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

Mephedrone concentrations in clinical intoxications and fatal cases: a systematic review

BACKGROUND/PURPOSE

Mephedrone, a ring-substituted synthetic cathinone derivative, gained popularity as a recreational drug in the late 2000s. Reports of fatalities related to mephedrone use have emerged with varying concentrations of blood mephedrone upon forensic investigations. This study aims to evaluate the existing literature on mephedrone concentrations in instances of clinical intoxication and fatal cases.

METHODS

We comprehensively searched electronic databases, including Web of Science, PubMed, Embase, and the Cochrane Library, from inception to July 26, 2023. We selected case reports or case series of mephedrone intoxication presented with individual blood mephedrone concentration. Patient demographics, clinical characteristics, blood mephedrone concentrations, and outcomes were extracted for analysis.

RESULTS

77 cases from 14 case reports and 6 case series were identified for review. There were 34 deaths and 43 non-fatal intoxication cases. The median patient's age was 24 years (IQR: 10), and 91.4% were male. Forty-five of the 63 cases (71.4%) were reported with alcohol or other illicit drugs detected. The median blood mephedrone concentration was 0.37 mg/L (IQR: 1.09 mg/L). Death cases were older than non-fatal cases (median = 30 vs. 22 years, p = 0.029). The median blood mephedrone concentration was higher in death cases (1.30 mg/L vs. 0.12 mg/L, p < 0.0001).

CONCLUSIONS

Blood mephedrone concentration in dead patients is approximately 11 times higher than in non-fatal cases. This finding could serve as a stepping stone to the diagnosis of concentrations in clinical poisoning cases and deaths, especially in the treatment of poisoning patients. In more extensive prospective studies, further research is necessary to establish a standardized, real-time available methodology and validate the predictive value of mephedrone concentrations in the prognostic value of mephedrone concentrations.

Methamphetamine and the Synthetic Cathinone 3,4-Methylenedioxypyrovalerone (MDPV) Produce Persistent Effects on Prefrontal and Striatal Microglial Morphology and Neuroimmune Signaling Following Repeated Binge-like Intake in Male and Female Rats

Psychostimulants alter cellular morphology and activate neuroimmune signaling in a number of brain regions, yet few prior studies have investigated their persistence beyond acute abstinence or following high levels of voluntary drug intake. In this study, we examined the effects of the repeated binge-like self-administration (96 h/week for 3 weeks) of methamphetamine (METH) and 21 days of abstinence in female and male rats on changes in cell density, morphology, and cytokine levels in two addiction-related brain regions-the prefrontal cortex (PFC) and dorsal striatum (DStr). We also examined the effects of similar patterns of intake of the cocaine-like synthetic cathinone derivative 3,4-methylenedioxypyrovalerone (MDPV) or saline as a control. Robust levels of METH and MDPV intake (~500-1000 infusions per 96 h period) were observed in both sexes. We observed no changes in astrocyte or neuron density in either region, but decreases in dendritic spine densities were observed in PFC pyramidal and DStr medium spiny neurons. The microglial cell density was decreased in the PFC of METH self-administering animals, accompanied by evidence of microglial apoptosis. Changes in microglial morphology (e.g., decreased territorial volume and ramification and increased cell soma volume) were also observed, indicative of an inflammatory-like state. Multiplex analyses of PFC and DStr cytokine content revealed elevated levels of various interleukins and chemokines only in METH self-administering animals, with region- and sex-dependent effects. Our findings suggest that voluntary binge-like METH or MDPV intake induces similar cellular perturbations in the brain, but they are divergent neuroimmune responses that persist beyond the initial abstinence phase.

Effects of repeated binge intake of the pyrovalerone cathinone derivative 3,4-methylenedioxypyrovalerone on prefrontal cytokine levels in rats - a preliminary study

Drugs of abuse activate neuroimmune signaling in addiction-related regions of the brain, including the prefrontal cortex (PFC) which mediates executive control, attention, and behavioral inhibition. Traditional psychostimulants including methamphetamine and cocaine are known to induce PFC inflammation, yet the effects of synthetic cathinone derivatives are largely unexplored. In this study, we examined the ability of repeated binge-like intake of the pyrovalerone cathinone derivative 3,4-methylenedioxypyrovalerone (MDPV) to alter cytokine profiles in the PFC. Male and female rats were allowed to intravenously self-administer MDPV (0.05 mg/kg/infusion) or saline as a control under conditions of prolonged binge-like access, consisting of three 96 h periods of drug access interspersed with 72 h of forced abstinence. Three weeks following cessation of drug availability, PFC cytokine levels were assessed using antibody arrays. Employing the unsupervised clustering and regression analysis tool CytoMod, a single module of co-signaling cytokines associated with MDPV intake regardless of sex was identified. With regards to specific cytokines, MDPV intake was positively associated with PFC levels of VCAM-1/CD106 and negatively associated with levels of Flt-3 ligand. These findings indicate that prolonged MDPV intake causes changes in PFC cytokine levels that persist into abstinence; however, the functional ramifications of these changes remain to be fully elucidated.

Acute, chronic, and post-mortem toxicity: a review focused on three different classes of new psychoactive substances

PURPOSE

New psychoactive substances (NPS) are not controlled under the Single Convention on Narcotic Drugs of 1961 or the 1971 Convention, but they may pose a public health threat. Knowledge of the main properties and toxicological effects of these substances is lacking. According to the current Drugs Law (Law n. 11.343/2006), the Brazilian Surveillance Agency issues directives for forbidden substances in Brazil, and structural classes of synthetic cannabinoids, cathinones, and phenylethylamines are considered illicit drugs. Considering that data on these controlled substances are scattered, the main objective of this work was to collect and organize data to generate relevant information on the toxicological properties of NPS.

METHODS

We carried out a literature review collecting information on the acute, chronic, and post-mortem toxicity of these classes of NSP. We searched info in five scientific databases considering works from 2017 to 2021 and performed a statistical evaluation of the data.

RESULTS

Results have shown a general lack of studies in this field given that many NPS have not had their toxicity evaluated. We observed a significant difference in the volume of data concerning acute and chronic/post-mortem toxicity. Moreover, studies on the adverse effects of polydrug use are scarce.

CONCLUSIONS

More in-depth information about the main threats involving NPS use are needed.

Use of innovative, cross-disciplinary in vitro, in silico and in vivo approaches to characterize the metabolism of chloro-alpha-pyrrolidinovalerophenone (4-Cl-PVP)

Synthetic cathinones constitute a family of new psychoactive substances, the consumption of which is increasingly worldwide. A lack of metabolic knowledge limits the detection of these compounds in cases of intoxication. Here, we used an innovative cross-disciplinary approach to study the metabolism of the newly emerging cathinone chloro-alpha-pyrrolidinovalerophenone (4-Cl-PVP). Three complementary approaches (in silico, in vitro, and in vivo) were used to identify putative 4-Cl-PVP metabolites that could be used as additional consumption markers. The in silico approach used predictive software packages. Molecular networking was used as an innovative bioinformatics approach for re-processing high-resolution tandem mass spectrometry data acquired with both in vitro and in vivo samples. In vitro experiments were performed by incubating 4-Cl-PVP (20 µM) for four different durations with a metabolically competent human hepatic cell model (differentiated HepaRG cells). In vivo samples (blood and urine) were obtained from a patient known to have consumed 4-Cl-PVP. The in silico software predicted 17 putative metabolites, and molecular networking identified 10 metabolites in vitro. On admission to the intensive care unit, the patient's plasma and urine 4-Cl-PVP concentrations were, respectively, 34.4 and 1018.6 µg/L. An in vivo analysis identified the presence of five additional glucuronoconjugated 4-Cl-PVP derivatives in the urine. Our combination of a cross-disciplinary approach with molecular networking enabled the detection of 15 4-Cl-PVP metabolites, 10 of them had not previously been reported in the literature. Two metabolites appeared to be particular relevant candidate as 4-Cl-PVP consumption markers in cases of intoxication: hydroxy-4-Cl-PVP (m/z 282.1254) and dihydroxy-4-Cl-PVP (m/z 298.1204).

N-isopropylbenzylamine, a methamphetamine mimics, produces toxicity via increasing nitric oxide in vitro

N-isopropylbenzylamine, an isomer of methamphetamine, has been used to adulterate methamphetamine, and distributed as fake "Ice" methamphetamine by illicit manufacturers, leading to a world problem of N-isopropylbenzylamine exposure. Though it is unclear whether N-isopropylbenzylamine has addictive potential like methamphetamine, N-isopropylbenzylamine users reported side effects such as headaches and confusion. However, the pharmacological targets and cytotoxicity of this chemical remained unknown. In this study, in vitro toxicity of N-isopropylbenzylamine and its toxicity-related targets were investigated in SN4741, SH-SY5Y or PC12 cell lines that model neurons. The cell viability was analyzed by using MTT assay after incubation with N-isopropylbenzylamine for 24 h in cells. N-isopropylbenzylamine caused cell death with IC₅₀ values at around 1-3 mM in these cell lines. N-isopropylbenzylamine time- and concentration-dependently facilitated the expression of neuronal nitric oxide synthase (nNOS), and increased intracellular nitric oxide (NO) in SN4741 cells. Furthermore, 7-nitroindazole, a specific inhibitor of nNOS, significantly prevented N-isopropylbenzylamine-induced toxicity in vitro. These results suggested that N-isopropylbenzylamine-induced toxicity is at least partially related to the increased intracellular NO levels and the activated nNOS. Considering the circumstances that N-isopropylbenzylamine was used to adulterate and mimic methamphetamine, and the side effects associated with N-isopropylbenzylamine in abusers, our findings sounded an alarm for abuser and warn the dangerousness of N-isopropylbenzylamine for public health.

Facile synthesis of core–shell structured magnetic Fe3O4@SiO2@Au molecularly imprinted polymers for high effective extraction and determination of 4-methylmethcathinone in human urine samples

In this study, a novel material of core–shell structured magnetic molecularly imprinted polymers (Fe3O4@SiO2@Au (FSA)-MIPs) was successfully prepared for the rapid and selective determination of 4-methylmethcathinone (mephedrone, 4-MMC). The adsorption capacity of FSA-MIPs is 34.7 mg·g−1 at 308 K, which is significantly higher than magnetic non-imprinted polymers profiting from the imprinting effect. The FSA-MIPs have a short equilibrium (20 min) and could be reused more than six times. Moreover, the selectivity coefficients of FSA-MIPs for 4-MMC, 3,4-dimethylmethcathinone, butylone, 4-ethylmethcathinone, acetylfentanyl, and methylene blue are 4.01, 5.65, 7.62, 12.30, and 20.87 respectively, further indicating the markedly enhanced binding selectivity of FSA-MIPs. As an adsorbent, the FSA-MIPs were successfully applied for effective extraction of 4-MMC in three human urine samples with the recovery rates ranging from 85.5–92.6%. The results confirmed that the FSA-MIPs have good prospects in the extraction and separation of synthetic cathinones, which is suitable for further application in the criminal sciences field.

Reports of Adverse Events Associated with Use of Novel Psychoactive Substances, 2017-2020: A Review

An important role of modern forensic and clinical toxicologists is to monitor the adverse events of novel psychoactive substances (NPS). Following a prior review from 2013 to 2016, this critical literature review analyzes and evaluates published case reports for NPS from January 2017 through December 2020. The primary objective of this study is to assist in the assessment and interpretation of these cases as well as provide references for confirmation methods. Chemistry, pharmacology, adverse events and user profiles (e.g., polypharmacy) for NPS are provided including case history, clinical symptoms, autopsy findings and analytical results. Literature reviews were performed in PubMed and Google Scholar for publications using search terms such as NPS specific names, general terms (e.g., ‘designer drugs’ and ‘novel psychoactive substances’), drug classes (e.g., ‘designer stimulants’) and outcome-based terms (e.g., ‘overdose’ and ‘death’). Government and website drug surveillance databases and abstracts published by professional forensic science organizations were also searched. Toxicological data and detailed case information were extracted, tabulated, analyzed and organized by drug category. Case reports included overdose fatalities (378 cases), clinical treatment and hospitalization (771 cases) and driving under the influence of drugs (170 cases) for a total of 1,319 cases providing details of adverse events associated with NPS. Confirmed adverse events with associated toxidromes of more than 60 NPS were reported including synthetic cannabinoid, NPS stimulant, NPS hallucinogen, NPS benzodiazepine and NPS opioid cases. Fifty of these NPS were reported for the first time in January 2017 through December 2020 as compared to the previous 4 years surveyed. This study provides insight and context of case findings described in the literature and in digital government surveillance databases and websites during a recent 4-year period. This review will increase the awareness of adverse events associated with NPS use to better characterize international emerging drug threats.

Knowledge and Use of Novel Psychoactive Substances in an Italian Sample with Substance Use Disorders

This study aims to determine prevalence and frequency of use of novel psychoactive substances (NPS) and to identify the factors associated with NPS use in an Italian sample of patients diagnosed with substance use disorder (SUD). Prevalence and correlates of NPS knowledge and use were assessed in 185 patients with SUD in three addiction services (Padova, Belluno, Feltre) in the Veneto region with an ad-hoc designed survey. Two thirds of the samples reported knowing NPS and one third reported using them. NPS were considered by them less dangerous than "regular" substances of abuse (t = 6.06 mean 0.78, p < 0.001). Factors associated with NPS use were youth (OR = 4.81; p < 0.001), studentship (OR = 4.99; p = 0.004), subsequent mental disorders diagnosis (OR = 2.49; p = 0.027), suicide attempt history (OR = 11.67; p < 0.001), home detention (OR = 2.30; p = 0.040), residential care (OR = 5.66; p = 0.002), and polysubstance abuse (t = 8.99 mean 2.65 p < 0.001). NPS use in patients with SUD is highly prevalent, particularly in the youngest age group, and associated with psychiatric comorbidity and worse prognosis. It is crucial to systematically assess NPS use and inform addiction service users with SUD of the toxic and potentially lethal side effects. Mental healthcare professionals working in addiction services should receive education and training. Cohort and longitudinal studies are needed.

Application of liquid chromatography coupled to data-independent acquisition mass spectrometry for the metabolic profiling of N-ethyl heptedrone

We have investigated the metabolic profile of N-ethyl heptedrone, a new designer synthetic stimulant drug, by using data independent acquisition mass spectrometry. Phase I and phase II metabolism was studied by in vitro models, followed by liquid-chromatography coupled to mass spectrometry, to characterize and pre-select the most diagnostic markers of intake. N-ethyl heptedrone was incubated in the presence of pooled human liver microsomes. The contribution of individual enzymatic isoforms in the formation of the phase I and phase II metabolites was further investigated by using human recombinant cDNA-expressed cytochrome P450 enzymesand uridine 5'-diphospho glucuronosyltransferases. The analytical workflow consisted of liquid-liquid extraction with tert-butyl-methyl-ether at alkaline pH, performed before (to investigate the phase I metabolic profile) and after (to investigate the glucuronidation profile) enzymatic hydrolysis. The separation, identification, and determination of the compounds formed in the in vitro experiments were carried out by using liquid chromatography coupled to either high- or low-resolution mass spectrometry. Data independent acquisition method, namely sequential window acquisition of all theoretical fragment-ion spectra (SWATH®) and product ion scan were selected for high-resolution mass spectrometry, whereas multiple reaction monitoring was used for low-resolution mass spectrometry. Thirteen phase-I metabolites were isolated, formed from reactions being catalyzed mainly by CYP1A2, CYP2C9, CYP2C19 and CYP2D6 and, to a lesser degree, by CYP3A4 and CYP3A5. The phase I biotransformation pathways included hydroxylation in different positions, reduction of the ketone group, carbonylation, N-dealkylation, and combinations of the above. Most of the hydroxylated metabolites underwent conjugation reactions to form the corresponding glucurono-conjugated metabolites. Based on our in vitro observation, the metabolic products resulting from reduction of the keto group, N-dealkylation and hydroxylation of the aliphatic chain appear to be the most diagnostic target analytes to be selected as markers of exposure to N-ethyl heptedrone.

Substance use among adolescents and young adults with chronic kidney disease or kidney failure

Substance use, a significant public health issue, is well described in the adult chronic kidney disease (CKD) population. Knowledge about substance use in the adolescent and young adult (AYA) CKD population such as prevalence, impact on kidney function, medication adherence, and psychosocial well-being remain largely unknown. Awareness of and inquiring about substance use is paramount to providing evidence-based care and preparation to transition to adult-focused health services. The authors in this review identify commonly used substances (alcohol, tobacco, marijuana, etc.) and how they impact kidney function and care of the AYA with CKD or kidney failure. Recommendations for screening and intervention strategies are provided.

Ethanol pre-exposure differentially impacts the rewarding and aversive effects of α-pyrrolidinopentiophenone (α-PVP): Implications for drug use and abuse

RATIONALE

Exposure to a drug can subsequently impact its own reactivity as well as that of other drugs. Given that users of synthetic cathinones, i.e., "bath salts", typically have extensive and varied drug histories, an understanding of the effects of drug history on the behavioral and physiological consequences of synthetic cathiones may be important to their abuse liability.

OBJECTIVES

The goal of the current work was to assess the effects of an ethanol pre-exposure on the rewarding and aversive effects of α-PVP.

METHODS

Adult male Sprague Dawley rats were exposed to ethanol prior to combined conditioned taste avoidance/conditioned place preference training in which rats were injected with 1.5, 3 or 5 mg/kg of racemic α-PVP or vehicle. Following a 7-day washout period, rats were then tested for thermoregulatory effects of α-PVP using subcutaneous probes to measure body temperature changes over the course of 8 h. This was followed 10 days later by assessments for α-PVP-induced locomotor activity and stereotypies over a 1-h session.

RESULTS

α-PVP induced significant dose- and trial-dependent taste avoidance that was significantly attenuated by ethanol history and dose- and time-dependent increases in locomotor activity that were significantly increased by ethanol. α-PVP also induced place preferences and dose- and time-dependent increases in body temperature, but these measures were unaffected by ethanol history.

CONCLUSIONS

α-PVP's aversive effects (as measured by taste avoidance) were attenuated, while its rewarding effects (as indexed by place preference conditioning) were unaffected, by ethanol pre-exposure. Such a pattern may indicate increased α-PVP abuse liability, as changes in the balance of aversion and reward may impact overall drug effects and likelihood of drug intake. Future self-administration studies will be necessary to explore this possibility.

Early Warning System for Illicit Drug Use at Large Public Events: Trace Residue Analysis of Discarded Drug Packaging Samples

Inspired by Locard's exchange principle, which states "every contact leaves a trace", a trace residue sampling strategy has been developed for the analysis of discarded drug packaging samples (DPS), as part of an early warning system for illicit drug use at large public events including music/dance festivals. Using direct analysis in real time/mass spectrometry and tandem mass spectrometry, rapid and high-throughput identification and characterization of a wide range of illicit drugs and adulterant substances was achieved, including in complex polydrug mixtures and at low relative ion abundances. A total of 1362 DPS were analyzed either off-site using laboratory-based instrumentation or on-site and in close to real time using a transportable mass spectrometer housed within a mobile analytical laboratory, with each analysis requiring less than 1 min per sample. Of the DPS analyzed, 92.2% yielded positive results for at least one of 15 different drugs and/or adulterants, including cocaine, MDMA, and ketamine, as well as numerous novel psychoactive substances (NPS). Also, 52.6% of positive DPS were found to contain polydrug mixtures, and a total of 42 different drug and polydrug combinations were observed throughout the study. For analyses performed on-site, reports to key stakeholders including event organizers, first aid and medical personnel, and peer-based harm reduction workers could be provided in as little as 5 min after sample collection. Following risk assessment of the potential harms associated with their use, drug advisories or alerts were then disseminated to event staff and patrons and subsequently to the general public when substances with particularly toxic properties were identified.

Problem-solving deficits in methcathinone use disorder

RATIONALE

The use of methcathinone (MCAT), a psychostimulant drug that can lead to long-term health risks and executive dysfunction, increased to an alarming rate in recent years. Impairments in low-level executive function have been reported in substance use disorder. However, little empirical evidence is available regarding high-level executive function (e.g., problem solving), which may act as a risk factor for relapse.

OBJECTIVES

The present study aimed to investigate whether the problem-solving ability was altered in abstinent individuals with methcathinone use disorder (MCUD). Here, we tested fifty male MCUD individuals (short-term MCUD group: twenty-nine patients with MCAT use less than 3 years, long-term MCUD group: twenty-one patients with MCAT use longer than 3 years, which were split by medium years of drug use) and twenty-four well-matched healthy controls (HC) in the Tower of Hanoi task (TOH) to assess the impact of task difficulty on drug-related changes in problem-solving performance. We used several measures to characterize problem-solving performance: the number of mistakes made, the completion time of the task, and the thinking time before the first move.

RESULTS

In the low task difficulty condition, the MCUD group and HC group showed similar levels of mistakes and completion time, while in the high task difficulty condition, the MCUD group reported more mistakes (the mean number of mistakes in each trial: 1.41 ± 1.15 vs 0.79 ± 0.76, P = 0.019, Cohen's d = 0.635) and longer completion time in the task (the mean completion time in each trial: 45.83 ± 20.51 s vs 33.40 ± 15.10 s, P = 0.010, Cohen's d = 0.690) than the HC group. The thinking time before the first move did not differ significantly between groups (P = 0.257). We further found that the long-term (more than 3 years) MCUD group made more mistakes than the short-term MCUD group and HC group, mainly in the highly difficult subtasks. The longer time than HCs was reported in the long-term MCUD group among high task difficulty of subtasks. In addition, there was a positive correlation between years of MCAT use and the number of mistakes made in high task difficulty TOH task (r = 0.326, P = 0.021).

CONCLUSIONS

Chronic methcathinone use was associated with deficits in problem-solving performance, which depended on the degree of task difficulty. The impairment was more evident in the long-term (> 3 years) MCAT group.

Synthesis, characterization, and evaluation of selective molecularly imprinted polymers for the fast determination of synthetic cathinones

As a kind of new psychoactive substance (NPS), synthetic cathinones have drawn great worldwide attention. In this study, molecularly imprinted polymers (MIPs), as adsorbents for the extraction and determination of 4-methyldimethcathinone (4-MDMC), were first synthesized by coprecipitation polymerization. The physicochemical analyses of MIPs were successfully performed by XRD, FTIR, FESEM and TGA techniques. Furthermore, rebinding properties of temperature and pH dependence, and selectivity and reusability tests for MIPs and non-imprinted polymers (NIPs) were performed using an ultraviolet-visible spectrometer (UV-vis). The obtained results indicate that the imprinting efficiency has strong dependence on temperature and pH, and the optimal adsorption for targets is achieved under the condition of 318 K and pH = 6.0. This means that the combination between the polymers and 4-MDMC is a strong spontaneous and endothermic process. Compared with NIPs, MIPs exhibit prominent adsorption capacity (Q_e = 9.77 mg g⁻¹, 318 K). The selectivity coefficients (k) of MIPs for 4-MDMC, methylenedioxypentedrone (βk-MBDP), 4-ethylmethcathinone (4-EMC), methoxetamine (MXE) and tetrahydrofuranylfentanyl (THF-F) were found to be 1.70, 3.49, 7.14 and 5.82, respectively. Moreover, it was found that the adsorption equilibrium was achieved within 30 min. The aim of this work is the simple synthesis of MIPs and the optimal performance of the molecular recognition of 4-MDMC. Moreover, the synthesized MIPs can be easily regenerated and repeatedly used with negligible loss of efficiency (only 9.94% loss after six times adsorption–desorption tests). Satisfying recoveries in the range of 69.3–78.9% indicate that MIPs have good applicability for analyte removal from urine samples. Ultimately, this material shows great promise for the rapid extraction and separation of synthetic cathinones, which are dissolved in the liquid for the field of criminal sciences.

Molecularly imprinted polymers, as an adsorbent for extraction and selective recognition of 4-methyldimethcathinone, were firstly synthesized through coprecipitation polymerization.

Drug-related medical hospital admissions during and after a period of head shop expansion

BACKGROUND

New psychoactive substance (NPS) use can negatively impact health and may result in drug-related hospital admissions (DRHAs). Irish youth reported very high rates of NPS use by international standards, the most common being synthetic cannabinoids and cathinones. There was a rapid expansion in specialist shops, called head shops, selling NPS in 2010. Government responded to public protests about head shops by enacting legislation in May and August 2010 to end this trade. Many academics argued that such actions would prove futile. We sought to determine if changes in head shop activity coincided with changes in DRHA.

METHODS

The national database on admissions to general hospitals hospital in-patient enquiry was examined focusing on young adults admitted from 2008 to 2012, and all emergency admissions with an International Classification of Diseases-10 diagnosis of mental disorder related to any drug (F11-F19) were identified. Joinpoint regression analysis was utilized to explore for the presence of trend changes in DRHA.

RESULTS

Joinpoint regression analysis identified a significant downward trend change which occurred in June 2010 (95% CI February 2010 to January 2011). DRHA increased by 0.5% (95% CI 0.1-0.9) per month prior to this and then fell by 2.6% (95% CI -1.4 to -3.8) per month over the next 16 months.

CONCLUSIONS

Cessation of NPS sale by head shops coincided with a reversal in the upward trend of emergency hospital admissions related to drugs. Although correlation does not confirm causation, legislation which successfully curtails the commercial sale of NPS may result in reduced hospitalizations.

Reinforcing effects of synthetic cathinones in rhesus monkeys: Dose-response and behavioral economic analyses

The abuse of synthetic cathinones ("bath salts") with psychomotor stimulant and/or entactogenic properties emerged as a public health concern when they were introduced as "legal" alternatives to drugs of abuse such as cocaine or MDMA. In this study, experiments were conducted in nonhuman primates to examine how differences in transporter selectivity might impact the reinforcing effects of synthetic cathinones. Rhesus monkeys (N = 5) were trained to respond for intravenous injections under a fixed-ratio (FR) 30, timeout 60-s schedule of reinforcement. The reinforcing effects of selected cathinones (e.g., MDPV, αPVP, MCAT, and methylone) with a range of pharmacological effects at dopamine and serotonin transporters were compared to cocaine and MDMA using dose-response analysis under a simple FR schedule and behavioral economic procedures that generated demand curves for two doses of each drug. Results show that one or more doses of all drugs were readily self-administered in each subject and, excepting MDMA (21 injections/session), peak levels of self-administration were similar across drugs (between 30 and 40 injections/session). Demand elasticity for the peak and the peak + 1/2-log dose of each drug did not significantly differ, and when data for the two doses were averaged for each drug, the following rank-order of reinforcing strength emerged: cocaine > MCAT = MDPV = methylone > αPVP = MDMA. These results indicate that the reinforcing strength of synthetic cathinones are not related to their selectivity in binding dopamine or serotonin transporter sites.

Synthetic drugs of abuse

Synthetic drugs of abuse contain various psychoactive substances. These substances have recently emerged as novel drugs of abuse in public; thus, they are known as novel psychoactive substances (NPS). As these compounds are artificially synthesized in a laboratory, they are also called designer drugs. Synthetic cannabinoids and synthetic cathinones are the two primary classes of NPS or designer drugs. Synthetic cannabinoids, also known as "K2" or "Spice," are potent agonists of the cannabinoid receptors. Synthetic cathinones, known as "Bath salts," are beta-keto amphetamine derivatives. These compounds can cause severe intoxication, including overdose deaths. NPS are accessible locally and online. NPS are scheduled in the US and other countries, but the underground chemists keep modifying the chemical structure of these compounds to avoid legal regulation; thus, these compounds have been evolving rapidly. These drugs are not detectable by traditional drug screening, and thus, these substances are mainly abused by young individuals and others who wish to avoid drug detection. These compounds are analyzed primarily by mass spectrometry.

Fatal α-PVP and amphetamine poisoning during a sauna and autoerotic practices

We describe the sudden death of a middle-aged man while having a sauna under the influence of α-pyrrolidinovalerophenone (α-PVP) (PM blood concentration: 0.8 mg/L), amphetamine (0.34 mg/L), and other drugs (buprenorphine, benzodiazepines), and engaging in solitary sexual activities. The drugs’ effects on the cardio-circulatory system and on body thermoregulation combined with the high temperatures are likely to have been central mechanisms leading to death. The high levels of adrenaline triggered by sexual arousal and the respiratory depression caused by buprenorphine, in association with benzodiazepines, may have also contributed to his death. This previously unreported type of accidental autoerotic death illustrates the risk of using amphetamine-like sympathomimetic drugs (e.g. cathinone derivates) in hot environments such as a sauna, and during sexual activities therein.

Legislation targeting head shops selling new psychoactive substances and changes in drug-related psychiatric admissions: A national database study

AIM

New psychoactive substance (NPS) use can negatively impact mental health and may result in drug-related psychiatric admissions (DRPA). Irish youth reported very high rates of NPS use by international standards, the most common being synthetic cannabinoids and cathinones. This occurred in the context of a rapid expansion in specialist high street shops, called head shops, selling NPS in 2010. Government responded to public protests about head shops by enacting legislation in May and August 2010 to end this trade. Many academics argued that such actions were futile. We sought to determine if changes in head shop activity coincided with changes in DRPA.

METHOD

The national database on psychiatric admissions was examined focusing on young adults admitted from 2008 to 2012. Joinpoint regression analysis was utilized to examine for the presence of trend changes in DRPA.

RESULTS

The monthly rate of DRPA was higher in 2010 than 2008, 2009 and 2012 (P < 0.01). Joinpoint regression analysis identified a significant downward trend change which occurred in July 2010 (95% CI Feb 2010 to April 2011). Young males aged 18 to 24 years showed evidence of greatest change, DRPA falling by 1.4% per month (95% CI 0.7 to 3.7% decline) from May 2010 to December 2012.

CONCLUSIONS

Cessation of NPS sale by head shops coincided with a reversal in the upward trend of DRPA, this change being most evident in young men. While correlation does not imply causation, legislation which successfully targets the sale of NPS may result in reduced drug-related mental disorders.

Reinforcing Effects of the Synthetic Cathinone α-Pyrrolidinopropiophenone (α-PPP) in a Repeated Extended Access Binge Paradigm

Synthetic cathinones are designer psychostimulants that are derivatives of the natural alkaloid cathinone, and produce effects similar to more traditional illicit stimulants such as cocaine and methamphetamine. The pyrovalerone cathinones methylenedioxypyrovalerone (MDPV) and α-pyrrolidinopropiophenone (α-PPP) exert their effects via inhibition of presynaptic dopamine and norepinephrine reuptake transporters. While the reinforcing effects of MDPV in rodents are well-established, very few studies have examined self-administration patterns of α-PPP. Users of synthetic cathinones often engage in repeated binge episodes of drug intake that last several days. We therefore sought to determine the reinforcing effects of three doses of α-PPP (0.05, 0.1 and 0.32 mg/kg/infusion) under conditions of prolonged binge-like access conditions, with three 96-h periods of drug access interspersed with 72 h of abstinence. MDPV (0.05 mg/kg/infusion) was used as a comparison drug. Our results show that both MDPV and the high (0.32 mg/kg/infusion) dose of α-PPP are readily self-administered at high levels across all three extended access periods, whereas lower doses of α-PPP produce variable and less robust levels of self-administration. These results indicate that higher doses of α-PPP have reinforcing effects under conditions of extended access, suggesting the potential for abuse and a need for consideration in drug control policies.

Self-administration of the synthetic cathinones 3,4-methylenedioxypyrovalerone (MDPV) and α-pyrrolidinopentiophenone (α-PVP) in rhesus monkeys

RATIONALE

The availability and abuse of synthetic analogues of cathinone have increased dramatically around the world. Synthetic cathinones, such as 3,4-methylenedioxypyrovalerone [MDPV] and α-pyrrolidinopentiophenone [α-PVP], are cocaine-like inhibitors of monoamine transporters and common constituents of "bath salts" or "flakka" preparations. Studies in rats suggest that MDPV and α-PVP are 3 to 4-fold more effective reinforcers than cocaine; however, comparisons of the relative reinforcing effectiveness of MDPV and α-PVP have not been reported in other species.

OBJECTIVES

Accordingly, in the present study, 4 adult male rhesus monkeys responding under a progressive ratio schedule of reinforcement were used to characterize the reinforcing effects of MDPV and α-PVP and to compare directly these effects with those of cocaine and methamphetamine.

RESULTS

MDPV was the most potent reinforcer, followed by α-PVP, methamphetamine, and cocaine. α-PVP was the most effective reinforcer, followed by MDPV, cocaine, and methamphetamine. In addition to making more responses to obtain MDPV and α-PVP, monkeys also responded for longer periods of time when MDPV or α-PVP was available compared with when either cocaine or methamphetamine was available for infusion.

CONCLUSIONS

These studies confirm recent reports from rodents and provide strong evidence that the synthetic cathinones MDPV and α-PVP are capable of maintaining high levels of responding for prolonged periods of time, and that they function as more effective reinforcers than either cocaine or methamphetamine. The relative strength of these reinforcing effects may account for the high rates of "bath salts" use reported in humans.

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.

The public health evidence-base on novel psychoactive substance use: scoping review with narrative synthesis of selected bodies of evidence

Background

This review aimed to address what was known about the public health burden associated with novel psychoactive substances (NPS) use, and the effectiveness of responses targeting NPS use and/or associated problems.

Methods

Relevant literature was identified through a range of searches covering the period from January 2006 to June 2016. Data synthesis was undertaken in three stages. Firstly we mapped the evidence available in order to characterize the literature according to a set of analytic categories developed a priori. Secondly, we identified evidence gaps from a set of a priori research questions. Finally, we then undertook a narrative synthesis of selected bodies of evidence, interpreting data using a conceptual framework specifically designed for use in this review.

Results

A total of 995 articles were included in the scoping review with the majority being case reports/series on individual level adverse effects due to NPS use. We synthesized UK data from 29 surveys and 7 qualitative studies, and international data in 10 systematic reviews on harms associated with NPS use, and 17 evaluations of policy responses. We found little data on risk factors, harms associated with long-term NPS use, and interventions.

Conclusion

In all cases we found the available evidence to be at an early stage of development.

α-Pyrrolidinopentiophenone ("Flakka") Catalyzing Catatonia: A Case Report and Literature Review

: Synthetic cathinones are a class of novel psychoactive substances. α-Pyrrolidinopentiophenone (α-PVP), or "Flakka", is one of these substances. Users often present acutely psychotic or agitated. We present the case of a 20-year-old male without prior psychiatric history who was brought to the hospital by his family because of increasingly bizarre and erratic behavior after reported ingestion of Flakka. What ensued was a prolonged course of psychosis and severe catatonia. Synthetic cathinones are thought to cause catatonia in approximately 1% of cases. Awareness of the possible presentations associated with α-PVP intoxication is increasingly important and should be further explored, as they can have important implications in setting expectations for care. Additionally, providers should have a low threshold for asking patients about bath salt ingestion.

Evidence for public health on novel psychoactive substance use: a mixed-methods study

Background

Novel psychoactive substances (NPSs) contribute to the public health impact of substance misuse. This report provides research evidence addressing 11 research questions related to NPSs, covering types, patterns and settings of use; supply sources; and implications for policy and practice.

Methods

The study used a conceptually linked three-phase mixed-methods design with a shared conceptual framework based on multiple-context risk and protective factors. Phase 1 was a quantitative phase involving secondary data analysis of the longitudinal Belfast Youth Development Study (BYDS), a latent class analysis using the 2039 BYDS participants. Phase 2 was an extensive qualitative analysis via narrative interviews with participants, sampled from BYDS, drug/alcohol services and prisons, to explore NPS use trajectories. Phase 3 was the final quantitative phase; generalisability of the shared risk factor part of the model was tested using the manual three-step approach to examine risk factors associated with latent class membership. The quantitative and qualitative analyses were integrated, thus allowing emerging findings to be further explored.

Results

The data suggest that NPSs have a place within a range of polydrug use trajectories. Models showed no distinctive NPS class, with no clear evidence of differential risks for NPS use compared with the use of other substances. From the qualitative analysis, a taxonomy of groups was derived that explored how and where NPSs featured in a range of trajectories. This taxonomy was used to structure the analysis of factors linked to use within a risk and protective framework. Drivers for use were considered alongside knowledge, perceptions and experience of harms. Suggestions about how interventions could best respond to the various patterns of use – with special consideration of synthetic cannabinoids (SCs), including how they relate to the use of heroin and the potential for NPSs to operate as a ‘snare’ to more problem use – were also presented.

Limitations

The study was conducted during 2016/17; generalisability beyond this sample and time point is limited. The level of missing data for some of the BYDS analysis was a limitation, as was the fact that the BYDS data were collected in 2011, so in a different context from the data collected during the narrative interviews. The Psychoactive Substances Act 2016 (Great Britain. Psychoactive Substances Act 2016. London: The Stationery Office; 2016) came into force during qualitative fieldwork and, although not particularly influential in this study, may be influential in future work. It is acknowledged that many of the data related to SCs and mephedrone. Although drug use was measured by self-report, the strength of rapport within interviews, reflective diaries and methodological acceptability checks helped to mitigate self-report bias.

Conclusions

NPSs continue to present significant challenges for legislation and monitoring, researching and developing interventions. Understanding of usage patterns remains poor, with most information based on populations and settings where problems have already occurred. This research contributes to the evidence base by providing much needed further empirical data on the lived experiences of NPS users across a range of settings. In the light of these data, implications for policy and practice are discussed.

Future work

Future research must generate improved epidemiological data on the extent, patterns and motivations for use longitudinally. The uniqueness of the information concerning SC use points to a specific set of findings not evidenced in other literature (e.g. intensity of SC withdrawal). Future research should focus on the symbiotic link between SC and heroin use.

Funding

The National Institute for Health Research Public Health Research programme.

Stimulant Use in Pregnancy: An Under-recognized Epidemic Among Pregnant Women

Stimulant use, including cocaine, methamphetamines, ecstasy, and prescription stimulants, in pregnancy is increasingly common. In the United States, stimulants are the second most widely used and abused substances during pregnancy and pregnant women using stimulants in pregnancy are at increased risk of adverse perinatal, neonatal, and childhood outcomes. In this review, we describe the pharmacology, pathophysiology, and epidemiology of stimulants, summarize the maternal and neonatal effects of perinatal stimulant use, and outline treatment options for stimulant use disorders among pregnant women. Development of effective treatment strategies for stimulant use disorders identified among pregnant women are urgently needed.

A fatal case of poisoning of a 19-year-old after taking 3-MMC

The significant increase in the number of new psychoactive substances on the drug market has recently been a serious problem. The manuscript presents a fatal case of suicide poisoning with 3-MMC (3-methylmethcathinone). The biological material collected during the autopsy of a 19-year-old woman, transferred to the toxicological Laboratory in Katowice ToxLab, was subjected to a chemical and toxicological analysis. The toxicological analysis of blood, vitreous humor and gastric contents revealed 3-methylmetcatinone at a concentration of 800 ng/ml, 153 ng/ml and 5,5 mg, respectively. The presence of 3-MMC has also been confirmed in physical evidence secured on site. 3-methylmethcathinone is a dangerous psychoactive substance that caused the death of the 19-year-old.

Synthetic Cathinone Use Among Polysubstance Users: Indirect Indicator of Indiscriminate Drug Taking or Preferred Drug of Abuse?

A survey pertaining to synthetic cathinone (SC) use was completed by 499 polysubstance users enrolled in a residential recovery program in the Southeastern United States. Of the final sample, 28% reported ever SC use. SC-users, compared with nonusers, were more often younger (32.7 vs. 36.0, p = .001), White (93.4% vs. 80.8%, p = .001), and on probation/parole since 2010 (80.9% vs. 70.9%, p = .032). SC-users evidenced extensive drug histories and were less likely to be enrolled in an urban-based program, compared to a rural, Appalachian-based program (73.8% vs. 86.6%, p = .001). Use of synthetic cannabinoids (adjusted odds ratio [AOR] = 1.9, p = .044), kratom (AOR = 1.7, p = .045), and inhalants (AOR = 2.3, p = .001) were significantly associated with SC use. Approximately 23% of SC-users preferred SCs to amphetamines or cocaine; however, only 3.6% ranked SC as their most preferred drug. Past-year SC use declined to 6.6%. Among polysubstance users in this sample, SC use may be a potential indicator of versatile and indiscriminate drug-taking.

The Explosion of a New Designer Drug, Flakka: Implications for Practice

There are many challenges facing healthcare professionals. One such challenge is the continuous introduction of new synthetic drugs. Synthetic drugs pose many difficulties to providers, including identification of the drug ingested, management of symptoms, ensuring safety of the patient and his or her environment, and continual monitoring after the initial symptoms, because synthetic cathinones have many long-term effects on an individual. One such synthetic drug, flakka, is a potent second-generation synthetic cathinone. Because flakka inhibits the reuptake of norepinephrine and dopamine, which are involved in one's perception of pleasure, it causes inflated feelings and also causes signs and symptoms of psychosis. Flakka also induces various exaggerated symptoms, such as feelings of incredible strength, disorientation, aggression, and altered thought processes, and also can cause hyperthermia, coma, and death. Healthcare professionals need to understand the nature of flakka ingestion, the various symptoms a user may exhibit, and the long-term symptoms a person may have once the acute recovery phase has ended. Once the initial phase of ingestion is over and the patient is medically stabilized, the patient may experience signs and symptoms of psychosis or other psychiatric disorders. It is paramount that healthcare professionals are able to recognize the signs and symptoms of flakka ingestion, know the steps to take to ensure safety of the patient and those around him or her, and also know how to facilitate the patient's recovery.

Molecularly imprinted polymer solid-phase extraction of synthetic cathinones from urine and whole blood samples

In forensic drug analysis, extractive pretreatment is required prior to instrumental analysis to ensure successful detection of the target compounds. However, conventional extraction methods such as hydrophilic polymer-based solid-phase extraction and liquid-liquid extraction are unsuitable for an emerging class of new psychoactive substances, namely, synthetic cathinones, because they exhibit a lack of class selectivity and increased risk of target analyte decomposition during extraction. To address these issues, we describe a highly class-selective sample clean-up method for the extraction of synthetic cathinones from urine and whole blood samples, exploiting a molecularly imprinted polymer solid-phase extraction cartridge. In terms of the influence of the synthetic cathinone molecular structure on the extraction recovery, we showed that while longer alkyl side chains slightly reduced the extraction efficiency, substituent variation on the aromatic ring exerted no effect. Molecularly imprinted polymer solid-phase extraction of 11 synthetic cathinones from urine samples yielded higher recoveries than the two conventional extraction methods, and smaller matrix effect was observed than that with hydrophilic polymer-based solid-phase extraction. Molecularly imprinted polymer solid-phase extraction from whole blood samples gave recoveries comparable to those of urine samples. Therefore, the proposed method is applicable for the extraction and quantitative determination of synthetic cathinones in biological samples.

Synthetic and Other Drug Use among High School Students: The Role of Perceived Prevalence, Access, and Harms

BACKGROUND

Synthetic and other drugs have become available to teens, yet little is known about risk factors of use.

OBJECTIVE

To examine adolescent use of one class of synthetic drugs and its association with perceptions about its prevalence, access, and risk of substance use.

METHODS

Adolescents from a convenience sample of 104 middle and high schools (N = 59,218) participated in an anonymous survey to assess school climate and substance use in 2013-2014. Multilevel logistic regression examined the association between risk for synthetic and other drug use, perceptions of substance use, and school-level characteristics.

RESULTS

Results indicated that 2,407 (4.3%) students reported synthetic and other drug use in the past 30 days. A large proportion of youth perceived drugs to be problematic at school but underestimated the harms associated with drug use. Participants also perceived tobacco, alcohol, marijuana, and prescription drugs are easy to obtain. Risk factors for synthetic and other drug use included the perception that substance use was a large problem at school, ease of access to drugs, and limited harm associated with drug use. School enrollment and socio-economic status of students reduced odds of drug use. Similar trends were found regarding marijuana use. Conclusion/Importance: Synthetic and other drug use is an emerging public health concern. Many youth identified substances as problematic and easily accessible in their schools but underestimated their potential harms. Health and education professionals need to increase effective education around substance use, including common risk factors for synthetic drug use.

Drug and Alcohol-Related Crime Among University Students

The aim of the article is to determine the approximate prevalence of drug and alcohol-related crime among university students in seven universities in the United Kingdom and to assess whether there are differences between substance users who offend and substance users who do not offend. In total, 7,855 students submitted a questionnaire. The results of the study show that 10% of students who used drugs and about the same percentage who used alcohol had committed substance-related crimes in the current academic year. The most prolific offenders in relation to both drug and alcohol-related offending were males, those who frequently went out to socialise, frequent users of nightclubs off campus, and those in poor physical or mental health. The article proposes that preventative interventions should be used to address alcohol and drug-related crime and its consequences.

Fingertip Necrosis due to Intravascular Use of Mephedrone: A Case Report

Mephedrone is a new synthetic cathinone-derived drug. It is a sympathomimetic drug, and its structure is similar to amphetamines, although its specific pharmacokinetics and metabolism remain unknown. We performed a literature search in PUBMED with the following key words: Mephedrone AND Necrosis AND Hand. No results were found. We performed a second literature search with the following key words: Mephedrone AND Physiopathology AND Side effects, obtaining a total of 7 articles that we read before writing this case report. We will present a case report of a 28-year-old man with distal ischemia in his left hand associated to intra-arterial drug use of mephedrone. The patient ended up having superficial necrosis involving skin and subcutaneous tissue in his thumb, which was treated with wound care. Good quality healing, full range of motion, and normal sensitivity were achieved. There are no previous publications related to any side effects secondary to its intravascular use. The ultimate mechanism producing this distal fingertip necrosis remains undefined.

Patterns of NPS Use and Risk Reduction in Slovenia

BACKGROUND

The following study presents factors influencing the decision to use/not to use new psychoactive substances (NPS), various patterns of NPS use, the problems experienced by users, and the methods for reducing the risks associated with NPS use.

OBJECTIVES

The study seeks to provide an in-depth look into the characteristics of NPS use and support the planning of targeted interventions in the field of NPS.

METHODS

The study involved 19 in-depth interviews carried out with 25 individuals divided into three subsamples in order to gain insight into the various experiences of NPS users. The interviews were conducted in Slovenia between December 2013 and October 2014. The sample was obtained by using the convenience sampling and snowball sampling methods.

RESULTS

The main pattern of NPS use determined by the study concerned synthetic cathinones, specifically 3-MMC, with binge use spanning several days being a prominent feature. The main risks involving NPS use were: mixing various drugs, inappropriate dosing, lack of information prior to use, and the use of unknown substances. Several users spoke about effective strategies for reducing risks, such as obtaining information beforehand, using one's own implements and using only small quantities of unknown substances. Conclusions/Importance: The study revealed various factors based on which users decide to use NPS. Furthermore, users reported a number of problems resulting from NPS use, while risk reduction strategies are employed to a much lesser extent. Based on the results obtained, specific intervention efforts concerning NPS use and targeting specific groups of younger users were designed.

Illicit and Counterfeit Drug Analysis by Morphologically Directed Raman Spectroscopy

Morphologically directed Raman spectroscopy (MDRS) is a novel tool for the forensic analysis of illicit and counterfeit drug samples. MDRS combines Raman microspectroscopy with automated particle imaging so that physical and chemical information about the components of a mixture sample can be obtained. Results of automated particle imaging are used to determine samples for Raman analysis. The use of MDRS for these types of samples can be employed for both forensic investigations and adjudications of cases. The method provides insight about the physical and chemical composition of the sample, as well as about manufacturing and sample history. Here, MDRS was used in four different illicit and counterfeit drug analyses: (1) examination of a multicomponent drug mixture where the results could be used for comparative source attribution, (2) the detection of low (or trace) concentration particles in a drug sample, (3) the analysis of synthetic cathinone samples (i.e., bath salts), and (4) a study of counterfeit pharmaceutical products.

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.

Polysubstance use profiles among electronic dance music party attendees in New York City and their relation to use of new psychoactive substances

BACKGROUND

Electronic Dance Music (EDM) party attendees are often polysubstance users and are at high risk for use of new psychoactive substances (NPS). We sought to identify patterns of use of common illegal drugs among EDM party attendees, sociodemographic correlates, and use of NPS as a function of patterns of use of more common drugs to inform prevention and harm reduction.

METHOD

Using time-space-sampling, 1045 individuals aged 18-40 were surveyed entering EDM parties in New York City. We queried past-year use of common illegal drugs and 98 NPS. We conducted latent class analysis to identify polysubstance use profiles of use of eight common drugs (i.e., ecstasy, ketamine, LSD, mushrooms, powder cocaine, marijuana, amphetamine, benzodiazepines). Relationships between drug classification membership and sociodemographics and use of drugs within six NPS categories were examined.

RESULTS

We identified four profiles of use of common drugs: non-polysubstance use (61.1%), extensive polysubstance use (19.2%), moderate polysubstance use/stimulants (12.8%), and moderate polysubstance use/psychedelics (6.7%). Those in the moderate/psychedelic group were at higher odds of using NPS with psychedelic-type effects (2C, tryptamines, and other "new" psychedelics; Ps<0.05). Extensive polysubstance users were at increased odds of reporting use of 2C drugs, synthetic cathinones ("bath salts"), tryptamines, other new (non-phenethylamine) psychedelics, new dissociatives, and synthetic cannabinoids (Ps<0.05).

CONCLUSION

NPS preference is linked to the profile of use of common drugs among individuals in the EDM scene. Most participants were identified as non-polysubstance users, but findings may help inform preventive and harm reduction interventions among those at risk in this scene.

Prediction of designer drugs: Synthesis and spectroscopic analysis of synthetic cathinone analogs that may appear on the Swedish drug market

The use of hyphenated analytical techniques in forensic drug screening enables simultaneous identification of a wide range of different compounds. However, the appearance of drug seizures containing new substances, mainly new psychoactive substances (NPS), is steadily increasing. These new and other already known substances often possess structural similarities and consequently they exhibit spectral data with slight differences. This situation has made the criteria that ensure indubitable identification of compounds increasingly important. In this work, 6 new synthetic cathinones that have not yet appeared in any Swedish drug seizures were synthesized. Their chemical structures were similar to those of already known cathinone analogs of which 42 were also included in the study. Hence, a total of 48 synthetic cathinones making up sets of homologous and regioisomeric compounds were used to challenge the capabilities of various analytical techniques commonly applied in forensic drug screening, ie, gas chromatography-mass spectrometry (GC-MS), gas chromatography-Fourier transform infrared spectroscopy (GC-FTIR), nuclear magnetic resonance (NMR), and liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QTOF-MS). Special attention was paid to the capabilities of GC-MS and GC-FTIR to distinguish between the synthetic cathinones and the results showed that neither GC-MS nor GC-FTIR alone can successfully differentiate between all synthetic cathinones. However, the 2 techniques proved to be complementary and their combined use is therefore beneficial. For example, the structural homologs were better differentiated by GC-MS, while GC-FTIR performed better for the regioisomers. Further, new spectroscopic data of the synthesized cathinone analogs is hereby presented for the forensic community. The synthetic work also showed that cathinone reference compounds can be produced in few reaction steps.

Systematic review of nephrotoxicity of drugs of abuse, 2005-2016

BACKGROUND

The United States is faced with an unprecedented epidemic of drug abuse. Every year thousands of Americans visit the emergency departments all over the country with illicit drug related complaints. These drugs have been known to be associated with a range of renal pathologies, from reversible acute kidney injuries to debilitating irreversible conditions like renal infarction. So far, no comprehensive study or systematic review has been published that includes the commonly used street drugs and designer drugs with potential nephrotoxic outcomes.

METHODS

We conducted a systematic review of published case reports, case series, and cross sectional studies of nephrotoxicities related to drugs of abuse. Literature review was conducted using PubMed/Medline from January 1, 2005 -December 31, 2016 to search for publications related to drug abuse with a defined renal outcome. Publications which reported renal injury in relation to the use of illicit drugs were selected, specifically those cases with raised creatinine levels, clinically symptomatic patients, for instance those with oliguria and proven renal biopsies.

RESULTS

A total of 4798 publications were reviewed during the search process and PRISMA flow chart and Moose protocol regarding systematic reviews were followed. 110 articles were shortlisted for the review. A total of 169 cases from case reports and case series, and 14 case studies were analyzed. Renal manifestations of specific illicit drug abuse were included in this review.

CONCLUSION

Based on the evidence presented, a wide range of renal manifestations were found to be associated with drug abuse. If the trend of increasing use of illicit drug use continues, it will put a significant percentage of the population at an elevated risk for poor renal outcomes. This study is limited by the nature of the literature reviewed being primarily case reports and case series.

Neurocognitive dysfunction following repeated binge-like self-administration of the synthetic cathinone 3,4-methylenedioxypyrovalerone (MDPV)

Synthetic cathinones, frequently referred to as "bath salts", have significant abuse potential, and recent evidence suggests that these novel psychoactive substances can also produce cognitive deficits as well as cytotoxic effects. However, most of these latter findings have been obtained either using high concentrations in vitro or following non-contingent high dose administration in vivo. The present study utilized a model of long-term voluntary binge-like self-administration to determine potential detrimental effects of synthetic cathinones on cognitive function and their known underlying neural circuits, collectively referred to as neurocognitive dysfunction. Male Sprague-Dawley rats were allowed to self-administer the cocaine-like synthetic cathinone 3,4-methylenedioxypyrovalerone (MDPV, 0.03 mg/kg/infusion i.v.) in 96-hr sessions, or saline as a control. A total of five 96-hr sessions were conducted, each separated by 3 days of abstinence in the home cage. Three weeks following the last 96-hr session, animals underwent assessment of cognitive function using spatial object recognition (SOR) and novel object recognition (NOR) tasks, after which brains were harvested and assessed for neurodegeneration using FluoroJade C (FJC). Compared to animals self-administering saline, animals self-administering MDPV demonstrated (1) robust drug intake that escalated over time, (2) deficits in NOR but not SOR, and (3) neurodegeneration in the perirhinal and entorhinal cortices. These results indicate that repeated binge-like intake of MDPV can induce neurocognitive dysfunction. In addition, utilization of rodent models of extended binge-like intake may provide insight into potential mechanisms and/or approaches to prevent or reverse the detrimental effects of abused substances on cognitive and neurobiological functioning. This article is part of the Special Issue entitled 'Designer Drugs and Legal Highs.'

Examination of Synthetic Cannabinoid and Cathinone Use among a Drug-Using Offender Sample, 2013-2015

Use of novel psychoactive substances (NPS) such as synthetic cannabinoids (e.g., "Spice," "Serenity") and cathinones (e.g., "bath salts") has proliferated in recent years; however, there is a gap in research examining prevalence among offender samples. This study examined demographics, drug use, mental health characteristics, and criminal histories of NPS users compared to non-NPS users within an offender sample entering drug treatment. Using logistic regression analysis, combined 2013-2015 assessment data were examined (N = 8,791). NPS users offended more often (x̄ = 10.3), were more likely to have experienced homelessness (12.2%), and to have lived in a metro area (59.0%). NPS users reported significantly more past-year drug use, including substances not readily detected by standard urine analysis (e.g., hallucinogens, alcohol, and inhalants). Individuals with higher anxiety symptom counts (OR = 1.07; p < .001) and those who reported drinking to intoxication (OR = 1.30; p < .001) had an increased likelihood of NPS use. Older individuals (OR = 0.95; p < .001) and those who began using drugs at an older age (OR = 0.95; p < .001) were less likely to report NPS use. NPS use may be a marker of more severe using patterns in an offender sample. Future investigation should focus on NPS use as a possible method for bypassing drug testing measures.

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.

Impact of common clandestine structural modifications on synthetic cathinone "bath salt" pharmacokinetics

Since 2009, the synthetic cathinones ("bath salts") have risen in popularity as drugs of abuse. However, there are a paucity of studies that have determined the impact of functional group modifications in the synthetic cathinone chemical structures on plasma and central nervous system (CNS) pharmacokinetics. In the present study, we investigated the in vivo plasma and CNS pharmacokinetics of three synthetic cathinones whose structures differ by lengthening of the α-alkyl chain: methylone (-CH₃), butylone (-CH₂CH₃), and pentylone (-CH₂CH₂CH₃). Male Sprague-Dawley rats were treated with a 20mg/kg subcutaneous dose of the individual synthetic cathinone. Blood samples were obtained at specific times from a jugular vein cannula over an 8hour period. Over a separate three-hour period, CNS samples were obtained using a microdialysis cannula surgically implanted into the lateral ventricle. In the plasma, pentylone, with the longest α-alkyl chain, displayed the highest C_max and AUC_0-∞, and the longest t_1/2. Decreasing the α-alkyl chain length as in butylone and methylone significantly decreased the C_max, AUC_0-∞, and t_1/2. The plasma pharmacokinetic values are consistent with the greater lipophilicity associated with α-alkyl side chain lengthening. Conversely, in the CNS, methylone and butylone displayed higher C_max and AUC_0-∞ values than pentylone. These contrary findings in the CNS and plasma demonstrate that lengthening of the α-alkyl chain of methylone, butylone, and pentylone yields differential pharmacokinetic properties in the CNS as compared to the plasma.

Patterns of use and toxicity of new para-halogenated substituted cathinones: 4-CMC (clephedrone), 4-CEC (4-chloroethcatinone) and 4-BMC (brephedrone)

OBJECTIVE

This paper aims to present results of the analysis of clephedrone (4-CMC), 4-chloroethcathinone (4-CEC), and brephedrone (4-BMC) on recreational drug markets and a systematic review of all the available information concerning these substances.

MATERIAL AND METHODS

Samples collected by the drug checking service of the Spanish harm reduction NGO-Energy Control were analyzed and systematic research was conducted. Between June 2014 and October 2016, 1,471 samples with at least one NPS were analyzed, 397 of which contained cathinones.

RESULTS

Clephedrone was found in 29 samples, brephedrone in 8, and both were present in 2 samples. 4-Chloroethcathinone was detected in 5 samples. Eleven out of the 47 purchased samples (23.4%) were tested to contain the substance the user expected. Samples received were mainly sold as 3-MMC, MDMA, ketamine, and other cathinones. No literature on the effects or toxicity of these substances was found; the only information available was on internet fora. On many posts, users exhibit concerns about potential toxicity and side effects of using these substances.

CONCLUSION

Since the emergence of these substances could prove to be the next step to the cat-and-mouse game existing between drug producers and legislation, further clinical and epidemiological research should be carried out in order to build evidence to support policy for public health issues.