Drops of madness? Recreational misuse of tropicamide collyrium; early warning alerts from Russia and Italy

Ocular Surface Fluid: More than a Matrix

Although the eye can be subjected to therapeutic manipulation, some of its structures are highly inaccessible. Thus, conventional therapeutic administration pathways, such as topical or systemic routes, usually show significant limitations in the form of low ocular penetration or the appearance of side effects linked to physiology, among others. The critical feature of many xenobiotics is the drug gradient from the concentrated tear reservoir to the relatively barren corneal and conjunctival epithelia, which forces a passive route of absorption. The same is true in the opposite direction, towards the ocular surface (OS). With the premise that tears can be regarded as equivalent to or a substitute for plasma, researchers may determine drug concentrations in the OS fluid. Within this framework, a survey of scholarly sources on the topic was conducted. It provided an overview of current knowledge, allowing the identification of relevant theories, methods, and gaps in the existing research that can be employed in subsequent research. OS fluid (tears particularly) has enormous potential as a source of biological material for external drug screening and as a biomarker of various systemic diseases. Given the numerous alternate matrices, knowledge of their properties is very important in selecting the most appropriate specimens in toxicological analyses.

Ingestion of Fluids of the Ocular Surface Containing Eye Drops of Imidazole Derivatives-Alpha Adrenergic Receptor Agonists as Paragons

Accidental poisonings by ingesting conjunctival fluid mixed with eye drops commonly involve alpha-2 adrenergic receptor agonists and tetrahydrozoline. These substances are recognized in commonly reported ingestions. Victims of all ages, otherwise in good health, often present as pale and lethargic to the emergency department (ED) after unintentionally ingesting topical eye medication. While eye drop poisoning cases in childhood include accidents during the play and poisonings in adults mean either suicide attempts or side effects caused by the systemic absorption of the substance, fluid of the ocular surface is a risk to all age groups. With this in mind, this study aimed to summarize data in the literature on tetrahydrozoline and alpha-2 adrenergic receptor agonists as dangerous medications, even when administered in low-bioavailability forms, such as eye drops. With this aim, a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant systematic review of relevant studies was conducted. A search of PubMed, Scopus, Web of Science, and EBSCOhost yielded nine studies that met the rigorous inclusion criteria. The primary studies were subject to a meta-analysis once a quality appraisal of the studies and a narrative synthesis of the extracted data had been conducted. The author hopes that this information will provide observations that will lead to better designs for over-the-counter eye drops, off-label drug usage policies, and parental attention.

Structure-Activity Relationship Study of Psychostimulant Synthetic Cathinones Reveals Nanomolar Antagonist Potency of α-Pyrrolidinohexiophenone at Human Muscarinic M2 Receptors

Synthetic cathinones (SCs) are designer, psychostimulant drugs of abuse that primarily act on monoamine transporters; little is known about their off-target liability. Abuse of pyrrolidine-containing SCs, such as α-PHP, has been linked to clinical features, including tachycardia and hypertension, and psychiatric events, including delusions and memory impairments-effects mimicking deliriant hallucinogens that are acetylcholine muscarinic receptor (MR) antagonists. α-PHP and nine analogs with modifications in the α-carbon side chain length and/or containing a methylenedioxy moiety were screened for activity at each of the five human MRs. Increasing the length of the α-carbon side chain of 1-phenyl-2-(pyrrolidin-1-yl)ethan-1-one analogs from a methyl (α-PPP) to a propyl (α-PVP) group caused a steep increase in affinity at all MR subtypes, and one extra carbon (α-PHP) further enhanced MR affinity; the presence of a methylenedioxy moiety generally hindered this effect. Highest MR affinity was observed with α-PHP at M₂Rs-its M₂R affinity (K_i = 251 nM) was 302-fold higher than α-PPP's. M₂R-cAMP inhibition and β-arrestin recruitment assays showed that α-PHP is an M₂R antagonist (K_b = 120 and 502 nM, respectively). Additional experiments showed α-PHP is also an antagonist of M₁R-inositol phosphate production (K_b = 1.4 μM). Human toxicology studies report blood concentrations of pyrrolidine-containing SCs, including α-PHP, that reach micromolar levels during intoxication, indicating α-PHP's MR activity might have physiological relevance. As M₂Rs and M₁Rs are widely expressed in the autonomic and central nervous systems, α-PHP's anticholinergic activity might be relevant to adverse events associated with α-PHP intoxication.

Focus on Clozapine Withdrawal- and Misuse-Related Cases as Reported to the European Medicines Agency (EMA) Pharmacovigilance Database

BACKGROUND

Clozapine is of high clinical relevance for the management of both treatment-resistant schizophrenia and psychotic disturbances with concurrent drug misuse. Although the molecule presents with a range of well-known side-effects, its discontinuation/withdrawal syndrome has been only anecdotally described.

AIMS

the 2005-2018 European Medicines Agency (EMA) dataset of Adverse Drug Reactions (ADRs) was analyzed to identify and describe possible clozapine withdrawal- and misuse-/abuse-/dependence-related issues.

METHOD

A descriptive analysis of clozapine-related ADRs was performed when available, data on ADRs' outcome, dosage, and possible concomitant drug(s) were considered.

RESULTS

Out of 11,847 clozapine-related ADRs, some 599 (5.05%) were related to misuse/abuse/dependence/withdrawal issues, including 258 withdrawal-related (43.1%); 241 abuse-related (40.2%); and 80 intentional product misuse-related (13.3%) ADRs. A small number of overdose- and suicide-related ADRs were reported as well. Clozapine was typically (69.2%) identified alone, and most (84.7%) fatalities/high-dosage intake instances were reported in association with a history of substance abuse.

CONCLUSIONS

Previous suggestions about the possibility of a clozapine discontinuation/withdrawal occurrence are here supported, but further studies are needed. However, the misuse/abuse cases here identified might be difficult to interpret, given the lack of studies highlighting the possible recreational use of clozapine. The high-dosage intake, fatal outcomes and clozapine/polydrug abuse issues reported here may, however, be a reason for concern.

DARK Classics in Chemical Neuroscience: Atropine, Scopolamine, and Other Anticholinergic Deliriant Hallucinogens

Anticholinergic drugs based on tropane alkaloids, including atropine, scopolamine, and hyoscyamine, have been used for various medicinal and toxic purposes for millennia. These drugs are competitive antagonists of acetylcholine muscarinic (M-) receptors that potently modulate the central nervous system (CNS). Currently used clinically to treat vomiting, nausea, and bradycardia, as well as alongside other anesthetics to avoid vagal inhibition, these drugs also evoke potent psychotropic effects, including characteristic delirium-like states with hallucinations, altered mood, and cognitive deficits. Given the growing clinical importance of anti-M deliriant hallucinogens, here we discuss their use and abuse, clinical importance, and the growing value in preclinical (experimental) animal models relevant to modeling CNS functions and dysfunctions.

Ophthalmic drug abuse: An observational study from community pharmacies

BACKGROUND

There has been a trend in the past five years in Jordan for ophthalmic anticholinergic preparations to be misused or abused. This is done mainly to experience mental altering effects such as mood changes, euphoria or hallucinations. Such products are mostly obtained from community pharmacies without a prescription.

OBJECTIVES

This study aimed to observe the requests of ophthalmic preparations in community pharmacies in Amman, Jordan, and evaluating the most popular and frequently requested ophthalmic drops suspected of abuse. Also, it aimed to describe the current methods that Jordanian community pharmacists use to manage such requests.

METHODS

A prospective cross-sectional observational study was conducted between November 2016 and January 2017 at sixteen different community pharmacies in Amman. All ophthalmic products requested were observed during this period.

RESULTS

A total of 140 ophthalmic product requests for 130 customers were observed. Dry eye was the most common complaint for which the customer requested the medication (n = 30, 23.1%) and direct self-medication (ie-requesting the product by name), was the most frequent method of purchase (n = 63, 48.5%). In 19 cases (14.6%), product requests were suspected to be for non-medical (ie-abuse) purposes. Most of the suspected cases were for Pentolate^® (n = 11, 57.9%), whereas 7 were for Prisoline^® (36.8%) and 1 for Naphcon-A^® (5.3%). The majority of observed cases were for products requested without a prescription (n = 16, 84.2%), and in 12 cases out of which, sale was refused (63.2%).

CONCLUSION

More effort and enforcement of pharmacy regulation for safe dispensing is needed to reduce the abuse of ophthalmic products. Educating pharmacists and ophthalmologists would help raise awareness and control the type of drug abuse.

"Spice," "kryptonite," "black mamba": an overview of brand names and marketing strategies of novel psychoactive substances on the web

Abstract Introduction: Novel Psychoactive Substances (NPSs) are often sold online as "legal" and "safer" alternatives to International Controlled Drugs (ICDs) with captivating marketing strategies. Our aim was to review and summarize such strategies in terms of the appearance of the products, the brand names, and the latest trends in the illicit online marketplaces.

METHODS

Scientific data were searched in PsychInfo and Pubmed databases; results were integrated with an extensive monitoring of Internet (websites, online shops, chat rooms, fora, social networks) and media sources in nine languages (English, French, Farsi, Portuguese, Arabic, Russian, Spanish, and Chinese simplified/traditional) available from secure databases of the Global Public Health Intelligence Network.

RESULTS

Evolving strategies for the online diffusion and the retail of NPSs have been identified, including discounts and periodic offers on chosen products. Advertisements and new brand names have been designed to attract customers, especially young people. An increased number of retailers have been recorded as well as new Web platforms and privacy systems.

DISCUSSION

NPSs represent an unprecedented challenge in the field of public health with social, cultural, legal, and political implications. Web monitoring activities are essential for mapping the diffusion of NPSs and for supporting innovative Web-based prevention programmes.

The Experience Elicited by Hallucinogens Presents the Highest Similarity to Dreaming within a Large Database of Psychoactive Substance Reports

Ever since the modern rediscovery of psychedelic substances by Western society, several authors have independently proposed that their effects bear a high resemblance to the dreams and dreamlike experiences occurring naturally during the sleep-wake cycle. Recent studies in humans have provided neurophysiological evidence supporting this hypothesis. However, a rigorous comparative analysis of the phenomenology (“what it feels like” to experience these states) is currently lacking. We investigated the semantic similarity between a large number of subjective reports of psychoactive substances and reports of high/low lucidity dreams, and found that the highest-ranking substance in terms of the similarity to high lucidity dreams was the serotonergic psychedelic lysergic acid diethylamide (LSD), whereas the highest-ranking in terms of the similarity to dreams of low lucidity were plants of the Datura genus, rich in deliriant tropane alkaloids. Conversely, sedatives, stimulants, antipsychotics, and antidepressants comprised most of the lowest-ranking substances. An analysis of the most frequent words in the subjective reports of dreams and hallucinogens revealed that terms associated with perception (“see,” “visual,” “face,” “reality,” “color”), emotion (“fear”), setting (“outside,” “inside,” “street,” “front,” “behind”) and relatives (“mom,” “dad,” “brother,” “parent,” “family”) were the most prevalent across both experiences. In summary, we applied novel quantitative analyses to a large volume of empirical data to confirm the hypothesis that, among all psychoactive substances, hallucinogen drugs elicit experiences with the highest semantic similarity to those of dreams. Our results and the associated methodological developments open the way to study the comparative phenomenology of different altered states of consciousness and its relationship with non-invasive measurements of brain physiology.

Can mobile phone technology support a rapid sharing of information on novel psychoactive substances among health and other professionals internationally?

BACKGROUND

The diffusion of novel psychoactive substances (NPSs), combined with the ability of the Internet to act as an online marketplace, has led to unprecedented challenges for governments, health agencies, and substance misuse services. Despite increasing research, there is a paucity of reliable information available to professionals working in the field. The paper will present the pilot results of the first mobile application (SMAIL) for rapid information sharing on NPSs among health professionals.

METHODS

The development of SMAIL was divided into 2 parts: (a) the creation of the application for registered users, enabling them to send an SMS or email with the name or "street name" of an NPS and receive within seconds emails or SMS with the information, when available and (b) the development of a database to support the incoming requests.

RESULTS

One hundred twenty-two professionals based in 22 countries used the service over the pilot period of 16 months (from May 2012 to September 2013). Five hundred fifty-seven enquires were made. Users received rapid information on NPSs, and 61% of them rated the service as excellent.

CONCLUSIONS

This is the right time to use mobile phone technologies for rapid information sharing and prevention activities on NPSs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Could Hallucinogens Induce Permanent Pupillary Changes in (Ab)users? A Case Report from New Zealand

An eighteen-year-old female patient of the Caucasian ethnicity from Australasia presented with a persistently dilated pupil causing her discomfort and occasional burning sensation when she is outdoors due to oversensitivity to sunlight. However, her pupillary reaction to light (pupillary light reflex) was intact. The patient is a known user of psychedelic substances (entheogens) including LSD, NBOMe, psilocybin, and DMT. The condition affects both eyes to the same extent. Thorough medical, neurological, and radiological examinations, including an EEG and an MRI of the head and neck region, were completely normal. All these tests failed to detect any pathophysiological or anatomical abnormalities. The patient is a known case of chronic endogenous depression in association with attention deficit hyperactivity disorder, for which she is taking citalopram and Ritalin, respectively. There was neither a family history nor a similar congenital condition in her family.

Digital danger: a review of the global public health, patient safety and cybersecurity threats posed by illicit online pharmacies

BACKGROUND

Amidst the rise of e-commerce, there has been a proliferation of illicit online pharmacies that threaten global patient safety by selling drugs without a prescription directly to the consumer. Despite this clear threat, little is known about the key risk characteristics, central challenges and current legal, regulatory and law enforcement responses.

SOURCES OF DATA

A review was conducted of the English literature with search terms 'online pharmacies', 'Internet pharmacies', 'cyber pharmacies', 'rogue pharmacies', and 'e-pharmacies' using PubMed, JSTOR, and Google Scholar from 1999-2005.

AREAS OF AGREEMENT

Illicit online pharmacies are a rapidly growing public health threat and are characterized by a number of complex and interrelated risk factors.

AREAS OF CONTROVERSY

Solutions are varied and are of questionable utility in the face of evolving technology that enables this form of transnational cybercrime.

GROWING POINTS

Legal, regulatory and technology solutions must address the entire illicit online pharmacy ecosystem in order to be effective.

AREAS TIMELY FOR DEVELOPING RESEARCH

There is a critical need to build international consensus, conduct additional research and develop technology to combat illicit online pharmacies.

[The distribution of tropicamide in the body of warm-blooded animals after its intragastric administration]

The objective of the present study was to elucidate the peculiar features of the distribution of N-ethyl-3-hydroxy-2-phenyl-N-(piridin-4-yl-methyl)propanamide (tropicamide) in the body of warm-blooded animals (rats) after its intragastric administration. The following methods were employed in the study: TLC, chromogenic reactions, electronic spectrophotometry, and GC-MS. The results of the quantitative analysis of N-ethyl-3-hydroxy-2-phenyl-N-(piridin-4-yl-methyl)propanamide in different organs of warm-blooded animals (rats) were compared within 20 minutes, 2.5 and 6 hours after its single intragastric administration at a dose equivalent to 1.5 LD50 of the toxic substance. It was shown that at all time intervals the maximum amount of tropicamide was present in the tissues of the stomach. Small intestines, their contents, brain, lungs, and spleen.

The potential utility of some legal highs in CNS disorders

Over the last decade there has been an explosion of new drugs of abuse, so called legal highs or novel psychoactive substances (NPS). Many of these abused drugs have unknown pharmacology, but their biological effects can be anticipated from their molecular structure and possibly also from online user reports. When considered with the findings that some prescription medications are increasingly abused and that some abused drugs have been tested clinically one could argue that there has been a blurring of the line between drugs of abuse and clinically used drugs. In this review we examine these legal highs/NPS and consider whether, based on their known or predicted pharmacology, some might have the potential to be clinically useful in CNS disorders.

Adverse Psychiatric Effects Associated with Herbal Weight-Loss Products

Obesity and overeating are among the most prevalent health concerns worldwide and individuals are increasingly using performance and image-enhancing drugs (PIEDs) as an easy and fast way to control their weight. Among these, herbal weight-loss products (HWLPs) often attract users due to their health claims, assumed safety, easy availability, affordable price, extensive marketing, and the perceived lack of need for professional oversight. Reports suggest that certain HWLPs may lead to onset or exacerbation of psychiatric disturbances. Here we review the available evidence on psychiatric adverse effects of HWLPs due to their intrinsic toxicity and potential for interaction with psychiatric medications.

Psyclones: a roller coaster of life? Hidden synthetic cannabinoids and stimulants in apparently harmless products

OBJECTIVE

The urge to gain information on a new drug marketed online as 'Psyclone' has emerged after the death of a 38-year-old man in Bolton (UK). The fatality appeared to be a consequence of smoking this psychoactive product.

METHODS

From October to December 2013, qualitative searches of the Web have been carried out in English and Italian, using the keywords 'Psyclone', 'Psyclone legal high', 'Psyclone incense' and 'Psyclone research chemical' on the Google search engine and on the database provided by the Global Public Health Intelligence Network.

RESULTS

Our research highlighted the existence of two psychoactive products labelled as Psyclone but with different contents and packaging: a herbal blend containing two synthetic cannabinoids (AKB-48 and 5f-PB-22) and a research chemical containing 50% ethylphenidate, 30% caffeine and 20% lidocaine. Desired and side effects of both compounds are explored in the paper.

CONCLUSIONS

Being sold as a legal product, Psyclone may appeal to recreational users, who remain unaware of its real content. This is a serious public health threat, which may lead to acute intoxications and fatalities. Further studies in the field, including Internet monitoring, are therefore required.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Injecting eye-drops: a mini-review on the non-clinical use of tropicamide

OBJECTIVES

The intravenous (IV) injection of tropicamide for non-clinical purposes is a new and widespread drug trend. The aim of this study is to provide the first literature review on the topic.

METHODS

Relevant literature was identified through a search of MEDLINE, Psycinfo, Google Scholar, conference proceedings and select citations.

RESULTS

Cases of tropicamide (IV) injection have been reported in Russia, Italy, Turkey and Kazakhstan. This phenomenon is mainly secondary to primary opioid (especially heroin) addiction. Several key factors can be associated with its rapid diffusion: (i) enhancement of the 'positive' effects of heroin; (ii) decrease and delay of heroin withdrawal symptoms; (iii) easy availability; (iv) low costs; (v) fast effects; and (vi) visibility of self-reported experiences on Internet. Acute tropicamide intoxications can lead to anticholinergic syndrome, hyperthermia, tremors and convulsions. Chronic tropicamide-related problems include cardiovascular toxicity, psychosis, renal or liver failures, severe weight loss and infections. Fatalities due to tropicamide IV injection have been reported in non evidence-based/peer-reviewed sources, such as drug fora, websites and media news.

CONCLUSIONS

Tropicamide IV injections represent a serious health risk. Specific prevention programmes should be implemented for the general population as well as for the high-risk population of polydrug abusers.

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

Purpose

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

Design/methodology/approach

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

Findings

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

Research limitations/implications

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

Practical implications

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

Social implications

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

Originality/value

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

Drug abuse monitoring: which pharmacoepidemiological resources at the European level?

Monitoring the potential for abuse and dependence of psychoactive substances falls within the scope of international conventions on narcotic drugs. At the European level, this monitoring is based on activities controlled by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) for substance abuse in general and by the European Medicines Agency (EMA) for marketed drugs, in the context of pharmacovigilance. If France has set up in the early 1990s an original system to assess potential for abuse of psychoactive substances, with specific tools combining both the evaluation of the use of these substances (illicit substances or diverted drugs), and the consequences of that use in terms of morbidity and mortality, there is no equivalent in other European countries. Indeed, unlike the USA, who, for several decades, organized this type of surveillance, with a multisource approach (sentinel systems, databases, medical and administrative data, databases for seeking care in relation abuse), we have not found in other European countries integrated system for identifying a signal of drug abuse, or to assess the impact of measures for minimizing the risk of abuse. However, some recent examples show a growing concern about drug addiction, based on a pharmacoepidemiological approach using pharmacovigilance databases or medical administrative data. These examples illustrate the interest of these approaches in the field of drug of abuse.

Legal highs: staying on top of the flood of novel psychoactive substances

There has been growing clinical, public, and media awareness and concern about the availability and potential harmfulness of so-called 'legal highs', which are more appropriately called new or novel psychoactive substances (NPS). A cat-and-mouse process has emerged wherein unknown chemists and laboratories are producing new, and as yet nonproscribed, compounds for human consumption; and as soon as they are banned, which they inevitably are, slightly modified analogues are produced to circumvent new laws. This rapidly changing environment, 81 new substances were identified in 2013 alone, has led to confusion for clinicians, psychopharmacologists, and the public at large. Our difficulties in keeping up with the process has had a two-fold negative effect: the danger of ignoring what is confusing; and the problem that some of the newer synthesized compounds appear ever more potent. This review aims to circumscribe a quick moving and growing field, and to categorize NPS into five major groups based upon their 'parent' compounds: stimulants similar to cocaine, amphetamines and ecstasy; cannabinoids; benzodiazepine based drugs; dissociatives similar to ketamine and phencyclidine (PCP); and those modelled after classic hallucinogens such as LSD and psilocybin. Pharmacodynamic actions, subjective and physical effects, harmfulness, risk of dependency and, where appropriate, putative clinical potentials are described for each class. Clinicians might encounter NPS in various ways: anecdotal reportage; acute intoxication; as part of a substance misuse profile; and as a precipitant or perpetuating factor for longer-term physical and psychological ill health. Current data are overall limited, and much of our knowledge and treatment strategies are based upon those of the 'parent' compound. There is a critical need for more research in this field, and for professionals to make themselves more aware of this growing issue and how it might affect those we see clinically and try to help: a brave new world of so-called 'psychonauts' consuming NPS will also need informed 'psychotherapeutonauts'. The paper should serve as a primer for clinicians and interested readers, as well as provide a framework into which to place the new substances that will inevitably be synthesized in the future.

Novel psychoactive substances of interest for psychiatry

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

The diffusion of performance and image-enhancing drugs (PIEDs) on the internet: the abuse of the cognitive enhancer piracetam

INTRODUCTION

Performance and image-enhancing drugs (PIEDs), also known as "lifestyle drugs," are increasingly sold on the Internet to enhance cognitive as well as sexual, muscular, attentive, and other natural capacities. Our analysis focuses on the misuse of the cognitive enhancer piracetam.

METHODS

A literature review was carried out in PsychInfo and Pubmed database. Considering the absence of peer-reviewed data, review of additional sources of unstructured information from the Internet was carried out between February 2012 and July 2013. Additional searches were conducted using the Global Public Health Intelligence Network (GPHIN), a secure Internet-based early warning system developed by Health Canada and the World Health Organization (WHO), which monitors media reports in six languages, Arabic, Chinese, English, French, Russian, and Spanish.

RESULTS

Piracetam is sold via illicit online pharmacies with no need of prescription at low prices. Buyers, mainly healthy individuals, purchase the product to enhance study- and work-related performances as well as for recreational purposes. Its nonmedical use is often associated with the occurrence of side effects such as hallucinations, psychomotor agitation, dysphoria, tiredness, dizziness, memory loss, headache, and severe diarrhoea; moreover, several users declared to have neither felt any cognitive improvement nor psychedelic effects.

CONCLUSIONS

This is a new and fast-growing trend of abuse that needs to be extensively monitored and studied also by using near real-time and unstructured sources of information such as Internet news and online reports in order to acquire rapid knowledge and understanding. Products sold online might be counterfeits and this enhances related health risks.

New drugs on the Internet: the case of Camfetamine

Introduction. The number of new psychoactive substances (NPS) advertised for sale online is constantly increasing and it has become a phenomenon of global concern. Among NPS, Camfetamine has been rediscovered as recreational drug in 2011. Very little information is still available in the scientific literature on its nature and potential health risks. Methods. Data in scientific literature were integrated with a multilingual qualitative assessment of a range of online resources over the period of 32 months (May 2011–January 2014). Results. N-Methyl-3-phenyl-norbornan-2-amine (Camfetamine) may act as an indirect dopaminergic agonist in the central nervous system and may have mild-moderate opioid activity too. There are no current epidemiological data about recreational use of Camfetamine; our research shows that it is indeed used especially by individuals with a history of recreational polydrug misuse. It facilitates mental alertness, induces relaxation, and, unlike many other stimulants, seems not to be associated with severe physical effects. Valid causes for concern issued in our research may be Camfetamine intravenous or intramuscular administration as well as its use in conjunction with other psychoactive substances. Conclusions. It is here highlighted that more large-scale studies need to be carried out to confirm and better describe both the extent of Camfetamine misuse and possible psychotropic/adverse effects.

25C-NBOMe: preliminary data on pharmacology, psychoactive effects, and toxicity of a new potent and dangerous hallucinogenic drug

Introduction. The use of novel psychoactive substances (NPSs) has rapidly increased as well as their online availability. The aim of this paper is to provide a comprehensive review of the nature and the risks associated with 25C-NBOMe, which has recently appeared in the drug market. Methods. A systematic analysis of the scientific literature and a qualitative assessment of online and media resources (e.g., e-newsgroups, chat-rooms, and e-newsletters) in 10 languages were carried out. Results. 25C-NBOMe is sold online as legal LSD or as research chemical with different designations such as “Boom,” “Pandora,” “Holland film,” or “N-bomb.” It is a partial agonist of 5-HT2A receptors. It is usually ingested orally/sublingually and, less commonly, nasally, through injection, vaginally, rectally, and smoked. Its effects include sublingual numbing, stimulation, “body high,” hallucinations, dissociation, and anxiety. 25C-NBOMe presents high risk of overdoses; acute toxicity and fatalities have been reported. Conclusions. 25C-NBOMe consumption represents an emerging phenomenon with potential harmful effects. Its use is increased by its online availability at low costs. Health and other professionals should be informed about this new trend of substance use.

Intravenous Abuse of Tropicamide in Opioid Use Disorder: Presentation of 2 Cases

BACKGROUND

Tropicamide is an antimuscarinic ophthalmic solution used to produce short-acting mydriasis and cycloplegia. Topical abuse of ophthalmic solutions has been reported, but intravenous (IV) abuse of tropicamide seems to be a new phenomenon.

CASES

The authors present 2 patients with concomitant IV tropicamide abuse and opioid use disorder. Patients were hospitalized and started on buprenorphine/naloxone treatment for opioid withdrawal. Patients' reports about tropicamide effects are remarkable, as they claimed that tropicamide increased the efficacy of heroin while decreasing and delaying the withdrawal symptoms.

DISCUSSION

Although anticholinergics have been known to be abused for their euphoric effects, these cases' motivation to use tropicamide seemed to extend beyond its euphoric effect and was also based on its interaction with heroin. It is feared that tropicamide abuse may become more frequent. Health professionals should be aware of this trend so that symptoms of misuse and intoxication can be recognized, and ophthalmologists should consider the abuse potential of anticholinergic eye drops when prescribing them.