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Cannabis use is decreasing in England and Wales, while demand for cannabis treatment in addiction services continues to rise. This could be partly due to an increased availability of high-potency cannabis. Adults residing in the UK were questioned about their drug use, including three types of cannabis (high potency: skunk; low potency: other grass, resin). Cannabis types were profiled and examined for possible associations between frequency of use and (i) cannabis dependence, (ii) cannabis-related concerns. Frequent use of high-potency cannabis predicted a greater severity of dependence [days of skunk use per month: b = 0.254, 95% confidence interval (CI) 0.161-0.357, p < 0.001] and this effect became stronger as age decreased (b = -0.006, 95% CI -0.010 to -0.002, p = 0.004). By contrast, use of low-potency cannabis was not associated with dependence (days of other grass use per month: b = 0.020, 95% CI -0.029 to 0.070, p = 0.436; days of resin use per month: b = 0.025, 95% CI -0.019 to 0.067, p = 0.245). Frequency of cannabis use (all types) did not predict severity of cannabis-related concerns. High-potency cannabis was clearly distinct from low-potency varieties by its marked effects on memory and paranoia. It also produced the best high, was preferred, and most available. High-potency cannabis use is associated with an increased severity of dependence, especially in young people. Its profile is strongly defined by negative effects (memory, paranoia), but also positive characteristics (best high, preferred type), which may be important when considering clinical or public health interventions focusing on cannabis potency.

Summary Background Prescription drug misuse has become a public health problem in several developed countries. In the UK, there has been no increase in people seeking treatment for prescription drug dependence, but there has been a progressive rise in fatal overdoses involving tramadol. Objectives To explore the source, motivations for use and patterns of use of tramadol in the UK. Methods We conducted anonymous online survey of drug use and related behaviours as part of an ongoing drug trend monitoring initiative. We included questions assessing the patterns of use, source and function of tramadol. Results UK Survey respondents (n = 7360) were predominantly young (mean age 29), and 90% reported being employed or studying. Less than 1% reported past‐year use of heroin or methadone, but about 1/3 reported past‐year use of cocaine. 326 (5% of respondents) reported having used tramadol in the preceding year, usually obtained by prescription but in 1/3 of cases from a friend; rarely from a dealer or from the internet. Most used the drug for pain relief, but 163 respondents (44%) reported using tramadol for reasons other than pain relief – particularly, using it to relax, to sleep, to get high or to relieve boredom. Nineteen per cent took doses higher than prescribed, and 10% reported difficulty discontinuing. Twenty‐eight per cent combined tramadol with alcohol or other drugs to enhance its effect. Conclusion Misuse and sharing of tramadol, supplied by prescription, was common.

Use of betel nut (areca nut) and its products is widespread, particularly in the Indo‐Chinese continents, being the fourth most widely used substance after tobacco, alcohol and caffeine, affecting approximately 20% of the world's population. Betel nut, with or without admixed tobacco, is widely used among UK Indo‐Asian immigrants, particularly Gujurate speakers. To date most research has concentrated on oral submucous fibrosis and malignancy. This paper reports detailed socio‐demographic, clinical, laboratory and psychological studies in 11 current and former heavy betel nut users, referred by an Oral Medicine Unit in NW London. The patients, nine males, two females, had a high incidence of cardiovascular disease and truncal obesity. Laboratory investigations showed a high incidence of reduced serum B12 levels (4/9) and raised urinary cotinine levels (6/11), although none were current cigarette smokers. These findings are consistent with heavy usage of tobacco‐areca combinations by this group. Routine biochemical and haematological investigations and clinical examination revealed no consistent abnormalities. Subjects had used areca for an average of 35 years with the mean age of first use being 13 years. Most subjects reported beneficial psychosocial effects. Ten subjects reported cessation withdrawal effects with the mean Severity of Dependence Score of 7.3. These findings are consistent with the existence of a dependency syndrome among those who use areca nut products. Further research is required to delineate the relative contributions of areca nut and tobacco to this clinical picture. Use of the areca nut, especially with tobacco, represents an area of health prevention among the UK minority populations that has, to date, been overlooked.

Since viral hepatitis among intravenous drug users continues to be a major cause of morbidity and mortality, the present study was conducted to survey drug agencies in England and Wales in order to identify the prevalence of hepatitis B and C testing and vaccination being provided. A postal survey of all 539 drug agencies in England and Wales was thus conducted to assess their current treatment provisions and practices. An analysis of the responses provided by the 373 agencies that returned usable data (69.2% response rate) revealed that only one-quarter (26.6%) of the drug agencies conducted routine hepatitis B testing, and 26.9% did not offer it at all. Just over half (55.7%) of the agencies provided hepatitis B vaccination, but only 21.7% did so routinely. Seventy percent provided hepatitis C testing, but only 24% did so routinely. Nevertheless, the majority of respondents, of whom 40.3% were nurses and 25.1% drug workers, believed that clients and their partners should be offered hepatitis B and C screening. The paucity of hepatitis testing and vaccination services being offered to injecting drug users is unacceptable, with users, their partners and children being needlessly exposed to continued risk. The disparity between recommended policy and current practice needs to be urgently addressed.

SUMMARY POINTS New drugs of misuse, including ketamine, γ-hydroxybuty rate (GHB), and a range of synthetic stimulants, have become part of global recreational drug culture Use in combination with other substances (especially alcohol) is common and increases the associated health risks These drugs are associated with non-specific risks of intoxication and substance specific toxicological harms Assessment and feedback using a motivational approach and provision of information about harm reduction are useful interventions that can be delivered in primary care Referral to specialist services might be needed to manage complex withdrawal or specific harms

We should focus on crafting the most effective public health response

The findings support Hall's cautious view on the likely impact of roadside drug testing on driving while under the influence of drugs. Competing interests: ARW is founder and director of Global Drug Survey, an independent drug use data mapping exchange hub. 1 Hall W. Driving while under the influence of cannabis.

Donald Winstock was born in 1924, the youngest of six children, and was brought up in east London to a family of immigrant Russian Jews. Happiest when seeing patients or sharing surgical skills on visits to warmer climates, he won the Cartwright prize in 1966 and was awarded a Hunterian professorship in 1981.

[...]there have been reports of mixtures of ketamine and ephedrine, as well as other substitutes such as mixtures of lysergide (LSD) and amphetamine or of lysergide and ephedrine, being sold as ecstasy.