Clinical and pharmacological aspects of bath salt use: a review of the literature and case reports

Neurotoxicology and drug-related disorders

Neuropsychiatric disorders caused by toxic substances pose a great diagnostic challenge due to the large variety of changes caused in the central and peripheral nervous system. The pathogenetic mechanisms at work are multifaceted and partly not solved. In human drug abusers (cannabis, opiates, cocaine, amphetamines, methamphetamine and "designer drugs"), a broad spectrum of central nervous system alterations are observed including infarction, intracerebral and subarachnoidal hemorrhage, hypoxic-ischemic leukoencephalopathy, infections, neuronal loss, specific astroglial and microglial reaction patterns, and vascular changes, including the endothelial cell as well as the basal lamina.

Electrophysiological Actions of Synthetic Cathinones on Monoamine Transporters

Products containing psychoactive synthetic cathinones, such as mephedrone and 3,4-methylenedioxypyrovalerone (MDPV) are prevalent in our society. Synthetic cathinones are structurally similar to methamphetamine, and numerous synthetics have biological activity at dopamine, serotonin, and norepinephrine transporters. Importantly, monoamine transporters co-transport sodium ions along with their substrate, and movement of substrates and ions through the transporter can generate measurable ionic currents. Here we review how electrophysiological information has enabled us to determine how synthetic cathinones affect transporter-mediated currents in cells that express these transporters. Specifically, drugs that act as transporter substrates induce inward depolarizing currents when cells are held near their resting membrane potential, whereas drugs that act as transporter blockers induce apparent outward currents by blocking an inherent inward leak current. We have employed the two-electrode voltage-clamp technique in Xenopus laevis oocytes overexpressing monoamine transporters to determine whether synthetic cathinones found in the so-called bath salts products behave as blockers or substrates. We also examined the structure-activity relationships for synthetic cathinone analogs related to the widely abused compound MDPV, a common constituent in "bath salts" possessing potent actions at the dopamine transporter.

A Prospective Analysis of Patients Presenting for Medical Attention at a Large Electronic Dance Music Festival

Mass-Gathering Medicine studies have identified variables that predict greater patient presentation rates (PPRs) and transport to hospital rates (TTHRs). This is a descriptive report of patients who presented for medical attention at an annual electronic dance music festival (EDMF). At this large, single EDMF in New York City (NYC; New York, USA), the frequency of patient presentation, the range of presentations, and interventions performed were identified.

This descriptive report examined consecutive patients who presented to the medical tent of a summertime EDMF held at an outdoor venue with an active, mobile, bounded crowd. Alcohol was available for sale. Entry was restricted to persons 18 years and older. The festival occurred on three consecutive days with a total cumulative attendance of 58,000. Medical staffing included two Emergency Medicine physicians, four registered nurses, and 86 Emergency Medical Services (EMS) providers. Data collected included demographics, past medical history, vital signs, physical exam, drug and alcohol use, interventions performed, and transport decisions.

Eighty-four patients were enrolled over 2.5 days. Six were transported and zero died. The ages of the subjects ranged from 17 to 61 years. Forty-three (51%) were male. Thirty-eight (45%) initially presented with abnormal vital signs; four (5%) were hyperthermic. Of these latter patients, 34 (90%) reported ingestions with 3,4-methylenedioxymethamphetamine (MDMA) or other drugs. Eleven (65%) patients were diaphoretic or mydriatic. The most common prehospital interventions were intravenous normal saline (8/84; 10%), ondansetron (6/84; 7%), and midazolam (3/84; 4%).

Electronic dance music festivals are a growing trend and a new challenge for Mass-Gathering Medicine as new strategies must be employed to decrease TTHR and mortality. Addressing common and expected medical emergencies at mass-gathering events through awareness, preparation, and early, focused medical interventions may decrease PPR, TTHR, and overall mortality.

FriedmanMS, PlockiA, LikourezosA, PushkarI, BazosAN, FrommC, FriedmanBW. A prospective analysis of patients presenting for medical attention at a large electronic dance music festival. Prehosp Disaster Med.2017; 32(1):78–82.

Structure-Activity Relationships of Substituted Cathinones, with Transporter Binding, Uptake, and Release

Synthetic cathinones are components of "bath salts" and have physical and psychologic side effects, including hypertension, paranoia, and hallucinations. Here, we report interactions of 20 "bath salt" components with human dopamine, serotonin, and norepinephrine transporters [human dopamine transporter (hDAT), human serotonin transporter (hSERT), and human norepinephrine transporter (hNET), respectively] heterologously expressed in human embryonic kidney 293 cells. Transporter inhibitors had nanomolar to micromolar affinities (K_i values) at radioligand binding sites, with relative affinities of hDAT>hNET>hSERT for α-pyrrolidinopropiophenone (α-PPP), α-pyrrolidinobutiophenone, α-pyrrolidinohexiophenone, 1-phenyl-2-(1-pyrrolidinyl)-1-heptanone, 3,4-methylenedioxy-α-pyrrolidinopropiophenone, 3,4-methylenedioxy-α-pyrrolidinobutiophenone, 4-methyl-α-pyrrolidinopropiophenone, α-pyrrolidinovalerophenone, 4-methoxy-α-pyrrolidinovalerophenone, α-pyrrolidinopentiothiophenone (alpha-PVT), and α-methylaminovalerophenone, and hDAT>hSERT>hNET for methylenedioxypentedrone. Increasing the α-carbon chain length increased the affinity and potency of the α-pyrrolidinophenones. Uptake inhibitors had relative potencies of hDAT>hNET>hSERT except α-PPP and α-PVT, which had highest potencies at hNET. They did not induce [³H]neurotransmitter release. Substrates can enter presynaptic neurons via transporters, and the substrates methamphetamine and 3,4-methylenedioxymethylamphetamine are neurotoxic. We determined that 3-fluoro-, 4-bromo-, 4-chloro-methcathinone, and 4-fluoroamphetamine were substrates at all three transporters; 5,6-methylenedioxy-2-aminoindane (MDAI) and 4-methylethcathinone (4-MEC) were substrates primarily at hSERT and hNET; and 3,4-methylenedioxy-N-ethylcathinone (ethylone) and 5-methoxy-methylone were substrates only at hSERT and induced [³H]neurotransmitter release. Significant correlations between potencies for inhibition of uptake and for inducing release were observed for these and additional substrates. The excellent correlation of efficacy at stimulating release versus K_i/IC₅₀ ratios suggested thresholds of binding/uptake ratios above which compounds were likely to be substrates. Based on their potencies at hDAT, most of these compounds have potential for abuse and addiction. 4-Bromomethcathinone, 4-MEC, 5-methoxy-methylone, ethylone, and MDAI, which have higher potencies at hSERT than hDAT, may have empathogen psychoactivity.

Cooling down the bath salts: Carvedilol attenuation of methylone and mephedrone mediated hyperthermia

The use of the synthetic cathinones ("bath salts"), methylone and mephedrone, has been associated with the development of life-threatening hyperthermia. To date, no direct pharmacological intervention to mitigate the hyperthermia induced by synthetic cathinones has been identified. Here, we investigated the effects of the non-selective α₁ and β adrenergic receptor antagonist carvedilol (5mg/kg ip) on established hyperthermia mediated by methylone and mephedrone (30mg/kg sc) in Sprague-Dawley rats. Methylone and mephedrone induced a hyperthermic response that peaked 60min post treatment. The administration of carvedilol 30min after methylone or mephedrone significantly attenuated these hyperthermic responses. Analysis of the Temperature Area Under the Curve (TAUC) demonstrated carvedilol significantly reduced the TAUC associated with methylone or mephedrone alone. The present study provides the first direct pharmacological intervention for the treatment of synthetic cathinone induced hyperthermia.

[New patterns of substance use and abuse among French adolescents, a knowledge synthesis]

AIM

There have been significant changes in adolescent consumption habits over the past fifteen years. New molecules have been synthesized, new devices created and a number of products have increased in popularity; and as a result clinicians sometimes lack information. We chose to focus on this population because of its vulnerability, as adolescents show low sensitivity to long-term outcomes of their actions and may be easily influenced by peers as regards experimentation of new drugs. The most consumed products by adolescents in France are tobacco, alcohol and cannabis with the physiological effects and consumption patterns of these drugs well documented. The purpose of this review is to identify and describe other products that are frequently used by adolescents to get high, to increase performance, for purposes of self-medication or because of peer pressure. We summarized the current scientific evidence regarding drug availability, physical and chemical properties, pharmacodynamics and adverse effects.

METHOD

A literature review was conducted from 2000 to 2015 based on Pudmed, Google Scholar and governmental websites, using the following keyword alone or in combination: "adolescent", "new", "misuse", "abuse", "toxicity", "pharmacology" "cocaine", "MDMA", "inhalant", "poppers", "magic mushroom", "psilocybin", "designer drug", "legal high", "smart drug", "cathinone", "mephedrone", "cannabinoid", "prescription drug", "codeine", "opioid", "methylphenidate", "cough syrup", "purple drank".

RESULTS

New products, including synthetic cannabis, cathinone or purple drank seem to be the most dangerous. They are easily accessible and may lead to short-term severe or lethal complications. Other substances do not pose a major short-term health risk by themselves. However, their consumption may be an indication of other unhealthy risk behaviors, such as prescription drug use, which may be related to psychiatric comorbidity. Unfortunately, we do not have enough data to determine the long-term consequences of the use of these substances. Moreover, these products have a strong addictive potential and may be a risk factor for other addictions. For this reason, increased supervision is justified, both for surveillance and reduction of harm.

CONCLUSION

Taking care of an adolescent with substance abuse can be difficult. Updated information regarding these new substances and the particular danger they pose to adolescent health is needed. Informed clinicians can provide up to date and accurate information to the patient and family, assess potential risk factors and comorbidities, and provide appropriate support. Furthermore, because of the high prevalence of substance abuse in the adolescent population, systematic screening of adolescent consumption habit is useful to avoid or anticipate complications. Often, problematic substance consumption behaviors are signs of more complicated psychological or psychiatric issues. Substance abuse behaviors will often disappear over time but they can also become a major problem as the adolescent moves into adulthood. If problems persist, consultation with an addiction specialist may be warranted.

Investigations of the genotoxic properties of two synthetic cathinones (3-MMC, 4-MEC) which are used as psychoactive drugs

Synthetic cathinones (SCAs) are consumed worldwide as psychostimulants and are increasingly marketed as surrogates of classical illicit drugs via the internet. The genotoxic properties of most of these drugs have not been investigated. Results of earlier studies show that amphetamines which are structurally closely related to these compounds cause damage to the genetic material. Therefore, we tested the genotoxic properties of two widely consumed SCAs, namely, 3-MMC (2-(methylamino)-1-(3-methylphenyl) propan-1-one) and 4-MEC (2-(ethylamino)-1-(4-methylphenyl) propan-1-one) in a panel of genotoxicity tests. We found no evidence for induction of gene mutations in Salmonella/microsome assays, but both drugs caused positive results in the single cell gel electrophoresis (SCGE) assay which detects single and double strand breaks of DNA in a human derived buccal cell line (TR146). 3-MMC induced similar effects as 4-MEC and also caused significant induction of micronuclei which are formed as a consequence of structural and chromosomal aberrations. Negative results obtained in SCGE experiments with lesion specific enzymes (FPG and Endo III) show that these drugs do not cause oxidative damage of DNA. However, moderate induction of TBARS (which leads to the formation of DNA-reactive substances) was observed with 4-MEC, indicating that the drug causes lipid peroxidation while no clear effect was detected with 3-MMC. Results obtained with liver homogenate in SCGE-experiments show that phase I enzymes do not lead to the formation of DNA reactive metabolites. Taken together, our findings indicate that consumption of certain SCAs may cause adverse health effects in users as a consequence of damage to the genetic material.

Parachuting: a dangerous trend in recreational psychoactive substance delivery

INTRODUCTION

Medicine diversion for recreational use is a constant concern for health authorities. Parachuting, also refered to as bombing, is used in order to increase the expected effect, to accelerate time-to-onset and to create mixtures of medicines and substances. Aeras covered: Firstly, we analyzed all available scientific literature (PRISMA) and internet forums without any limiting timeframe. Secondly, we collected cases of parachuting reported in the west of France by the addictovigilance and poison control centres. Our study confirms the reality of this emerging issue associated with a higher medical risk (60% of intoxication cases were moderate-to-severe in our study). The substances involved in parachuting were primarily stimulants, with a majority of MDMA, although the use of diverted medication and psychotropes is also of concern. Expert opinion: Parachuting is a dangerous way of using substances and of diverting medicines. This type of administration gives users a certain pharmacokinetic latitude to 'play' with respect to substances and medicines. Medicine abuse deterrent formulations do not seem to be sufficient in preventing diversions. This dangerous method of using substances and of diverting medicines should drive pharmaceutical companies to innovate in the interest of public health and safety.

Effectiveness of a universal internet-based prevention program for ecstasy and new psychoactive substances: a cluster randomized controlled trial

AIM

To evaluate the effectiveness of an online school-based prevention program for ecstasy (MDMA) and new psychoactive substances (NPS).

DESIGN

Cluster randomized controlled trial with two groups (intervention and control).

SETTING

Eleven secondary schools in Australia.

PARTICIPANTS

A total of 1126 students (mean age: 14.9 years).

INTERVENTION

The internet-based Climate Schools: Ecstasy and Emerging Drugs module uses cartoon storylines to convey information about harmful drug use. It was delivered once weekly, during a 4-week period, during health education classes. Control schools received health education as usual.

MEASUREMENT

Primary outcomes were self-reported intentions to use ecstasy and NPS at 12 months. Secondary outcomes were ecstasy and NPS knowledge and life-time use of ecstasy and NPS. Surveys were administered at baseline, post-intervention and 6 and 12 month post-baseline.

FINDINGS

At 12 months, the proportion of students likely to use NPS was significantly greater in the control group (1.8%) than the intervention group [0.5%; odds ratio (OR) = 10.17, 95% confidence interval (CI) = 1.31-78.91]. However, students' intentions to use ecstasy did not differ significantly between groups (control = 2.1%, intervention = 1.6%; OR = 5.91, 95% CI = 1.01-34.73). There was a significant group difference in the change from baseline to post-test for NPS knowledge (β = -0.42, 95% CI = -0.62 to -0.21, Cohen's d = 0.77), with controls [mean = 2.78, standard deviation (SD = 1.48] scoring lower than intervention students (mean = 3.85, SD = 1.49). There was also evidence of a significant group difference in ecstasy knowledge at post-test (control: mean = 9.57, SD = 3.31; intervention: mean = 11.57, SD = 3.61; β = -0.54, 95% CI = -0.97 to -0.12, P = 0.01, d = 0.73).

CONCLUSIONS

The Climate Schools: Ecstasy and Emerging Drugs module, a universal online school-based prevention program, appeared to reduce students' intentions to use new psychoactive substances and increased knowledge about ecstasy and new psychoactive substances in the short term.

Medical complications of psychoactive substances with abuse risks: Detection and assessment by the network of French addictovigilance centres

The use of psychoactive substances, whether occasional or regular, can induce a large number of clinical and/or biological complications. These complications may be related to the effects of the active substance itself and/or adulterants, but also to the modalities for use (administrations route, contexts of use). The detection and evaluation of these potentially severe complications are a public health issue. Beyond the assessment of the potential for abuse of and dependence on psychoactive substances, the collection and evaluation of complications related to the use of the substances are one of the roles of addictovigilance centres. In this article, the expertise of the French addictovigilance centres in the detection and assessment of medical complications related to psychoactive substances, adulterants or route of administration of substances is advanced through a few recent examples.

A multicenter retrospective survey of poisoning after consumption of products containing novel psychoactive substances from 2013 to 2014 in Japan

BACKGROUND

In Japan, fatalities among patients who experienced an acute reaction following self-administration of novel psychoactive substances (NPS) have been more frequently reported since June 2014.

OBJECTIVE

This survey aimed to document and analyze trends in NPS consumption in emergency patients.

METHODS

We conducted a multicenter retrospective survey of patients who were transported to emergency facilities after consuming NPS-containing products between January 2013 and December 2014. Letters requesting participation were sent to 467 emergency facilities, and questionnaires were mailed to facilities that agreed to participate.

RESULTS

We surveyed 589 patients from 85 (18.2%) facilities. Most patients were male (89.6%) and young (median age, 30 years), and inhaled (88%) NPS contained in herbal products (80.5%). Harmful behavior was observed at the scene of acute reaction, including violence (6.9%), traffic accidents (4.9%), and self-injury or suicidal attempts (1.1%). Other than neuropsychiatric and physical symptoms, many patients also had physical complications such as rhabdomyolysis (17.5%), liver injury (12.4%), acute kidney injury (9%), and physical injury (1.9%). Of the 256 patients (43.5%) admitted to hospitals, 35 (5.9%) were hospitalized for seven or more days. Most patients (93.2%) completely recovered, although a few (1.4%) died. However, synthetic cannabinoids and synthetic cathinones were only detected in the blood of five patients.

CONCLUSION

Consumption of NPS-containing products have been associated with harmful behaviors such as violence and traffic accidents, physical complications (e.g., rhabdomyolysis, liver injury), death, or physical and neuropsychiatric symptoms. Compared to a previous survey (2006-2012), the present survey revealed more severe toxicity.

Detection of "bath salts" and other novel psychoactive substances in hair samples of ecstasy/MDMA/"Molly" users

BACKGROUND

Ecstasy (MDMA) in the US is commonly adulterated with other drugs, but research has not focused on purity of ecstasy since the phenomenon of "Molly" (ecstasy marketed as pure MDMA) arose in the US.

METHODS

We piloted a rapid electronic survey in 2015 to assess use of novel psychoactive substances (NPS) and other drugs among 679 nightclub/festival-attending young adults (age 18-25) in New York City. A quarter (26.1%) of the sample provided a hair sample to be analyzed for the presence of select synthetic cathinones ("bath salts") and some other NPS. Samples were analyzed using fully validated UHPLC-MS/MS methods. To examine consistency of self-report, analyses focused on the 48 participants with an analyzable hair sample who reported lifetime ecstasy/MDMA/Molly use.

RESULTS

Half (50.0%) of the hair samples contained MDMA, 47.9% contained butylone, and 10.4% contained methylone. Of those who reported no lifetime use of "bath salts", stimulant NPS, or unknown pills or powders, about four out of ten (41.2%) tested positive for butylone, methylone, alpha-PVP, 5/6-APB, or 4-FA. Racial minorities were more likely to test positive for butylone or test positive for NPS after reporting no lifetime use. Frequent nightclub/festival attendance was the strongest predictor of testing positive for MDMA, butylone, or methylone.

DISCUSSION

Results suggest that many ecstasy-using nightclub/festival attendees may be unintentionally using "bath salts" or other NPS. Prevention and harm reduction education is needed for this population and "drug checking" (e.g., pill testing) may be beneficial for those rejecting abstinence.

[Cathinones use in Paris]

BACKGROUND

The pattern of recreational drug use has changed over the last decade and now includes a multitude of substances sold as "research chemicals" or new psychoactive substances, "NPS". In France, synthetic cathinones emerged in 2008 (while first mentioned by the French police force in 2007 first alerts among users appeared in 2008) and have grown to be popular drugs of abuse. Under the Official Journal dated 11th June 2010, only mephedrone has been listed as narcotics but "designer drugs" have synthesized new substitute cathinones in order to avoid anti-drug laws. However, since July 2012, in France, all synthetic drugs from the cathinones family have been banned and listed as narcotics following the example of United Kingdom. Despite their recent classification and inclusion on narcotic list, they are readily available on Internet and used widely. Paris Addictovigilance Centre observed a signal of derivate cathinones abuse (21 cases over a two-year period).

OBJECTIVE

Paris Addictovigilance Centre and Marmottan Hospital wanted to describe the use of cathinones in the Paris area and alert the health care community about the abuse identification and risk assessment problems of these compounds. After a review of derivated cathinone's chemical structure, pharmacology and toxicology, this article seeks to provide patricians with a clinical description and treatment's modality.

RESULTS

Most users of synthetic cathinones will experience euphoria, increased energy, talkativeness, openness and increased sexual arousal. Signs and symptoms of toxicity are consistent with a sympathomimetic toxidrome. The main reasons for care access are psychiatric (hallucinations, psychotic symptoms, agitation) and addiction disorders. Somatic complications were described with various patterns of symptoms such as headache, tachycardia, confusional states, rhabdomyolysis with renal failure or serotonin syndrome. The most important fact is the apparition of the "slam" phenomenon among men who have sex with men (MSM). The "slam" is a compound of three characteristic elements: injection, sexual party and psychostimulant drug. According to users, "slam" is convenient for group sex and is used it to put them into a good mood and a disinhibition state. These compounds cause fast dependence syndrome with strong craving and prolonged psychiatric symptoms and increase infectious risk (HIV, VHC, VHB…). The cathinones family is not detected in conventional urine drug screenings. We point out the lack of confirmatory analytic testing data which remains the only way to determine the actual etiology of the clinical effects observed since drug users do not always know exactly what they took. These substances can be identified by special analyses using gas chromatography or liquid chromatography and mass spectroscopy technology.

CONCLUSION

This injection drug is used in order to increase sexual desire, delay orgasm and decrease sexual inhibition and is prevalent in many studies on MSM samples. Cathinones would popularize the "slam". Harm reduction policy requires specific MSM interventions on both sexual and drug addiction networks.

Novel psychoactive substance use by US adolescents: Characteristics associated with use of synthetic cannabinoids and synthetic cathinones

INTRODUCTION AND AIMS

The current study documents the characteristics associated with the use of two novel psychoactive substances: synthetic cannabinoids and synthetic cathinones.

DESIGN AND METHODS

Nationally representative samples of students in 8th (n = 9665), 10th (n = 10 655) and 12th (n = 10 057) grades across the US were included in the Monitoring the Future study from 2012 to 2014.

RESULTS

There were relatively few differences in prevalence based on sociodemographic characteristics, although boys were at greater risk for use of synthetic cannabinoids in 12th grade (used by 10.3% of boys and 6.4% of girls) and for use of synthetic cathinones in 10th grade (used by 1.0% of boys and 0.4% of girls). Synthetic drug use was also associated with truancy and use of cigarettes, alcohol, and marijuana.

DISCUSSION AND CONCLUSIONS

Prevention and intervention efforts for novel psychoactive substance use should focus primarily on polysubstance users and youth who are disengaged from school.[Patrick M, O'Malley P, Kloska D, Schulenberg J, Johnston L, Miech R, Bachman J. Novel psychoactive substance use by US adolescents: Characteristics associated with use of synthetic cannabinoids and synthetic cathinones. Drug Alcohol Rev 2016;35:586-590].

Illicit drugs or medicines taken by parachuting

Parachuting (also called bombing) is a method of drug delivery where illicit drugs or medicines are ingested after wrapping the substance. There are little data describing parachuting in the literature. To provide a description of this practice, all cases of parachuting reported to the national addictovigilance network up to 31 December 2014 were identified from spontaneous reports and specific surveillance programs. Cases were described according to the type of substance used, patient age and gender, type of complications, context of use and year of the event. Forty-five cases of parachute use were identified and most (n = 43) occurred after 2011. Patients were mostly men (60%), and mean age was 28.9 years. The context of use, known in 19 cases, was mostly recreational. Complications were present in 24 cases, of which eight were serious. The substance was supposed to be 3,4-methylenedioxymethamphetamine (MDMA) in the majority of cases (64.4%); research chemicals were more involved in the most recent years. The physical form was mainly granular (51.6%). The wrappers were a cigarette paper (nine cases) and in one case plastic package; in the other cases, the term of parachute was used without further details. The reason for use was not explained in the majority of cases; two patients indicated using a parachute for faster effect than with a methadone capsule. Clinicians should be aware of this delivery form as the results suggest that it is common and can involve a great variability of drugs.

Characteristics of novel psychoactive substance exposures reported to New York City Poison Center, 2011-2014

BACKGROUND

Novel psychoactive substances (NPS) are emerging at an unprecedented rate. Likewise, prevalence of use and poisonings has increased in recent years.

OBJECTIVE

To compare characteristics of NPS exposures and non-NPS-drug-related exposures and to examine whether there are differences between exposures involving synthetic cannabinoid receptor agonists (SCRAs) and other NPS.

METHODS

Poison control center data from the five counties of New York City and Long Island were examined from 2011-2014. We examined prevalence and characteristics of NPS exposures (classified as intentional abuse) and compared characteristics of cases involving SCRAs and other NPS.

RESULTS

Prevalence of NPS exposures was 7.1% in 2011, rising to 12.6% in 2014. Most exposures (82.3%) involved SCRA use. The second and third most prevalent classes were phenethylamines/synthetic cathinones ("bath salts"; 10.2%) and psychedelic phenethylamines (4.3%). Compared to other drug-related exposures (i.e. involving licit and illicit drugs), those who used NPS were more likely to be younger, male, and to have not co-used other drugs (ps < 0.001). SCRA exposures increased sharply in 2014 and the mean age of users increased over time (p < 0.01). Females exposed to SCRAs were younger than males (p < 0.001), and in 2014, individuals exposed to SCRAs were more likely to report concomitant use of alcohol than users of other NPS (p = 0.010). Users of other NPS were more likely than SCRA users to report concomitant use of ecstasy/3,4-methylenedioxymethamphetamine (MDMA)/"Molly" (p < 0.001).

CONCLUSION

Exposures reported to the poison center that involve NPS are increasing and the majority involve SCRAs. These findings should inform prevention and harm reduction approaches.

Pharmacokinetics, pharmacodynamics and toxicology of new psychoactive substances (NPS): 2C-B, 4-fluoroamphetamine and benzofurans

BACKGROUND

Recently, the number of new psychoactive substances (NPS) appearing on the illicit drug market has shown a marked increase. Although many users perceive the risk of using NPS as medium or low, these substances can pose a serious health risk and several NPS have been implicated in drug-related deaths. In Europe, frequently detected NPS are 4-bromo-2,5-dimethoxyphenethylamine (2C-B), 4-fluoroamphetamine (4-FA) and benzofurans (5-(2-aminopropyl)benzofuran (5-APB) or 6-(2-aminopropyl)benzofuran (6-APB)). However, little is known about the health risks of these specific NPS.

METHODS

In this paper, existing literature on the pharmacokinetics and pharmacodynamics of 2C-B, 4-FA and benzofurans (5-APB/6-APB) was reviewed.

RESULTS

Our review showed that the clinical effects of 2C-B, 4-FA and benzofurans (5-APB/6-APB) are comparable with common illicit drugs like amphetamine and 3,4-methylenedioxymethamphetamine (MDMA). Therefore, NPS toxicity can be handled by existing treatment guidelines that are based on clinical effects instead of the specific drug involved. Even so, information on the health risks of these substances is limited to a number of case reports that are complicated by confounders such as analytical difficulties, mislabelling of drugs, concomitant exposures and interindividual differences.

CONCLUSION

To aid in early legislation, data on clinical effects from poisons centres and user fora should be combined with (in vitro) screening methods and collaboration on an (inter)national level is essential. As a result, potentially hazardous NPS could be detected more quickly, thereby protecting public health.

The new psychoactive substances 5-(2-aminopropyl)indole (5-IT) and 6-(2-aminopropyl)indole (6-IT) interact with monoamine transporters in brain tissue

In recent years, use of psychoactive synthetic stimulants has grown rapidly. 5-(2-Aminopropyl)indole (5-IT) is a synthetic drug associated with a number of fatalities, that appears to be one of the newest 3,4-methylenedioxymethamphetamine (MDMA) replacements. Here, the monoamine-releasing properties of 5-IT, its structural isomer 6-(2-aminopropyl)indole (6-IT), and MDMA were compared using in vitro release assays at transporters for dopamine (DAT), norepinephrine (NET), and serotonin (SERT) in rat brain synaptosomes. In vivo pharmacology was assessed by locomotor activity and a functional observational battery (FOB) in mice. 5-IT and 6-IT were potent substrates at DAT, NET, and SERT. In contrast with the non-selective releasing properties of MDMA, 5-IT displayed greater potency for release at DAT over SERT, while 6-IT displayed greater potency for release at SERT over DAT. 5-IT produced locomotor stimulation and typical stimulant effects in the FOB similar to those produced by MDMA. Conversely, 6-IT increased behaviors associated with 5-HT toxicity. 5-IT likely has high abuse potential, which may be somewhat diminished by its slow onset of in vivo effects, whereas 6-IT may have low abuse liability, but enhanced risk for adverse effects. Results indicate that subtle differences in the chemical structure of transporter ligands can have profound effects on biological activity. The potent monoamine-releasing actions of 5-IT, coupled with its known inhibition of MAO A, could underlie its dangerous effects when administered alone, and in combination with other monoaminergic drugs or medications. Consequently, 5-IT and related compounds may pose substantial risk for abuse and serious adverse effects in human users.

Comparative pharmacological evaluation of the cathinone derivatives, mephedrone and methedrone, in mice

Mephedrone and methedrone are cathinone-related compounds, which act as non-selective substrates for monoamine transporters, facilitating a neurotransmitter release. We compared the acute pharmacological effects of mephedrone and methedrone, attempting to further evaluate the action mechanisms of methedrone by responsibly and ethically using mice under approved procedures. The effects of both compounds were examined from 10 to 60 min, in a series of behavioral paradigms, namely open-field, plus-maze, hot-plate and tail suspension tests, whereas neurotransmitter brain tissue levels were determined ex vivo by HPLC. Separate groups were pre-treated with the dopamine (DA) antagonist haloperidol, or the serotonin (5-HT) synthesis inhibitor ρCPA, to further assess the mechanisms underlying methedrone effects. The compounds caused marked hyperlocomotion, displaying dissimilar stereotyped behavior, in an open-field arena. Mephedrone caused anxiolytic-like effects, while methedrone induced anxiogenic-like actions in the elevated plus-maze. Both compounds displayed thermal antinociception, with a reduced immobility time in the tail suspension model. Mephedrone triggered a 2- and 3-fold increment of dopamine and serotonin tissue levels, respectively, in the nucleus accumbens, with a 1.5-fold elevation of tissue dopamine in the frontal cortex. Methedrone caused a 2-fold increment of tissue dopamine in the nucleus accumbens and in the striatum, and a 1.5-fold increment of serotonin tissue levels in the hippocampus and striatum. In vivo methedrone effects were partially inhibited by a pre-treatment with haloperidol or ρCPA. Despite similar actions on locomotion, analgesia, and depression-like behavior, the acute administration of mephedrone and methedrone elicited divergent effects on anxiety-like behavior and stereotyped movements in mice, which might be related to the distinct modulation of brain tissue neurotransmitter levels.

Detection and quantification of 56 new psychoactive substances in whole blood and urine by LC–MS/MS

Background: New psychoactive substances (NPS) have become increasingly prevalent and are sold in internet shops as ‘bath salts’ or ‘research chemicals’ and comprehensive bioanalytical methods are needed for their detection. Methodology: We developed and validated a method using LC and MS/MS to quantify 56 NPS in blood and urine, including amphetamine derivatives, 2C compounds, aminoindanes, cathinones, piperazines, tryptamines, dissociatives and others. Instrumentation included a Synergi Polar-RP column (Phenomenex) and a 3200 QTrap mass spectrometer (AB Sciex). Run time was 20 min. Conclusion: A novel method is presented for the unambiguous identification and quantification of 56 NPS in blood and urine samples in clinical and forensic cases, e.g., intoxications or driving under the influence of drugs.

Psychostimulants and movement disorders

Psychostimulants are a diverse group of substances with their main psychomotor effects resembling those of amphetamine, methamphetamine, cocaine, or cathinone. Due to their potential as drugs of abuse, recreational use of most of these substances is illegal since 1971 Convention on Psychotropic Substances. In recent years, new psychoactive substances have emerged mainly as synthetic cathinones with new molecules frequently complementing the list. Psychostimulant related movement disorders are a known entity often seen in emergency rooms around the world. These admissions are becoming more frequent as are fatalities associated with drug abuse. Still the legal constraints of the novel synthetic molecules are bypassed. At the same time, chronic and permanent movement disorders are much less frequently encountered. These disorders frequently manifest as a combination of movement disorders. The more common symptoms include agitation, tremor, hyperkinetic and stereotypical movements, cognitive impairment, and also hyperthermia and cardiovascular dysfunction. The pathophysiological mechanisms behind the clinical manifestations have been researched for decades. The common denominator is the monoaminergic signaling. Dopamine has received the most attention but further research has demonstrated involvement of other pathways. Common mechanisms linking psychostimulant use and several movement disorders exist.

Characteristics of the use of 3-MMC and other new psychoactive drugs in Slovenia, and the perceived problems experienced by users

BACKGROUND

The study presents the characteristics of the use of new psychoactive substances (NPS), the perceived problems experienced by users, and the reasons for cessation or cutting down. The research focused mainly on synthetic cathinones and the use of 3-MMC in Slovenia.

METHODS

In order to research the characteristics of NPS use, we used a questionnaire which had been developed to determine the characteristics of the use of ATS and cocaine in the context of nightlife and was elaborated in our study on the use of mephedrone. The final non-representative sample included 249 users of NPS from Slovenia, who had completed an on-line survey over a period of 5 months in 2014. Part of the sampling was conducted on the ground and with the help of peer-groups. DrogArt's outreach workers and correspondents visited open public places, clubs, and discotheques to encourage users to participate in the survey.

RESULTS

Most users of NPS in Slovenia have tried NPS from the groups of synthetic cathinones and amphetamines. Most respondents included in the sample (67.9%) have tried 3-MMC, while 43.0% have tried methylone and 37.3% have tried mephedrone (4-MMC). Users attributed greater risks to the use of new drugs and preferred the effects of traditional drugs to those of new drugs. The most frequently reported problems were depression (55.2% of users), concentration difficulties (44.0%), damage to the mucous membrane of the nose and to the throat (39.8%), feelings of fear and anxiety (39.4%), and tingling in the arms or legs (34.4%). The main reasons for cutting down or discontinuing the use of NPS were 'fear of the health consequences', 'actual health consequences', and 'growing weary of using'. Among users of NPS, 7% have sought help, while 9.1% have considered doing so. The results also highlight differences between the NPS drug markets in Slovenia and the United Kingdom.

CONCLUSIONS

In 2014, the most frequently used NPS in Slovenia were synthetic cathinones such as 3-MMC. Users experienced various problems related to the use of NPS. However, they are familiar with recommendations on harm reduction and want additional information on the harmful effects of the use of NPS. Based on the obtained results, we can develop specific interventions in the area of harm reduction.

Legal highs: staying on top of the flood of novel psychoactive substances

There has been growing clinical, public, and media awareness and concern about the availability and potential harmfulness of so-called 'legal highs', which are more appropriately called new or novel psychoactive substances (NPS). A cat-and-mouse process has emerged wherein unknown chemists and laboratories are producing new, and as yet nonproscribed, compounds for human consumption; and as soon as they are banned, which they inevitably are, slightly modified analogues are produced to circumvent new laws. This rapidly changing environment, 81 new substances were identified in 2013 alone, has led to confusion for clinicians, psychopharmacologists, and the public at large. Our difficulties in keeping up with the process has had a two-fold negative effect: the danger of ignoring what is confusing; and the problem that some of the newer synthesized compounds appear ever more potent. This review aims to circumscribe a quick moving and growing field, and to categorize NPS into five major groups based upon their 'parent' compounds: stimulants similar to cocaine, amphetamines and ecstasy; cannabinoids; benzodiazepine based drugs; dissociatives similar to ketamine and phencyclidine (PCP); and those modelled after classic hallucinogens such as LSD and psilocybin. Pharmacodynamic actions, subjective and physical effects, harmfulness, risk of dependency and, where appropriate, putative clinical potentials are described for each class. Clinicians might encounter NPS in various ways: anecdotal reportage; acute intoxication; as part of a substance misuse profile; and as a precipitant or perpetuating factor for longer-term physical and psychological ill health. Current data are overall limited, and much of our knowledge and treatment strategies are based upon those of the 'parent' compound. There is a critical need for more research in this field, and for professionals to make themselves more aware of this growing issue and how it might affect those we see clinically and try to help: a brave new world of so-called 'psychonauts' consuming NPS will also need informed 'psychotherapeutonauts'. The paper should serve as a primer for clinicians and interested readers, as well as provide a framework into which to place the new substances that will inevitably be synthesized in the future.

3,4-Methylenedioxypyrovalerone prevents while methylone enhances methamphetamine-induced damage to dopamine nerve endings: β-ketoamphetamine modulation of neurotoxicity by the dopamine transporter

Methylone, 3,4-methylenedioxypyrovalerone (MDPV), and mephedrone are psychoactive ingredients of 'bath salts' and their abuse represents a growing public health care concern. These drugs are cathinone derivatives and are classified chemically as β-ketoamphetamines. Because of their close structural similarity to the amphetamines, methylone, MDPV, and mephedrone share most of their pharmacological, neurochemical, and behavioral properties. One point of divergence in their actions is the ability to cause damage to the CNS. Unlike methamphetamine, the β-ketoamphetamines do not damage dopamine (DA) nerve endings. However, mephedrone has been shown to significantly accentuate methamphetamine neurotoxicity. Bath salt formulations contain numerous different psychoactive ingredients, and individuals who abuse bath salts also coabuse other illicit drugs. Therefore, we have evaluated the effects of methylone, MDPV, mephedrone, and methamphetamine on DA nerve endings. The β-ketoamphetamines alone or in all possible two-drug combinations do not result in damage to DA nerve endings but do cause hyperthermia. MDPV completely protects against the neurotoxic effects of methamphetamine while methylone accentuates it. Neither MDPV nor methylone attenuates the hyperthermic effects of methamphetamine. The potent neuroprotective effects of MDPV extend to amphetamine-, 3,4-methylenedioxymethamphetamine-, and MPTP-induced neurotoxicity. These results indicate that β-ketoamphetamine drugs that are non-substrate blockers of the DA transporter (i.e., MDPV) protect against methamphetamine neurotoxicity, whereas those that are substrates for uptake by the DA transporter and which cause DA release (i.e., methylone, mephedrone) accentuate neurotoxicity. METH (a) enters DA nerve endings via the DAT, causes leakage of DA into the cytoplasm and then into the synapse via DAT-mediated reverse transport. Methylone (METHY) and mephedrone (MEPH; b), like METH, are substrates for the DAT but release DA from cytoplasmic pools selectively. When METH is combined with METHY or MEPH (c), DA efflux and neurotoxicity are enhanced. MDPV (d), which is a non-substrate blocker of the DAT, prevents METH uptake and efflux of DA. Therefore, bath salts that are substrates for the DAT and release DA (METHY, MEPH) accentuate METH neurotoxicity, whereas those that are non-substrate blockers of the DAT (MDPV) are neuroprotective.

Monitoring new psychoactive substances (NPS) in The Netherlands: data from the drug market and the Poisons Information Centre

BACKGROUND

In recent years, the number of new psychoactive substances (NPS) appearing on the illicit drug market strongly increased. However, little is known about their toxic effects and risks. Therefore, we determined the most frequently occurring NPS in The Netherlands and combined this with data regarding drug-related intoxications.

METHODS

Data from the Drugs Information and Monitoring System (DIMS) and the Dutch Poisons Information Centre (DPIC) were combined and jointly analyzed.

RESULTS

The number of drug samples submitted to DIMS for analysis containing NPS increased from 22 in 2007 to 431 samples in 2013. The most frequently submitted NPS in 2013 included 4-bromo-2,5-dimethoxyphenethylamine (2C-B), 4-fluoroamphetamine (4-FA), methoxetamine (MXE) and 6-(2-aminopropyl)benzofuran (6-APB). From 2012 onwards, the number of NPS bought as drug of choice exceeded those appearing as adulterants in established drugs. The DPIC was consulted about 35 NPS exposures in 2013, most frequently involving 4-FA, mephedrone, MXE, 2C-B and 6-APB. Following NPS exposure, neurological and psychological symptoms were most frequently reported, like agitation and hallucinations. In addition, cardiovascular symptoms like hypertension and tachycardia often occurred.

CONCLUSIONS

NPS are currently being purchased as drug of choice in The Netherlands and their availability and use is increasing. Although pharmacological and toxicological data are scarce, NPS can induce pronounced clinical effects. Therefore, the monitoring of trends in NPS prevalence needs to be continued, combined with reported clinical effects, and preferably supported by analytical confirmation of exposures in such patients.

Investigation of "bath salts" use patterns within an online sample of users in the United States

"Bath salts" are synthetic stimulant "legal highs" that have recently been banned in the US. Epidemiological data regarding bath salts use are limited. In the present study, 113 individuals in the US reporting use of bath salts completed an anonymous, online survey characterizing demographic, experiential, and psychological variables. Respondents were more often male, 18-24 years old, and Caucasian/White with some college education. Past-year use was typically low (≤ 10 days), but marked by repeated dosing. Intranasal was the most frequently reported administration route and subjective effects were similar to other stimulants (e.g., cocaine, amphetamines). Bath salts use was associated with increased sexual desire and sexual HIV risk behavior, and met DSM-5 diagnostic criteria for disordered use in more than half of respondents. Bath salts use persists in the US despite federal bans of cathinone-like constituents. Self-reported stimulant-like effects of bath salts suggest their use as substitutes for traditional illicit stimulants. Data revealed more normative outcomes vis-à-vis extreme accounts by media and medical case reports. However, indications of product abuse potential and sexual risk remain, suggesting bath salts pose potential public health harm.

Toxicities associated with NBOMe ingestion-a novel class of potent hallucinogens: a review of the literature

BACKGROUND

A new class of synthetic hallucinogens called NBOMe has emerged as drugs of abuse.

OBJECTIVE

Our aim was to conduct a systematic review of published reports of toxicities associated with NBOMe ingestion.

METHODS

We searched PubMed for relevant English-language citations that described adverse effects from analytically confirmed human NBOMe ingestion. Demographic and clinical data were extracted.

RESULTS

A total of 10 citations met the criteria for inclusion, representing 20 individual patients. 25I-NBOMe was the most common analogue identified, followed by 25B-NBOMe and 25C-NBOMe. Fatalities were reported in 3 (15%) cases. Of all the patients, 7 (35%) were discharged after a period of observation, whereas 8 (40.0%) required admission to an intensive care unit. The most common adverse effects were agitation (85.0%), tachycardia (85.0%), and hypertension (65.0%). Seizures were reported in 8 (40.0%) patients. The most common abnormalities reported on laboratory tests were elevated level of creatinine kinase (45.0%), leukocytosis (25.0%), and hyperglycemia (20.0%).

CONCLUSION

NBOMe ingestion is associated with severe adverse effects. Clinicians need to have a high index of suspicion for NBOMe ingestion in patients reporting the recent use of hallucinogens.

Fatal intoxication with 3-methyl-N-methylcathinone (3-MMC) and 5-(2-aminopropyl)benzofuran (5-APB)

The emergence of a large number of new psychoactive substances (NPSs) in recent years poses a serious problem to clinical and forensic toxicologists. Here we report a patient who administrated ca. 500mg of 3-MMC (3-methyl-N-methylcathinone) and 400mg of 5-APB (5-(2-aminopropyl)benzofuran) in combination with 80g of ethyl alcohol. The clinical manifestations included agitation, seizures, hypertension, tachycardia, hyperthermia and bradycardia. The patient did not recover and died around 4h after the use of drugs. The cause of death was acute cardiovascular collapse that occurred following mixed intoxication with NPSs and alcohol. Toxicological analysis of post-mortem blood revealed 3-MMC and 5-APB in concentrations of 1.6μg/mL and 5.6μg/mL, respectively. Moreover, the serum alcohol concentration was 1.4g/L in ante-mortem sample collected 1h after admission to the hospital. This is the first report on blood concentration of 3-MMC and 5-APB in fatal intoxication.

Synthetic cathinones and their rewarding and reinforcing effects in rodents

Synthetic cathinones, colloquially referred to as "bath salts", are derivatives of the psychoactive alkaloid cathinone found in Catha edulis (Khat). Since the mid-to-late 2000's, these amphetamine-like psychostimulants have gained popularity amongst drug users due to their potency, low cost, ease of procurement, and constantly evolving chemical structures. Concomitant with their increased use is the emergence of a growing collection of case reports of bizarre and dangerous behaviors, toxicity to numerous organ systems, and death. However, scientific information regarding the abuse liability of these drugs has been relatively slower to materialize. Recently we have published several studies demonstrating that laboratory rodents will readily self-administer the "first generation" synthetic cathinones methylenedioxypyrovalerone (MDPV) and methylone via the intravenous route, in patterns similar to those of methamphetamine. Under progressive ratio schedules of reinforcement, the rank order of reinforcing efficacy of these compounds are MDPV ≥ methamphetamine > methylone. MDPV and methylone, as well as the "second generation" synthetic cathinones α-pyrrolidinovalerophenone (α-PVP) and 4-methylethcathinone (4-MEC), also dose-dependently increase brain reward function. Collectively, these findings indicate that synthetic cathinones have a high abuse and addiction potential and underscore the need for future assessment of the extent and duration of neurotoxicity induced by these emerging drugs of abuse.

Neurologic complications of illicit drug abuse

PURPOSE OF REVIEW

This review familiarizes clinicians with the symptoms of overdose and withdrawal, as well as neurologic complications, associated with particular illicit drugs.

RECENT FINDINGS

Recent arrivals on the recreational drug scene include synthetic cathinone analogs, synthetic cannabinoid agonists, and a variety of novel hallucinogens.

SUMMARY

Clinicians need to be aware of neurologic disorders associated with particular illicit drugs and should consider drug abuse in any patient with unexplained symptoms and signs.In addition to tobacco and alcohol, a large number of substances, legal and illegal, are used recreationally. Broad categories include opioids, psychostimulants, marijuana and related agents, sedatives, hallucinogens, inhalants, phencyclidine and related agents, and anticholinergics. Each type of agent has its own characteristic symptoms of overdose and withdrawal, and many agents are associated with trauma, infection, seizures, stroke, cognitive impairment, and teratogenicity. Some drugs have unique neurologic complications not encountered with other agents. A history of recreational drug use should be sought in any neurologic patient regardless of age or socioeconomic status.

A 3-year review of new psychoactive substances in casework

Following the initial popularity of mephedrone (4-methylmethcathinone) there has been a stream of new "recreational drugs" entering the global market. The lack of clinical studies on the effects and toxicity of these drugs has made interpretation of toxicological findings difficult. In an attempt to assist in a better understanding of the extent of their use and the fatalities that have been linked to these compounds we present our collated findings in post-mortem and criminal casework where these have been detected and/or implicated. Between January 2010 and December 2012 we have detected new psychoactive substances (NPS) in 203 cases, with 120 cases in 2012 alone. The drugs detected in in life or post-mortem blood and urine are, in order of decreasing frequency; mephedrone, 4-methylethcathinone, BZP, MDPV, TFMPP, methoxetamine, 4-fluoromethcathinone, 4-methylamphetamine, PMA, methylone, PMMA, naphyrone, alpha-methyltryptamine, butylone, MDAI, desoxypipradrol, D2PM, MPA, synthetic cannabinoids, 2-AI, 5-IAI, 5-MeODALT, MDPBP, 5/6-APB, pentedrone and pentylone. Other drugs or alcohol were detected in 84% of the cases including other NPS and in fatalities it should be noted that alternative causes of death (including mechanical suicide, accidental death and non-psychoactive drug overdose) accounted for the majority. Related to this was that of all fatalities involving cathinones, 41% of these were hangings or other mechanical suicides, this was a higher proportion than seen with other drugs found in such cases. The presence of multiple NPS and/or other stimulants was a particular feature in various cases, however, of the drug deaths only 7% solely involved NPS. Across all case types and including some cases investigated in 2013, NPS concentrations showed a wide range but these and selected cases are presented to assist toxicological interpretation in future cases.

Nephrotoxic effects of designer drugs: synthetic is not better!

Designer drugs are synthetic, psychoactive substances with similar structures and activity to existing scheduled drugs or controlled chemical compounds. The use of these drugs is not generally considered illegal and they cannot be detected using standard toxicology tests--essentially they are considered to be 'legal highs'. Over the past several years, increasing numbers of designer drugs have become available. These drugs are classified as amphetamine derivatives, phenylpiperazine derivatives, synthetic cathinones, synthetic cannabinoids, phencyclidine derivatives and synthetic opioids. Although euphoria is the desired effect, neuropsychiatric and cardiac manifestations are frequently observed in individuals using these drugs at high doses or using drugs that are contaminated with other substances. Some designer drugs are also associated with adverse renal effects, including acute kidney injury from pigment nephropathy, acute tubular necrosis, obstructive nephropathy and hyponatraemia. The misuse of these drugs should be recognized and clinicians made aware of the potential for acute nephrotoxicity as the health burden of these compounds increases.

The evolving high

Over the past decade, emerging drugs of abuse and synthetic derivatives of more traditional agents have flooded the market. While Europe was the first to experience a surge in the use of drugs such as synthetic cathinones and cannabinoids, poison centers throughout the United States have seen a dramatic rise in calls related to these new designer drugs of abuse. In the majority of cases, care is largely supportive but significant medical and traumatic complications may occur. Providers must be aware of the ever-changing trends in abuse, so that they may optimally care for poisoned patients.

Neuropathology of substance use disorders

Addictions to licit and illicit drugs are chronic relapsing brain disorders that affect circuits that regulate reward, motivation, memory, and decision-making. Drug-induced pathological changes in these brain regions are associated with characteristic enduring behaviors that continue despite adverse biopsychosocial consequences. Repeated exposure to these substances leads to egocentric behaviors that focus on obtaining the drug by any means and on taking the drug under adverse psychosocial and medical conditions. Addiction also includes craving for the substances and, in some cases, involvement in risky behaviors that can cause death. These patterns of behaviors are associated with specific cognitive disturbances and neuroimaging evidence for brain dysfunctions in a diverse population of drug addicts. Postmortem studies have also revealed significant biochemical and/or structural abnormalities in some addicted individuals. The present review provides a summary of the evidence that has accumulated over the past few years to implicate brain dysfunctions in the varied manifestations of drug addiction. We thus review data on cerebrovascular alterations, brain structural abnormalities, and postmortem studies of patients who abuse cannabis, cocaine, amphetamines, heroin, and "bath salts". We also discuss potential molecular, biochemical, and cellular bases for the varied clinical presentations of these patients. Elucidation of the biological bases of addiction will help to develop better therapeutic approaches to these patient populations.

Psychoactive substances--some new, some old: a scan of the situation in the U.S

New synthetic drugs are appearing as old hallucinogen psychedelic drugs are reappearing. This article combines the findings from a variety of datasets to characterize the users in terms of gender, age, drug use patterns, and adverse results, as well as provide an overview of the changes in formulations of these drugs and the impact of legal controls. Methods. Data from Monitoring the Future and the National Survey on Drug Use and Health are analyzed, along with the national DAWN emergency room admissions, Texas poison control center cases, and Texas treatment data, along with national forensic laboratory results. Results. Users of the synthetic cannabinoids, synthetic cathinones, phenethylamines, tryptamines, LSD, MDMA, and mushrooms tended to be young and male. They differed in terms of race and ethnicity. The effects of the drugs differed in terms of emergency room outcomes and poison center reports, and the treatment data showed they were similar in terms of education level, employment, and legal problems. Conclusion. Combining the different data sources provided a first picture of the characteristics of these users and their needs. Creditable descriptions on the risks of these drugs should be disseminated. Intervention programs should be targeted to these young users and new neuropsychobiological deficits from some of these drugs should be monitored. Because of the ever-changing chemical combinations to stay legal and the need for information on content and dosage, a more effective approach may be needed basing control on the effects of the substances rather than their changing chemical composition.