Nicola Jayne Kalk

Background: Acute behavioural disturbance (ABD) is a contested term describing severe agitation and behavioural dysregulation, often preceding sudden death. Concerns regarding diagnostic clarity, racial bias and law enforcement restraint have been raised, and its clinical and forensic utility have been questioned. Aims: To characterise fatal ABD cases following substance use to inform clinical management, forensic interpretation and policy. Method: Fifty-one deaths consistent with ABD were identified from the National Programme on Substance Use Mortality (NPSUM) using textual screening and Royal College of Emergency Medicine and Faculty of Forensic & Legal Medicine criteria. Results: All cases met Royal College of Emergency Medicine criteria and most met Faculty of Forensic & Legal Medicine (84.3%) criteria. Agitation was the most frequently observed sign (86.3% of cases). Stimulants, particularly cocaine and amphetamines, were also detected in 86.3% of cases, but not necessarily in the same cases, and the rate of stimulant detection was almost three times higher than that in in the broader NPSUM cohort (32.1%). Cocaine concentrations were higher in ABD cases than in all NPSUM cocaine-related deaths (0.848 mg/L v . 0.105 mg/L). Compared with the NPSUM cohort, ABD decedents were significantly younger (30.2 ± 7.5 v . 40.5 ± 13.4) and more likely to be male (92.2 v . 73.4%), from racially minoritised backgrounds (21.7 v . 3.9%) and living in deprived areas (87.0 v . 75.9%). Conclusions: Variability in diagnostic criteria highlights a need for clearer ABD definitions. Toxicology testing may assist in refining the ABD construct, but its results must be interpreted within broader clinical and social contexts. These findings support avoiding use of ABD as a stand-alone cause of death but retaining it as a clinical descriptor prompting urgent treatment, monitoring and reduced reliance on prolonged restraint.

Introduction Smartphone ownership among UK adolescents is near universal, and teachers report phones increasingly being involved in classroom disruption, with misuse during school hours among the more common serious behavioural issues in secondary schools. Evidence on whether restrictive policies improve behaviour, attainment, or wellbeing remains limited. The primary objective is to assess the impact of a lockable smartphone pouch on educational attainment and behaviour. Secondary objectives are to assess impacts on general functioning, psychological wellbeing, and school-level indicators such as exclusions, and to examine whether effects differ for pupils who may be most at risk. Methods and analysis We will conduct a mixed methods cohort study in secondary schools across Northern Ireland and England during the 2025 to 2026 academic year. The quantitative component uses a serial cross-sectional design, with students completing an online questionnaire at 0, 4, and 8 weeks covering homework completion, classroom disruption, participation in PE and extracurricular activities, peer interaction, and smartphone use. Measures include the Strengths and Difficulties Questionnaire, the Revised Child Anxiety and Depression Scale, the short form of the Smartphone Addiction Scale, and the Bergen Social Media Addiction Scale. Schools will also supply half-termly aggregate data on exclusions, detentions, CAMHS referrals, counsellor visits, and parent visits from September 2023 to May 2026. Assuming 90% power, a two-sided type 1 error of 0.05, an intracluster correlation of 0.02, and 25% loss to follow up, we aim to recruit a minimum of 3,200 students from six or more schools to detect a small effect (Cohen's d = 0.2) on SDQ hyperactivity score. Continuous outcomes will be analysed with linear regression and binary outcomes with logistic regression. Aggregate school data will be analysed using an interrupted time series design. Prespecified subgroup analyses cover SEN or neurodivergent status, area-level deprivation, and existing school phone policy. Qualitative data from focus groups with students and staff and semi-structured interviews with school leads will be analysed thematically using Braun and Clarke's six-phase approach. Ethics and dissemination The study has been approved by the King's College London Research Ethics Committee. A Data Protection Impact Assessment has been agreed with the Northern Ireland Department of Education. Findings will be disseminated through a final report to the Department of Education, peer-reviewed publications, conference presentations, and accessible summaries for participating schools, pupils, parents, and policy makers. Keywords: Smartphone; Schools, Secondary; Adolescent Behavior; Mental Health; Academic Performance

Early detection of alcohol use disorder (AUD) amongst people admitted to general hospitals offers an opportunity for early intervention and accesses to evidence-based care. However, current operational models for the management of AUD in these settings are poorly defined, limiting the ability to assess their impact on individual patient outcomes, treatment effectiveness, or healthcare system efficiency. This scoping review aims to identify and characterize existing models of AUD management within general hospitals. A scoping review approach was adopted, including relevant peer-reviewed publications between 1990 and 2025. Studies needed to report on ≥2 care components (systematic screening, brief interventions, medically assisted alcohol withdrawal, relapse prevention initiation, psychosocial interventions, transition to community, provision of training) to be included. Screening and data extraction were performed independently by at least reviewers. Fifty-one (n = 51) records were included, and four distinct models of care were identified (consultation liaison; screening, brief intervention, and referral to treatment; protocol implementation; supported diversion). Models varied in their clinical purpose, target population, and care delivery focus. Within each model, differences in aims, context, and implementation resulted in substantial heterogeneity. Consultation liaison models provided the most multifaceted care, with a specialist team providing clinical leadership, access to evidence-based interventions, transition to community services, and training of the wider workforce, but rarely described any wider systematic screening for AUD. A consistent observation across all identified models was the limited interface with mental health care, representing a critical gap in current AUD management within general hospitals.

The British Association for Psychopharmacology guidelines for the management of substance dependence focus primarily on the pharmacological aspects of treatment. A group of international experts from a wide range of disciplines reviewed the current evidence in their field, considered the strength of the evidence and discussed the clinical implications at a consensus meeting. The guidelines focus on the pharmacological management of dependence on alcohol, benzodiazepines, ‘z-drugs’, γ-hydroxybutyrate (GHB), gabapentinoids, opioids, nicotine, cannabis and synthetic cannabinoids, cocaine, amphetamine and methamphetamine, dissociative drugs and their analogues. They are based on the available evidence and make recommendations to aid clinical decision making, as well as highlighting the gaps in the current evidence-base.

Background and aims: There has been limited evidence synthesis examining the treatment of buprenorphine precipitated opioid withdrawal (BPOW). We aimed to conduct the first systematic review to assess the clinical utility of any pharmacological intervention in the management of BPOW. Methods: Systematic review searching Medline, Embase, PsychINFO and CENTRAL from the date of database inception to 26 August 2025 for studies of any design reporting any pharmacological intervention in the management of BPOW compared with any or no other interventions, using adult participants aged 18 or over receiving buprenorphine and experiencing BPOW. We planned to combine outcomes using random‐effects meta‐analysis; where this was not possible results were reported narratively. We considered two outcomes and extracted (1) any reported measure or description of the change in opioid withdrawal symptoms (OWS) and (2) the number of individuals retained in buprenorphine treatment. Outcome quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Results: Forty‐three studies met inclusion criteria reporting on 137 participants. These comprised one pilot randomised controlled trial and 42 uncontrolled observational case series or case reports. Meta‐analysis was not possible, and all evidence was of low or very low quality. The currently available randomised evidence suggests that use of intravenous magnesium sulphate, in addition to symptomatic treatment with clonidine, paracetamol and diazepam, may statistically significantly reduce OWS when compared with symptomatic treatment alone. The currently available observational evidence suggests that treatment strategies which include additional doses of transmucosal buprenorphine may demonstrate higher rates of symptom control and treatment retention than strategies which do not include additional doses of transmucosal buprenorphine. Conclusions: There is a paucity of research into pharmacological management of buprenorphine precipitated opioid withdrawal. The limited very low to low quality evidence suggests treatment regimens that include magnesium sulphate and additional doses of transmucosal buprenorphine are potentially the most salient current options and avenues for future research in the management of buprenorphine precipitated opioid withdrawal.

Aims: This study aimed to identify (i) the number of alcohol care teams (ACTs) in England, (ii) the characteristics of patients supported by ACTs, and (iii) the service structure and care components offered by ACTs. Methods: All acute hospitals (i.e. those providing short-term high-dependency medical care) in England were approached to complete a survey of alcohol care provision. Surveys were completed through researcher-guided interviews by staff familiar with the hospital’s alcohol provision. It featured questions on service structure, patient characteristics, service functions, and policies. Data collection took place between May and October 2023. Results: Of 170 hospitals approached, 122 completed a survey and 80 reported having an ACT. Most ACT patients were male (mean 64.1%; 95% confidence interval (CI) 61.8–66.4), white (mean 79.2%; 95% CI 75.1–83.4), aged 45–54 (mean 27.8%; 95% CI 25.0–30.5), and experiencing severe alcohol dependence (mean 66.2%; 95% CI 36.8–95.7). Most services had a clinical lead but only 58% funded this role. Fifty-nine percent of services operated 7 days per week. Most services reported identification and brief advice, though it was rarely systematized. Nearly all supported medically assisted alcohol withdrawal, though a quarter of patients did not complete medically assisted alcohol withdrawal before discharge. Conclusions: ACT numbers increased significantly between 2019 and 2024. They offer a clinical service to highly vulnerable and complex patients. There is significant variation in ACT operational models, training, and leadership which will impact the effectiveness of identification strategies and management of patients with comorbid alcohol use disorder within acute medical settings.

The opioid overdose epidemic remains a critical public health crisis. In recent years, synthetic opioids like fentanyl and nitazenes, have driven a sharp rise in deaths. Naloxone, an opioid receptor antagonist, has been established as a key intervention for reversing opioid overdoses and saving lives. However, there remains a critical need to optimize naloxone dosing strategies. This article examines the challenges of both under‐dosing and over‐antagonism in naloxone administration, emphasizing the importance of a tailored approach to overdose management. A ‘just the right dose’ approach is essential for minimizing the risks of over‐antagonism while still reversing opioid overdose. This involves starting with a modest naloxone dose and carefully titrating it based on the patient's response, considering factors such as opioid type, overdose severity, and opioid tolerance. A tailored approach to naloxone dosing may present challenges for non‐medically trained responders but it can ensure that as many people as possible receive the right dose of naloxone when they need it. Training programs should also emphasize the importance of first aid and supportive care, including airway management and alerting emergency services, as well as careful monitoring of the patient's response.

Background & Aim: Globally, more than 100 000 people die annually from opioid overdose. Although strongly implicated in heroin overdose deaths, acute opioid‐induced respiratory depression is poorly understood, and few laboratory studies have been completed in human subjects. It is an area of undone science. Using a human laboratory overdose model, our research question was: what is the strength of the association between increasing dose of diamorphine and degree of respiratory depression in people prescribed injectable diamorphine for heroin use disorder? Design: Single‐blind, Phase IV, non‐randomised, dose‐escalation clinical trial. Setting: King's Clinical Research Facility, London, UK. Participants: Four participants prescribed injectable diamorphine as treatment for heroin use disorder [all male, median (range) age 63 (59–72)]. Interventions: The following dosing schedule was implemented (as a % of participant's usual prescribed diamorphine dose): visit 1–100%; visit 2–110%; visit 3–120%; visit 4–100%. Usual dose: 97.5 mg (30 mg–200 mg). Measurements: Physiological measures included: pulse oximetry (SpO ₂ %), end‐tidal CO ₂ (ETCO ₂ %), transcutaneous CO ₂ , respiratory rate and parasternal electromyography to measure neural respiratory drive index (NRDI). Recordings were made continuously from 3 mins pre‐dose to 60 mins post‐dose. Findings: Respiratory measures from baseline to post‐dose across all dose sessions had ranges of: 89.7%–99.5% SpO ₂ %; 4.8%–7.7% ETCO ₂ %; 5.2–13.4 breaths/minute respiratory rate; 51.2 min ⁻¹ –165.9 min ⁻¹ NRDI across all participants. All diamorphine doses caused some reduction in respiratory function. There was no clear difference between diamorphine dose and the degree of respiratory depression, based on descriptive analyses. Conclusions: A dose‐escalation clinical trial of people prescribed injectable diamorphine for heroin addiction found that the degree of respiratory depression caused by diamorphine does not appear to be dose dependent; however, the changes seen at diamorphine doses to which participants were accustomed suggest that participants had only partial tolerance to the respiratory depressant effect of diamorphine.

Summary: Chemsex occurs primarily among gay, bisexual and other men who have sex with men (GBMSM), and there is evidence of a subgroup of users who carry out chemsex-related criminal offences and experience harm. Challenges with chemsex can present to various settings; there are concerns that harm is increasing, including at interfaces between health, social care and criminal justice systems. The UK response to date has lacked a coordinated approach. An expert reference group was convened to share chemsex knowledge, articulate priorities for research and pathway development, and foster collaborative working between agencies. It made three key recommendations: develop and increase training and awareness across all services; implement a coordinated research programme with the development of a common data-set and assessment tool to fully characterise population-level needs; develop a professional network to share information, provide professional support and act as a knowledge hub. There was support for a unified multi-agency strategy incorporating the priorities identified as overarching principles.