"Not for human consumption": a review of emerging designer drugs

Synthesis and pharmacological activity of the epimers of hexahydrocannabinol (HHC)

Cannabis is a multifaceted plant with numerous therapeutic properties on one hand, and controversial psychotropic activities on the other hand, which are modulated by CB1 endocannabinoid receptors. Δ9-Tetrahydrocannabinol (Δ9-THC) has been identified as the main component responsible for the psychotropic effects, while its constitutional isomer cannabidiol (CBD) has shown completely different pharmacological properties. Due to its reported beneficial effects, Cannabis has gained global popularity and is openly sold in shops and online. To circumvent legal restrictions, semi-synthetic derivatives of CBD are now frequently added to cannabis products, producing "high" effects similar to those induced by Δ9-THC. The first semi-synthetic cannabinoid to appear in the EU was obtained through cyclization and hydrogenation of CBD, and is known as hexahydrocannabinol (HHC). Currently, there is limited knowledge regarding HHC, its pharmacological properties, and its prevalence, as it is not commonly investigated in routine toxicological assays. In this study, synthetic strategies were explored to obtain an excess of the active epimer of HHC. Furthermore, the two epimers were purified and individually tested for their cannabinomimetic activity. Lastly, a simple and rapid chromatographic method employing a UV detector and a high-resolution mass spectrometer was applied to identify and quantify up to ten major phytocannabinoids, as well as the HHC epimers, in commercial cannabis samples.

Persistent Coagulopathy After Synthetic Cannabinoid Use

Synthetic cannabinoids (SCs) are chemical compounds created and manufactured, without quality control standards or requirements, to mimic tetrahydrocannabinol (THC). They are widely available in the USA, and they are sold under various brand names, including "K2" and "spice." Many adverse effects have been attributed to SCs, but most recently, they have also been associated with bleeding. There have been reported cases around the globe of SCs contaminated with long-acting anticoagulant rodenticide (LAAR) or superwarfarins. They are developed from compounds such as bromethalin, brodifacoum (BDF), and dicoumarol. LAAR exhibits their mechanism as a vitamin K antagonist inhibiting vitamin K 2,3-epoxide reductase, preventing activation of vitamin K1 (phytonadione). Therefore, reducing the activation of clotting factors II, VII, IX, and X and proteins C and S. In contrast to warfarin, BDF has an extremely long-acting biological half-life of 90 days due to minimal metabolism and limited clearance. Here, we report a 45-year-old male who presented to the emergency room with a 12-day history of gross hematuria and mucosal bleeding without previous history of coagulopathy and recurrent SCs use.

Combined exposure to alcohol and cannabis during development: mechanisms and outcomes

Exposure to substances of abuse during pregnancy can have long-lasting effects on offspring. Alcohol is one of the most widely used substances of abuse that leads to the most severe consequences. Recent studies in the United States, Canada, and the United Kingdom showed that between 1% and 7% of all children exhibit signs and symptoms of fetal alcohol spectrum disorder (FASD). Despite preventive campaigns, the rate of children with FASD has not decreased during recent decades. Alcohol consumption often accompanies exposure to such drugs as tobacco, cocaine, opioids, and cannabis. These interactions can be synergistic and exacerbate the deleterious consequences of developmental alcohol exposure. The present review focuses on interactions between alcohol and cannabis exposure and the potential consequences of these interactions.

Substance Use and Attendance Motives of Electronic Dance Music (EDM) Event Attendees: A Survey Study

EDM event attendees are a high-risk population for substance use and associated adverse effects. The aim of this study was to examine substance use at EDM events, focusing on associations between attendance motives and substance use. Sociodemographic characteristics, event specifics, past-year use, and attendance motives were assessed through an online survey. Participants were 1345 Belgian EDM event attendees (69.44% male, M_age = 22.63, SD_age = 4.03). Ecstasy/MDMA/Molly (52.28%), other synthetic hallucinogens (53.68%), ketamine (42.13%), amphetamines (40.45%), and alkyl nitrites (poppers) (32.76%) were most frequently used at festivals/outdoor parties/raves. In nightclubs, cocaine (32.29%) was shown to be prevalent as well, while other synthetic hallucinogens (15.79%) were less often consumed. At events with a more private character, cannabis (68.88%) and magic mushrooms (66.44%) were most frequently used. Aside from alcohol (47.76%), substance use in pubs/bars was negligible. Overall enjoyment was demonstrated to be the key attendance motive, which was succeeded by those relating to music and socialization. A wide range of motives proved to be more important to users (e.g., dance, exploration, escapism, excitement, alcohol, drugs) than non-users, while some were associated with the use of particular substances. The prevalence of substance use was shown to be dependent on the specifics of the setting. Moreover, the idea of a three-dimensional classification of the most principal motives for music event attendance was supported. Finally, correlations were estimated between attendance motives and substance use as well as specific substances. Results could enable more tailored approaches in prevention and harm reduction efforts as well as event management strategies.

An Update on the Implications of New Psychoactive Substances in Public Health

The emergence of new psychoactive substances has earned a great deal of attention, and several reports of acute poisoning and deaths have been issued involving, for instance, synthetic opiates. In recent years, there have been profound alterations in the legislation concerning consumption, marketing, and synthesis of these compounds; rapid alert systems have also been subject to changes, and new substances and new markets, mainly through the internet, have appeared. Their effects and how they originate in consumers are still mostly unknown, primarily in what concerns chronic toxicity. This review intends to provide a detailed description of these substances from the point of view of consumption, toxicokinetics, and health consequences, including case reports on intoxications in order to help researchers and public health agents working daily in this area.

Comparison of LC-MS and LC-DAD Methods of Detecting Abused Piperazine Designer Drugs

Recreational use of piperazine designer drugs is a serious threat to human health. These compounds act on the body in a similar fashion to illegal drugs. They induce psychostimulatory effects as well as visual and auditory hallucinations to varying degrees. In many cases of poisoning and deaths, the presence of two or even several psychoactive substances have been demonstrated. Piperazine derivatives are often found in such mixtures and pose a great analytical problem during their identification. Additionally, some piperazine derivatives can be detected in biological material as a result of metabolic changes to related drugs. Therefore, it is necessary to correctly identify these compounds and ensure repeatability of determinations. This article presents a comparison of the methods used to detect abused piperazine designer drugs using liquid chromatography in combination with a diode-array detector (LC-DAD) or mass spectrometer (LC-MS). Each of methods can be used independently for determinations, obtaining reliable results in a short time of analysis. These methods can also complement each other, providing qualitative and quantitative confirmation of results. The proposed methods provide analytical confirmation of poisoning and may be helpful in toxicological diagnostics.

Rapid Targeted Method of Detecting Abused Piperazine Designer Drugs

Piperazine derivatives belong to the popular psychostimulating compounds from the group of designer drugs. They are an alternative to illegal drugs such as ecstasy and amphetamines. They are being searched by consumers for recreational use due to their stimulating and hallucinogenic effects. Many NPS-related poisonings and deaths have been reported where piperazines have been found. However, a major problem is the potential lack of laboratory confirmation of the involvement of piperazine derivatives in the occurrence of poisoning. Although many methods have been published, piperazine derivatives are not always included in a routine analytical approach or targeted toxicological analysis. There is an increasing need to provide qualitative evidence for the presence of piperazine derivatives and to ensure reproducible quantification. This article describes a new rapid method of detecting piperazine derivatives in biological material, using LC-MS. All target analytes were separated in a 15 min run time and identified based on the precursor ion, at least two product ions, and the retention time. Stable isotopically labeled (SIL) internal standards: BZP-D7, mCPP-D8 and TFMPP-D4 were used for analysis, obtaining the highest level of confidence in the results. The proposed detection method provides the analytical confirmation of poisoning with piperazine designer drugs.

Methylenedioxymethamphetamine-like discriminative stimulus effects of seven cathinones in rats

Synthetic cathinone derivatives are commonly considered quasi-legal alternatives for stimulant drugs, such as cocaine and methamphetamine, but some derivatives are increasingly being detected in club drug formulations of Ecstasy or 'Molly' as substitutes for methylenedioxymethamphetamine (±-MDMA). Although several studies have evaluated the psychostimulant-like effects of synthetic cathinones, few cathinone compounds have been assessed for MDMA-like activity. In order to determine their likelihood of interchangeability with entactogenic club drugs, the discriminative stimulus effects of methcathinone, 4-fluoromethcathinone, 4-methylmethcathinone, 4-methylethcathinone, 3-fluoromethcathinone, pentedrone, and ethylone were assessed in Sprague-Dawley rats trained to discriminate 1.5 mg/kg racemic methylenedioxymethamphetamine (±-MDMA) from vehicle. Methamphetamine and the cathinones 4-fluoromethcathinone, 4-methylmethcathinone, 4-methylethcathinone, 3-fluoromethcathinone, pentedrone, and ethylone fully substituted for the discriminative stimulus effects of ±-MDMA. In contrast, methcathinone produced a maximum of only 43% ±-MDMA-appropriate responding and higher doses suppressed responding. Most, but not all of the cathinone compounds tested have discriminative stimulus effects similar to those of MDMA as well as psychostimulant-like effects; however, the potency of MDMA versus psychostimulant substitution varies substantially among the compounds, suggesting that a subset of synthetic cathinones are more MDMA-like than psychostimulant-like. These findings further highlight the highly-variable pharmacology of this class of compounds and suggest that those cathinones with MDMA-like effects may also have increased use as club drugs.

Pharmacotherapy of Patients Taking New Psychoactive Substances: A Systematic Review and Analysis of Case Reports

Background: In recent years, an increase in the frequency of hospitalizations of patients taking newer and newer psychoactive substances has been observed around the world. Each year, authors publish case reports of patients who consumed previously unknown NPS. Most publications of this type concern the period between 2014 and 2016. However, no publication systematically reviews the pharmacotherapy used in these cases. This study aims to review the case reports of patients taking NPS published between 2010 and 2019, as well as analyzing the pharmacotherapy used. Methods: We searched the Thomson (Web of Knowledge), PubMed/Medline, Science Direct, Scopus and Google Scholar databases. The search was performed using all possible combinations of the term "case report" describing the use of NPS, also referred to as designer medications, internet medications, research chemicals and herbal highs. Results: We analyzed 51 case reports on the intake of various types of NPS. Most of them (p < 0.001) concerned the use of synthetic cannabinoids (41.2%) and cathinones (31.4%). The pharmacotherapy applied primarily (p < 0.001) consisted of administering benzodiazepines to patients (62.7%), most of whom took only this group of medications (25.5%), followed by groups receiving benzodiazepines combined with neuroleptics (15.7%) and muscle relaxants (11.8%). Opioids were administered primarily to patients taking synthetic opioids (p < 0.001). Of the 5 cases of deaths from NPS reported in the literature, three relate specifically to the synthetic opioid MT-45. The later the time period, the more medications patients were administered (p = 0.02). Conclusion: In the pharmacotherapy for NPS poisoning, one should focus primarily on combating psychomotor agitation.

Piperazine derivatives as dangerous abused compounds

Piperazine derivatives are a group of compounds with a psychostimulant effect. They are an alternative to illegal drugs. They are being searched for recreational use due to their psychoactive and hallucinogenic effects. The high popularity of these compounds can be noticed all over the world due to easy purchase, lack of legal regulations and incorrect assessment of the safety of use. The recreational use of piperazine derivatives can often result in chronic and acute health problems and additionally with unpredictable remote effects. It is also common to take mixtures of psychoactive compounds. This hinders the correct diagnosis and treatment of patients with poisoning. The presented work is an illustration of the wide problem of piperazine derivatives abuse. The health effects and the possibility of identifying these compounds in preparations and biological material are described.

Metabolic profile of the synthetic drug 4,4′-dimethylaminorex in urine by LC–MS-based techniques: selection of the most suitable markers of its intake

Purpose

In this study, the phase I and II metabolic pathways of 4,4′-dimethylaminorex were characterized to select the marker(s) of intake allowing the unequivocal identification of this novel psychoactive substance in urine samples.

Methods

The metabolic profile of 4,4′-dimethylaminorex was characterized using both in vitro and in vivo models. In detail, for the in vitro experiments, either pooled human liver microsomes or recombinant cytochrome P450 isoforms were selected, whereas the in vivo investigation was performed on male mice ICR (CD-1®). Sample preparation included enzymatic hydrolysis followed by liquid/liquid extraction. The instrumental analysis was performed by ultra-high-performance liquid chromatography coupled to either high- or low-resolution tandem mass spectrometry.

Results

Five metabolic products were isolated only for the cis-isomer: the phase I metabolic reactions included hydrolysis, carboxylation, hydroxylation, and carbonylation. CYP2D6 was the principal isoenzyme involved, and the incubation in the presence of different allelic variants showed significant alteration on the metabolic profile. Once formed, the phase I metabolites underwent extensive conjugation. Not only the most abundant compounds detected, but also those with the most extended window of detection, were the carboxylated and the hydroxylated metabolites. These analytes together with the parent compound were selected as the most suitable markers of intake.

Conclusions

Knowledge of the metabolic profiles of the new drugs is essential for their fast identification. Phase I and phase II metabolites of 4,4′-dimethylaminorex were identified and selected as markers of intake, to be considered as the most suitable analytical targets in forensic toxicology.

Designers Drugs—A New Challenge to Emergency Departments—An Observational Study in Poland

Background and Objective: In the last decade, the phenomenon of using new psychoactive substances (NPS), called designer drugs, has been on rise. Though their production and marketing in Poland is prohibited, reports of the Supreme Audit Office noted that young people are increasingly reaching for new intoxication agents in the form of designer drugs. There is a significant increase in the number of patients with NPS abuse admitted to the emergency departments. As NPS cannot be detected by standard tests for the presence of psychoactive substances, it is difficult to choose the appropriate therapeutic intervention. Therefore, the aim of the present study was to evaluate the patient characteristics in the population of adults and children suspected of using NPS and formulate the protocol for diagnosis and treatment. Materials and Method: The paper is based on a retrospective analysis of medical records of hospitalized patients in the Clinical Emergency Department of The Regional Specialist Hospital in Olsztyn (SKOR WSS, emergency department (ED)) and the Pediatric Emergency Department of the Provincial Specialist Children′s Hospital in Olsztyn (SORD WSSD, pediatric emergency department (PED)) between years 2013 to 2018. The patient records related to their general symptoms at admission, mental state and laboratory diagnostic tests were evaluated. Results: The majority of patients hospitalized due to the suspected use of NPS were adolescents in 2013–2016 and a reversal of this trend was observed in 2017–2018 when number of adults admitted to the emergency department (ED) due to NPS use was higher. The NPS abuse was significantly higher among male patients, alcoholics, people using other psychoactive substances, patients suffering from mental disorders and teenagers in difficult socio-economic family situations. Whereas, the most common symptoms among pediatric patients were co-ordination disorder and aggression, in adults mainly tachycardia and aggression was observed. The laboratory tests in significant number of adult patients showed leukocytosis and ketonuria. Conclusions: In the present study, no unambiguous toxidrome or biochemical pattern characteristic for using NPS was observed. However, evaluation of blood morphology, coagulation parameters, liver and kidney function can be helpful in the diagnostic and therapeutic process. Symptomatic treatment of patients, fluid therapy and sedation was sufficient in most cases to resolve the patient symptoms in 48 h.

Illicit Drugs in the Nightlife Setting: Changes in Employee Perceptions and Drug Use over a Fifteen-Year Period

Illicit drug use is common in nightlife settings and associated with various public health-related problems, making this an important arena for prevention. Purpose/objectives: To assess perceived prevalence of illicit drug use in the Stockholm nightlife setting, use of and attitudes toward illicit drugs among employees at licensed premises. Also, to make comparisons with two identical measurements from 2001 and 2007/08, and to explore potential differences related to own drug use, type of licensed premise, age or gender. Methods: Cross-sectional surveys were conducted at three time-points: 2001, 2007/08, and 2016/17, comprising employees at licensed premises in Stockholm participating in STAD's Responsible Beverage Service training program. A total of 665 persons (mean age 28 years, 53% women) were included in the 2016/2017 measurement. Results: A majority of the respondents reported having observed patrons intoxicated by illicit drugs in the last six months, and agreed that patrons intoxicated by illicit drugs should be asked to leave licensed premises. The belief that one had observed patrons intoxicated by illicit drugs was more common among respondents who had themselves been using illicit drugs during the last year, and also among employees at nightclubs. Furthermore, comparisons with previous time-points showed a significant increase in the proportion of employees using illicit drugs. Almost half of the respondents in the youngest age group (18-24 years) reported illicit drug use during the last year. Conclusions/importance: Observation and use of illicit drugs are common among employees in the Stockholm nightlife setting and has increased significantly during the past decade.

DARK Classics in Chemical Neuroscience: Synthetic Cannabinoids (Spice/K2)

This Review covers the background, pharmacology, adverse effects, synthesis, pharmacokinetics, metabolism, and history of synthetic cannabinoid compounds. Synthetic cannabinoids are a class of novel psychoactive substances that act as agonists at cannabinoid receptors. This class of compounds is structurally diverse and rapidly changing, with multiple generations of molecules having been developed in the past decade. The structural diversity of synthetic cannabinoids is supported by the breadth of chemical space available for exploitation by clandestine chemists and incentivized by attempts to remain ahead of legal pressures. As a class, synthetic cannabinoid products have a more serious adverse effect profile than that of traditional phytocannabinoids, including notable risks of lethality, as well as a history of dangerous adulteration. Most synthetic cannabinoids are rapidly metabolized to active species with prolonged residence times and peripheral tissue distribution, and analytical confirmation of use of these compounds remains challenging. Overall, the emergence of synthetic cannabinoids serves as a noteworthy example of the pressing public health challenges associated with the increasing development of easily synthesized, structurally flexible, highly potent, psychoactive drugs.

Synthetic cathinones: an evolving class of new psychoactive substances

Synthetic cathinones (SCat) are amphetamine-like psychostimulants that emerged onto drug markets as "legal" alternatives to illicit drugs such as ecstasy, cocaine, and amphetamines. Usually they are sold as "bath salts," "plant food," or "research chemicals," and rapidly gained popularity amongst drugs users due to their potency, low cost, and availability. In addition, internet drug sales have been replacing the old way of supplying drugs of abuse, contributing to their rapid spread. Despite the legislative efforts to control SCat, new derivatives continue to emerge on the recreational drugs market and their abuse still represents a serious public health issue. To date, about 150 SCat have been identified on the clandestine drugs market, which are one of the largest groups of new psychoactive substances (NPS) monitored by the United Nations Office on Drugs and Crime and the European Monitoring Center for Drugs and Drug Addiction. Similar to the classical stimulants, SCat affect the levels of catecholamines in the central nervous system, which results in their psychological, behavioral and toxic effects. Generally, the effects of SCat greatly differ from drug to drug and relatively little information is available about their pharmacology. The present work provides a review on the development of SCat as substances of abuse, current patterns of abuse and their legal status, chemical classification, known mechanisms of action, and their toxicological effects.

Idiopathic Thrombocytopenic Purpura Induced by Synthetic Cannabinoid

: Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder defined as low platelet count with normal bone marrow in the absence of other causes of thrombocytopenia. It is caused by autoantibodies binding to several platelet surface antigens which lead to premature destruction of the platelet by the reticuloendothelial system. ITP can be primary or secondary, and it is known to be associated with various infections and drugs. K2/Spice, or synthetic marijuana, acts on cannabinoid receptors CB1 (cannabinoid type-1) and CB2 (cannabinoid type-2) with increased binding capacity compared to marijuana. A white male was brought to the emergency department with signs of acute drug toxicity. His urine drug test was negative but he admitted to a year long history of synthetic marijuana use. His platelet count was 12,000/mm and he was diagnosed with ITP. After receiving 2 doses of oral dexamethasone his platelets improved. Synthetic cannabinoids are widely available and used psychoactive drugs. Little is known about the complete chemical composition of the synthetic products thus there is relatively little information available on the pharmacodynamic and pharmacokinetic effects. A high index of suspicion is needed to diagnose toxicity to these drugs since there are no readily available on-site lab tests. Currently there exists 1 case report of ITP induced by K2/Spice. Here, we discuss another case of K2/Spice a as a potential cause of immune thrombocytopenia.

Inflammation and oxidative stress are key mediators in AKB48-induced neurotoxicity in vitro

Synthetic cannabinoids were introduced into market in early 2000s; since these "legal highs" are dramatically popular among youth, it becomes a deadly problem. Synthetic cannabinoids have high affinity to cannabinoid receptors; leading to various clinical symptoms. AKB48 (Apinaca) has been classified as a third-generation synthetic cannabinoid for the first time in 2014. The toxicity profile of AKB48 is unclear due to little information that mainly obtained from clinical and forensic cases; however, it is believed to be similar with other psychoactive substances. Thus, we aimed to investigate the possible toxicity mechanisms of AKB48 in SH-SY5Y (human bone marrow neuroblastoma) cell line. IC₅₀ value of AKB48 was calculated as 160.91 μM by MTT assay. AKB48 treatment enhanced (≥1.2-fold) the fluorescence intensity indicating increased reactive oxygen species production; however, glutathione levels did not changed in the range of 25-200 μM exposure concentrations. Cannabinoid type-1 receptor (CB1) expression was increased ≥15-fold in the range of 25-50 μM of AKB48, while cannabinoid type-2 receptor (CB2) did not expressed in SH-SY5Y cells. Interleukin-6 (IL-6) and tumor necrosis factor-α (TNF- α) were up-regulated with a dose-dependent manner, and the profiles were almost identical; however, mitogen-activated protein kinase 8 (MAPK 8) was only upregulated with 25 μM of AKB48 and nuclear factor kappa B (NF-ĸB) did not change. Our results should raise the concerns about the safety associated with synthetic cannabinoids uses.

A Difficult Challenge for the Clinical Laboratory: Accessing and Interpreting Manufacturer Cross-Reactivity Data for Immunoassays Used in Urine Drug Testing

Urine drug testing by immunoassay is widely used to detect nonmedical drug use and to monitor patients prescribed controlled substances. A key attribute of urine drug testing immunoassays is cross-reactivity, namely the response of various compounds compared to the target of the assay. In this report, we analyzed the variability in how manufacturer cross-reactivity data are summarized in package inserts for commercially available amphetamines, benzodiazepines, and opiates immunoassays, 3 broad drug classes commonly included in routine drug testing panels. Specifically, we determined the number of compounds tested for cross-reactivity, manner in which cross-reactivity is measured, concentration units used, how often compounds known to be cross-reactive with marketed urine drug testing immunoassays prior to 2010 were tested, availability of the package insert online, and how often cross-reactivity on "designer drugs" was found in the package inserts. There was wide variability in the number of compounds tested (both positive and negative), with the highest number of tested compounds generally found in point-of-care urine drug testing applications. Most package inserts used ng/mL as the concentration units and expressed cross-reactivity in terms of equivalent concentrations to the assay calibrator. Approximately 50% of package inserts were directly available online. Cross-reactivity data were sparse with respect to "off-target" drugs known to be cross-reactive prior to 2010 (an example being quinolone antibiotics and opiates immunoassays) and designer drugs. The present study indicates lack of consistency in cross-reactivity information in package inserts, complicating the interpretation of urine drug testing results. We use 3 example clinical cases to illustrate practical challenges accessing and interpreting cross-reactivity data.

Trends in DMT and other tryptamine use among young adults in the United States

BACKGROUND AND OBJECTIVES

The popularity of tryptamines such as N,N-dimethyltryptamine (DMT) appears to be increasing in the United States (US), but epidemiologic literature on prevalence of use is scant. This paper aims to determine trends in prevalence and correlates of past-year tryptamine use among a nationally representative sample of young adults in the US.

METHODS

Participants in the National Survey on Drug Use and Health survey were queried about past-year use of tryptamines-specifically DMT, α-methyltryptamine (AMT), and 5-MeO-DIPT ("Foxy"). Data were examined from young adults (ages 18-25), years 2007-2014 (N = 144,787). Linear trends in prevalence of past-year tryptamine use were examined in the full sample and stratified by specific demographic and drug use characteristics.

RESULTS

Tryptamine use is rare, but increased from .2% in 2007/08 to .7% in 2013/14, a 273% relative increase (p < .001). While prevalence increased among all demographic groups, prevalence was substantially higher among individuals who use other drugs. In particular, between 2007/08 and 2013/14, prevalence of tryptamine use increased among past-year ecstasy users (from 2.1% to 10.0%) and LSD users (from 7.0% to 15.5%) (ps < .01). Prevalence of tryptamine use tended to be higher among lifetime and past-year users of psychedelic drugs compared to users of non-psychedelic drugs.

CONCLUSION

While tryptamine use is not prevalent in the general young adult population, prevalence is increasing. Users of various other drugs-particularly drugs with psychedelic effects-report higher prevalence of tryptamine use.

SCIENTIFIC SIGNIFICANCE

Users of other drugs can be targeted when disseminating information about tryptamines to ensure user safety. (Am J Addict 2018;27:578-585).

The ongoing challenge of novel psychoactive drugs of abuse. Part I. Synthetic cannabinoids (IUPAC Technical Report)

In the past decade, the world has experienced a large increase in the number of novel compounds appearing on the illicit drug market for recreational purposes. Such substances are designed to circumvent governmental regulations; the illegal drug manufacturers take a known psychoactive compound reported in the scientific literature and slightly modify its chemical structure in order to produce analogues that will mimic the pharmacological activity of the original substance. Many of these novel substances are sold via the Internet. Among the various chemical classes, synthetic cannabinoid receptor modulators, commonly referred to as “synthetic cannabinoids” have been at the forefront, as demonstrated by the frequency of drug seizures, numerous severe toxic effects, and fatalities associated with some of these substances. This review presents the chemical structures of relevant synthetic cannabinoids and describes their mechanism of action, pharmacological features, metabolic pathways, and structure-activity relationships. It illustrates the approaches used in forensic testing, both for bulk analysis (drug seizures) and for analytical toxicology (biological matrices) and discusses aspects of regulation surrounding this drug class. This report is intended to provide pertinent information for the purposes of informing scientific, medical, social, and governmental bodies about this ever-evolving recreational drug class and the challenges it poses worldwide.

Dopaminergic neurotoxic effects of 3-TFMPP derivatives

Designer drugs are synthetically formulated to mimic the psychostimulatory effects of an original controlled/illegal drug of abuse. Designer drugs have similar chemical structure or functional analog as compared to existing controlled psychostimulatory drugs. There is a substantial rise in the production and use of designer drugs globally. Piperazine designer drugs were synthesized as an alternative to MDMA and have shown to induce numerous toxic effects leading to huge health, safety, law enforcement & monetary problems, and lethality. Currently, there are very few studies on the dopaminergic neurotoxicity of 1-(3-trifluoromethylphenyl) piperazine (3-TFMPP) and its derivatives (structural congeners). N27 rat dopaminergic neurons are valid cells to investigate the neurotoxic effects and establish the neurotoxic mechanisms of various substances. In the current study, we studied the time and dose-dependent neurotoxicity mechanisms of dopaminergic neurotoxicity of 3-TFMPP (parent compound) and its derivatives (2-TFMPP, 4-TFMPP). TFMPP derivatives-induced significant neurotoxicity (induced dopaminergic neuronal death. TFMPP derivatives-induced oxidative stress, mitochondrial dysfunction, apoptosis and decreased tyrosine hydroxylase expression. If the use of designer drugs are not strictly regulated and restricted around the world, this can lead to numerous central and peripheral disorders leading to a liability to the current and future society.

New and Emerging Illicit Psychoactive Substances

Several novel psychoactive substances have emerged in recent years. Users are typically young men who use other substances. In the category of stimulants, cathinones ("bath salts") have predominated and can lead to agitation, psychosis, hyperthermia, and death. Synthetic cannabinoids ("spice") are more potent than marijuana and can lead to agitation, psychosis, seizures, and death. There are no rapid tests to identify these substances and general treatment includes benzodiazepines for agitation and supportive therapy. Many Synthetic opioids are potent analogues of fentanyl and carry a high risk of overdose. In addition, there are several designer benzodiazepines that have emerged.

Detectability of fentanyl and designer fentanyls in urine by 3 commercial fentanyl immunoassays

In recent times, structural variants of fentanyl (designer fentanyls) have appeared on the recreational drug market for new psychoactive substances (NPS). These potent opioids have caused harmful intoxications and increased opioid-related mortality in many countries. This work evaluated 3 commercial immunoassays for fentanyl screening in urine and investigated whether they are useful also for screening of designer fentanyls. The assays examined were the Thermo DRI® Fentanyl Enzyme Immunoassay, the ARK™ Fentanyl Assay homogeneous enzyme immunoassay, and the Immunalysis® Fentanyl Urine SEFRIA™ Drug Screening Kit. A liquid chromatography-high-resolution mass spectrometry method was used as reference. The DRI fentanyl immunoassay generated somewhat higher assay imprecision values (%CV) compared with the ARK™ and SEFRIA™ assays, but all assays showed %CV values acceptable for routine use. The 3 assays showed overall good detectability (33%-95% cross-reactivity) for blank urine samples spiked with acetylfentanyl, acrylfentanyl, butyrfentanyl, 4-chloroisobutyrfentanyl, 4-fluorobutyrfentanyl, 4-fluorofentanyl, 4-fluoroisobutyrfentnyl, isobutyrfentanyl, methoxyacetylfentanyl, or tetrahydrofuranfentanyl, whereas 4-methoxybutyrfentanyl (all assays) and 2-fluorofentanyl (DRI assay) showed low cross-reactivity. A good detectability of designer fentanyls was confirmed in urine samples from authentic acute intoxications. In conclusion, the present results demonstrate that the urinary fentanyl immunoassays are generally useful also for preliminary screening of fentanyl analogs sold as NPS. When the SEFRIA™ assay was applied for testing of 980 urine samples from patients treated for drug dependence in Sweden, only 1 sample was confirmed positive for fentanyl.

When good times go bad: managing 'legal high' complications in the emergency department

Patients can use numerous drugs that exist outside of existing regulatory statutes in order to get "legal highs." Legal psychoactive substances represent a challenge to the emergency medicine physician due to the sheer number of available agents, their multiple toxidromes and presentations, their escaping traditional methods of analysis, and the reluctance of patients to divulge their use of these agents. This paper endeavors to cover a wide variety of "legal highs," or uncontrolled psychoactive substances that may have abuse potential and may result in serious toxicity. These agents include not only some novel psychoactive substances aka "designer drugs," but also a wide variety of over-the-counter medications, herbal supplements, and even a household culinary spice. The care of patients in the emergency department who have used "legal high" substances is challenging. Patients may misunderstand the substance they have been exposed to, there are rarely any readily available laboratory confirmatory tests for these substances, and the exact substances being abused may change on a near-daily basis. This review will attempt to group legal agents into expected toxidromes and discuss associated common clinical manifestations and management. A focus on aggressive symptom-based supportive care as well as management of end-organ dysfunction is the mainstay of treatment for these patients in the emergency department.

New Psychoactive Substances in Pediatric Patients

New psychoactive substances (NPS), namely cannabinoids, cathinones, and opioids, have surged in popularity among school-age children, resulting in serious morbidity and mortality globally. In the last decade, there has been a rapid evolution of NPS resulting in hundreds of new compounds. Little to no evidence for humans is available on most compounds. The clinical presentations of patients intoxicated with cannabinoids and cathinones are highly variable but most commonly present with a sympathomimetic toxidrome, for example, agitation, delirium, and tachycardia. Those with opioids present with a classic opioid toxidrome: coma, dilated pupils, and respiratory failure.

A randomized trial of brief assessment interventions for young adults who use drugs in the club scene

BACKGROUND

Efficacious interventions to reduce drug use and its consequences for club drug using populations are not apparent in the literature. We tested interviewer- (CAPI) and self-administered (ACASI) comprehensive health and social risk assessments as distinct interventions compared to waitlist control.

METHODS

750 men and women ages 18-39 with multidrug use and heterosexual behavior were randomized in equal proportions to the three conditions. Instrumentation included well-tested measures of drug use, risky sex, mental distress and substance dependence.

RESULTS

The sample was 56% male; mean age=25. Reported risk behaviors and health consequences did not differ by assessment modality. Adjusted HLM analyses showed a significant main effect of assigned condition on all outcomes. CAPI participants had greater reductions in drug use, risky sex, mental distress and substance dependence symptoms, and greater increases in abstinence, compared to ACASI intervention or control participants at 12months, except that the CAPI and ACASI conditions had similar efficacy for reductions in drug use. Effect sizes for CAPI versus ACASI participants were d=0.2-0.3, and between CAPI and controls d=0.2-0.4. Effect sizes for improved outcomes between ACASI compared to controls were small to non-significant.

CONCLUSIONS

The study established the therapeutic benefit of interviewer interaction in reducing risky behavior among this young drug using population. The study demonstrated the efficacy and acceptability of a low threshold intervention in reducing drug use, sexual risk and related co-morbidities among a not-in-treatment young adult population that exhibits severe and complex levels of drug use, but that is also highly resistant to intervention.

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.

Cluster of Acute Toxicity from Ingestion of Synthetic Cannabinoid-Laced Brownies

INTRODUCTION

Synthetic cannabinoid receptor agonists (SCRAs) are emerging designer drugs of abuse. Most reports on the health effects of these drugs are case reports. Unlike SCRAs, marijuana has classically been used via many routes of exposure including oral, such as in brownies. We report on 11 symptomatic patients who unknowingly ingested brownies laced with analytically confirmed SCRA and presented with mostly neuropsychiatric and cardiovascular symptoms.

CASE SERIES

All 11 patients were taken to the ED within 1 h of exposure with the onset of various symptoms. There were five males and six females, age range 20-57 years. Neuropsychiatric and cardiovascular symptoms predominated: memory impairment (91 %, 10/11) and inappropriate giggling (36 %, 4/11). All the patients had light-headedness, perioral and facial numbness and tingling sensation, dry mouth, difficulty focusing/blurring of vision, and sluggishness. No patient had depressed consciousness. Two patients had heart rates >100, and 4 of 11 (36 %) had BP >140/80. One patient had chest pain. All the symptoms were completely resolved 4 h following their onset except two patients who had ongoing weakness and fatigue. All patients had negative urine drugs of abuse immunoassays and ethanol, acetaminophen, and salicylate concentrations, as well as normal electrocardiograms (ECGS) and metabolic panels. The SCRA was confirmed to be AM-2201. All the patients were discharged from the ED in stable condition within 10 h of the exposure.

CONCLUSION

Oral exposure of 11 patients to brownies laced with analytically confirmed SCRA resulted in neuropsychiatric and cardiovascular symptoms. This series reflects that like marijuana, oral exposures to SCRAs can lead to symptoms.

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

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

Determination of "new psychoactive substances" in postmortem matrices using microwave derivatization and gas chromatography-mass spectrometry

Despite worldwide efforts aiming to ban the marketing and subsequent abuse of psychoactive substances such as synthetic cathinones and phenethylamines, there has been an alarming growth of both in recent years. Different compounds similar to those already existing are continuously appearing in the market in order to circumvent the legislation. An analytical methodology has been validated for qualitative and quantitative determinations of D-cathine (D-norpseudoehedrine), ephedrine, methcathinone, 1-(4-methoxyphenyl)-propan-2-amine (PMA), mephedrone, methedrone, 2,5-dimethoxy-4-methylamphetamine (DOM), 4-bromo-2,5-dimethoxyamphetamine (DOB), 2,5-dimethoxyphenethylamine (2C-H), 4-bromo-2,5-dimethoxyphenethylamine (2C-B), 4-iodo-2,5-dimethoxyphenethylamine (2C-I), 2-[2,5-dimethoxy-4-(ethylthio)phenyl]ethanamine (2C-T-2), 2,5-dimethoxy-4-isopropylthiophenethylamine (2C-T-4) and 2-[2,5-dimethoxy-4-(propylthio)phenyl]ethanamine (2C-T-7), in low volumes of vitreous humor (100 μL), pericardial fluid (250 μL) and whole blood (250 μL), using deutered amphetamine, ephedrine and mephedrone as internal standards. The validation parameters included selectivity, linearity and limits of detection and quantification, intra- and interday precision and trueness, recovery and stability. The method included mixed-mode solid phase extraction, followed by microwave fast derivatization and analysis by gas chromatography-mass spectrometry operated in selected ion monitoring mode. The procedure was linear between 5 and 600 ng/mL, with determination coefficients higher than 0.99 for all analytes. Intra- and interday precision ranged from 0.1 to 13.6%, while accuracy variability was within 80-120% interval from the nominal concentration at all studied levels. The extraction efficiencies ranged from 76.6 to 112.8%. Stability was considered acceptable for all compounds in the studied matrices. The developed assay was applied to authentic samples of the Laboratory of Chemistry and Forensic Toxicology, Centre Branch, of the National Institute of Legal Medicine and Forensic Sciences, Portugal.

New psychoactive substances as part of polydrug abuse within opioid maintenance treatment revealed by comprehensive high-resolution mass spectrometric urine drug screening

OBJECTIVE

At present, polydrug abuse comprises, besides traditional illicit drugs, new psychoactive substances (NPS) and non-prescribed psychotropic medicines (N-PPM). Polydrug abuse was comprehensively evaluated among opioid-dependent patients undergoing opioid maintenance treatment (OMT).

METHODS

Two hundred consecutively collected urine samples from 82 OMT patients (52 male) treated with methadone or buprenorphine-naloxone medication were studied using a liquid chromatography/time-of-flight mass spectrometry screening method. The method enables simultaneous detection of hundreds of abused substances covering the traditional drugs of abuse and many NPS as well as N-PPM.

RESULTS

Ninety-two (45.8%) samples were positive for the abused substances. Benzodiazepines (29.0%), amphetamines (19.5%), cannabinoids (17.0%), NPS (13.0%), N-PPM (9.0%), and opioids (9.0%) were detected in different combinations. The simultaneous occurrence of up to three groups of abused substances was common (40.0%), and in one sample, all six groups were found. The stimulant NPS alpha-pyrrolidinovalerophenone was found in 10.0% and the sedative N-PPM pregabalin in 4.0% of the samples. The patients were seldom aware of what particular NPS they had abused.

CONCLUSIONS

A widespread occurrence of abused substances beyond the ordinary was revealed. Identifying these patients is essential as polydrug abuse is a safety risk to the patient and may cause attrition from OMT.

Designer Drugs: A Synthetic Catastrophe

Synthetic stimulants can cause hallucinations, aggressive behaviors, death and are sometimes legal. These substances are sold as plant food and bath salts that are “Not for Human Consumption”, therefore skirting the 1986 Federal Analogue Act and giving a false pretense of safety. Studies have proved that these substances are toxic, have a high abuse potential, and are becoming extremely prevalent in the United States. This creates a dilemma for law enforcement agents, hospitals, and substance use disorder treatment centers. Urine Drug Testing is utilized as a clinical diagnostic tool in substance use disorder treatment centers, and the furious pace at which new synthetic stimulants are introduced to the black market are making the detection via urine increasingly difficult. This article will discuss the prevalence, pharmacology and difficulty developing laboratory assays to detect synthetic stimulants.

New synthetic drugs in addictovigilance

New substances, also known as "designer drugs" or "legal highs" are increasingly available to drug users. Two hundred and fifteen hitherto unlisted substances have been notified by European Union member states since 2005. These synthetic drugs, which have been developed to side-step the legislation on drugs, are analogues or derivatives of existing drugs and medications. The availability of these "legal highs", sold on Internet under various denominations such as bath salt, plant fertilizer, chemical not intended for human use, or spice, is unlimited. The effects felt by users vary, and the substances may be stimulant, entactogenic, hallucinogenic, psychedelic or dissociative. The pharmacological targets also vary, and may be either the increase of extracellular levels of neurotransmitters via different mechanisms (reuptake inhibition, stimulation of intracellular release) or else fixation on specific receptors. Several chemical classes, themselves divided into sub-classes, are involved: phenethylamines, tryptamines, piperazines, cathinones, cannabinoids etc. The toxicity of the main members of these categories is increasingly well known, the most deleterious being behavioural effects, physical manifestations, and cardiovascular consequences. However, small variations in their chemical structure can generate effects that are quantitatively different, thus enhancing their toxicity or addictive potential, and much remains to be achieved in terms of knowledge about these new drugs. These substances are indeed present on the French territory, as shown by data provided by the Observatoire Français des Drogues et Toxicomanies, and notifications by the French Addictovigilance network. Screening in clinical toxicology laboratories is not widespread, since these molecules are not detected by the standard screening tests, so that there is probably an under-estimation of the use of these new drugs. The legislation on these substances changes regularly, with more and more countries classifying them as "narcotics" or illegal psychotropic drugs so as to restrict their use, applying a generic classification when possible.

"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.

Recreational use, analysis and toxicity of tryptamines

The definition New psychoactive substances (NPS) refers to emerging drugs whose chemical structures are similar to other psychoactive compounds but not identical, representing a "legal" alternative to internationally controlled drugs. There are many categories of NPS, such as synthetic cannabinoids, synthetic cathinones, phenylethylamines, piperazines, ketamine derivatives and tryptamines. Tryptamines are naturally occurring compounds, which can derive from the amino acid tryptophan by several biosynthetic pathways: their structure is a combination of a benzene ring and a pyrrole ring, with the addition of a 2-carbon side chain. Tryptamines include serotonin and melatonin as well as other compounds known for their hallucinogenic properties, such as psilocybin in 'Magic mushrooms' and dimethyltryptamine (DMT) in Ayahuasca brews.

AIM

To review the scientific literature regarding tryptamines and their derivatives, providing a summary of all the available information about the structure of these compounds, their effects in relationship with the routes of administration, their pharmacology and toxicity, including articles reporting cases of death related to intake of these substances.

METHODS

A comprehensive review of the published scientific literature was performed, using also non peer-reviewed information sources, such as books, government publications and drug user web fora.

CONCLUSIONS

Information from Internet and from published scientific literature, organized in the way we proposed in this review, provides an effective tool for specialists facing the emerging NPS threat to public health and public security, including the personnel working in Emergency Department.