Shabu is a crystal methamphetamine whose consumption is common among the community of Philippine immigrants in Spain.

To describe the sociodemographic, healthcare and clinical characteristics of patients using shabu who have been treated by the psychiatry and addiction department of a tertiary hospital.

We describe the cases of patients treated in the psychiatry and addiction department of the hospital del Mar in Barcelona, Spain with methamphetamine use disorder. We collected sociodemographic variables, monitoring features and psychiatric comorbidity from the review of medical records.

Ten cases of patients with severe use disorder of shabu were identified. Eight patients are from the Philippines. Nine are men (90%). At the beginning of the medical follow-up the average age was 30 years (21–41 years). All of them reported being unemployed. Four patients were referred urgently to the hospital from an ambulatory care center, two belonged to a specific program for children and adolescents, two were treated at the emergency department and two were assessed during their admissions in other departments. Regarding clinical characteristics, six had associated psychiatric disorders: two have paranoid schizophrenia, two had induced psychotic episode, one had unspecified psychosis and other had conduct disorder.

Shabu is a drug that the Philippine community in Spain consumes in their daily life in a social context. However, consumption of this drug could be linked to the onset of psychotic symptoms. Registration is necessary to standardize the consumption pattern in order to establish a relationship between consumption and the appearance of psychotic and organic symptoms.

The authors have not supplied their declaration of competing interest.

Disturbances in inflammatory processes may play a role in the pathophysiology of psychiatric disorders. The neutrophil lymphocyte ratio (NLR) and C-reactive protein (CRP) are indicators of the systemic inflammatory response.

The current study was prepared based on the assumption that dysregulated immune function and elevated inflammation markers may be seen in substance use disorders.

Our aim was to investigate whether NLR and CRP are higher in patients diagnosed with substance use disorders than in healthy subjects.

The participants in the study included 115 male inpatients diagnosed with alcohol (n = 41), heroin (n = 46), or synthetic cannabinoid (n = 28) dependence according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR), and 32 healthy male volunteers. We used NLR and CRP as measures of systemic inflammation. Blood samples were taken on the next morning of admission for detoxification. Addiction severity was assessed using the Addiction Profile Index (API).

The difference between the groups with respect to NLR was statistically significant (P = 0.014). Patients diagnosed with alcohol, heroin or synthetic cannabinoid dependence had similar NLR. Patients with alcohol or synthetic cannabinoid dependence had significantly higher NLR than healthy controls (P = 0.001 and P = 0.029, respectively). Patients with heroin dependence trended towards statistically significantly higher NLR compared to healthy controls (P = 0.067). CRP levels did not differ significantly between the patient and control groups. NLR and CRP were not significantly correlated with API scores.

Our findings suggest that NLR is elevated in patients with substance use disorders in comparison to healthy controls.

The authors have not supplied their declaration of competing interest.

Until recently community opiate detoxification strategies have largely been limited to gradual dose reductions in opiate substitute treatment (OST). These detoxes are often lengthy leading to “windows of opportunities” in patients’ motivation to detox being missed. Furthermore, many patients remain on sub-optimal OST doses for long periods of time, during which they are more vulnerable to relapse to illicit opiate use.

Within our community service, we adapted and implemented a novel two-week community opiate detoxification programme using buprenorphine front-loading and lofexidine. We worked in partnership with Bristol drugs project (BDP) to offer an 8-week psychosocial intervention alongside the medically assisted detoxification.

Assessing the completion rates and clinical safety of this intervention.

Data collection was performed through retrospective review of patients’ case notes over a 9-month period.

Seventy-five percent of the patients starting an opiate detox successfully completed the intervention.

Lofexidine improved the mean opiate withdrawal scores by 28% at 45 min after the first dose and this was a sustained effect throughout the detox. Mean systolic blood pressure dropped by 6.2 mmHg at 45 min after the first dose of lofexidine and by 16.5 mmHg two days later however this was asymptomatic in all patients. There was no significant change in the heart rate and no adverse events.

Our team innovatively adapted and tailored a cost-effective community opiate detoxification programme using a multi-agency strategy in a climate of limited funding and staff resources. Our data clearly indicates positive outcomes in terms of completion rates and clinical safety.

The authors have not supplied their declaration of competing interest.

Alcohol use disorder is a pressing problem in our society. However, only a small percentage of patients with alcohol use disorder are ever treated. Nalmefene acts as an antagonist of mu opioid receptors preventing the pleasurable sensation that often accompanies alcohol consumption, while its modulation of kappa opioid receptors can decrease the dysphoria associated with alcohol withdrawal.

Studying the effect of nalmefene on patients with alcohol use disorder who are trying to reduce their daily alcohol consumption.

This is a descriptive study that pretends to assess the effect of nalmefene 18 mg/day on alcohol intake in a sample of five patients (3 men and 2 women) that came to our psychiatric consultation from March to September 2016. They all had tried in the past to stop or reduce their alcohol consumption but were unable to do so. We initiate follow-up with the patients in psychiatric consultation for the next three months with a monthly frequency.

Out of the 5 patients, 4 reported to have reduced their alcohol consumption over the observation time, going from 32 drinks per week to 18 drinks per week on average. The fifth patient abandoned prematurely the treatment due to the appearance of side effects (nausea). No other relevant side effects were detected.

Nalmefene appears to be effective and safe reducing abusive alcohol intake and avoiding alcohol withdrawal syndrome. Therefore, nalmefene can be considered a good therapeutic option helping reduce alcohol consumption in patients with alcohol use disorder.

The authors have not supplied their declaration of competing interest.

Substance use disorder (SUD) is a growing health problem which needs a very complex range of care due to the chronic and relapsing nature of the disorder and the multiple psychosocial problems involved. There are often difficulties in current outpatient programs to deliver and coordinate ongoing care and access to different health care providers. To improve treatment outcomes various case management (CM) models have been developed, at first in other psychiatric domains but also for patients with SUD.

The aim was to assess the effectiveness of CM for patients with SUD using existing studies.

Systematic review of CM interventions for patients with SUD by analyzing randomized controlled studies on this matter found on the electronic database PubMed published between 1996 and 2016.

Most of the analyzed studies showed improvement on the chosen outcome measures, although, these varied in the different studies. Mainly the treatment adherence improved, but substance use only reduced in a third of the studies. Overall functioning improved in about half of the studies. Further, studies are necessary to determine inclusion criteria for CM treatment for patients suffering from SUD in order to orientate patients most likely to benefit from this approach to the specific CM programs. There are still only few studies on this intervention and SUD. Further, studies are needed to examine the effect of treatment intensity of the CM intervention. Also longitudinal studies are needed to ensure the effectiveness of these treatments.

The authors have not supplied their declaration of competing interest.

New designer benzodiazepines such as phenazepam, etizolam, diclazepam, clonazolam and flubromazolam have appeared in the recreational drug market due to that they provide an attractive alternative to prescription-only benzodiazepines as they are readily available over the Internet.

To describe the presence of new designer benzodiazepines in samples delivered to energy control since 2010 to 2016 in Barcelona.

From 2010 to 2016, 24,551 samples were delivered to energy control. Among this samples 43 (0.175%) were analysed as benzodiazepines. They were analyzed by energy control, a Spanish harm reduction NGO that offers the possibility of analyzing the substances that users report. Analysis was done by gas chromatography-mass spectrometry.

From the 43 samples analyzed as benzodiazepines, 1 (2.32%) was delivered in 2010, none in 2011, 2 (4.65%) in 2012, 2 (4.65%) in 2013, 1 (2.32%) in 2014, 15 (34.88%) in 2015 and 21 (48.83%) in 2016.

The data shows that new designer benzodiazepines use is increasing in Barcelona, especially in the last two years. Abuse an addiction to these drugs may be a new public health problem in Barcelona. Unknown side effects may appear due to lack of information about pharmacokinetic profile of these drugs.

The authors have not supplied their declaration of competing interest.

Denial is a common feature of alcohol addiction that is apparent in the early and late stages of the disease. Defensive psychological mechanisms and cognitive failure have been reported as reasons for addiction denial. Effective therapeutic approaches should consider the reasons for anosognosic denial.

The study investigates the correlations between the degree of denial of alcohol addiction and cognitive status of people in the early stages of alcohol dependence.

Subjects were identified using clinical interview the AUDIT questionnaire investigating compulsive drinking, impaired control of drinking, alcohol tolerance, and symptoms of withdrawal.

Forty-nine alcoholic patients at early stage of alcohol dependence were identified. At assessment, all had been abstinent for at least 7 days. They reported compulsive drinking, impaired control over it, increased alcohol tolerance, but no withdrawal symptoms followed by relief drinking. The level of denial was defined by summing up the quantitative ratings of awareness of alcohol addiction and its harmful effects. Three groups emerged of non/mild, moderate, and severe levels of addiction denial. Neuropsychological evaluation of verbal memory, logical memory, visual-motor coordination, and motor and mental speed was conducted.

The identified cognitive deficiencies in the 3 groups were mild. Correlation between the poorer test performance and higher levels of denial was not significant. In the early stages of alcohol addiction, the anosognosic denial appears to be an unconscious ego defense mechanism leading to rejection of all the addiction-related problems.

The authors have not supplied their declaration of competing interest.

Seasonal and geographic variations in light exposure influence human mood and behavior, including alcohol consumption. In literature alcohol consumption have a clear seasonal rhythm, with specific differences during the year . Seasonal changes in mood and behavior (seasonality) may be closely related to alcoholism. The aim of our study is to evaluate the relationship between alcohol consumption and seasonal variation.

One hundred and nine inpatient are assessed with: the SCID-P for axis I diagnosis. Inclusion criteria are: (1) acute alcohol intoxication at the admission. All the socio-demographic characteristics are explained.

The peak period of alcohol admission is in the autumn, the lowest period is in spring in April and May. There is any significant difference related to gender. The 76% of the admission are coerced admission. The rates of co-morbidity are: personality disorders (30.3%), affective disorders (22.9%) and psychotic disorders (12.8%).

Some patients with alcoholism have a seasonal pattern to their alcohol misuse. Several lines of evidence suggest that changes in the circadian system are also involved in the development of non-seasonal mood disorders, such as major depression and bipolar disorder. Thus, developmental alcohol exposure produces subtle abnormalities in circadian rhythms that may contribute to the development of seasonal and non-seasonal mood disorders. Further research is warranted to replicate our clinical and qualitative observations and, in general, quantitative studies in large samples followed up over time are needed. Methodological limitations, clinical implications and suggestions for future research directions are considered.

The authors have not supplied their declaration of competing interest.

Novel psychoactive drugs (NPS) have rapidly increase in the last years in the drug market as a recreational use. A new group of toxic phenethylamine derivates named NBOMe of 2 C class present have emerged recently, are frequently bought using the internet and have similar effects to other hallucinogenic drugs; however, they may pose larger risks, due to the limited knowledge about them, their relatively low price and availability via the internet. The purpose of this report is to review the clinical evidence for the potential of abuse of NBOMe compounds. We propose a case report and literature review.

We conducted a systematic review of the literature with the principal database (PubMed, Enbase, PsychInfo) and we present a case report.

The effects of 25C-NBOMe is characterized by hallucination, violent agitation, rhabdomyolysis and kydney injury.

Effects from 25C-NBOMe in our case report were similar to previous individual case reports in literature. The clinical features were also similar to effects from other analogues in the class (25I-NBOMe, 25B-NBOMe). In our case, violent agitation (signs of serotonergic stimulation), rhabdomyolysis and kidney injury were observed. Further research is warranted to replicate our clinical and qualitative observations and, in general, quantitative studies in large samples followed up over time are needed. Methodological limitations, clinical implications and suggestions for future research directions are considered.

The authors have not supplied their declaration of competing interest.

Paramethoxymethamphetamine and paramethoxyamphetamine (PMMA and PMA) are two so-called designer amphetamines, which appear from time to time on the illegal narcotics market in many countries. They are frequently sold as ecstasy or amphetamine, often mixed with amphetamine or methamphetamine [1, 2]. Paramethoxyamphetamine (PMA) is a hallucinogenic synthetic substituted amphetamine with capable of development of dependence [3]. The purpose of this report is to review the clinical evidence for the potential of abuse of paramethoxyamphetamine. We propouse a case report and literature review.

We conducted a systematic review of the literature with the principal database (PubMed, Enbase, PsychInfo) and we present a case report.

The effects of paramethoxyamphetamine is characterized at the beginning with symptoms like euphoria, derealizzation, psychomotor activation, feeling in tune with surroundings and in love for friends, who come to visual and auditory illusions and hallucinations, paranoid delusion, and violent agitation.

The use of these recreational drugs is especially common among young people participating in rave parties. Occasionally paramethoxymethamphetamine (PMMA) or paramethoxyamphetamine (PMA) are found in street drugs offered as ecstasy. Further research is warranted to replicate our clinical and qualitative observations and, in general, quantitative studies in large samples followed up over time are needed. Methodological limitations, clinical implications and suggestions for future research directions are considered.

The authors have not supplied their declaration of competing interest.

AUD, with a prevalence of 7.5% in Europe, is a common disorder among general population. Reports show higher incidence in military personnel.

To detect possible AUD in mentally healthy military personnel, and estimate the need for a more regular screening.

Using the AUDIT questionnaire, we assessed personnel (n = 248) visiting our outpatient department, from January to June 2016, diagnosed as having “no major psychopathology”, by gender, age, marital status, rank and education. The results were processed using the SPSS Mann–Whitney-U and Kruskal Wallis tests.

We tested n = 215 men and n = 33 women, most aged over 35, married, n = 97 officers and n = 151 NCOs (non-commissioned officers), of medium or higher education; 59.7%, scored very low (0–2), n = 11 had a borderline score of 6–7, 6 scored > 8, with one scoring 16, all men and NCOs. Women had very low scores (72.7% P = 0.009). Older personnel concentrated on lower scores, while the younger (18–24) have higher odds of AUD (12.6% scored 6+). Married personnel scored lower (P < 0.001). No significant correlation between AUDIT scores and education (P = 0.705), however, lower education personnel seem to concentrate on very low scores (82.6%).

Female gender, age, marriage, and rank may have a positive effect on alcohol use. Lower educated personnel possibly drink less due to their more physical duties. The fact that 17 diagnosed as mentally healthy personnel had a score implying borderline to problematic alcohol use, could underline the need for a more regular screening for alcohol use disorder in the armed forces.

The authors have not supplied their declaration of competing interest.

Russia has one of the highest alcoholism (alcohol dependence) and alcoholic psychoses incidence/prevalence rates in Europe, which may be explained by high overall population drinking and prevalence of irregular heavy drinking of vodka. The role of binge drinking in modifying the effect of alcohol on the risk of alcoholic psychoses in Russia has been emphasized in clinical and aggregate-level studies.

The present study aims to examine the phenomenon of dramatic fluctuations in alcoholism and alcoholic psychoses rates in Russia during the late Soviet (1970–1991) to post-Soviet period (1992–2015).

To examine the relation between changes in the sales of alcohol and alcoholism/alcoholic psychoses incidence/prevalence rates across the study period a time-series analysis was performed.

According to the results, alcohol sales is a statistically significant associated with alcoholic psychoses incidence/prevalence rates, implying that a 1 litre increase in per capita alcohol sales is associated with an increase in the alcoholic psychoses incidence/prevalence rates of 17.6% and 14.0% correspondingly. The association between alcohol sales per capita and alcoholism incidence/prevalence rates was also positive, but statistically not significant.

These findings suggest that the alcoholic psychoses incidence/prevalence rates are the reliable indicators of alcohol-related problems at the population level. The outcomes of this study also provide indirect support for the hypothesis that the dramatic fluctuations in the alcoholic psychoses incidence/prevalence rates in Russia during the last decades were related to the availability/affordability of alcohol.

The author has not supplied his/her declaration of competing interest.

Substance use disorder is a growing phenomenon among old adults. It is usually significantly undervalued, misidentified, under diagnosed and poorly treated. It has been related to cognitive impairment but there are few studies focused on the elderly.

To evaluate the relationship between drug use and cognitive impairment in old adults.

We conducted a prospective study (basal and 6 month follow up) in 67 patients over 65 years old seeking for treatment for drug misuse (alcohol and prescription drugs, mainly benzodiacepines) in addiction and dual diagnosis unit in Barcelona. A specific protocol was performed to evaluate attention, executive function, working memory, learning capacity, fonetic and visual fluency, decision-making, visual construction and cognitive flexibility (FCT, CPT-II, N-BACK, COWAT FAS, TAP, SDMT, IGT, CVLT, TOL, RFFT, STROOP). Patients were compared with a control group (healthy non drug users) with same characteristics (gender, age range and education status). The protocol consisted in two separated sessions of 90 minutes each one performed by a neuropsychologist.

Results obtained suggested that patients under drug misuse had worse scores in fluency, visual construction, memory and attention compared with controls. After 6 month treatment and achieving abstinence patients improve in cognitive skills as verbal learning, short-term memory and free recall of verbal information. Cognitive impairment profile changes depending on the substance abused (alcohol or benzodiacepines).

Drug use can produce deleterious effects in old adults. However, those who achieve abstinence may improve some cognitive functioning as verbal learning, short-term memory and free recall of verbal information.

The authors have not supplied their declaration of competing interest.

Pain medication misuse is commonly found in patients under headache treatment and may produce co-morbid anxiety and depressive symptomatology. Management of this issue requires a comprehensive and integrative treatment including psychotherapy. Group interventions have been scarcely studied in addictive disorders, those interventions aims to decrease drug misuse and improve related psychiatric symptoms.

To study the efficacy of group interventions base on cognitive-behavior approach in patients with pain medication misuse.

Patients with pain medication misuse were included and were evaluated with BDI, STAI, SF36 and HIT scales (basal and at the end of treatment sessions). Patients were recruited from headache outpatient unit. Twelve sessions of one hour were performed with a cognitive-behavior approach (weekly).

We present preliminary results about the efficacy of group interventions in patients with pain medication misuse. Descriptive results pre- and post- treatment were analyzed in depressive symptoms (M = 20.14, SD = 12.25; M = 14.67, SD = 19.50) and in areas of quality of life: physical functioning (M = 48.75, SD = 31.13; M = 60.50, SD = 41.68), bodily pain (M = 12, SD = 9.25; M = 42.75, SD = 34.09), general health perceptions (M = 25.75, SD = 16.96; M = 44.25, SD = 22.33), vitality (M = 33.75, SD = 13.82; M = 48, SD = 34.82).

Pain medication misuse is commonly found in chronic headache patients, consequently worst outcomes for both pathologies. Group interventions may be useful in management of pain, anxiety and other comorbidities. Furthermore, it may favor drug use decrease and even abstinence.

The authors have not supplied their declaration of competing interest.

Alcohol use disorder (AUD) is an important global public health problem with complex aetiology and relapsing remitting course. Clinical measures of alcohol dependence severity and alcohol-craving, are largely unreliable in identifying individuals at high-risk for relapse. Functional human neuroimaging methods that employ symptom provocation paradigms have shown promise in identifying critical brain regions with cue-elicited alcohol-craving response.

The present study aimed at examining the utility of fMRI cue-reactivity (CR) in predicting relapse risk.

The study was conducted on inpatients of a tertiary care neuropsychiatric hospital. Thirty-two treatment-seeking right-handed men were recruited for the study after informed consent. Following detoxification and 3-day drug-washout period, they underwent a task-based fMRI while viewing images of alcohol-related and control cues presented to them using a previously validated fMRI paradigm. All patients received anti-craving medications (baclofen: 60–80 mg/d, n = 16; naltrexone: 50–100 mg/d, n = 16) and were prospectively followed-up till their first alcohol lapse.

Random-effect analysis using one-sample test revealed significant CR to alcohol-related cues (relative to implicit baseline) with activation in salience-reward related regions [insula, cingulate, dorsal striatum (DS)], visual-attention regions [occipito-temporal] and deactivation of default-mode regions [posterior cingulate (PCC)] (all significant at PFWE < 0.05, whole-brain corrected). Cox-proportional hazard regressions revealed that greater CR in Insula (Chi2 = 10.33; P = 0.001; HR = 3.1; 95% CI = 1.5–6.3) and DS (Chi2 = 10.87; P = 0.001; HR = 2.8; 95% CI = 1.5–5.2) predicts faster subsequent time to first drink after accounting for the role of clinical measures.

These findings indicate that CR can serve as potential marker to identify individuals at high-risk for relapse. Further examination of intervention-related CR change may aid in personalizing treatment of AUD.

The authors have not supplied their declaration of competing interest.

Modafinil is approved to treat excessive somnolence but it is also off-spec used as a treatment for ADHD and as a cognitive enhancer. Research on the effects of modafinil on cognitive function have yielded mixed results. Modafinil interact with dopamine, noradrenaline, serotonin, glutamate, orexin, histamine and GABA levels. The regulation of these neurotransmitters is widely known to be implicated in most of the neuropsychiatric disorders.

A review was conducted aiming to clarify the biological mechanisms of action of modafinil; its effects on attention, learning, executive functions and creative thinking; as well as possible neuropsychiatric disorders associated to its intake. The literature search was conducted in PubMed data reviewing articles dating between 2015 and 2016.

(1) Empirical evidence for cognitive enhancing effects of one of the most frequently used substances, modafinil, is sparse. Studies suggest that with more protracted and complex testing, more benefits are associated to modafinil use.

(2) Modafinil may be implicated in alterations of reward-related behaviour. Compared to placebo, modafinil leads to an enhanced tendency to make previously rewarded choices compared to the avoidance of previously punished choices. This pattern of altered choice behaviour is probably induced by an increase of the dopamine level and a potential contribution of elevated noradrenaline.

Some people share information about this drug in social network. Off-label use of this drug may be implicated in alterations of reward-related behaviour and patients with previous psychiatric disorders should be aware of its possible adverse effects.

The authors have not supplied their declaration of competing interest.

The “nootropic” or simplified as a “smart drug”, is a common term that will tag along with the compound responsible for the enhancement of mental performance. Certain individuals with a history of mental or substance use disorders might be particularly vulnerable to its adverse effects.

A review was conducted aiming to clarify the mechanisms associated of how these drugs increase mental functions including memory, motivation, concentration, and attention; and which kind of individuals are at risk of developing adverse effects when taking these drugs. The literature search was conducted in PubMed data reviewing articles dating between 2015 and 2016.

– Glutaminergic Signalling, Cholinergic System, Amyloid Precursor Protein and Secondary Messenger may be related to the cognitive enhancement achieved by Nootropics. Others, like insulin and angiotensin receptor may involved too.

– Some of them, like Ginkgo biloba, seem to have neuroprotective effects observed in human and animal models, acting as antioxidant and antiapoptotic, also inducing inhibition effects against caspase-3 activation and amyloid-aggregation toward Alzheimer's disease.

– Synthetic nootropics, a lab created compound such as piracetam, especially in people with history of drug abuse, may be associated with psychiatric exacerbations of some patients.

Young adults all over Europe, especially university students, are starting to use nootropic drugs to improve their academic results. Some of them seem to have beneficial effects over mental health but others are sometimes related with sudden and unexplained exacerbations in stable psychiatric patients. It is important to early identify symptoms and to treat them properly.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

Alexithymia is considered as a deficit in emotion processing. It includes difficulty to identify and describe feelings as well as discriminate between feelings and physical sensations. Alexithymia may be a risk factor for substance use (SUD).

The objective of this work is to identify the prevalence and correlates of alexithymia among patients with SUD.

This study concerns 40 subjects who were hospitalized in a rehabilitation center in Sfax. The subjects completed a form investigating sociodemographic and drug use characteristics. Alexithymia was assessed using the Toronto Alexithymia Scale TAS-20 a. The TAS-20 have three factors: difficulty in identifying feelings (F1), difficulty in describing feelings (F2), and externally oriented thinking (F3).

The mean age of 30.86 ± 8.07 years. The mean score of alexithymia was 65.39 ± 9.65 (42→83). The scores of its dimensions were 25.3 ± 6.10 for F1, 17.16 ± 3.3 for F2 and 23.16 ± 3.18 for F3. The prevalence of alexithymia was 62.8% among addicts. High alexithymic patients did not differ from low or moderate alexithymic patients in terms of, employment, education or the type of substance. TAS-20 was correlated to socio-economic status (P = 0.002). No correlation was observed between age and alexithymia (total TAS-20) when measured as a continuous variable (P = 0.802). High alexithymic patients exhibited a higher preference for poly-substance use compared with no alexithymic patients (P = 0.05).

Findings suggest that alexithymia is frequent in SUD patients. It should be noted in clinical practice that many patients with SUD may have a reduced capacity to identify and describe feelings during detoxification.

The authors have not supplied their declaration of competing interest.

Recreational use of nitrous oxide (N20) or ‘laughing gas’ inhalation is a common phenomenon in countries like UK and US where it is associated with music festivals and parties. However, as far as we know, recreational N20 use in Singapore has hitherto not been reported in the press or scientific journals. We report the first case of N20 use and addiction in a young Singaporean male who was introduced to it by a friend from a Western country where its use is prevalent.

A 20-year-old Singaporean male with an existing psychiatric diagnosis of major depression, presented with a 3 year history of solitary regular N20 inhalation that escalated from infrequent low dose use to the current daily high-dose use which he was unable to control. He exhibited symptoms of dependence — including preoccupation, tolerance, withdrawal and difficulty in cutting down. No major adverse medical complications were noted so far.

The patient was assessed to have Nitrous Oxide Dependence; and is currently undergoing regular counselling sessions in an attempt to motivate him to cut down or stop his N20 use.

This case is unique for 2 reasons:

– extant literature suggests that only anectodal evidence exists for psychological dependence of N20 in Singapore; yet our patient clearly demonstrates psychological dependence;

– this is the first reported case of N20 use disorder in Singapore; and perhaps ASEAN, with the unusual presentation in a young male whose use is solitary and private.

The authors have not supplied their declaration of competing interest.