 in the UK. 185 consecutive patients attending a methadone clinic to collect a methadone prescription were the subject of an anonymous survey. Issues of safety of methadone consumption, storage and safety information provisions were assessed. A telephone survey of the community pharmacists dispensing the methadone covered the availability of measuring devices and provision of advice on safety was undertaken. RESULTS: Methadone was stored in a variety of locations, a cupboard being most frequent. 95 patients (60.1%) had children either living in or visiting their home. All stored their methadone in a bottle with a child resistant lid; the majority measured doses using either the container supplied by the pharmacist or a plastic measure. 126 patients (78%) confirmed that a pharmacist provided a measuring container on their first visit, 24 (15%) were given a measure on every visit to the pharmacist. Advice on safe storage was recalled by 30% of the patients, and advice on measuring methadone by 28%. Methadone was seen as potentially dangerous by 82% of the patients. CONCLUSION: The risks resulting from unsafe storage of methadone may be reduced by daily installment prescribing and provision of measuring containers on request. Recall of provision of information on safety issues is poor and the adoption of a standard policy on provision information should be seen as a priority. A re-audit of safety of storage of methadone is recommended following the introduction of a standard policy on information provision.

Substance misuse and psychiatric comorbidity in adolescents.

PURPOSE OF REVIEW: Many young people are misusing and becoming dependent on multiple substances (especially nicotine, alcohol, and cannabis), with a complex variety of psychological effects. RECENT FINDINGS: Analysis of interactions between smoking, drinking, and cannabis use indicates that the relationship between substance use and psychiatric comorbidity is primarily explained by regular smoking. In some studies the use of cannabis on a regular basis was associated with an increased risk of psychiatric illness. This is by no means the case for all studies, so this area of work remains controversial. Children with attention deficit hyperactivity disorder who are substance misusers have a poorer prognosis than those without it so there is concern about treatment with stimulant drugs: this fear appears not to be substantiated by one study. Young people with anxiety disorders are at increased risk of substance use disorders. Clinical trials for adolescent substance abuse treatment have provided support for the benefits of cognitive behavioural interventions. There is an accumulating evidence base for pharmacological treatment for adult substance misusers that can inform treatment for younger patients. It is estimated that, of those adolescents who were likely to be in need of help, only about 9% received treatment. SUMMARY: Since psychiatric disorders beginning in childhood may continue into adult life, there is an opportunity to intervene to prevent or reduce conditions complicated by substance misuse, if services are accessible. The need for longitudinal work is vital to explore the patterns of comorbidity, and implement and evaluate appropriate treatment interventions.

A training course for psychiatric nurses in Russia.

This article describes the impact on mental health services in Russia of a training course for psychiatric nurses in the management of aggression. This project, which is part of a seven-year international partnership between mental health professionals in the UK and Russia, demonstrates the importance of nurse training to effect change in healthcare organisations.

A postmarketing study of relative abuse liability of hypnotic sedative drugs.

AIMS: To demonstrate the utility of postmarketing studies using in-treatment drug and alcohol abusers as informants for assessing the relative abuse liability of sedative-hypnotic drugs. DESIGN: A survey was conducted that ascertained exposure to a variety of drugs with hypnotic/sedative properties and elicited subjective evaluations indicative of abuse liability. METHODS: Complete data were obtained from 297 admissions (78% male) to three addiction treatment sites in the United Kingdom. Subjects were asked 15 questions about 12 different drugs, including five benzodiazepines, three antidepressants, two non-benzodiazepine hypnotics and two antihistamines (plus one fictitious drug). Three of the benzodiazepines (diazepam, nitrazipam, temazepam) emerged as having substantially more abuse liability than any of the other drugs tested, as revealed by higher scores on abuse liability items (purchased on street, taken to get high, like drug, potential for addiction to drug). The antihistamines (chlorpheniramine, diphenhydramine) had lowest abuse liability profiles, while the antidepressants (amitriptyline, fluoxetine, trazadone) and non-benzodiazepine hypnotics (zolpidem, zopiclone) had similar profiles. CONCLUSION: This pilot study suggests that postmarketing information on hypnotic drug use obtained from drug addicts entering treatment produces data consistent with other measures of abuse liability. The data suggest that the risk of misuse of newer non-benzodiazepine hypnotics may be less than that of benzodiazepine drugs, and similar to that of sedating antidepressants. The new methodology may serve to clarify or validate premarketing abuse liability data, and may help to inform the regulatory process and physician practice.