Identifying emerging trends in recreational drug use; outcomes from the Psychonaut Web Mapping Project

Adverse drug reaction early warning using user search data

Purpose

The purpose of this paper is to propose a framework to detect adverse drug reactions (ADRs) using internet user search data, so that ADR events can be identified early. Empirical investigation of Avandia, a type II diabetes treatment, is conducted to illustrate how to implement the proposed framework.

Design/methodology/approach

Typical ADR identification measures and time series processing techniques are used in the proposed framework. Google Trends Data are employed to represent user searches. The baseline model is a disproportionality analysis using official drug reaction reporting data from the US Food and Drug Administration’s Adverse Event Reporting System.

Findings

Results show that Google Trends series of Avandia side effects search reveal a significant early warning signal for the side effect emergence of Avandia. The proposed approach of using user search data to detect ADRs is proved to have a longer leading time than traditional drug reaction discovery methods. Three more drugs with known adverse reactions are investigated using the selected approach, and two are successfully identified.

Research limitations/implications

Validation of Google Trends data’s representativeness of user search is yet to be explored. In future research, user search in other search engines and in healthcare web forums can be incorporated to obtain a more comprehensive ADR early warning mechanism.

Practical implications

Using internet data in drug safety management with a proper early warning mechanism may serve as an earlier signal than traditional drug adverse reaction. This has great potential in public health emergency management.

Originality/value

The research work proposes a novel framework of using user search data in ADR identification. User search is a voluntary drug adverse reaction exploration behavior. Furthermore, user search data series are more concise and accurate than text mining in forums. The proposed methods as well as the empirical results will shed some light on incorporating user search data as a new source in pharmacovigilance.

The Growing Problem of New Psychoactive Substances (NPS)

The term "new psychoactive substances" (NPS) can be defined as individual drugs in pure form or in complex preparations that are not scheduled under the Single Convention on Narcotic Drugs (1961) or the Convention on Psychotropic Substances (1971). NPS may be categorized by chemical structure, by psychoactive properties, by biological targets, or by source (plant, synthetic, or combined). The emergence of hundreds of NPS in the past decade is challenging for public health and drug policies globally. The novelty of NPS, their ambiguous legal status, ability to evade toxicological tests, swift adaptation to legal restrictions, global Internet marketing, and scant public knowledge of their adverse effects are among the key drivers of this twenty-first century phenomenon. Multi-disciplinary research in areas of biology, epidemiology, prevention, and web analytics are needed to develop effective responses in a domain capable of overwhelming current international conventions and national drug control policies. Ultimately, research-guided prevention education will fortify societies against this tidal wave.

The Novel Psychoactive Substances in the UK Project: empirical and conceptual review work to produce research recommendations

Background

Although illegal drug use has largely been declining in the UK over the past decade, this period has witnessed the emergence of a range of novel psychoactive substances (NPS) (‘legal highs’). These are new, mostly synthetic, substances that mimic the effects of existing drugs). Despite there being many causes for concern in relation to NPS, there has been little prior study of the burden associated with their use in public health terms. Clarity is lacking on research priorities in this rapidly developing literature.

Objectives

To inform the development of public health intervention research on NPS by reviewing existing data on their use, associated problems and potential responses to such problems.

Design

A scoping review and narrative synthesis of selected bodies of evidence was undertaken to summarise and evaluate what is known about NPS use and the related harms of, and responses to, such use. Relevant literature was identified from electronic databases (covering January 2006 to June 2016 inclusive), Google (Google Inc., Mountain View, CA, USA), relevant websites and online drug forums and by contacting experts. Articles were included if they were primary studies, secondary studies involving the analysis and interpretation of primary research or discussion papers. A conceptual framework postulating an evidence-informed public health approach to NPS use in the UK was developed through a pragmatic literature review, the iterative development of concepts and finalisation in light of the results from the empirical review work. The process also involved feedback from various stakeholders. Research recommendations were developed from both strands of work.

Results

A total of 995 articles were included in the scoping review, the majority of which related to individual-level health-related adverse effects attributable to NPS use. The prevalence of lifetime NPS use varied widely between (e.g. with higher prevalence in young males) and within population subgroups. The most commonly reported adverse effects were psychiatric/other neurological, cardiovascular, renal and gastrointestinal manifestations, and there is limited evidence available on responses. In these and other respects, available evidence is at an early stage of development. Initial evidence challenges the view that NPS should be treated differently from other illicit drugs. The conceptual framework indicated that much of the evidence that would be useful to inform public health responses does not yet exist. We propose a systems-based prevention approach that develops existing responses, is multilevel and life course informed in character, and emphasises commonalities between NPS and other legal and illegal drug use. We make 20 recommendations for research, including nine key recommendations.

Limitations

Scoping reviews do not interrogate evidence in depth, and the disjunction between the scoping review and the conceptual framework findings is worthy of careful attention.

Conclusions

Key research recommendations build on those that have previously been made and offer more evidence-based justification and detail, as previous recommendations have not yet been acted on. The case for decision-making on commissioning new research based on these recommendations is both strong and urgent.

Future work

The validity of recommendations generated through this project could be enhanced via further work with research commissioners, policy-makers, researchers and the public.

Study registration

The systematic review element of this study is registered as PROSPERO CRD42016026415.

Funding

The National Institute for Health Research Public Health Research programme.

Home Manufacture of Drugs: An Online Investigation and a Toxicological Reality Check of Online Discussions on Drug Chemistry

Emerging trends in market dynamics and the use of new psychoactive substances are both a public health concern and a complex regulatory issue. One novel area of investigation is the availability of homemade opioids, amphetamines and dissociatives, and the potential fueling of interest in clandestine home manufacture of drugs via the Internet. We illustrate here how online communal folk pharmacology of homemade drugs on drug website forums may actually inform home manufacture practices or contribute to the reduction of harms associated with this practice. Discrepancies between online information around purification and making homemade drugs safer, and the synthesis of the same substances in a proper laboratory environment, exist. Moderation and shutdown of synthesis queries and discussions online are grounded in drug websites adhering to harm-reduction principles by facilitating discussions around purification of homemade drugs only. Drug discussion forums should consider reevaluating their policies on chemistry discussions in aiming to reach people who cannot or will not refrain from cooking their own drugs with credible information that may contribute to reductions in the harms associated with this practice.

Novel psychoactive substance consumption is more represented in bipolar disorder than in psychotic disorders: A multicenter-observational study

OBJECTIVE

Comorbidities between psychiatric diseases and use of traditional substances of abuse are common. Nevertheless, there are few data regarding the use of novel psychoactive substances (NPS) among psychiatric patients. Aim of this multicentre survey is to investigate the consumption of a number of psychoactive substances in a young psychiatric sample.

METHODS

Between December 2013 and September 2015, a questionnaire was administered in 10 Italian psychiatric care facilities to a sample of 671 patients, aged 18-26 (mean age 22.24; SD 2.87).

RESULTS

About 8.2% of the sample declared to have used NPS at least once, and 2.2% had consumed NPS in the previous 3 months. The three psychiatric diagnoses most frequently associated with NPS use were bipolar disorder (23.1%), personality disorders (11.8%), and schizophrenia and related disorders (11.6%). In univariate regression analysis, bipolar disorder was positively associated with NPS consumption, an association that did not reach statistical significance in the multivariate analysis.

CONCLUSIONS

The use of NPS in a young psychiatric population appears to be frequent, and probably still underestimated. Bipolar disorder shows an association with NPS use. Careful and constant monitoring and an accurate evaluation of possible clinical effects related to NPS use are necessary.

Intended and unintended use of cathinone mixtures

INTRODUCTION

Cathinones are one of the most popular categories of new psychoactive substances (NPS) consumed. Cathinones have different pharmacological activities and receptor selectivity for monoamine transporters based on their chemical structures. They are incorporated into NPS mixtures and used with other NPS or 'traditional' drugs. Cathinone use represents significant health risks to individuals and is a public health burden.

METHODS

Evidence of poly-NPS use with cathinones, seizure information, and literature analyses results on NPS mixtures was systematically gathered from online database sources, including Google Scholar, Scopus, Bluelight, and Drugs-Forum.

RESULTS AND DISCUSSION

Results highlight the prevalence of NPS with low purity, incorporation of cathinones into NPS mixtures since 2008, and multiple members of the cathinone family being present in individual UK-seized samples. Cathinones were identified as adulterants in NPS marketed as being pure NPS, drugs of abuse, branded products, herbal blends, and products labelled "not for human consumption." Toxicity resulting from cathinone mixtures is unpredictable because key attributes remain largely unknown. Symptoms of intoxication include neuro-psychological, psychiatric, and metabolic symptoms. Proposed treatment includes holistic approaches involving psychosocial, psychiatric and pharmacological interventions.

CONCLUSION

Raising awareness of NPS, education, and training of health care professionals are paramount in reducing harms related to cathinone use.

From concept(ion) to life after death/the grave: The 'natural' history and life cycle(s) of novel psychoactive substances (NPS)

A range of information needs should be met in order to better understand and predict the longevity/existence of novel psychoactive substances (NPS). This conceptual paper argues that one way of assessing how long a molecule may be around is to document how the life cycles or natural histories of 'traditional' drugs and NPS evolve. The earliest indication of the possible appearance of a new substance might be evidenced on the DeepWeb. However, this means they are less visible, in line with the clandestine nature of drug use and supply. Therefore, monitoring discussion groups/fora needs the development of new methods compared to those used in the Surface Net. Issues needing consideration in establishing NPS life cycles are outlined here, together with the probable outcomes that could result. The approach advocated means that it should be easier to identify which NPS are likely to come up or are emerging in real time, and, therefore, pre-empt/prevent their supply.

The effects and toxicity of cathinones from the users' perspectives: A qualitative study

OBJECTIVE

The objective of this study is to explore the users' perspectives regarding the effects and toxicity of cathinones.

METHODS

A systematic search of Internet discussion forums yielded 303 threads relevant to the research objectives. The threads were analysed by conventional content analysis where concepts were developed from codes and themes.

RESULTS

The study identified 3 main themes in relation to cathinone use, effects, and toxicity. The first theme considered the modalities of intake of cathinones in relation to the derivative taken (mainly mephedrone, 3-methylmethcathinone, and methylenedioxypyrovalerone), route of administration (eyeballing, insufflation, smoking, intravenous, oral, rectal, and sublingual), multidrug use, and purity of the cathinone derivative. The second theme characterised the main effects of cathinones, that is, increased energy, euphoria, and empathogenic. Toxic effects were reported regarding the nervous system (anxiety, hallucinations, nervousness, and paranoia), cardiovascular system (angina, myocardial infarction, and tachycardia), skin (discolouration, itching, and allergy), and renal system (difficulty in urination). Drug-drug interactions were also reported including multiple drug use between cathinones, stimulants, depressants, and hallucinogens.

CONCLUSIONS

The Internet discussion forums provide useful sources of information regarding the effects and toxicity of cathinones, which can be taken into account when assessing the safety of drugs.

Forecasting state-level premature deaths from alcohol, drugs, and suicides using Google Trends data

BACKGROUND

Vital statistics on the number of, alcohol-induced death (AICD) drug-induced death (DICD), and suicides at the local-level are only available after a substantial lag of up to two years after the events occur. We (1) investigate how well Google Trends search data explain variation in state-level rates in the US, and (2) use this method to forecast these rates of death for 2015 as official data are not yet available.

METHODS

We tested the degree to which Google Trends data on 27 terms can be fit to CDC data using L₁-regularization on AICD, DICD, and suicide. Using Google Trends data, we forecast 2015 AICD, DICD, and suicide rates.

RESULTS

L₁-regularization fit the pre-2015 data much better than the alternative model using state-level unemployment and income variables. Google Trends data account for substantial variation in growth of state-level rates of death: 30.9% for AICD, 23.9% for DICD, and 21.8% for suicide rates. Every state except Hawaii is forecasted to increase in all three of these rates in 2015.

LIMITATIONS

The model predicts state, not local or individual behavior, and is dependent on continued availability of Google Trends data.

CONCLUSIONS

The method predicts state-level AICD, DICD, and suicide rates better than the alternative model. The study findings suggest that this methodology can be developed into a public health surveillance system for behavioral health-related causes of death. State-level predictions could be used to inform state interventions aimed at reducing AICD, DICD, and suicide.

Integrating Personalized Technology in Toxicology: Sensors, Smart Glass, and Social Media Applications in Toxicology Research

Rapid proliferation of mobile technologies in social and healthcare spaces create an opportunity for advancement in research and clinical practice. The application of mobile, personalized technology in healthcare, referred to as mHealth, has not yet become routine in toxicology. However, key features of our practice environment, such as frequent need for remote evaluation, unreliable historical data from patients, and sensitive subject matter, make mHealth tools appealing solutions in comparison to traditional methods that collect retrospective or indirect data. This manuscript describes the features, uses, and costs associated with several of common sectors of mHealth research including wearable biosensors, ingestible biosensors, head-mounted devices, and social media applications. The benefits and novel challenges associated with the study and use of these applications are then discussed. Finally, opportunities for further research and integration are explored with a particular focus on toxicology-based applications.

Desomorphine (Krokodil): An overview of its chemistry, pharmacology, metabolism, toxicology and analysis

BACKGROUND

"Krokodil" or "Crocodile" is an illegal homemade desomorphine drug obtained from chemical reactions of commercial codeine drugs with several other powerful and highly toxic chemical agents increasing its addiction and hallucinogenic effects when compared with other morphine analogues.

METHODS

This paper summarizes a complete review about an old drug called desomorphine (Krokodil), presenting its chemistry, pharmacology, metabolism, toxicology and analysis.

RESULTS

It is of particular interest and concern because this cheaper injectable semisynthetic opioid drug has been largely used in recent years for recreational purposes in several Eastern European as well as North and South American countries, despite known damage to health that continuous use might induce. These injuries are much stronger and more aggressive than morphine's, infecting and rotting skin and soft tissue to the bone of addicts at the point of injection in less than three years, which, in most cases, evolves to death. On this basis, it is imperative that literature reviews focus on the chemistry, pharmacology, toxicology and analysis of dangerous Krokodil to find strategies for rapid and effective determination to mitigate its adverse effects on addicts and prevent consumption.

CONCLUSIONS

It is crucial to know the symptoms and consequences of the use of Krokodil, as well as METHODS: for identification and quantification of desomorphine, contaminants and metabolites, which can help the forensic work of diagnosis and propose actions to control and eradicate this great danger to public health around the world.

Infodemiology of systemic lupus erythematous using Google Trends

Objective People affected by chronic rheumatic conditions, such as systemic lupus erythematosus (SLE), frequently rely on the Internet and search engines to look for terms related to their disease and its possible causes, symptoms and treatments. 'Infodemiology' and 'infoveillance' are two recent terms created to describe a new developing approach for public health, based on Big Data monitoring and data mining. In this study, we aim to investigate trends of Internet research linked to SLE and symptoms associated with the disease, applying a Big Data monitoring approach. Methods We analysed the large amount of data generated by Google Trends, considering 'lupus', 'relapse' and 'fatigue' in a 10-year web-based research. Google Trends automatically normalized data for the overall number of searches, and presented them as relative search volumes, in order to compare variations of different search terms across regions and periods. The Menn-Kendall test was used to evaluate the overall seasonal trend of each search term and possible correlation between search terms. Results We observed a seasonality for Google search volumes for lupus-related terms. In the Northern hemisphere, relative search volumes for 'lupus' were correlated with 'relapse' (τ = 0.85; p = 0.019) and with fatigue (τ = 0.82; p = 0.003), whereas in the Southern hemisphere we observed a significant correlation between 'fatigue' and 'relapse' (τ = 0.85; p = 0.018). Similarly, a significant correlation between 'fatigue' and 'relapse' (τ = 0.70; p < 0.001) was seen also in the Northern hemisphere. Conclusion Despite the intrinsic limitations of this approach, Internet-acquired data might represent a real-time surveillance tool and an alert for healthcare systems in order to plan the most appropriate resources in specific moments with higher disease burden.

Evolutionary Considerations on the Emerging Subculture of the E-psychonauts and the Novel Psychoactive Substances: A Comeback to the Shamanism?

BACKGROUND

Evolutionary research on drug abuse has hitherto been restricted to proximate studies, considering aetiology, mechanism, and ontogeny. However, in order to explain the recent emergency of a new behavioral pattern (e.g. 'the e-psychonaut style') of novel psychoactive substances' (NPS) intake, a complementary evolutionary model may be needed.

OBJECTIVE

A range of evolutionary interpretations on the 'psychonaut style' and the recent emergency of NPS were here considered.

METHOD

The PubMed database was searched in order to elicit evolutionary theory-based documents commenting on NPS/NPS users/e-psychonauts.

RESULTS

The traditional 'shamanic style' use of entheogens/plant-derived compounds may present with a range of similarities with the 'e-psychonauts' use of mostly of hallucinogen/psychedelic NPS. These users consider themselves as 'new/technological' shamans.

CONCLUSION

Indeed, a range of evolutionary mechanisms, such as: optimal foraging, costly signaling, and reproduction at the expense of health may all cooperate to explain the recent spread and diffusion of the NPS market, and this may represent a reason of concern.

Clinical Pharmacology of the Synthetic Cathinone Mephedrone

4-Methyl-N-methylcathinone (mephedrone) is a popular new psychoactive substance (NPS) that is structurally related to the parent compound cathinone, the β-keto analogue of amphetamine. Mephedrone appeared on the street drug market as a substitute for 3,4-methylenedioxy-N-methylamphetamine (MDMA, ecstasy) and was subsequently banned due to the potential health risks associated with its use. Nevertheless, mephedrone continues to be widely consumed among specific populations, with unique patterns of misuse. To date, most information about the biological effects of mephedrone comes from user experiences, epidemiological data, clinical cases, toxicological findings, and animal studies, whilst there are very few data regarding its human pharmacodynamics and pharmacokinetics. This chapter reviews the available published data on patterns of mephedrone use, its acute and chronic effects, and its pharmacokinetic properties. More human research is needed to elucidate the safety, toxicity, and addiction potential of mephedrone and related NPS.

NPS: Medical Consequences Associated with Their Intake

Over the last decade, the 'traditional' drug scene has been supplemented - but not replaced - by the emergence of a range of novel psychoactive substances (NPS), which are either newly created or existing drugs, including medications, now being used in novel ways. By the end of 2014, in excess of 500 NPS had been reported by a large number of countries in the world. Most recent data show, however, that synthetic cathinones, synthetic cannabinoids, and psychedelics/phenethylamines account for the largest number of NPS.The present chapter aims at providing an overview of the clinical and pharmacological issues relating to these most popular NPS categories. Given the vast range of medical and psychopathological issues associated with the molecules here described, it is crucial for health professionals to be aware of the effects and toxicity of NPS. A general overview of the acute management of NPS adverse events is provided as well, although further studies are required to identify a range of evidence-based, index molecule-focused, treatment strategies. The rapid pace of change in the NPS online market constitutes a major challenge to the provision of current and reliable scientific knowledge on these substances.

Neurocognitive performance following acute mephedrone administration, with and without alcohol

Recreational use of mephedrone, alone and in combination with alcohol, has increased over the past years. Pharmacological properties of mephedrone share similarities with methylenedioxymethamphetamine (MDMA), but its effect on neurocognitive function has not been well established in humans. The present study assessed the effect of mephedrone alone and after co-administration with alcohol on neurocognitive function. It was hypothesised that mephedrone would improve psychomotor performance but impair memory performance, when administered alone. Neurocognitive performance was expected to be impaired following mephedrone when combined with alcohol. Eleven participants received single doses of 200 mg mephedrone or placebo combined with 0.8 g/kg alcohol or placebo. Neurocognitive performance was assessed at baseline (T₀), at one hour (T₁) and four hours after (T₂) mephedrone administration, by means of the Divided Attention Task (DAT), Critical Tracking Task (CTT), and the Spatial Memory Test (SMT). Mephedrone intoxication impaired short-term spatial memory at T₁ and improved critical tracking performance at T₂ Mephedrone alone did not affect divided attention, but did show an interaction with alcohol on reaction time at T₂ Reaction time decreased when mephedrone was combined with alcohol as compared to alcohol alone. Alcohol intoxication impaired both short- and long-term spatial memory at T₁ and divided attention at T₁ and T₂ Critical tracking performance was not affected by alcohol intoxication. The current findings support the hypothesis that mephedrone improves psychomotor performance, impairs spatial memory and does not affect divided attention performance. Stimulatory effects of mephedrone were not sufficient to compensate for the impairing effects of alcohol on most performance parameters.

Human Pharmacology of Mephedrone in Comparison with MDMA

Mephedrone (4-methylmethcathinone) is a novel psychoactive substance popular among drug users because it displays similar effects to MDMA (3,4-methylenedioxymethamphetamine, ecstasy). Mephedrone consumption has been associated with undesirable effects and fatal intoxications. At present, there is no research available on its pharmacological effects in humans under controlled and experimental administration. This study aims to evaluate the clinical pharmacology of mephedrone and its relative abuse liability compared with MDMA. Twelve male volunteers participated in a randomized, double-blind, crossover, and placebo-controlled trial. The single oral dose conditions were: mephedrone 200 mg, MDMA 100 mg, and placebo. Outcome variables included physiological, subjective, and psychomotor effects, and pharmacokinetic parameters. The protocol was registered in ClinicalTrials.gov (NCT02232789). Mephedrone produced a significant increase in systolic and diastolic blood pressure, heart rate, and pupillary diameter. It elicited stimulant-like effects, euphoria, and well-being, and induced mild changes in perceptions with similar ratings to those observed after MDMA administration although effects peaked earlier and were shorter in duration. Maximal plasma concentration values for mephedrone and MDMA peaked at 1.25 h and 2.00 h, respectively. The elimination half-life for mephedrone was 2.15 h and 7.89 h for MDMA. In a similar manner to MDMA, mephedrone exhibits high abuse liability. Its earlier onset and shorter duration of effects, probably related to its short elimination half-life, could explain a more compulsive pattern of use as described by the users.

Educated Guesses and Other Ways to Address the Pharmacological Uncertainty of Designer Drugs: An Exploratory Study of Experimentation Through an Online Drug Forum

This study examines how experimentation with designer drugs is mediated by the Internet. We selected a popular drug forum that presents reports on self-experimentation with little or even completely unexplored designer drugs to examine: (1) how participants report their "trying out" of new compounds and (2) how participants reduce the pharmacological uncertainty associated with using these substances. Our methods included passive observation online, engaging more actively with the online community using an avatar, and off-line interviews with key interlocutors to validate our online findings. This article reflects on how forum participants experiment with designer drugs, their trust in suppliers and the testimonials of others, the use of ethno-scientific techniques that involve numerical weighing, "allergy dosing," and the use of standardized trip reports. We suggest that these techniques contribute to a sense of control in the face of the possible toxicity of unknown or little-known designer drugs. The online reporting of effects allows users to experience not only the thrill of a new kind of high but also connection with others in the self-experimenting drug community.

"Trip-Sitting" in the Black Hole: A Netnographic Study of Dissociation and Indigenous Harm Reduction

An array of dissociative novel psychoactive substances, including "methoxetamine," "3-MeO-PCP," and "methoxphenidine," have emerged as substitutes for the illicit substance "ketamine." A netographic research methodology aimed to describe online, dissociative novel psychoactive substance users' perceptions of risk, informed knowledge around use, and indigenous harm-reduction practices as advocated within online drug fora, so as to provide credible information which can be used to inform public online health education and drug prevention. Systematic Internet searches were performed using the terms "synthetic dissociative," "methoxetamine," "methoxphenidine," "diphenidine," "3-MeO-PCP," "4-MeO-PCP," "2-MDP," and "dissociative research chemical" in combination with "forum." Following screening of 3,476 forum threads with removal of duplicates and exclusion criteria, 90 user trip reports and 115 fora threads from seven drug fora websites were analyzed by conducting content analysis. Five themes emerged with 43 categories. The findings illustrated how forum activity within the cyber drug user community disseminated and exchanged "communal folk pharmacology" relating to the use of dissociative novel psychoactive substances. Further research and consistent monitoring of Internet drug fora are advised to explore variations in harm-reduction tactics throughout dissociative NPS populations, and to consider how existing harm-reduction initiatives are influencing these hard-to-reach groups.

Characterization of the hepatic cytochrome P450 enzymes involved in the metabolism of 25I-NBOMe and 25I-NBOH

The dimethoxyphenyl-N-((2-methoxyphenyl)methyl)ethanamine (NBOMe) compounds are potent serotonin 5-HT2A receptor agonists and have recently been subject to recreational use due to their hallucinogenic effects. Use of NBOMe compounds has been known since 2011, and several non-fatal and fatal intoxication cases have been reported in the scientific literature. The aim of this study was to determine the importance of the different cytochrome P450 enzymes (CYP) involved in the metabolism of 2-(4-iodo-2,5-dimethoxyphenyl)-N-(2methoxybenzyl)ethanamine (25I-NBOMe) and 2-[[2-(4-iodo-2,5dimethoxyphenyl)ethylamino]methyl]phenol (25I-NBOH) and to characterize the metabolites. The following approaches were used to identify the main enzymes involved in primary metabolism: incubation with a panel of CYP and monoamine oxidase (MAO) enzymes and incubation in pooled human liver microsomes (HLM) with and without specific CYP chemical inhibitors. The study was further substantiated by an evaluation of 25I-NBOMe and 25I-NBOH metabolism in single donor HLM. The metabolism pathways of 25I-NBOMe and 25I-NBOH were NADPHdependent with intrinsic clearance values of (CLint) of 70.1 and 118.7 mL/min/kg, respectively. The biotransformations included hydroxylation, O-demethylation, N-dealkylation, dehydrogenation, and combinations thereof. The most abundant metabolites were all identified by retention time and spectrum matching with synthesized reference standards. The major CYP enzymes involved in the metabolism of 25I-NBOMe and 25INBOH were identified as CYP3A4 and CYP2D6, respectively. The compound 25I-NBOH was also liable to direct glucuronidation, which may diminish the impact of CYP2D6 genetic polymorphism. Users of 25I-NBOMe may be subject to drug-drug interactions (DDI) if 25I-NBOMe is taken with a strong CYP3A4 inhibitor. Copyright © 2016 John Wiley & Sons, Ltd.

Variation in commercial smoking mixtures containing third-generation synthetic cannabinoids

Variation in ingredients (qualitative variation) and in quantity of active compounds (quantitative variation) in herbal smoking mixtures containing synthetic cannabinoids has been shown for older products. This can be dangerous to the user, as accurate and reproducible dosing is impossible. In this study, 69 packages containing third-generation cannabinoids of seven brands on the UK market in 2014 were analyzed both qualitatively and quantitatively for variation. When comparing the labels to actual active ingredients identified in the sample, only one brand was shown to be correctly labelled. The other six brands contained less, more, or ingredients other than those listed on the label. Only two brands were inconsistent, containing different active ingredients in different samples. Quantitative variation was assessed both within one package and between several packages. Within-package variation was within a 10% range for five of the seven brands, but two brands showed larger variation, up to 25% (Relative Standard Deviation). Variation between packages was significantly higher, with variation up to 38% and maximum concentration up to 2.7 times higher than the minimum concentration. Both qualitative and quantitative variation are common in smoking mixtures and endanger the user, as it is impossible to estimate the dose or to know the compound consumed when smoking commercial mixtures. Copyright © 2016 John Wiley & Sons, Ltd.

Neuropharmacology of New Psychoactive Substances (NPS): Focus on the Rewarding and Reinforcing Properties of Cannabimimetics and Amphetamine-Like Stimulants

New psychoactive substances (NPS) are a heterogeneous and rapidly evolving class of molecules available on the global illicit drug market (e.g smart shops, internet, “dark net”) as a substitute for controlled substances. The use of NPS, mainly consumed along with other drugs of abuse and/or alcohol, has resulted in a significantly growing number of mortality and emergency admissions for overdoses, as reported by several poison centers from all over the world. The fact that the number of NPS have more than doubled over the last 10 years, is a critical challenge to governments, the scientific community, and civil society [EMCDDA (European Drug Report), 2014; UNODC, 2014b; Trends and developments]. The chemical structure (phenethylamines, piperazines, cathinones, tryptamines, synthetic cannabinoids) of NPS and their pharmacological and clinical effects (hallucinogenic, anesthetic, dissociative, depressant) help classify them into different categories. In the recent past, 50% of newly identified NPS have been classified as synthetic cannabinoids followed by new phenethylamines (17%) (UNODC, 2014b). Besides peripheral toxicological effects, many NPS seem to have addictive properties. Behavioral, neurochemical, and electrophysiological evidence can help in detecting them. This manuscript will review existing literature about the addictive and rewarding properties of the most popular NPS classes: cannabimimetics (JWH, HU, CP series) and amphetamine-like stimulants (amphetamine, methamphetamine, methcathinone, and MDMA analogs). Moreover, the review will include recent data from our lab which links JWH-018, a CB1 and CB2 agonist more potent than Δ⁹-THC, to other cannabinoids with known abuse potential, and to other classes of abused drugs that increase dopamine signaling in the Nucleus Accumbens (NAc) shell. Thus the neurochemical mechanisms that produce the rewarding properties of JWH-018, which most likely contributes to the greater incidence of dependence associated with “Spice” use, will be described (De Luca et al., 2015a). Considering the growing evidence of a widespread use of NPS, this review will be useful to understand the new trends in the field of drug reward and drug addiction by revealing the rewarding properties of NPS, and will be helpful to gather reliable data regarding the abuse potential of these compounds.

Novel psychoactive substances: the pharmacology of stimulants and hallucinogens

There are increasing levels of concern relating to the rapidly evolving novel psychoactive substances/NPS and web markets' scenarios. The paper aims at providing an overview of the clinical pharmacological issues related to some of the most popular NPS categories, e.g. stimulants and hallucinogens. NPS intake is typically associated with the imbalance of a complex range of neurotransmitter pathways/receptors, namely: dopamine; cannabinoid/CB1; and 5-HT2A. The intake is almost invariably undetectable with standard screening tests. Hence, it may frequently occur that the acute management of NPS misusers will need to focus on decreasing levels of both self/outward-directed aggression and agitation. Benzodiazepines may be considered as first line treatment. Alternatively, propofol and/or antipsychotics can be administered. Focus will be as well on treatment of possible rhabdomyolysis and hyperthermia. Indeed, future studies should inform better tailored management/treatment strategies.

Sex Differences in Hookah-Related Images Posted on Tumblr: A Content Analysis

Hookah tobacco smoking is prevalent, widespread, and associated with large amounts of toxicants. Hookah tobacco smoking may be viewed differently by males and females. For example, females have been drawn to types of tobacco that are flavored, milder, and marketed as more social and exotic. Individuals often use the growing segment of anonymous social networking sites, such as Tumblr, to learn about potentially dangerous or harmful behaviors. We used a systematic process involving stratification by time of day, day of week, and search term to gather a sample of 140 Tumblr posts related to hookah tobacco smoking. After a structured codebook development process, 2 coders independently assessed all posts in their entirety, and all disagreements were easily adjudicated. When data on poster sex and age were available, we found that 77% of posts were posted by females and 35% were posted by individuals younger than 18. The most prominent features displayed in all posts were references to or images of hookahs themselves, sexuality, socializing, alcohol, hookah smoke, and tricks performed with hookah smoke. Compared with females, males more frequently posted images of hookahs and alcohol-related images or references. This information may help guide future research in this area and the development of targeted interventions to curb this behavior.

Synthetic cannabinoids 2015: An update for pediatricians in clinical practice

Synthetic cannabinoids are a group of substances in the world of designer drugs that have become increasingly popular over the past few years. Synthetic cannabinoids are a chemically diverse group of compounds functionally similar to THC. Since first appearing on the world market a few years ago these compounds have evolved rapidly. Newer more potent analogues have been developed. Identifying youth who abuse these substances can be difficult. Newer forms of consumption have also evolved. These products are now manufactured in products that look like natural cannabis resin and in liquid cartridges used in electronic cigarettes. Synthetic cannabinoids appear to be associated with potentially dangerous health effects that are more severe than that of marijuana. Some synthetic cannabinoid compounds have been associated with serious physical consequences, such as, seizures, myocardial infarction and renal damage. In addition, psychoactive effects, such as aggression, confusion, anxiety and psychosis have also been reported. The diagnosis remains primarily clinical with toxicological confirmation difficult due to manufacturers constantly developing new analogues to avoid detection. Pediatricians are urged to familiarize themselves with these drugs and the typical presentations of patients who use them.

Mind navigators of chemicals' experimenters? A web-based description of e-psychonauts

Within online drug fora communities, there are some "educated and informed" users who can somehow provide reliable information on psychoactive compounds and combinations. These users, also called "e-psychonauts," may possess levels of technical knowledge relating to a range of novel psychoactive substances (NPS). The present project aimed at identifying and describing the e-psychonauts' socio-demographic characteristics and their motivations and patterns of drug intake. A netnographic research methodology, carried out through an unobtrusive observational approach of a list of cyber drug communities (blogs, fora, Facebook, and Twitter pages) was carried out. The fora posts and threads were accurately reviewed, analyzed, and compared using the empirical phenomenological psychological (EPP) method. Data were collected between January and February 2014. Psychonauts typically considered themselves as "psychedelic researchers," "new Shamans," "philosophers," or "alchemists." They appeared to be mainly young, males, unmarried, and Caucasians. They presented with good or excellent employment conditions and with a set of key skills, including attention to their inner "soul"; high standards of knowledge about drugs' chemical and pharmacological issues; and high levels of both IT skills and verbal fluency in reporting their own "on drug" experiences. The e-psychonauts seemed to "test" and at times synthesize a range of drugs to achieve the state of consciousness they find most pleasurable. There is the need to improve both the existing levels of professionals' knowledge on this novel generation of drug misusers and to design and develop novel prevention approaches that are able to attract the attention of the e-psychonauts.

Intravenous self-administration of entactogen-class stimulants in male rats

The intravenous self-administration (IVSA) of 3,4-methylenedioxymethamphetamine (MDMA) is inconsistent in rats, with up to half of subjects failing to acquire reliable drug intake. It is unknown if this changes under long-access conditions (6 h sessions) under which the IVSA of cocaine and methamphetamine escalates. The entactogen class cathinone stimulants which exhibit MDMA-like monoamine effects in the nucleus accumbens, mephedrone (4-methylmethcathinone) and methylone (3,4-methylenedioxymethcathinone), may support more reliable IVSA but results have been mixed. This study was designed to directly compare the IVSA of these three compounds. Groups of male Wistar rats were trained to self-administer mephedrone, methylone or MDMA (0.5 mg/kg/inf) under a Fixed-Ratio (FR) 1 schedule of reinforcement for 14 sessions. Following the acquisition interval, animals were evaluated in FR (0.0, 0.125, 0.25, 0.5, 1.0, 2.5 mg/kg/inf) and Progressive Ratio (PR; 0.125, 1.0 mg/kg/inf) dose-substitution procedures. Long access conditions escalated MDMA intake over the 6 h session but not in the first 2 h. In short access, drug intake was significantly higher in mephedrone-trained rats compared with either the methylone-trained or MDMA-trained groups during acquisition. Mephedrone resulted in the highest intakes during FR and PR dose-substitution in MDMA- and mephedrone-trained groups. Overall it was found that mephedrone is a more effective reinforcer than methylone or MDMA and represents a higher risk for compulsive use.

Olanzapine as the ideal "trip terminator"? Analysis of online reports relating to antipsychotics' use and misuse following occurrence of novel psychoactive substance-related psychotic symptoms

OBJECTIVE

The pharmacological self-management of novel psychoactive substance (NPS)-induced psychopathological consequences represents a fast growing phenomenon. This is facilitated by the frequent sharing of NPS intake experiences online and by the ease of access to a range of psychotropic medications from both the online and street market. Olanzapine is anecdotally reported by Web users to be the most frequent self-prescribed medication to cope with NPS-induced psychoses. Hence, we aimed here at better assessing olanzapine use/misuse for this purpose.

METHODS

Exploratory qualitative searches of 163 discussion fora/specialized websites have been carried out in four languages (English, German, Spanish, and Italian) in the time frame November 2012-2013.

RESULTS

Most NPS-users allegedly self administer with olanzapine to manage related psychotic crises/"bad trips". This may be typically taken only for a few days, at a dosage range of 5-50 mg/day.

CONCLUSIONS

Only a few research studies have formally assessed the effectiveness of olanzapine and indeed of other second-generation antipsychotics to treat NPS-induced psychosis. Olanzapine was suggested here from a range of pro drug websites as being the "ideal" molecule to terminate "bad trips". Health professionals should be informed about the risks related to olanzapine misuse.

Venlafaxine as the 'baby ecstasy'? Literature overview and analysis of web-based misusers' experiences

INTRODUCTION

Venlafaxine is one of the most frequently prescribed antidepressants worldwide, despite its toxicity risk in overdose. Furthermore, the molecule has been recently identified at the EU-wide level as one of the novel psychoactive substances. This paper aims at investigating the potential of misuse, taking into account both the existing literature and the analysis of the misusers' experiences as described in venlafaxine misuse web reports.

METHODS

A literature search was performed using PubMed, Embase, and Medline. Posts/threads relating to venlafaxine misuse issues were identified through Google® and Yahoo® English-language searches. Resulting websites' data were then qualitatively assessed, and information was collected on a range of issues, including dosage, drug intake modalities, untoward drug effects, and association with other recreational drugs.

RESULTS

A few literature case reports focusing on venlafaxine as a misusing drug were here identified. The molecule was here typically ingested or snorted at dosages up to 10-15 times higher than those clinically advised, obtaining MDMA/amphetamine-like stimulant and psychedelic effects. Polydrug misuse was commonly reported. Venlafaxine appeared to be widely available online for sale.

CONCLUSIONS

Physicians should carefully evaluate patients for history of drug dependence and observe them for signs of venlafaxine misuse.

Detecting a signal in the noise: monitoring the global spread of novel psychoactive substances using media and other open-source information

OBJECTIVE

To determine the feasibility and utility of using media reports and other open-source information collected by the Global Public Health Intelligence Network (GPHIN), an event-based surveillance system operated by the Public Health Agency of Canada, to rapidly detect clusters of adverse drug events associated with 'novel psychoactive substances' (NPS) at the international level.

METHODS AND RESULTS

Researchers searched English media reports collected by the GPHIN between 1997 and 2013 for references to synthetic cannabinoids. They screened the resulting reports for relevance and content (i.e., reports of morbidity and arrest), plotted and compared with other available indicators (e.g., US poison control center exposures). The pattern of results from the analysis of GPHIN reports resembled the pattern seen from the other indicators.

CONCLUSIONS

The results of this study indicate that using media and other open-source information can help monitor the presence, usage, local policy, law enforcement responses, and spread of NPS in a rapid effective way. Further, modifying GPHIN to actively track NPS would be relatively inexpensive to implement and would be highly complementary to current national and international monitoring efforts.

The interest in eight new psychoactive substances before and after scheduling

BACKGROUND

In recent years the recreational use of new psychoactive substances (NPS) has increased. NPS are considered a threat to public health and the main response to this threat is to make the selling and buying of these substances illegal. In Sweden, during the last 5 years, 62 new substances have been classified as narcotics but little is known of the effects of making a particular substance illegal. The aim of this work is to study how legal status influences the interest in NPS in Sweden.

METHODS

Forty-five thousand posts made in a Swedish Internet discussion forum (Flashback Forum) related to eight NPS (MDPV, Methylone, 4-MEC, 4-HO-MET, MXE, 6-APB, AH-7921, and 3-MMC) were used to derive time-dependent measures of interest in these substances. Intervention analyses were used to investigate the effects of legal status on the forum interest.

RESULTS

For all eight substances the activity on the forum (measured as number of posts per day) showed a drastic decrease around the time of classification. The statistical analysis showed that in seven of eight cases, the drop in activity could be accounted for by the legal status of the substances.

CONCLUSIONS

The legal status of the substances was shown to have a substantial effect on the interest in the substances. The novel measure used to trace the interest in particular NPS could be a useful tool to follow trends in substance use in almost real-time.

Survey of knowledge of legal highs (novel psychoactive substances) amongst London pharmacists

Purpose

– The purpose of this paper is to determine pharmacists’ knowledge of legal highs (novel psychoactive substances (NPS)).

Design/methodology/approach

– A questionnaire was handed out at two London pharmacist continuing education events in mid-2014. These events update pharmacists about developments of interest/relevance to the profession and to improve their practice. A total of 54 forms were returned; a response rate of 26 percent.

Findings

– Most pharmacists had poor knowledge of NPS and many considered that NPS were not important to their work, with few having had to advise customers in this area. Despite this, the majority thought that they had insufficient information about NPS. There was a negative correlation between the age of the pharmacist and knowledge of NPS.

Research limitations/implications

– The sample is a self-selected one drawn from registered pharmacists working in community pharmacies in northwest London, and thus does not include hospital pharmacies. Self-selection means that respondents may only reflect those who are interested in the NPS phenomenon and not the wider pharmacy community. The geographical area covered may not be representative of London as a whole, or indeed other parts of the UK or other EU countries.

Practical implications

– It is clear that pharmacists do not know much about NPS but would like to know more. This information might improve their practice.

Social implications

– Pharmacists, easier to see than general practitioners, could be a useful source of information for NPS misusers.

Originality/value

– There have been no previous attempts to gauge the level of knowledge by pharmacists of legal highs/NPS in the UK or elsewhere to our knowledge.

"Legal Highs"--An Emerging Epidemic of Novel Psychoactive Substances

During the last decade, there has been an increase in the availability and use of novel psychoactive substances (NPS), also known as "legal highs," across the world. They include a wide range of products, from natural plant-originated substances to synthetic compounds, that can be purchased both online and from high street retailers. "Legal highs" mimic psychoactive effects of illicit drugs of abuse. However, they are claimed to consist of compounds that are legal to sell, possess, and use, often labeled as "not for human consumption" to circumvent drug abuse legislation. Based on the spectrum of their actions on cognitive processes, mood, and behavior, "legal highs" can be classified into four basis categories: amphetamine- and ecstasy-like stimulants, synthetic cannabinoids (SCs), hallucinogenic/dissociative, and opioid-like compounds. NPS may, however, exhibit a combination of these actions due to their designed chemical structure. Although the prevalence and pattern of NPS use differ between various countries, the most popular groups are SCs and psychostimulants, described in this chapter. Currently, there is limited information available on the potential acute toxicity (harms) associated with the use of these substances. However, the number of intoxicated people presenting with emergencies is constantly increasing, providing evidence that negative health and social consequences may indeed seriously affect recreational and chronic users.

"Chasing the high" - experiences of ethylphenidate as described on international internet forums

Ethylphenidate is a novel psychoactive substance with undocumented effects, risks, and motivation for use. In this study, we investigated the experience of ethylphenidate by analyzing self-reports published on Internet forums, which revealed seven overarching themes: (1) compulsive redosing and addiction; (2) impacts on the mental state; (3) bodily agitation; (4) increased sociableness; (5) administration; (6) diverse evaluations based on intention; and (7) safety and precaution. Ethylphenidate appeared as a potent psychostimulant with an imminent abuse potential. It was mainly used for recreational purposes. The effects included not only pleasurable stimulation, euphoria, and cognitive enhancement but also indecisiveness, anxiety, and cognitive fragmentation. The users reported an increase in body temperature, heart rate, and blood pressure, but they also experienced profuse sweating and muscle tension. Ethylphenidate acted as a social lubricant, enhancing intimacy, communication, and social skills. Two opposing user mentalities were uncovered: (1) pleasure seeking and risk neglecting, and (2) safety-first orientation. This information could be of importance to legislators, public health personnel, and prevention strategists.

Novel psychoactive substances (NPS): clinical and pharmacological issues

Purpose

– The purpose of this paper is to provide health professionals with novel psychoactive substances (NPS) clients with up to date information relating to the background, clinical pharmacology and, when possible, clinical management for each of these categories.

Design/methodology/approach

– The world of NPS is complex and diverse, including a range of different molecules such as: psychedelic phenethylamines; synthetic cannabinoids, cathinone derivatives; novel stimulants; synthetic opiates/opioids; tryptamine derivatives; phencyclidine-like dissociatives; piperazines; GABA-A/GABA-B receptor agonists; a range of prescribing medications; psychactive plants/herbs; and a large series of performance and image-enhancing drugs. These molecules are sought by users for their psychactive effects.

Findings

– The NPS categorization and classification provided here is an attempt to identify and better understand some of these substances. Given the vast range of medical and psychopathological issues associated with the NPS described it is crucial for health professionals to be aware of the effects and toxicity of NPS. The EU-MADNESS project aims to both better understand the pharmacology of the available/forthcoming NPS and to disseminate the most current NPS-related information to practising and training health professionals.

Research limitations/implications

– Further studies are required to identify a range of evidence-based, NPS-focused, clinical management and treatment strategies.

Social implications

– The rapid pace of change in the NPS online market constitutes a major challenge to the provision of current and reliable scientific knowledge on these substances.

Originality/value

– The present review will provide an overview of the clinical and pharmacological issues related to a few hundred NPS.

Manganese-enhanced magnetic resonance imaging reveals differential long-term neuroadaptation after methamphetamine and the substituted cathinone 4-methylmethcathinone (mephedrone)

BACKGROUND

In recent years there has been a large increase in the use of substituted cathinones such as mephedrone (4-methylmethcathinone, 4-MMC), a psychostimulant drug that shows a strong resemblance to methamphetamine (METH). Unlike METH, which can produce clear long-term effects, the effects of 4-MMC have so far remained elusive. We employ manganese-enhanced magnetic resonance imaging (MEMRI), a highly sensitive method for detecting changes in neuronal activation, to investigate the effects of METH and 4-MMC on the brain.

METHODS

In Wistar rats we performed a MEMRI scan two weeks after binge treatments (twice daily for 4 consecutive days) of METH (5 mg/kg) or 4-MMC (30 mg/kg). Furthermore, locomotor activity measurements and novel object recognition tests were performed.

RESULTS

METH produced a widespread pattern of decreased bilateral activity in several regions, including the nucleus accumbens, caudate putamen, globus pallidus, thalamus, and hippocampus, as well as several other cortical and subcortical areas. Conversely, 4-MMC produced increased bilateral activity, anatomically limited to the hypothalamus and hippocampus. Drug treatments did not affect the development of locomotor sensitization or novel object recognition performance.

CONCLUSIONS

The pattern of decreased brain activity seen after METH corresponds closely to regions known to be affected by this drug and confirms the validity of MEMRI for detecting neuroadaptation two weeks after amphetamine binge treatment. 4-MMC, unlike METH, produced increased activity in a limited number of different brain regions. This highlights an important difference in the long-term effects of these drugs on neural function and shows precisely the anatomical localization of 4-MMC-induced neuroadaptation.

Novel psychoactive substances of interest for psychiatry

Novel psychoactive substances include synthetic cannabinoids, cathinone derivatives, psychedelic phenethylamines, novel stimulants, synthetic opioids, tryptamine derivatives, phencyclidine-like dissociatives, piperazines, GABA-A/B receptor agonists, a range of prescribed medications, psychoactive plants/herbs, and a large series of performance and image enhancing drugs. Users are typically attracted by these substances due to their intense psychoactive effects and likely lack of detection in routine drug screenings. This paper aims at providing psychiatrists with updated knowledge of the clinical pharmacology and psychopathological consequences of the use of these substances. Indeed, these drugs act on a range of neurotransmitter pathways/receptors whose imbalance has been associated with psychopathological conditions, including dopamine, cannabinoid CB1, GABA-A/B, 5-HT2A, glutamate, and k opioid receptors. An overall approach in terms of clinical management is briefly discussed.

Synthetic cathinones: a new public health problem

New psychoactive substances (NPS) have completely modified the drug scene and the current landscape of addiction. Synthetic substances, such as substituted or synthetic cathinones, also known as « legal highs », are often produced and used to mimic the effects of controlled drugs such as cocaine, methylenedioxymethamphetamine (MDMA, ecstasy), and methamphetamine. The overwhelming majority of synthetic cathinones are produced in China and South East Asian countries. The Internet has emerged as the new marketplace for NPS, playing a major role in providing information on acquisition, synthesis, extraction, identification, and substance use. All these compounds are intentionally mislabeled and sold on-line under slang terms such as bath salts, plant food, plant feeders and research chemicals. They are sometimes labeled « not for human use » or « not tested for hazards or toxicity ». The rapid spread of NPS forces member countries of the European Union to adapt their response to the potential new dangers that may cause. To date, not only health actors but also the general public need to be clearly informed and aware of dangers resulting from NPS spread and use. Here, we review the major clinical effects of synthetic cathinones to highlight their impact on public health. A literature search was conducted from 2009 to 2014 based on PubMed, Google Scholar, Erowid, and governmental websites, using the following keywords alone or in combination: "new psychoactive substances", "synthetic cathinones", "substituted cathinones", "mephedrone", "methylone", "MDPV", "4-MEC", "addiction", and "substance use disorder".