Acute psychotropic, autonomic, and endocrine effects of 5,6-methylenedioxy-2-aminoindane (MDAI) compared with 3,4-methylenedioxymethamphetamine (MDMA) in human volunteers: A self-administration study

The acute psychoactive, autonomic, and endocrine effects of the new psychoactive substance (NPS) 5,6-methylenedioxy-2-aminoindane (MDAI; 3.0 mg/kg, range 180-228 mg) were investigated in six healthy volunteers (four males, two females) in a non-blinded fashion without placebo. Subjective, cardiovascular, and endocrine responses were compared with two different doses of 3,4-methylenedioxymethamphetamine (MDMA) (75 mg and 125 mg) described in previously published placebo-controlled studies, which used identical outcome measures including Visual Analogue Scales (VAS), the Adjective Mood Rating Scale (AMRS), and the 5 Dimensions of Altered States of Consciousness (5D-ASC) scale. MDAI was well tolerated and produced subjective effects comparable with those of 125 mg MDMA. MDAI increased blood pressure similar to 125 mg MDMA but did not increase heart rate or body temperature. MDAI increased cortisol and prolactin levels and could be detected in serum about 20 min post ingestion and remained detectable at least for 4 days. In urine, MDAI was detectable over a period of at least 6 days. Further clinical investigations are warranted to assess whether MDAI could serve as drug with medicinal properties.

Determination of 465 psychoactive substances, drugs and their metabolites in urine by LC-MS/MS

Due to the emergence of novel psychoactive substances on the drug market, there is a growing demand for analytical methods allowing identification and determination of as many psychoactive substances as possible in the shortest possible time, which can be easily expanded to include additional analytes appearing in street trade. Immunochemical methods are not sufficient to meet constantly growing requirements. Therefore, the aim of the study was to develop an analytical method enabling quick analysis of urine samples for psychoactive substances, drugs and their metabolites. Liquid-liquid extraction (LLE) and liquid chromatography coupled with mass spectrometry (LC-MS/MS) were used for this purpose. Using available analytical standards, the operating parameters of the mass spectrometer were selected for each of the 477 analytes, and MRM (multiple reaction monitoring) acquisition was selected for each of them. The use of analytical standards allowed for the identification of analytes separated on the chromatography column. The exceptions are methylmethcathinone isomers (3-MMC and 4-MMC), which we were unable to separate using the gradient elution method used. Extraction using acetonitrile with the addition of ammonium formate and formic acid allowed us to obtain high recoveries without the use of β-glucuronidase. Recovery values ranged from 18.43 to 119.94%. The matrix effect was eliminated by obtaining a calibration curve in the matrix. The developed analytical method was validated in accordance with SWGTOX guidelines. Only 12 substances did not meet the validation criteria (CV: ±20% and bias: ±20%). Thus the validated method makes it possible to determine 465 psychoactive substances in just 30 minutes. In the validation process, values such as the limit of detection (LOD) and the limit of quantification (LOQ) were also determined. The LODs are in the range of 3-30 ng mL-1, and the LOQs are in the range of 10-100 ng mL-1. The method was successfully applied to toxicological analyses of urine samples, which was an opportunity to develop it further to meet the needs of toxicology.

Accuracy of substance exposure history in patients attending emergency departments after substance misuse; a comparison with biological sample analysis

CONTEXT

Acute toxicity caused by illicit substance use is a common reason for emergency department (ED) presentation. Knowledge of the substances involved is helpful for predicting and managing potential toxicity, but limited information is available about the accuracy of patient-reported substance exposure. This study assessed the accuracy of the history of exposure in those reporting use of a single substance by comparison with those identified by detailed toxicological analysis, focusing on synthetic cannabinoid receptor agonists (SCRA).

METHODS

Adults (≥16 years) presenting between March 2015 and July 2021 to participating UK hospitals with toxicity after reporting use of a single illicit substance were included. Exposure details were documented from medical records and blood and/or urine samples analysed using high-resolution accurate mass liquid chromatography-mass spectrometry (HRAM LCMS). Sensitivity, specificity, and positive and negative predictive values of the exposure history were calculated by comparison with biological sample analysis ("gold standard").

RESULTS

Single substance exposure was reported for 474 (median age 33 years, IQR: 18 range 16-75, 80% males) patients. Analysis commonly identified multiple substances (Median 3, IQR 2-5). A history of exposure was documented for 121 of 151 patients where a SCRA or metabolite was detected on analysis (sensitivity 80.1%, 95% CI 72.9, 86.2%). Corresponding proportions were lower for 3,4-methylenedioxymethamphetamine (MDMA, 44/70, 62.9%., 95% CI 50.5%, 74.1%), heroin 41/108 (38.0% 95% CI 28.8-47.8%) and cocaine (22/56, 31.3%, 95% CI 20.9, 43.6%).

CONCLUSIONS

Multiple undeclared substances were detected analytically in most patients reporting single substance use. Clinicians should be alert to the potential presence and toxicity of unreported substances when managing patients presenting after substance misuse.

Gas chromatography-mass spectrometry of eight aminoindanes: 2-Aminoindane, N-methyl-2-, 5-methoxy-, 5-methoxy-6-methyl-, 4,5-methylenedioxy-, 5,6-methylenedioxy- and 5-iodo-2-aminoindane, and rasagiline

RATIONALE

Aminoindanes are one class of many new psychoactive substances that have emerged over the last decade. Analogues of 2-aminoindane (2-AI) are being encountered in crime laboratories and analytical data for most aminoindanes are limited. Interpretation and optimization of gas chromatography-mass spectrometry data will enhance reliability in characterizing aminoindanes.

METHODS

This study focuses on the electron ionization mass spectrometric fragmentation of eight aminoindane analogues and the gas chromatographic separation of these eight aminoindane analogues using four different column stationary phases, Rxi®-1Sil MS, Rxi®-5Sil MS, Rxi®-35Sil MS, and Rxi®-624Sil MS. Split injection (25:1) was utilized and each column had the same configuration (30 m × 25 mm × 0.25 μm), with the exception of the Rxi®-624Sil MS column (30 m × 25 mm ×1.4 μm).

RESULTS

Mass spectra showed strong molecular ions for all aminoindanes, except for rasagiline that produced a uniquely abundant [M - 1] ion. Other characteristic fragmentation that was present for all the aminoindanes included indane and indene ions (m/z 115-117), the tropylium ion (m/z 91), and subsequent loss of diene to produce smaller ions that followed: phenyl (m/z 77), cyclopentadienyl (m/z 65), cyclobutadienyl (m/z 51), and cyclopropenyl (m/z 39).

CONCLUSIONS

Separation of eight aminoindanes was optimized, and linear retention indices were determined for the compounds on four capillary columns. Based on the retention data, all eight aminoindanes were resolved on an Rxi®-624Sil MS column. Each aminoindane exhibited unique fragmentation ions in the mass spectra to distinguish between similar analogues. The results of this study will strengthen the analytical profiles of 2-AI and seven analogues, assisting forensic scientists in their analysis and identification of these substances.

Clinical value of analytical testing in patients presenting with new psychoactive substances intoxication

New psychoactive substances (NPS) have emerged worldwide in recent years, posing a threat to public health and a challenge to drug policy. NPS are usually derivatives or analogues of classical recreational drugs designed to imitate their effects while circumventing regulations. This article provides an overview of benefits and limitations of analytical screening in managing patients presenting with acute NPS toxicity. NPS typically cannot be analytically identified with the usual immunoassay tests. To detect NPS using an immunoassay, antibodies specifically binding to the new structures would have to be developed, which is complicated by the rapid change of the NPS market. Activity-based assays could circumvent this problem since no prior knowledge on the substance structure is necessary. However, classical recreational drugs activating the same receptors could lead to false positive results. Liquid or gas chromatography coupled with mass spectrometry is a valuable NPS analysis tool, but its costs (e.g. equipment), run time (results usually within hours vs minutes in case of immunoasssays) and the need for specialized personnel hinder its use in clinical setting, while factors such as lack of reference standards can pose further limitations. Although supportive measures are sufficient in most cases for adequate patient management, the detection and identification of NPS can contribute significantly to public health and safety in cases of e.g. cluster intoxications and outbreaks, and to the investigation of these novel compounds' properties. However, this requires not only availability of the necessary equipment and personnel, but also collaboration between clinicians, authorities and laboratories.

Epidemiology of NPS Based Confirmed Overdose Cases: The STRIDA Project

The Swedish STRIDA project on new psychoactive substances (NPS) monitored the occurrence and health hazards of novel recreational drugs in Sweden through evaluation of analytically confirmed adverse events presenting in emergency departments and intensive care units. During a ~6-year period from 2010 to early 2016, about 2,600 cases of suspected NPS intoxications were included in the project. About 75% of patients were men and the total age range was 8-71 (median 24) years and 57% were 25 years or younger. A large number of NPS belonging to many different drug classes were identified in project samples of urine and blood (serum/plasma) submitted for free drug testing, including synthetic cannabinoid receptor agonists, stimulants, cathinones, hallucinogens, dissociative drugs, benzodiazepines, and opioids, and also in drug materials from the cases forwarded to the laboratory along with the biological samples. The STRIDA project has been shown to serve as an effective early warning system for NPS by collecting data on incidence, distribution, and adverse effects and has supported healthcare professionals in the knowledge and critical care of intoxications caused by a wide range of novel substances. The results of the STRIDA project have also illustrated how drug regulations can drive the NPS market.

Rapid Identification of Novel Psychoactive and Other Controlled Substances Using Low-Field 1H NMR Spectroscopy

An automated approach to the collection of ¹H NMR (nuclear magnetic resonance) spectra using a benchtop NMR spectrometer and the subsequent analysis, processing, and elucidation of components present in seized drug samples are reported. An algorithm is developed to compare spectral data to a reference library of over 300 ¹H NMR spectra, ranking matches by a correlation-based score. A threshold for identification was set at 0.838, below which identification of the component present was deemed unreliable. Using this system, 432 samples were surveyed and validated against contemporaneously acquired GC-MS (gas chromatography-mass spectrometry) data. Following removal of samples which possessed no peaks in the GC-MS trace or in both the ¹H NMR spectrum and GC-MS trace, the remaining 416 samples matched in 93% of cases. Thirteen of these samples were binary mixtures. A partial match (one component not identified) was obtained for 6% of samples surveyed whilst only 1% of samples did not match at all.

Identification of new psychoactive substances (NPS) using handheld Raman spectroscopy employing both 785 and 1064nm laser sources

The chemical identification of new psychoactive substances (NPS) in the field is challenging due not only to the plethora of substances available, but also as a result of the chemical complexity of products and the chemical similarity of NPS analogues. In this study, handheld Raman spectroscopy and the use of two excitation wavelengths, 785 and 1064nm, were evaluated for the identification of 60 NPS products. The products contained a range of NPS from classes including the aminoindanes, arylalkylamines, benzodiazepines, and piperidines & pyrrolidines. Identification was initially assessed using the instruments' in built algorithm (i.e., % HQI) and then further by visual inspection of the Raman spectra. Confirmatory analysis was preformed using gas chromatography mass spectrometry. For the 60 diverse products, an NPS was successfully identified via the algorithm in 11 products (18%) using the 785nm source and 29 products (48%) using the 1064nm source. Evaluation of the Raman spectra showed that increasing the excitation wavelength from 785 to 1064nm improved this 'first pass' identification primarily due to a significant reduction in fluorescence, which increased S/N of the characteristic peaks of the substance identified. True positive correlations between internet products and NPS signatures ranged from 57.0 to 91.3% HQI with typical RSDs<10%. Tablet formulations and branded products were particularly challenging as a result of low NPS concentration and high chemical complexity, respectively. This study demonstrates the advantage of using a 1064nm source with handheld Raman spectroscopy for improved 'first pass' NPS identification when minimal spectral processing is required, such as when working in field. Future investigations will focus on the use of mixture algorithms, effect of NPS concentration, and further improvement of spectral libraries.

Drowning in diversity? A systematic way of clustering and selecting a representative set of new psychoactive substances

A systematic way of clustering NPS yields medoids with potential in the assignment of emerging substances to systematically defined categories.

Acute skin and hair symptoms followed by severe, delayed eye complications in subjects using the synthetic opioid MT-45

BACKGROUND

The introduction of unclassified new psychoactive substances (NPS) on the recreational drugs market through open online sale ('legal highs' or 'Internet drugs') continues unabated and represents a growing health hazard. The use of NPS has resulted in numerous, severe, adverse events and fatalities, due to unintended overdose or unknown toxic side-effects.

OBJECTIVES

To try to find a possible common underlying cause for the skin-hair-eye symptoms complex observed in three men.

METHODS

From late 2013 to mid-2014, three Swedish men aged 23-34 years with a history of recreational drug use independently presented with similar and very remarkable clinical signs, requiring extensive examination and prolonged treatment.

RESULTS

Common clinical signs included hair depigmentation, hair loss, widespread folliculitis and dermatitis, painful intertriginous dermatitis, dry eyes, and elevated liver enzymes. Two of them also showed transverse white Mees' lines (leukonychia striata) on the fingernails and toenails, suggesting a temporary, drug-induced, disorganized keratinization. The clinical signs gradually disappeared over time. However, later on, two developed severe bilateral secondary cataracts requiring surgery. Because drug tests within the Swedish STRIDA project had demonstrated intake of the NPS opioid MT-45 in all patients, this was suspected to be the common causative agent.

CONCLUSIONS

These cases highlight the importance for physicians and health professionals to consider the increasing number of novel, untested recreational drugs, as a potential cause of unusual and otherwise unrecognized clinical signs and symptoms.

Prevalence of Rhabdomyolysis in Sympathomimetic Toxicity: a Comparison of Stimulants

Synthetic cathinones have emerged as popular drugs of abuse and produce sympathomimetic toxicity. It is unknown if rhabdomyolysis occurs more frequently following the use of synthetic cathinones compared to other stimulants. This retrospective study sought to determine the prevalence of rhabdomyolysis in patients with sympathomimetic toxicity and compare rates among patients using specific agents. Patients greater than 14 years of age with sympathomimetic toxicity and detection of a stimulant agent in urine via gas chromatography-mass spectroscopy (GC-MS) were included. Patients were excluded if clinical sympathomimetic toxicity was not present, a serum creatine kinase (CK) was not measured, or urine GC-MS was not performed. Rhabdomyolysis and severe rhabdomyolysis were defined as CK > 1000 and 10,000 IU/L, respectively. Prevalence of rhabdomyolysis and severe rhabdomyolysis were reported. Logistic regression was performed to determine the relative effect in single-agent exposures of a synthetic cathinone compared to other sympathomimetics on rhabdomyolysis. A secondary outcome, a composite endpoint defined as need for mechanical ventilation, renal replacement therapy, development of compartment syndrome, or death, was also analyzed. One hundred two subjects met inclusion criteria; median age (IQR) was 32 (25-42) years with a range of 14-65 years; 74 % were male. Rhabdomyolysis occurred in 42 % (43/102) of subjects. Patients whose sympathomimetic toxicity could be ascribed to a single agent were considered for further statistical analysis and placed into four groups: methamphetamine (n = 55), synthetic cathinone (n = 19), cocaine (n = 9), and other sympathomimetic (n = 6). In 89 subjects with single stimulant exposure, the prevalence of rhabdomyolysis was as follows: synthetic cathinone, 12/19 (63 %); methamphetamine, 22/55 (40 %); cocaine, 3/9 (33 %); and other single agent, 0/6 (0 %). The occurrence of severe rhabdomyolysis (CK > 10,000 IU/L) for each of the four groups was synthetic cathinone with 5/19 (26 %), methamphetamine with 2/55 (3.6 %), cocaine with 1/9 (11 %), and other with 0/6 (0 %). Median maximal CK (range) by groups was as follows: synthetic cathinone, 2638 (62-350,000+) IU/L; methamphetamine, 665 (61-50,233) IU/L; cocaine, 276 (87-25,614) IU/L; and other, 142 (51-816) IU/L. A statistically significant difference (p = 0.004) was found when comparing maximal CK among the four groups. Exposure to a synthetic cathinone compared with other sympathomimetics was associated with increased risk of developing rhabdomyolysis and severe rhabdomyolysis with odds ratios of 3.09 and 7.98, respectively. In this cohort of patients with sympathomimetic toxicity, 42 % developed rhabdomyolysis. Synthetic cathinones were associated with an increased risk of rhabdomyolysis and severe rhabdomyolysis compared with other stimulants.

A novel psychoactive substance poses a new challenge in the management of paranoid schizophrenia

Novel psychoactive substances (NPS), or 'legal highs' are becoming more commonly used as recreational substances in the UK. Their clinical effects are little known and vary considerably between substances. This case discusses a psychiatric inpatient who repeatedly used a stimulant NPS called 'el blanco' while on leave, precipitating relapses of his schizophrenia. The patient initially denied drug use, considering legal highs as different from drugs. The relationship between NPS use and mental state was eventually revealed on careful direct questioning. He recovered and was discharged following treatment with clozapine and education about NPS use. We suggest that specific questioning about NPS usage is added to routine psychiatric history taking and that patients using NPS should be educated about the substances' use.

Effects and risks associated with novel psychoactive substances: mislabeling and sale as bath salts, spice, and research chemicals

BACKGROUND

The number of newly reported psychoactive substances in Europe is now higher than ever. In order to evade legal restrictions, old and novel psychoactive substances from medical research and their derivatives are commonly mislabeled as "not for human consumption" and offered for sale on the Internet and elsewhere. Such substances are widely taken by young people as "club drugs." Their consumption must be considered in the differential diagnosis of psychiatric, neurological, cardiovascular, or metabolic disturbances of unclear origin in a young patient.

METHOD

Selective review of pertinent literature retrieved by a PubMed search, including publications by government-sponsored organizations.

RESULTS

From 2010 to 2012, 163 substances were reported to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), mostly either synthetic cannabinoids (39.3%) or synthetic cathinones (16.6%). Synthetic cannabinoids alter mood and perception; intoxications cause agitation, tachy cardia, and arterial hypertension. Synthetic cathinones are hallucinogenic stimulants with predominantly cardiovascular and psychiatric side effects. Severe intoxications cause serotonin syndrome and potentially fatal rhabdomyolysis. Substances in either of these classes often escape detection in screening tests.

CONCLUSION

Young persons who present with agitation and cardiovascular and/or psychiatric manifestations of unclear origin and whose drug screening tests are negative may be suffering from an intoxication with a novel psychoactive substance. Physicians should know the classes of such substances and their effects. Targeted toxicological analysis can be carried out in a toxicology laboratory or a facility for forensic medicine.

Effects of caffeine and its metabolite paraxanthine on intracranial self-stimulation in male rats

Caffeine is the most widely used psychostimulant in the world, though preclinical studies suggest weaker evidence for abuse-related effects than stimulants with high abuse liability, such as amphetamine or cocaine. Intracranial self-stimulation (ICSS) is 1 procedure used to assess the abuse liability of drugs, and previous studies have produced mixed results regarding whether caffeine produces an abuse-related facilitation of ICSS. This study assessed both caffeine and its main metabolite in humans, paraxanthine, using a frequency-rate ICSS procedure and compared their effects to those of amphetamine and cocaine. Male Sprague-Dawley rats were implanted with intracranial electrodes targeting the medial forebrain bundle and trained to respond under a fixed-ratio 1 schedule for brain stimulation that varied across a range of frequencies (56-158 Hz in 0.05 log increments). Data analysis focused on 3 dependent measures: reinforced responding (defined as responses that produced brain stimulation), nonreinforced responding (defined as responses that occurred during each 0.5 s brain stimulation and that did not produce additional stimulation), and total responding (reinforced plus nonreinforced responding). Both amphetamine and cocaine produced robust increases in total, reinforced, and nonreinforced responses. Caffeine also increased total, reinforced, and nonreinforced responses, but the caffeine dose-effect curve had an inverted-U shape, and peak ICSS facilitation was less than that produced by amphetamine or cocaine. Paraxanthine increased only total responses and nonreinforced responses. These results suggest that paraxanthine has low abuse liability and does not mediate abuse-related effects of caffeine.

Flashback phenomenon and residual neurological deficits after the use of "bath salt" 3, 4- methylenedioxypyrovalerone

BACKGROUND

The use and abuse of designer drugs has been recognized for decades; however there are many derivatives of compounds that make their way into the community. Abuse of compound(s) known on the street as "bath salt" is on the rise.

METHODS

We report the case of a 33-year-old man who complained of "flashbacks" and right arm shaking that followed a night of "bath salt" snorting. The active compound methylenedioxypyrovalerone methamphetamine (MDPV) was confirmed; however, analysis of three different "bath salt" products showed difference in their active components.

RESULTS

The patient's symptoms remained stable and he was discharged home after observation in the emergency department with instructions to return for any symptom progression.

CONCLUSION

Practitioners should be aware of the abuse of the compounds and that not all "bath salt" products contain MDPV.

Raising awareness of new psychoactive substances: chemical analysis and in vitro toxicity screening of 'legal high' packages containing synthetic cathinones

The world's status quo on recreational drugs has dramatically changed in recent years due to the rapid emergence of new psychoactive substances (NPS), represented by new narcotic or psychotropic drugs, in pure form or in preparation, which are not controlled by international conventions, but that may pose a public health threat comparable with that posed by substances listed in these conventions. These NPS, also known as 'legal highs' or 'smart drugs', are typically sold via Internet or 'smartshops' as legal alternatives to controlled substances, being announced as 'bath salts' and 'plant feeders' and is often sought after for consumption especially among young people. Although NPS have the biased reputation of being safe, the vast majority has hitherto not been tested and several fatal cases have been reported, namely for synthetic cathinones, with pathological patterns comparable with amphetamines. Additionally, the unprecedented speed of appearance and distribution of the NPS worldwide brings technical difficulties in the development of analytical procedures and risk assessment in real time. In this study, 27 products commercialized as 'plant feeders' were chemically characterized by gas chromatography-mass spectrometry and nuclear magnetic resonance spectroscopy. It was also evaluated, for the first time, the in vitro hepatotoxic effects of individual synthetic cathinones, namely methylone, pentedrone, 4-methylethcathinone (4-MEC) and 3,4-methylenedioxypyrovalerone (MDPV). Two commercial mixtures ('Bloom' and 'Blow') containing mainly cathinone derivatives were also tested, and 3,4-methylenedioxymethamphetamine (MDMA) was used as the reference drug. The study allowed the identification of 19 compounds, showing that synthetic cathinones are the main active compounds present in these products. Qualitative and quantitative variability was found in products sold with the same trade name in matching or different 'smartshops'. In the toxicity studies performed in primary cultured rat hepatocytes, pentedrone and MDPV proved to be the most potent individual agents, with EC50 values of 0.664 and 0.742 mM, respectively, followed by MDMA (EC50 = 0.754 mM). 4-MEC and methylone were the least potent substances, with EC50 values significantly higher (1.29 and 1.18 mM, respectively; p < 0.05 vs. MDMA). 'Bloom' and 'Blow' showed hepatotoxic effects similar to MDMA (EC50 = 0.788 and 0.870 mM, respectively), with cathinones present in these mixtures contributing additively to the overall toxicological effect. Our results show a miscellany of psychoactive compounds present in 'legal high' products with evident hepatotoxic effects. These data contribute to increase the awareness on the real composition of 'legal high' packages and unveil the health risks posed by NPS.

Acute psychosis associated with recreational use of benzofuran 6-(2-aminopropyl)benzofuran (6-APB) and cannabis

INTRODUCTION

There is evidence from around Europe of the availability and use of 6-(2-aminopropyl)benzofuran (6-APB) as a recreational drug. However, there is currently limited information on the acute toxicity of this compound. We describe here a case of acute toxicity associated with recreational use of legal high (6-APB) and cannabis, in which the comprehensive toxicological analysis confirmed the presence of a significant amount of 6-APB together with metabolites of both tetrahydrocannabinol and the synthetic cannabinoid receptor agonist (JWH-122).

CASE REPORT

A 21-year-old gentleman with no previous medical and psychiatric history was brought to the emergency department (ED) after he had developed agitation and paranoid behaviour following the use of 6-APB purchased over the Internet. There was no obvious medical cause for his acute psychosis. He required diazepam to control his agitation and was subsequently transferred to a psychiatric hospital for ongoing management of his psychosis. Toxicological screening of a urine sample collected after presentation to the ED detected 6-APB, with an estimated urinary concentration of 2,000 ng/ml; other drugs were also detected, but at lower concentrations including metabolites of the synthetic cannabinoid receptor agonist JWH-122 and tetrahydrocannabinol.

CONCLUSION

This is the first case of analytically confirmed acute toxicity associated with the detection of 6-APB which will provide some information on acute toxicity of this drug to help clinicians with the management of such patients and legislative authorities in their consideration for the need of its control.

Detection of new psychoactive substance use among emergency room patients: results from the Swedish STRIDA project

The "STRIDA" project monitors the occurrence and trends of new psychoactive substances (NPS; "Internet drugs/designer drugs/legal highs") in Sweden, and collects information about their clinical symptoms, toxicity and associated health hazards. The initial results of the project documented a widespread use of many different NPS by mainly adolescents and young (age range 13-63 years, median 20), male (79%) adults, among cases of drug intoxications presenting at emergency departments and intensive care units across the country. The new substances were identified in samples of urine and blood by a multi-component LC-MS/MS method, and the severity of clinical symptoms were graded by the Poisoning Severity Score (PSS). Of the initial 189 samples submitted for laboratory investigation, 156 (83%) tested positive for at least one drug. Besides classical substances such as ethanol, cannabis and amphetamines, many NPS were detected comprising synthetic cannabinoid receptor agonists ("Spice"), piperazines, substituted phenethylamines, synthetic cathinones, hallucinogenic tryptamines, piperidines, opioid related substances, ketamine and related substances, and GABA analogues (in total more than 50 substances). About half of the cases were demonstrated to be multiple drug intoxications, sometimes making it hard to associate the clinical presentations with one specific substance. In conclusion, the STRIDA project has documented use of a broad variety of NPS among mainly young people all over Sweden.

Recreational use of 1-(2-naphthyl)-2-(1-pyrrolidinyl)-1-pentanone hydrochloride (NRG-1), 6-(2-aminopropyl) benzofuran (benzofury/ 6-APB) and NRG-2 with review of available evidence-based literature

OBJECTIVE

This study aimed to review the available evidence-based literature on novel psychoactive substances and to inform health care professionals.

METHODS

Internet searches were carried out using Google and Yahoo by using specific key words. For each set of key words, the first 100 websites identified by Google and Yahoo were fully assessed, together with a further 5% of random samples selected by research randomizer of the remaining websites. Thus, a list of unique web forums was identified, and qualitative information was extracted. Available evidence-based literature were reviewed along with a user's experimentation with mephedrone, NRG-1, NRG-2 and Benzofury.

RESULTS

It showed that when a substance (mephedrone) became controlled, the vendors aggressively promote the sale of other new compounds (NRG-1, NRG-2, Benzofury) to attract vulnerable adults. The characteristics, toxicity and suggested management of these new compounds (NRG-1, NRG-2, Benzofury) are discussed.

CONCLUSIONS

The arrival of hundreds of novel psychoactive substances for sale online has raised a number of public health and legal issues. Although evidence-based literature remains limited, few studies identified that most products do not contain the ingredients as advertised. Better levels of international cooperation and rapid share of available information may be needed to tackle this emerging problem.

MDAI (5,6-methylenedioxy-2-aminoindane; 6,7-dihydro-5H-cyclopenta[f][1,3]benzodioxol-6-amine; 'sparkle'; 'mindy') toxicity: a brief overview and update

OBJECTIVES

MDAI (5,6-methylenedioxy-2-aminoindane; 6,7-dihydro-5H-cyclopenta[f][1,3]benzodioxol-6-amine; 'sparkle'; 'mindy') is a psychoactive substance, sold primarily over the Internet and in 'head' shops as a 'legal high'. Synthesised and used as a research chemical in the 1990s, MDAI has structural similarities to MDMA (3,4-methylenedioxy-N-methylamphetamine) and shares its behavioural properties. Recreational use of MDAI appears to have started in Europe around 2007, with a noticeable increase after 2009 in the UK and other countries. Calls to National Poisons Information Services started in 2010, although there were few presentations to emergency departments by patients complaining of undesirable physical and psychiatric effects after taking MDAI. Recreational use of this drug has been reported only occasionally by online user fora. There is little scientifically based literature on the pharmacological, physiological, psychopharmacological, toxicological and epidemiological characteristics of this drug.

METHODS

Recent literature (including 'grey') was searched to update what is known about MDAI, especially on its toxicity.

RESULTS

The resultant information is presented, including on the first three UK deaths involving MDAI use in 2011 and 2012. 'Serotonin syndrome' appears to be a possible factor in these fatalities.

CONCLUSION

It is vital that any other cases, including non-fatal overdoses, are documented so that a scientific evidence base can be established for them.

Consumption of new psychoactive substances in a Spanish sample of research chemical users

OBJECTIVE

To know the pattern of use of new psychoactive substances (NPSs) in a Spanish sample of research chemical (RC) users and to deepen the RC user profile and risk reduction strategies employed.

METHODS

This study is a cross-sectional survey by means of a specific questionnaire. Recruitment was carried out at music festivals, at non-governmental organizations (NGOs), and through announcements on an online forum. Two RC user profiles were defined, according to whether they search information through online forums.

RESULTS

A total of 230 users participated. The most frequent RCs were hallucinogenic phenethylamines (2C-B 80.0%, 2C-I 39.6%) and cathinones (methylone 40.1%, mephedrone 35.2%). The most frequent combination of RC with other illegal drugs was with cannabis (68.6%) and 2C-B with MDMA (28.3%). Subjects who are consulting drug forums (group 1) use more RC, obtain RC by Internet, and use more frequently risk prevention strategies. Regarding the risk-reduction strategies in this group, users sought information concerning RC before consuming them (100%), used precision scales to calculate dosage (72.3%), and analyzed the contents before consumption (68.8%).

CONCLUSIONS

There is a specific RC user profile with extensive knowledge and consumption of substances, using different strategies to reduce risks associated to its consumption.

Mephedrone: Public health risk, mechanisms of action, and behavioral effects

The recent shortage of 3,4-methylenedioxymethamphetamine (MDMA, Ecstasy) has led to an increased demand for alternative amphetamine-like drugs such as the synthetic cathinone, 4-methylmethcathinone (mephedrone). Despite the re-classification of mephedrone as a Class B restricted substance by the United Kingdom and restrictive legislation by the United States, international policy regarding mephedrone control is still developing and interest in synthetic amphetamine-like drugs could drive the development of future mephedrone analogues. Currently, there is little literature investigating the mechanism of action and long-term effects of mephedrone. As such, we reviewed the current understanding of amphetamines, cathinones, and cocaine emphasizing the potentially translational aspects to mephedrone, as well as contrasting with the work that has been done specifically on mephedrone in order to present the current state of understanding of mephedrone in terms of its risks, mechanisms, and behavioral effects. Emerging research suggests that while there are structural and behavioral similarities of mephedrone with amphetamine-like compounds, it appears that serotonergic signaling may mediate more of mephedrone's effects unlike the more dopaminergic dependent effects observed in traditional amphetamine-like compounds. As new designer drugs are produced, current and continuing research on mephedrone and other synthetic cathinones should help inform policymakers' decisions regarding the regulation of novel 'legal highs.'

Clinical Toxicology and Management of Intoxications With Synthetic Cathinones (“Bath Salts”)

Synthetic cathinones are synthetic derivatives of the natural cathinone, one of the psychoactive compounds present in Catha edulis (khat). There are at least 12 different types of synthetic cathinones, with mephedrone and 3,4-methylendioxypyrovalerone (MDPV) being the most commonly used by the purchasers. The legal control of these substances is especially difficult because when a specific compound is banned, a new slightly modified chemical variant is introduced into the market. It has been described that patients after taking synthetic cathinones may show signs and symptoms of the sympathicomimetic toxidrome, including agitation, psychosis, tachycardia, hypertension, and seizures. Furthermore, some cases of deaths related to their consumption have also been reported. Nowadays, there is no established treatment protocol for the clinical management of these intoxications. Because of this, we have developed some recommendations that may be useful to determine the treatment of these patients.

Prevalence and co-existence of active components of 'legal highs'

The results of a study performed on samples of 'legal highs' seized in head shops by law enforcement and health services in Poland between mid-2008 and mid-2011 are presented. In total, 449 preparations which differed in labelling, net masses, forms of distribution, etc., were analyzed. A variety of sophisticated analytical methods, including gas chromatography-mass spectrometry (GC-MS), liquid chromatography-quadropole time-of-flight mass spectrometry (LC-QTOF-MS), high performance liquid chromatography (HPLC), and nuclear magnetic resonance (NMR) were applied for component identification and quantification. The most common ingredients of legal highs were (in descending order): MPDV, caffeine, butylone, TFMPP, lidocaine, 4-MEC, mephedrone, pFPP, BZP, and MDPBP. The scatter of substances changed over time, and piperazines were often ousted by cathinones. Most of the preparations were composed of two or more ingredients. Cathinones and piperazines were mixed mainly within the chemical classes (77.6% and 56.1% of dual links, respectively), caffeine was mixed both with piperazines (24 products) and cathinones (22 products), whereas lidocaine only with the latter class (47 products). A great inconsistency in the qualitative and quantitative composition of products with identical labelling was shown in an example of Coco products seized after August 2010; we found 10 different single component or mixture preparations, and the content of individual ingredients varied from several to hundreds of mgs. This paper summarizes potential dangers connected with the uncontrolled sale of psychoactive substances, and indicates important issues concerning the analysis of legal highs.

Impact of the emergence of designer drugs upon sports doping testing

Historically, dope-testing methods have been developed to target specific and known threats to the integrity of sport. Traditionally, the source of new analytical targets for which testing was required were derived almost exclusively from the pharmaceutical industry. More recently, the emergence of designer drugs, such as tetrahydrogestrinone that are specifically intended to evade detection, or novel chemicals intended to circumvent laws controlling the sale and distribution of recreational drugs, such as anabolic steroids, stimulants and cannabinoids, have become a significant issue. In this review, we shall consider the emergence of designer drugs and the response of dope-testing laboratories to these new threats, in particular developments in analytical methods, instrumentation and research intended to detect their abuse, and we consider the likely future impact of these approaches.