The use of cannabis in young people is an independent risk factor for the development of incident psychotic symptoms, a prospective cohort study has found. Data were analysed on 1,923 subjects drawn from the Early Developmental Stages of Psychopathology Study in Germany. Participants were aged 14-24 years, mean 18.3, at entry and followed up for 10 years. Dr Jez Thompson writes: 'The authors conclude that cannabis is a risk factor for the development of incident psychotic symptoms and that continued use of cannabis might increase the risk of psychotic disorder by impacting on the persistence of normally transitory psychotic symptoms in young people.'

The introduction of supervised methadone administration was followed by a reduction in deaths due to methadone overdose in England and Scotland. Deaths related to methadone declined four-fold in both countries, while methadone prescribing increased substantially, between 1993 and 2008.The past two decades have seen rapid growth in methadone prescribing for the management of heroin dependence and widespread adoption of supervised administration of methadone by pharmacists. The authors took the total quantity of methadone prescribed annually, and divided this by 60 mg (the approximate average daily dose) to give an estimate of the number of daily dispensed doses in a given year. This figure was then analysed with the number of deaths identified by coroners as involving methadone (both as the only drug involved, and when methadone was one of a number of substances), between 1993 and 2008. 'The study found that the OD4 index decreased substantially in both Scotland and England despite large increases in methadone prescribing. In England, for example, the OD4 for methadone-only deaths fell from 27.1 in 1993 to 5.8 in 2008, in a period when methadone prescribing increased seven-fold. In Scotland the respective values fell from 19.3 to 3.0 over the same period and methadone prescribing increased 18-fold. The study does not address any other potential cause for the decrease in fatal overdose rates apart from the introduction of supervised methadone dosing. However, it provides good evidence that methadone prescribing has become increasingly safe with the adoption of supervised administration. The OD4 provides a useful tool for monitoring any future changes.'

A large, prospective, population-based study has shown that people who drink no or little alcohol are at increased risk of anxiety and depression. Data on a sample of 38,390 people taking part in the HUNT study, in Norway, were analysed. Subjects filled in a questionnaire on alcohol intake which was based on the amount of alcohol consumed over the past two weeks. Anxiety and depression were measured using HADS. 'While the study demonstrates an association between low alcohol consumption and symptoms of anxiety and depression, limitations of the study mean that the causality of the relationship cannot be addressed. Possible causes discussed include a direct protective effect from moderate alcohol consumption, that mid-range drinking habits may be a consequence of psychological wellbeing in cultures where some alcohol consumption is the norm, and confounding from a range of social factors.'

Buprenorphine is safer during induction than methadone and, despite shorter retention in treatment, is not associated with a higher risk of death, a study from New South Wales has found. 'While treatment with methadone has been shown to reduce overall mortality in heroin users, both the early weeks of treatment and the period immediately after leaving treatment are associated with increased risk of death. Buprenorphine has been shown to be a safer option in some small studies.'

Patients can readily obtain controlled opioids and other POMs from internet pharmacies without a prescription, a research team from Edinburgh has shown. This study found that of 96 websites selling analgesics to customers in the UK, 46 provided POMs, and 35 of these did not require the customer to have a valid prescription. #Controlled analgesics with the potential for misuse and dependence are freely available in large amounts from internet pharmacies without prescription in the UK. Lack of regulation of online suppliers means that medication can be fake, may contain more, or less, active ingredient than advertised, and may contain harmful ingredients. This presents a risk to public health, and should be borne in mind when GPs prescribe.'

Stopping drinking a month after the diagnosis of cirrhosis is the most important predictor of survival, a British study has found. The severity of cirrhosis found on biopsy had little impact on survival. The study followed 100 patients consecutively diagnosed with biopsy proven alcohol-induced cirrhosis at Southampton General Hospital. Patients with additional disease processes which were non-cirrhotic and patients without accurate mortality data were excluded from the study. Biopsies were scored for severity of cirrhosis by two independent observers. Data on drinking 30 days after diagnosis were available on all but four subjects.'This study clearly confirms that the single most important determinant of long-term prognosis in alcohol-induced cirrhosis is for the patient to stop drinking. For patients with cirrhosis, it is never too late.'

Many opiate users entering prison require medication to aid detoxification. A study carried out at Leeds prison found buprenorphine to be significantly more effective than dihydrocodeine at producing opiate-negative urine samples at five days. 'The study supports the result of an earlier sister trial in the community in which buprenorphine was a more effective detoxification agent than dihydrocodeine. When choosing prescribed detoxification support in either community or secure environments GPs should not routinely use dihydrocodeine. GPs need to be aware of the high rate of relapse to opiate use following prison-based detoxification.'

In a large cohort study of infants born to mothers prescribed methadone for opioid dependence, 45.5% needed pharmacological treatment for neonatal abstinence syndrome. The syndrome was more likely in the babies of women taking high-dose methadone, whereas those who were breastfed were less likely to need pharmacological treatment. ' Substitute prescribing of methadone to opioid-dependent women in pregnancy helps stabilise aspects of lifestyle, reduces some drug-related risks, and reduces the risk of pre-term birth and intrauterine growth retardation. Higher doses of methadone may be associated with less risky patterns of illicit drug use. However, they are also associated with a greater risk of neonatal abstinence syndrome. Pregnant drug-misusing women should be maintained on the lowest dose of methadone compatible with stability and supported to breastfeed their infants.'

Pattern of women's drug use alters in prison Illegal drug use is reduced when women enter prison and their pattern of misuse changes from street drugs to prescription medicines. Prior to imprisonment, just over half of the women entered into the study had been using an illicit drug on a daily basis, and 38% were ever injectors. Following entry into custody, 14% of the sample continued to use an illicit drug daily, and 2% of women continued to inject. The study used participants from 13 women's prisons across England. 'This study highlights the many challenges facing prison-based primary care services. These include:
* providing adequate drug treatment services which are effective in reducing illicit drug use
* harm reduction initiatives to lower the prevalence of injecting use with its related risks
* policy and practice which minimise the opportunity for prescribed medication to be diverted as a source of illicit drugs
* prevention of post-release opiate overdose death in those who stop using heroin on admission to prison and lose opiate tolerance.'

Much is known about the negative health effects of substance misuse for the individual. This paper set out to explore the morbidity and health costs for family members of those with a substance problem compared with relatives of people with asthma and diabetes. 'Disability and chronic illness of any kind affects the whole family. Having a family member with an alcohol or drug problem may have a negative effect on family functioning and dynamics and is associated with an increased risk of being diagnosed with a substance use disorder, depression, and trauma. GPs should bear this in mind when managing the families of those with problem substance abuse.'

There was a significant drop in those smoking 20 cigarettes a day or more following the ban on smoking in public places in England, a survey has found. However, there was no change in the overall number who smoked. The authors carried out a postal survey of 3,500 people in Bury, Lancashire before, and three months after, the smoking ban came into force in 2007. Participants were randomly selected using the PCT database. 'Although primarily designed to reduce the health risks associated with second-hand smoke, it was also hoped that the 2007 legislation might motivate smokers to give up. It may disappoint GPs that the smoking ban did not bring about a significant reduction in the prevalence of smoking. However, it is encouraging that the number of heavy smokers fell.'

A study from the USA has provided further evidence that some people who tan excessively are tanning dependent.The study recruited 400 volunteers from an American university, who were asked to complete an online questionnaire that had been modified to identify tanning dependence (modified CAGE and DSM-IV-TR scales). The mean age of participants was 21 years, 75% were women and 66% were white. 'Despite extensive public health education about the risks of excessive exposure to ultraviolet radiation, some people continue to tan excessively. Similarities between excessive tanning and substance use disorders are increasingly being discussed. Both are particularly common in the young, associated with pleasurable reinforcing experiences such as relaxation and socialisation and represent health risk behaviours that continue despite health warnings. A possible mechanism, linking tanning to endogenous opioid release during ultraviolet radiation exposure, has been mooted.The concept of tanning dependence may be new to many GPs and may  help them provide health education for those who continue to tan excessively.'

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