Nod and wave: An Internet study of the codeine intoxication phenomenon

Multinational appraisal of the epidemiological distribution of opioid fatalities: a systematic review and meta-analysis

Background

The global or multinational scientific evidence on the distribution of opioid fatality is unknown. Hence, the current study collects epidemiological characteristics to shed light on the ongoing global or multinational opioid crisis and to promote the development of public health prevention/management strategies.

Method

All documents on PRISMA standards were retrieved via electronic databases.

Results

Among the 47 articles relevant to our studies, which depict a total population size of 10,191 individuals, the prevalence of opioid fatal overdose was 15,022 (14.74%). Among the 47 articles, 14 of them reported the gender of the participants, with 22,125 (15.79%) male individuals and 7,235 (5.17%) female individuals, and the age distribution of the participants that was most affected by the overdose was as follows: 29,272 (31.13%) belonged to the 18-34-year-old age group and 25,316 (26.92%) belonged to the less than 18-year-old age group. Eighteen studies qualified for the meta-analysis of the multinational prevalence of fatal opioid overdose, depicting an overall pooled prevalence estimate of 19.66%, with 95% CIs (0.13-0.29), I2 = 99.76% determined using the random-effects model, and Q statistic of 7198.77 (p < 0.0001). The Egger test models of publication bias revealed an insubstantial level of bias (p = 0.015). The subgroup analysis of the study design (cohort or other) revealed that others have the highest prevalence estimate of 34.37, 95% CIs (0.1600-0.5901), I2 = 97.04%, and a sample size of less than 1,000 shows the highest prevalence of 34.66, 95% CIs (0.2039-0.5234), I2 = 97.82%, compared to that of more than 1,000 with a prevalence of 12.28, 95% CIs (0.0675-0.2131), I2 = 99.85%. The meta-regression analysis revealed that sample size (less-than or greater-than 1,000), (p = 0.0098; R2 = 3.83%) is significantly associated with the observed heterogeneity.

Conclusion

Research-based findings of fatal opioid overdose are grossly lacking in middle- and low-income nations. We established that there is a need for opioid fatality surveillance systems in developing nations.

Internet-Based Inquiries From Users With the Intention to Overdose With Over-the-Counter Drugs: Qualitative Analysis of Yahoo! Chiebukuro

BACKGROUND

Public concern with regard to over-the-counter (OTC) drug abuse is growing rapidly across countries. OTC drug abuse has serious effects on the mind and body, such as poisoning symptoms, and often requires specialized treatments. In contrast, there is concern about people who potentially abuse OTC drugs whose symptoms are not serious enough to consult medical institutions or drug addiction rehabilitation centers yet are at high risk of becoming drug dependent in the future.

OBJECTIVE

Consumer-generated media (CGM), which allows users to disseminate information, is being used by people who abuse (and those who are trying to abuse) OTC drugs to obtain information about OTC drug abuse. This study aims to analyze the content of CGM to explore the questions of people who potentially abuse OTC drugs.

METHODS

The subject of this research was Yahoo! Chiebukuro, the largest question and answer website in Japan. A search was performed using the names of drugs commonly used in OTC drug abuse and the keywords overdose and OD, and the number of questions posted on the content of OTC drug abuse was counted. Furthermore, a thematic analysis was conducted by extracting text data on the most abused antitussive and expectorant drug, BRON.

RESULTS

The number of questions about the content of overdose medications containing the keyword BRON has increased sharply as compared with other product names. Furthermore, 467 items of question data that met the eligibility criteria were obtained from 528 items of text data on BRON; 26 codes, 6 categories, and 3 themes were generated from the 578 questions contained in these items. Questions were asked about the effects they would gain from abusing OTC drugs and the information they needed to obtain the effects they sought, as well as about the effects of abuse on their bodies. Moreover, there were questions on how to stop abusing and what is needed when seeking help from a health care provider if they become dependent. It has become clear that people who abuse OTC drugs have difficulty in consulting face-to-face with others, and CGM is used as a means to obtain the necessary information anonymously.

CONCLUSIONS

On CGM, people who abused or tried to abuse OTC drugs were asking questions about their abuse expectations and anxieties. In addition, when they became dependent, they sought advice to quit their abuse. CGM was used to exchange information about OTC drug abuse, and many questions on anxieties and hesitations were posted. This study suggests that it is necessary to produce and disseminate information on OTC drug abuse, considering the situation of those who abuse or are willing to abuse OTC drugs. Support from pharmacies and drugstores would also be essential to reduce opportunities for OTC drug abuse.

The subjective experience of heroin effects among individuals with chronic opioid use: Revisiting reinforcement in an exploratory study

Aims

Consistent with the opponent process theory individuals with chronic opioid use should predominantly endorse the avoidance of aversive negative emotional and/or physiological states as the motivation for continued opioid use (source of reinforcement: reductions in negative states). The primary aim of this study was to explore whether this view is supported by the subjective effects of heroin reported by individuals with opioid use disorder (OUD).

Methods

Responses during in-person interviews of participants to the question "What do you like about heroin? " were categorized as positive, negative, or mixed (positive and negative) reinforcement. In addition, we examined differences between these "reinforcement groups" in sociodemographic and clinical variables.

Results

Participants (N = 307) with OUD were predominantly male (78.1%), with chronic heroin use (M = 15.8 years, SD = 11.5), and 46.1% currently used heroin and were not enrolled in treatment. Agreement between two raters concerning the categorization of participant-reported effects of heroin into reinforcement categories was high, κ= 0.924, p < .0005. Approximately half (49.8%) of participant-reported effects of heroin were categorized as attributable to positive reinforcement. About one-fourth (22.8%) were categorized as negative reinforcement and 9.0% as "mixed ". There were no statistically significant differences between the three reinforcement groups in any of the socio-demographic variables, duration of heroin use, or treatment status/interest.

Conclusions

The results of this study indicate marked heterogeneity of heroin effects experienced by individuals with OUD and their source of reinforcement, respectively. Better integration of how individuals construe their drug use is important to understand the psychological-and neurobiological-processes in the development and maintenance of OUD.

Facebook as a source of access to medicines

Over the last decade, we've observed an enormous social media development, which have recently become commercial services. Hence, we aimed to verify if Facebook might be considered as a source of access to medicines. We also intended to identify prescription (Rx) and over the counter (OTC) medicines if available on that platform. The study was conducted from January 2019 to July 2020. We investigated offers of pharmaceuticals posted on Facebook (individual posts and communities) between 2016 and 2019. Medicines were divided into Rx and OTC brands and in accordance with their possible therapeutic use. We verified whether the medicines were for sale, to exchange, or available for free. Posts and groups were investigated for example, by entering the phrase "for free," followed by a city in Poland. Out of 409 offers, 380 (92.91%) concerned Rx brands and 29 (7.09%) OTC brands. 315 (77.02%) medications were available "for free". In 47 (11.49%) cases, an "exchange" was expected, and 47 (11.49%) announcements were marked as "for sale". Cardiovascular medicines (n = 125; 30.56%) were the most popular. There were also antidiabetics (n = 38; 9.29%) and antipsychotics (n = 28; 6.84%). We also found clear candidates for misuse. These were opioids (n = 7; 1.71%), benzodiazepines (n = 2; 0.48%), clomifene (n = 1; 0.24%), and letrozole (n = 1; 0.24%). Facebook provides the possibility of uncontrolled access to medicines. The majority of offers concerned Rx brands, including opioids and benzodiazepines. Medicines offered on Facebook were mainly accessible for free. The scope and the number of medications offered on Facebook should make this issue a hazardous phenomenon.

Cutaneous foreign body microemboli-induced occlusive vasculopathy: A complication of illicit intravenous injection of oral opioid tablets

Occlusive nonvasculitic vasculopathy is a process characterized clinically by retiform purpura and potential ulceration and necrosis of affected areas, secondary to blockage of small vessels without associated inflammatory vasculitis. Intravascular injection of foreign material is known to cause distal ischemia and necrosis due to thrombosis, local vasoconstriction, or microemboli formation. A 27-year-old male presented with retiform purpura and worsening distal fingertip necrosis of the right upper extremity accompanied by suspicious intravascular polarizable foreign material identified on skin, muscle, and vascular biopsies. We report a case that highlights concerning complications and dermatopathologic findings of intravascular injection of oral opioid tablets.

Identification of factors influencing tampering of codeine-containing medicines in England: a qualitative study

Background

Tampering of psychoactive medicines presents challenges to regulation and public health. However, little is currently known about what influences the decisions to treat codeine-containing medicines (CCM) with cold water extraction (CWE) from the perspective of individuals employing these techniques. The article identifies factors influencing utilisation of CWE to separate codeine from compounded analgesics, such as paracetamol and ibuprofen, found in CCM.

Methods

Purposive sampling of 27 participants residing in England who took part in a qualitative interview. Of these, 14 individuals (11 males and 3 females) reported tampering of psychoactive medicines, and the relevant transcripts were included in the analyses for the study. Participants were recruited from one addiction treatment service and from an online survey. The mean age of the participants was 31.5 years (range = 18–42 years). Qualitative data analysis followed the processes of iterative categorization (IC). The codes ‘harm reduction’, ‘information sources’ and ‘changes on the drug markets’ were grouped and summarised. The coding of the data was done in a Microsoft® Word document.

Results

Two groups of participants were identified in the data analysis: (i) individuals who used CCM (n = 5), and (ii) individuals who used CCM and heroin (n = 9). Participants in both groups used CWE due to concerns of paracetamol overdose from the use of excessive dosages of CCM. For both of them, information obtained from the internet encouraged the use of CWE. Participants using CCM described how the many steps involved in conducting CWE, including sourcing codeine boxes from pharmacies (over the counter), presented a barrier against using CWE. Participants using CCM and heroin explained how reduced availability in the local heroin supply influenced utilisation of CWE techniques to maintain their use of opioids and avoid withdrawal. Withdrawal symptoms and cravings outweighed the concerns about the quality of the extracted codeine mixtures in this participant group, especially the ability of CWE to remove paracetamol and tablet fillers.

Conclusions

Utilisation of CWE of codeine was influenced by several factors including drug market supply, the availability of detailed information on the internet about CWE and restrictions on codeine sourcing in pharmacies. Risks identified with CWE include consumption of unknown doses of paracetamol if the CWE techniques are not used correctly. Attempts at extracting codeine from CCM should be considered in risk assessments of opioid medicines.

Pharmacological Aspects of Over-the-Counter Opioid Drugs Misuse

Several over-the-counter (OTC) drugs are known to be misused. Among them are opioids such as codeine, dihydrocodeine, and loperamide. This work elucidates their pharmacology, interactions, safety profiles, and how pharmacology is being manipulated to misuse these common medications, with the aim to expand on the subject outlined by the authors focusing on abuse prevention and prevalence rates. The reviewed literature was identified in several online databases through searches conducted with phrases created by combining the international non-proprietary names of the drugs with terms related to drug misuse. The results show that OTC opioids are misused as an alternative for illicit narcotics, or prescription-only opioids. The potency of codeine and loperamide is strongly dependent on the individual enzymatic activity of CYP2D6 and CYP3A4, as well as P-glycoprotein function. Codeine can also be utilized as a substrate for clandestine syntheses of more potent drugs of abuse, namely desomorphine (“Krokodil”), and morphine. The dangerous methods used to prepare these substances can result in poisoning from toxic chemicals and impurities originating from the synthesis procedure. OTC opioids are generally safe when consumed in accordance with medical guidelines. However, the intake of supratherapeutic amounts of these substances may reveal surprising traits of common medications.

Injection of oral medication into the skin confirmed by infrared spectroscopy

"Skin popping" refers to the practice of injecting drugs, most commonly heroin, subcutaneously or into granulation tissue. Pharmaceutical tablets meant for oral consumption are modified into solutions for injection. Excipients-inactive substances that serve as vehicles for medication-are often not filtered out before injection and result in abscess formation, granulomatous inflammation, and scarring. Common excipients used in the production of pharmaceutical tablets include starch, microcrystalline cellulose, magnesium stearate, silica, and polyvinylpyrrolidone (PVP). Identification of these exogenous materials is valuable in confirming the diagnosis of skin popping, especially when patients may not be forthcoming about their drug use. We present a case of subcutaneous oral medication injection in which PVP and cellulose were identified by Fourier transform infrared spectroscopy. Considering the variable cutaneous manifestations of injection drug abuse, recognition of histopathologic and chemical characteristics of exogenous material from oral medications is helpful for diagnosis and intervention.

Cold water extraction of codeine/paracetamol combination products: a case series and literature review

Introduction: Tampering with opioid containing medications for use other than their prescribed indication is well documented; however, the published literature has concentrated on stronger, prescription opioids. Less potent opioids, such as codeine, are available without prescription in many European countries in the form of combination analgesic products and these can also be altered, with reports in particular of "cold-water extraction" being a tampering method achievable using household kitchen equipment.Methods: We searched a database of patients attending two South London emergency departments for cases of self-reported ingestion of the products of cold-water extraction, with subsequent review of their case notes. We searched the scientific and grey literature to identify current knowledge of this technique.Results: We identified seven presentations in six patients, none of whom developed paracetamol toxicity or had concentrations suggesting ingestion of a significant dose of paracetamol. A review of the scientific literature on the method also demonstrated that the technique reduces recovered paracetamol in experimental laboratory settings. Additionally, the established literature characterizes the use of codeine in a recreational setting and reports one fatality associated with the method. Review of grey literature user-forums further describes recreational codeine use in relation to the method and frequent adverse events including hospital admission for paracetamol toxicity.Discussion: Whilst the method appears capable of providing a recreational dose of codeine with reduction in the recovered paracetamol, it cannot be considered safe. Pharmaceutical production methods have been successfully developed to prevent tampering through other means but none thus far have been directed at the cold water extraction technique.Conclusions: Clinicians should be aware of the potential toxicity from tampered nonprescription analgesics. There is also the need for public health education regarding the potential risks associated with these methods.

Codeine Addiction and Internet Forum Use and Support: Qualitative Netnographic Study

BACKGROUND

The use of codeine as an analgesic is well-recognized, but there are increasing concerns that for some individuals continued use may lead to misuse, dependence, and fatalities. Research suggests that those affected may represent a hard-to-reach group who do not engage with formal treatment services.

OBJECTIVE

This study sought to explore the experiences of people with self-reported addiction to codeine and, specifically, how a social media forum is used to communicate with others about this issue.

METHODS

Using a qualitative netnographic methodology, the social media forum Mumsnet was used, with permission, and searches were undertaken in 2016 of any posts that related to codeine and addiction. A total of 95 relevant posts were identified; a purposive sample of 25 posts was selected to undertake subsequent six-stage thematic analysis and development of emerging themes. These 25 posts were posted between 2003 and 2016 and comprised 757 individual posts.

RESULTS

Individuals created posts to actively request help in relation to usually their own, but occasionally their partner's or relative's, problems relating to codeine use and self-reported "addiction." Varying levels of detail were provided in narratives of problematic codeine use. There were both positive and negative descriptions of side effects emerging, problems experiencing withdrawal, and failed attempts to discontinue codeine use. Mainly positive and supportive responses to posts were identified from those with either self-reported health profession experience or lay respondents, who often drew on their own experiences of similar problems. Treatment advice emerged in two main ways, either as signposting to formal health services or to informal approaches and often anecdotal advice about how to taper or use cold turkey techniques. Some posts were more critical of the original poster, and arguments and challenges to advice were not uncommon. Shame and stigma were often associated with users' posts and, while there was a desire to receive support and treatment advice in this forum, users often wanted to keep their codeine use hidden in other aspects of their lives. Distinctly different views emerged as to whether responsibility lay with prescribers or patients. Some users expressed anger toward doctors and their prescribing practices.

CONCLUSIONS

This study provides a unique insight into how a public internet forum is used by individuals to confirm and seek support about problematic codeine use and of the ways others respond. The pseudonymous use of internet forums for such information and variation in treatment options suggested by often lay respondents suggest that increased formal support and awareness about codeine addiction are needed. There may be opportunities for providing further support directly on such online forums. Improvements in prescribing codeine and in the over-the-counter supply of codeine are required to prevent problematic use from occurring.

What Are PWDs (People With Diabetes) Doing Online? A Netnographic Analysis

BACKGROUND

Social media have become a crucial channel for patient empowerment and peer support. New qualitative research underscores the fact that this "support" transcends mental health concerns, to actually provide patients with important practical tips and tricks for diabetes self-care, and product selection/decision-making information from peers.

METHODS

Netnography is an emerging methodology that applies an ethnographic research approach to studying activity on the social web. Researchers embed themselves in the online environment to take an observational "deep dive" into online conversations to identify themes, sentiments, and perceptions. Using this methodology in summer 2017, a team of researchers captured and analyzed hundreds of diabetes-related posts on prominent platforms Facebook, Twitter, YouTube, Instagram, Tumblr, Pinterest, Reddit, and Quora.

RESULTS

Our team identified 6 major trends, or "life themes," in diabetes patient social media, providing insights into patient sentiments and needs. A topology of social media channels emerged, indicating which platforms are used most often for each life theme.

CONCLUSIONS

Findings indicate that social media provides a significant source not only of moral support and camaraderie, but also critical education on thriving with diabetes. Importantly, we observed strong evidence of peer influence on patients' therapy and diabetes technology purchasing decisions.

Representations of Codeine Misuse on Instagram: Content Analysis

BACKGROUND

Prescription opioid misuse has doubled over the past 10 years and is now a public health epidemic. Analysis of social media data may provide additional insights into opioid misuse to supplement the traditional approaches of data collection (eg, self-report on surveys).

OBJECTIVE

The aim of this study was to characterize representations of codeine misuse through analysis of public posts on Instagram to understand text phrases related to misuse.

METHODS

We identified hashtags and searchable text phrases associated with codeine misuse by analyzing 1156 sequential Instagram posts over the course of 2 weeks from May 2016 to July 2016. Content analysis of posts associated with these hashtags identified the most common themes arising in images, as well as culture around misuse, including how misuse is happening and being perpetuated through social media.

RESULTS

A majority of images (50/100; 50.0%) depicted codeine in its commonly misused form, combined with soda (lean). Codeine misuse was commonly represented with the ingestion of alcohol, cannabis, and benzodiazepines. Some images highlighted the previously noted affinity between codeine misuse and hip-hop culture or mainstream popular culture images.

CONCLUSIONS

The prevalence of codeine misuse images, glamorizing of ingestion with soda and alcohol, and their integration with mainstream, popular culture imagery holds the potential to normalize and increase codeine misuse and overdose. To reduce harm and prevent misuse, immediate public health efforts are needed to better understand the relationship between the potential normalization, ritualization, and commercialization of codeine misuse.

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

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

Using Social Listening Data to Monitor Misuse and Nonmedical Use of Bupropion: A Content Analysis

Background

The nonmedical use of pharmaceutical products has become a significant public health concern. Traditionally, the evaluation of nonmedical use has focused on controlled substances with addiction risk. Currently, there is no effective means of evaluating the nonmedical use of noncontrolled antidepressants.

Objective

Social listening, in the context of public health sometimes called infodemiology or infoveillance, is the process of identifying and assessing what is being said about a company, product, brand, or individual, within forms of electronic interactive media. The objectives of this study were (1) to determine whether content analysis of social listening data could be utilized to identify posts discussing potential misuse or nonmedical use of bupropion and two comparators, amitriptyline and venlafaxine, and (2) to describe and characterize these posts.

Methods

Social listening was performed on all publicly available posts cumulative through July 29, 2015, from two harm-reduction Web forums, Bluelight and Opiophile, which mentioned the study drugs. The acquired data were stripped of personally identifiable identification (PII). A set of generic, brand, and vernacular product names was used to identify product references in posts. Posts were obtained using natural language processing tools to identify vernacular references to drug misuse-related Preferred Terms from the English Medical Dictionary for Regulatory Activities (MedDRA) version 18 terminology. Posts were reviewed manually by coders, who extracted relevant details.

Results

A total of 7756 references to at least one of the study antidepressants were identified within posts gathered for this study. Of these posts, 668 (8.61%, 668/7756) referenced misuse or nonmedical use of the drug, with bupropion accounting for 438 (65.6%, 438/668). Of the 668 posts, nonmedical use was discouraged by 40.6% (178/438), 22% (22/100), and 18.5% (24/130) and encouraged by 12.3% (54/438), 10% (10/100), and 10.8% (14/130) for bupropion, amitriptyline, and venlafaxine, respectively. The most commonly reported desired effects were similar to stimulants with bupropion, sedatives with amitriptyline, and dissociatives with venlafaxine. The nasal route of administration was most frequently reported for bupropion, whereas the oral route was most frequently reported for amitriptyline and venlafaxine. Bupropion and venlafaxine were most commonly procured from health care providers, whereas amitriptyline was most commonly obtained or stolen from a third party. The Fleiss kappa for interrater agreement among 20 items with 7 categorical response options evaluated by all 11 raters was 0.448 (95% CI 0.421-0.457).

Conclusions

Social listening, conducted in collaboration with harm-reduction Web forums, offers a valuable new data source that can be used for monitoring nonmedical use of antidepressants. Additional work on the capabilities of social listening will help further delineate the benefits and limitations of this rapidly evolving data source.

"Codeine Is My Helper": Misuse of and Dependence on Codeine-Containing Medicines in South Africa

Misuse of codeine-containing medicines is an emerging global public health concern. The majority of research has been conducted in developed countries (European Members States, Australia, the United States). This study aimed to gain an understanding of unique individual and collective experiences of trajectories of codeine misuse and dependence in South Africa. In-depth interviews were conducted with a purposive sample of adult codeine misusers and dependents ( n = 25). Narratives were analyzed using the empirical phenomenological psychological five-step method. Nine themes with 63 categories emerged, with two additional high levels of abstraction. Findings are illustrated: participant profile and product preferences, motives for use, transitioning to misuse and dependence, pharmacy purchasing and alternative sourcing routes, effects and withdrawal experiences, help-seeking and treatment experiences, and strategies for prevention. The study underscores the need for continued support for enhanced patient awareness of risk of habit forming use and related health consequences and professional pharmacovigilance.

Over-the-Counter Codeine-from Therapeutic Use to Dependence, and the Grey Areas in Between

Codeine is a widely used analgesic, that is available for sale in pharmacies over the counter (OTC) in a number of countries including the UK, South Africa, Ireland, France and Australia. In these countries with OTC codeine sales there has been emerging concerns about misuse of and dependence on codeine containing combination analgesics, with increasing numbers of people presenting for help with codeine dependence at primary care and addiction treatment services. This has led to many countries reviewing availability of codeine in OTC available preparations, and considering possible measures to reduce harms from misuse of OTC codeine containing combination analgesics.

Could Codeine Containing OTC Analgesics Sold in Romania be Used as Recreational Drugs?

Objective: Analgesic medicines containing combinations of nonsteroidal anti-inflammatory drugs and codeine are available without prescription. Codeine, in these combinations can not be used recreationally due to the high toxicity profile of the nonsteroidal anti-inflammatory drugs. However, methods for extracting codeine from these types of medication are available on the internet. The purpose of this work is to evaluate if codeine can be extracted from codeine containing analgesics sold without prescription.

Methods: High Performance Liquid Chromatography (HPLC) with UV detection was used to measure the amounts of codeine and nonsteroidal anti-inflammatory drugs recovered after applying an extraction method described on the internet.

Results: The results show that codeine can be very easily separated from NSAID as aspirin, acetaminophen, ibuprofen using the cold water extraction method. However, very large differences (20 to 90%) were recorded for the recovery of codeine depending on the OTC product that was used. That large difference increases the risk of potentially lethal overdoses when the user switches between “similar” products.

Conclusions: Our work shows that analgesic medication with codeine content can be recreationally used after the extraction of codeine. In order to prevent this, the sell of this type of products should be regulated or products that do not allow the extraction of codeine should be developed.

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

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

Misuse of OTC drugs in Poland

INTRODUCTION

The misuse of over-the-counter (OTC) drugs became a global public health concern. Although abuse with dextrometorphan (DXM), pseudoefedrine (PSD), codeine (COD) or benzydamine (BND) may lead even to psychosis, drugs containing these substances are relatively cheap and freely available. In Poland the Act on Counteracting Drug Addiction was amended in 2015, however it seems that there are still some points which could be improved.

METHODS

Study was conducted between October 2014 and June 2015 using a specially designed questionnaire delivered to pharmacists from the Greater Poland region. Questionnaire consisting of 11 closed questions was distributed by direct contact and via the Internet. From over 2500 distributed questionnaires, we received 761 sheets and 680 were included.

RESULTS

The misuse of OTC drugs is increasing in Poland from pharmacists point of view. The most popular substance was PSD followed by COD and DXM. The main reason of misuse of these drugs could be related to the use of Internet and free access to these medications. In respondents (58.2%) opinion OTC drugs containing analyzed substances should be moved into the prescription status.

CONCLUSIONS

The misuse of OTC drugs should be considered as a very dangerous phenomenon. Although the Act on Counteracting Drug Addiction was amended in Poland in 2015, there are some facets requiring improvement. Social education may play a key role in the limitation of misuse of OTC drugs.

A scoping review of home-produced heroin and amphetamine-type stimulant substitutes: implications for prevention, treatment, and policy

Several home-produced substances such as krokodil and boltushka are prevalent in many Eastern European countries. Anecdotal reports of its use have been circulating in Germany and Norway; however, this has not been confirmed. Its use has also been reported by the media in the USA, although only one confirmed report of its use exists. Home-produced drugs are associated with high levels of morbidity and a number of complex health issues such as the spread of blood borne viruses, gangrene, and internal organ damage. The high incidence of HIV rates amongst people who inject home-produced substances is a public health concern. The resulting physical health consequences of injecting these crude substances are very severe in comparison to heroin or amphetamine acquired in black markets. Due to this fact and the increased mortality associated with these substances, professionals in the area of prevention, treatment, and policy development need to be cognisant of the presentation, harms, and the dangers associated with home-produced substances globally. This scoping review aimed to examine existing literature on the subject of home-produced heroin and amphetamine-type stimulant substitutes. The review discussed the many implications such research may have in the areas of policy and practice. Data were gathered through the use of qualitative secondary resources such as journal articles, reports, reviews, case studies, and media reports. The home production of these substances relies on the utilisation of precursor drugs such as less potent stimulants, tranquillizers, analgesics, and sedatives or natural plant ingredients. The Internet underpins the facilitation of this practice as recipes, and diverted pharmaceutical sales are available widely online, and currently, ease of access to the Internet is evident worldwide. This review highlights the necessity of prevention, education, and also harm reduction related to home-produced drugs and also recommends consistent monitoring of online drug fora, online drug marketplaces, and unregulated pharmacies.

Concepts of illicit drug quality among darknet market users: Purity, embodied experience, craft and chemical knowledge

BACKGROUND

Users of darknet markets refer to product quality as one of the motivations for buying drugs there, and vendors present quality as a selling point. However, what users understand by quality and how they evaluate it is not clear. This article investigates how users established and compared drug quality.

METHODS

We used a two-stage method for investigating users' assessments. The user forum of a darknet market that we called 'Merkat' was analysed to develop emergent themes. Qualitative interviews with darknet users were conducted, then forum data was analysed again. To enhance the applicability of the findings, the forum was sampled for users who presented as dependent as well as recreational.

RESULTS

Quality could mean reliability, purity, potency, and predictability of effect. We focused on the different kinds of knowledge users drew on to assess quality. These were: embodied; craft; and chemical.

CONCLUSION

Users' evaluations of quality depended on their experience, the purpose of use, and its context. Market forums are a case of indigenous harm reduction where users share advise and experiences and can be usefully engaged with on these terms.

‘Codeine is my companion’: misuse and dependence on codeine containing medicines in Ireland

Objectives

Global concern around over the counter availability of codeine containing products and risk of misuse, dependence and related harms are evident. A phenomenological study of lived experiences of codeine misuse and dependence was undertaken in Ireland, following the Pharmaceutical Society of Ireland’s 2010 guidelines for restricted supply of non-prescription codeine containing products.

Methods

In-depth interviews were conducted with a purposive sample of adult codeine misusers and dependents (n=21), both actively using, in treatment and in recovery. The narratives were analysed using the Empirical Phenomenological Psychological five-step method (Karlsson, 1995). A total of 10 themes with 82 categories were identified. Two concepts at a higher level of abstraction above the theme-level emerged during the final stage of analysis. The concepts identified were ‘emotional pain and user self-legitimization of use’ and ‘entrapment into habit-forming and invisible dependent use’. These concepts were reported in different ways by a majority of participants.

Results

Findings are presented under the following themes: (1) profile and product preferences; (2) awareness of habit forming use and harm; (3) negotiating pharmacy sales; (4) alternative sourcing routes; (5) the codeine feeling; (6) the daily routine; (7) acute and chronic side effects; (8) social isolation; (9) withdrawal and dependence and (10) help-seeking and treatment experiences.

Conclusions

There is a public health and regulatory imperative to develop proactive responses tackling public availability of codeine containing medicines, risk minimisation in consumer self-treatment for pain, enhanced patient awareness of potential for habit forming use and its consequences and continued health professional pharmacovigilence.

Color synesthesia. Insight into perception, emotion, and consciousness

Purpose of review

Synesthesia is an extraordinary perceptual phenomenon, in which individuals experience unusual percepts elicited by the activation of an unrelated sensory modality or by a cognitive process. Emotional reactions are commonly associated. The condition prompted philosophical debates on the nature of perception and impacted the course of art history. It recently generated a considerable interest among neuroscientists, but its clinical significance apparently remains underevaluated. This review focuses on the recent studies regarding variants of color synesthesia, the commonest form of the condition.

Recent findings

Synesthesia is commonly classified as developmental and acquired. Developmental forms predispose to changes in primary sensory processing and cognitive functions, usually with better performances in certain aspects and worse in others, and to heightened creativity. Acquired forms of synesthesia commonly arise from drug ingestion or neurological disorders, including thalamic lesions and sensory deprivation (e.g., blindness). Cerebral exploration using structural and functional imaging has demonstrated distinct patterns in cortical activation and brain connectivity for controls and synesthetes. Artworks of affected painters are most illustrative of the nature of synesthetic experiences.

Summary

Results of the recent investigations on synesthesia offered a remarkable insight into the mechanisms of perception, emotion and consciousness, and deserve attention both from neuroscientists and from clinicians.