Introduction to the special issue: the changing use and misuse of khat (Catha edulis)--tradition, trade and tragedy

Epidemiology of Khat (Catha edulis) Chewing in Ethiopia: A Systematic Review and meta-analysis

In several countries, including Ethiopia, the shrub Catha edulis (khat) leaves are chewed for their stimulant properties. The present review summarizes evidence on the prevalence of khat use in Ethiopia and forwards recommendations for future action. PubMed, Embase, and Scopus were searched for studies examining the prevalence of Khat chewing among adolescent and/or adult populations in Ethiopia. A random-effects model was employed to estimate the pooled prevalence of khat chewing. Of the 568 articles identified, 26 were included in the review. The pooled prevalence of current and lifetime khat use was 19.55% (95% CI 14.62-25.64) and 26.14% (CI 17.66-36.87), respectively. The current prevalence of khat use was higher in men, 23.72% (CI 13.42-38.41), than in women 8.45% (CI 4.94-14.08). Lifetime prevalence of khat use was higher in men, 29.8% (CI: 22.80-37.99) than in women 13.02% (CI 8.96-18.56). The results of the meta-analysis demonstrated a higher odds of current (OR = 4.00, CI 2.80-5.73) and lifetime (OR = 2.84, CI 2.50-3.23) khat use in men than in women. Our review found a high prevalence of current (19.55%) and lifetime (26.14%) khat chewing in Ethiopia and demonstrated higher odds of current and lifetime khat use in men than in women. Awareness creation and integrated management of khat use problems at the primary health-care level is highly recommended.

Dhagan Celis (Cultural Rehabilitation): Somali Canadians Transnational Approach to Youth Substance Use

BACKGROUND

Evidence suggests that some Somali youth who settled in Canada struggle with substance use problems, yet research remains limited in understanding the Somali community's experiences and struggles in supporting their youth affected by substance use.

OBJECTIVE

This study aims to contribute important knowledge in understanding substance use among Somali Canadian youth and access to treatments in Canada and the transnational cultural healing services available in East Africa.

METHODS

Qualitative interviews (n = 37) were conducted in a metropolitan Canadian city and Nairobi, Kenya, from May 2016 to May 2017. In addition, a field study (n = 4) of rehabilitation centers in Kenya was carried out.

RESULTS

Through thematic analysis, five main themes were identified: (i) discrimination and racism in the school environment, (ii) emotional pain and self-medication, (iii) low literacy on substance use and treatment in the Canadian context, (iv) stigma, and (v) dhagan celis (cultural rehabilitation) in transnational setting.

CONCLUSIONS

The study provides evidence of the need to address substance use and trauma among refugee youth in the post-resettlement context especially as Canada currently deals with a significant public health crisis in the form of opioid overdose and substance use.

Prevalence of Khat (Catha edulis) Chewing and Its Determinants: A Respondent-Driven Survey from Hossana, Ethiopia

BACKGROUND

Ethiopia is a leading khat producer in East Africa, and almost all regions are involved in khat production. Hossana, a small town in Southern Ethiopia, is also actively involved in khat production and its use. However, very few studies have been conducted to investigate the habit of khat chewing in this area. This study was conducted to assess the prevalence and predictors of khat chewing among Hossana residents.

METHODS

The study was conducted on 1700 individuals in Hossana town from March 2018 to June 2019. A structured pre-tested self-administered questionnaire was designed and used for data collection. Descriptive statistics and logistic regression were carried out to study the prevalence and predictors of khat chewing in the study area.

RESULTS

The overall prevalence of khat chewing among the respondents was 58.0% (95% CI 53.4-63.3) of which 68.4% were daily khat users and 31.5% used it occasionally. About 24.7% of females and 75.2% of males had chewed khat. Muslim religion (AOR 2.37; 95% CI 1.58-4.32), male gender (AOR 3.48; 95% CI 2.16-5.61), Older age (AOR 1.36; 95% CI 0.84-2.21), participants having habitual khat chewing friends or a khat chewer family associate (OR 1.70; 95% CI 1.17-2.20) were found to be independent predictors of chewing.

CONCLUSION

Significant portion of the population in the study area chew khat. Khat use is significantly associated with the Muslim religion, gender, age, and habit of family and friends. Further studies with larger demographic area are warranted from the study area to reproduce these findings.

Drug-Induced Liver Injury Caused by "Khat," an Herbal Stimulant

We describe a case of Catha edulis (Khat) drug-induced liver injury in a 28-year-old man from Yemen. The patient presented with jaundice, fatigue, and anorexia. Extensive workup, including liver biopsy, was performed. This is the first reported case in the United States without definite autoimmune hepatitis. Diagnosis requires high clinical suspicion and extensive workup. Increasing migration and differences in cultural practices lead to the need for an increased awareness of this type of cases, which is underreported.

Exploring the Molecular Mechanisms of 17β-HSD5-induced Carcinogenicity of Catha edulis via Molecular Modeling Approach

BACKGROUND

The tradition of khat chewing has been deep-rooted in the African and Arabian Peninsula for centuries. Due to its amphetamine-like psycho-stimulant or euphoric effect, khat has been used by millions in Somalia, Ethiopia, Saudi Arabia and Yemen. The long-term use of khat can induce many major health outcomes, which may be serious and irreversible.

OBJECTIVE

Prolonged use of khat constituents has been associated with different types of cancers such as prostatic, breast and ovarian cancer. However, it has been very difficult to identify the molecular targets involved in khat carcinogenesis that interact with the Khat constituents by in vitro/in vivo experimental tools.

METHODS

In silico tools were used to predict potential targets involved in the carcinogenesis of khat. Pass on-line prediction server was used for the prediction of a potential molecular target for khat constituents. Molecular Dynamics simulation and MM-GBSA calculation of the predicted target were carried out.

RESULTS

Molecular Dynamics simulation and MM-GBSA calculation revealed that among khat constituents, β-sitosterol showed a high binding affinity towards 17β-HSD5. On the other hand, this study highlights for the first time some new interactions, which were observed in the case of cathine, cathinone and nerol during the simulation.

CONCLUSION

In silico molecular dynamic simulation tools were used for the first time to investigate the molecular mechanism of widely used leaves of psychoactive khat (Catha edulis) constituent. The present study provides deep insight to understand the effect of khat constituents involved in the impairment of the reproductive system and its binding to 17β-HSD5. ADMET profiling also suggested that few khat constituents do not fulfill the requirements of the Lipinski rule of five i.e. poor absorption and blood-brain barrier impermeability.

A Systematic Review of Treatments for Problematic Khat Use

Khat, a psychostimulant cultivated and commonly used in Eastern Africa and the Arabian penin-sula, has a longstanding history of use embedded within the cultures of these regions. Due to changing patterns of use and the adverse effects of dependence, khat has become a growing pub- lic health concern. Despite extensive findings regarding the detrimental psychiatric, physical, and social consequences of khat dependence, research on interventions in this area is glaringly sparse. The present paper aims to summarize the consequences of chronic khat use and review existing research on interventions.

Khat chewing prevalence and correlates among university staff in Ethiopia: a cross-sectional study

OBJECTIVES

Khat is an herbal cultivated plant growing mainly in Eastern Africa and Arabians. Chronic khat chewing leads to the development of liver toxicity, cardiovascular disease, sleeping disorder, psychosis, memory impairment, poor academic performance and variety of social and economic problems affecting the consumers and their families. Therefore, this study aimed to determine the prevalence of khat chewing and associated factors among Jimma university staff. An institution-based cross-sectional study was employed on 354 university staff. A self-administered questionnaire was used to collect the data. The analysis was done using Stata 14. A multivariable logistic regression model was used to identify associated factors of khat chewing among university staff. p ≤ 0.05 was employed to declare statistically significant factors.

RESULTS

The lifetime prevalence of khat chewing among university staff was 41.0% (95% CI 35.9-46.1%). The odds of khat chewing was higher among males (AOR = 2.66 95%, CI 1.52-4.68), participants who had khat chewer friends (AOR = 2.15 95% CI 1.18-3.93), alcohol users (AOR = 9.02, 95% CI 4.96-16.42) and participants who had khat chewer family member (AOR = 4.03, 95% CI 1.16-13.99). Since a significant proportion of staff chew khat, appropriate measures need to be taken to reduce its prevalence and adverse social and health consequences.

Epidemiology of khat (Catha edulis) consumption among university students: a meta-analysis

BACKGROUND

Khat is amphetamine-like substance commonly consumed by students when they wish to study for long hours especially during examination periods. Khat consumption is associated with increased rates of cardiovascular problems, stroke, myocardial infarction, cardiomyopathy, periodontal disease, gastritis, poor oral hygiene, psychosis, decreased quality of life, and poor academic performance.

METHODS

PubMed, EMBASE, and SCOPUS were systematically searched without restriction by publication status. Publications were screened according to predefined inclusion criteria. Twenty-five articles were included. Random effect model was used to calculate weighted prevalence, odds ratio (OR) and corresponding 95% confidence interval (CI). We assessed the risk of publication bias by using funnel plot and Eggers's regression tests.

RESULTS

The pooled prevalence of current khat use among university students was 14.16% (95% CI; 11.87-16.81). The pooled prevalence of current khat use was highest in Saudi Arabia 18.85% and it was 13.59% in Ethiopia and 13.04% in Yemen. In addition, the current pooled prevalence of khat use was higher in men at 19.26% than in women 6.41%. Regarding lifetime khat use, in this study, the pooled prevalence of lifetime khat use was 27.31%. The lifetime prevalence was higher in men at 31.47% than in women 11.79%. Moreover, the lifetime prevalence of khat use was 43.27% in Yemen, 37.32% in Saudi Arabia, and 24.82% in Ethiopia. We found significantly increased odds of current (OR 3.59; 95%CI 2.01-6.41) as well as lifetime (OR 3.48; 95%CI 2.09-5.78) khat chewing in men as compared to women.

CONCLUSION

The pooled prevalence of current and lifetime khat consumption was 14.16 and 27.31%, respectively. Both the current and lifetime prevalence of khat use was higher in men than in women. In addition, both the current and lifetime prevalence estimates of khat consumption were low in Ethiopia than in Saudi Arabia. Moreover, the odds of both current and lifetime khat consumption were higher in male students than in female students. Programmes that specifically aim at increasing awareness and that most motivate reduced khat consumption among university students were recommended.

High Seroprevalence of Autoantibodies Typical of Autoimmune Liver Disease in Eastern Ethiopia: Is Chewing of Khat (Catha edulis) a Triggering Factor?

BACKGROUND

Recent studies have identified chewing of khat (Catha edulis) as an independent risk factor for liver injury; however, the pathogenetic mechanism remains poorly understood. Case series have found markers of autoimmune hepatitis in patients with khat-related liver disease, suggesting that khat chewing might trigger an autoimmune response. The aims of the present study were (i) to assess the prevalence of autoantibodies typical for autoimmune liver diseases in a healthy population in Ethiopia and (ii) to explore the hypothesis that khat usage triggers autoimmunity.

METHODS

Consenting adults (≥18 years) without known autoimmune disease or manifest liver disease were included. One-hundred-and-sixty-nine individuals with current khat use were compared to 104 individuals who never used khat. Seroprevalence of antinuclear (ANA), antismooth muscle (SMA), and antimitochondrial antibodies (AMA) were determined and compared between the groups using logistic regression models to adjust for age and sex.

RESULTS

Overall, 2.6% of the study subjects were positive for ANA, 15.4% for SMA, and 25.6% for AMA. When comparing khat users to nonusers, ANA was detected in 4.1% vs. 0% (p=0.047), SMA in 16.0% vs. 14.4% (p=0.730), and AMA in 24.9% vs. 26.9% (p=0.704). ANA was excluded from multivariable analysis since there was no seropositive in the reference group. After adjusting for sex and age, no significant association between khat use and SMA or AMA was found.

CONCLUSIONS

No association between khat usage and the seropresence of SMA or AMA was found, weakening the hypothesis that khat-related liver injury is mediated through autoimmune mechanisms. However, the seroprevalences of AMA and SMA were strikingly high in this Ethiopian population compared to global estimates, suggesting that diagnostic algorithms for autoimmune liver diseases developed in Europe and North America might lead to misdiagnosis of patients on the African continent.

Food Security of Adolescents in Selected Khat- and Coffee-Growing Areas in the Sidama Zone, Southern Ethiopia

Whilst pervasive food insecurity exists among adolescents in Ethiopia, the available information is scant and inconsistent. Therefore, the main objective of this cross-sectional study was to contribute to these gaps by assessing the food security of adolescents in the selected khat- and coffee-growing areas. We selected 234 (117 girls and 117 boys) adolescents aged 12⁻18 years via stratified random sampling. We measured the height and weight of the adolescents and asked about their food insecurity experiences. We assessed the prevalence of stunting and thinness using the WHO 2007 growth reference standards. Out of the total, 17 (7.3%) and 30 (12.8%) adolescents were stunted and thin, respectively. In addition, 89 (38.0%) adolescents reported food insecurity experiences and nine (3.8%) were overweight. A regression analyses showed that the stunting was associated with the age of the adolescents and maternal education. Thinness was associated with area, gender, and the number of meals. Food insecurity experiences were associated with health problems in the past 30 days. In general, adolescents from the khat-growing area have better food security than those from the coffee-growing area, and the same is true, gender-wise, for girls compared to boys. We recommend possible interventions primarily for adolescents in coffee-growing areas.

Khat chewing increases the risk for developing chronic liver disease: A hospital-based case-control study

The chewing of the leaves of Catha edulis (khat) has been implicated in the development of liver disease, but no controlled observations have been undertaken. The objective of the present study was to determine whether khat chewing is associated with development of chronic liver disease (CLD). A case-control study was conducted at two public hospitals in Harar, Ethiopia, between April 2015 and April 2016. A consecutive sample of 150 adult hospital attendees with CLD were included as cases, and 300 adult hospital attendees without clinical or laboratory evidence of CLD were included as controls. Khat consumption was quantified in "khat years"; 1 khat year was defined as daily use of 200 g of fresh khat for 1 year. A logistic regression model was used to control for confounders. There was a significant association between chewing khat and the risk for developing CLD (crude odds ratio, 2.64; 95% confidence interval [CI], 1.56-4.58). In men, this risk, following adjustment for age, alcohol use, and chronic hepatitis B/C infection, increased with increasing khat exposure; thus, compared to never users the adjusted odds ratios were for low khat exposure 3.58 (95% CI 1.05-12.21), moderate khat exposure 5.90 (95% CI 1.79-19.44), and high khat exposure 13.03 (95% CI 3.61-47.02). The findings were robust in a post hoc sensitivity analysis in which individuals with identifiable risk factors for CLD were excluded.

CONCLUSION

A significant association was observed between chewing khat and the risk for developing CLD, and in men the association was strong and dose-dependent, suggesting a causal relationship; as the prevalence of khat chewing is increasing worldwide, these findings have major public health implications. (Hepatology 2018;68:248-257).

Using the Severity of Dependence Scale to screen for DSM-5 khat use disorder

OBJECTIVE

This study aimed to determine the efficacy of the Severity of Dependence Scale (SDS) as a screening tool for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-defined khat use disorder.

METHODS

Cross-sectional, purposive sample of past-year khat consumers aged 16 and above were recruited from khat markets and cafes from university and general community in Adama, Ethiopia. Participants self-completed a survey comprising current substance use disorder.

RESULTS

The SDS formed a unifactorial structure, consistent with the dependence construct. Almost three quarters (73%) of the sample were identified as experiencing Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition khat use disorder. The SDS demonstrated excellent discrimination (area under the curve = 0.92) and an optimal cut-off as a score of 3 or greater, with sensitivity of 81% and specificity of 96%. This classification validly identified a group with more frequent and higher dose khat use than participants that did not screen positive.

CONCLUSION

Although khat is a mild stimulant, there is clear evidence that some consumers are both concerned with their use and experience problems associated with their use. Consistent with its application for other drugs, the SDS is a brief and simple screening tool that appears to validly identify individuals experiencing a khat use disorder syndrome and experiencing high rates of adverse consequences in association with use.

The Epidemiology of Tobacco Use among Khat Users: A Systematic Review

Khat, an "amphetamine-like green leaf," may influence the consumption of tobacco. This study reviews the epidemiology of tobacco use among khat users. Electronic database searches using appropriate keywords/terms were conducted to identify observational studies of khat use. Assessment of quality and risk of bias of all included studies was conducted, and the results were synthesised descriptively. Nine eligible cross-sectional studies were identified. All assessed self-reported tobacco among khat users and were carried out in Africa and the Middle East. Eight reported cigarettes and one reported waterpipes as the mode of use. Methods of tobacco use prevalence assessment varied. Prevalence of "current" tobacco use among students and university teachers ranged from 29 to 37%; "lifetime" tobacco use in university teachers was 58% and "undefined" tobacco use in nonspecific adults and students ranged from 17 to 78%. Daily tobacco use among adults was reported as 17% whilst simultaneous tobacco and khat use was reported as between 14 and 30% in students. In conclusion, tobacco prevalence among khat users appears significant. Findings should be interpreted cautiously due to self-reported tobacco use, diversity in questions assessing tobacco use, and type of tobacco consumption. Future research should address the methodological shortcomings identified in this review before appropriate policy interventions can be developed.

Khat Chewing Practice and Associated Factors among Adults in Ethiopia: Further Analysis Using the 2011 Demographic and Health Survey

BACKGROUND

Khat chewing has become a highly prevalent practice and a growing public health concern in Ethiopia. Although there have been many small scale studies, very limited national information has been available in the general population. This study aimed to identify factors associated with khat chewing practice among Ethiopian adults.

METHODS

The study used the 2011 Ethiopian demographic and health survey data. The survey was cross-sectional by design and used a multistage cluster sampling procedure. Bivariate and multivariable logistic regression models with adjusted odds ratio (AOR) and their 95% confidence intervals (CI) were used to quantify the predictors.

RESULTS

The overall khat chewing prevalence was 15.3% (95% CI: 14.90-15.71). Regional variation was observed with the highest in Harari [(53.2% (95% CI: 43.04-63.28)] and lowest in Tigray regional state [(1.1% (95% CI: 0.72-1.66)]. Multivariable analysis showed that Islam followers were 23.8 times more likely to chew khat as compared to Orthodox followers. Being a resident in Oromiya, South Nation, Nationalities and People (SNNP), Gambella, Harari and Dire Dawa regions had 1.9, 1.6, 3.1, 5.2 and 3.5 times higher odds of chewing khat as compared to Addis Ababa residents, respectively. Adults in the age group 45-49 years were 3.6 times more likely to chew khat as compared to 15-19 years. The middle and richest wealth quintiles were 1.3 and 1.5 times more likely to chew khat, respectively, as compared to the poorest category. Rural residents had 1.3 odds of chewing khat than urban residents. Those individuals who had occupation in sales, agriculture, service sector, skilled and unskilled manual workers were 1.6, 1.3, 2.4, 1.7 and 2.3 times more likely to chew khat, respectively, as compared to those who have no occupation. Females were 77% less likely to chew khat as compared to males. Formerly married and those experienced in child death had 1.4 and 1.2 times higher odds to chew khat as compared with those never married and never had child death, respectively. Those who attended mass media were 1.4 times more likely to chew khat compared with not attended.

CONCLUSION

Khat chewing is a public health concern in Ethiopia. The highest wealth quintiles, older age group, rural residence, child death, formerly married, males, regions of Oromiya, SNNP, Gambella, Harari and Dire Dawa and Islamic followers had statistically significant association with khat chewing. Due attention needs to be given for these factors in any intervention procedures.

Khat Use, PTSD and Psychotic Symptoms among Somali Refugees in Nairobi - A Pilot Study

In East-African and Arab countries, khat leaves are traditionally chewed in social settings. They contain the amphetamine-like alkaloid cathinone. Especially among Somali refugees, khat use has been associated with psychiatric symptoms. We assessed khat-use patterns and psychiatric symptoms among male Somali refugees living in a disadvantaged urban settlement area in Kenya, a large group that has not yet received scientific attention. We wanted to explore consume patterns and study the associations between khat use, traumatic experiences, and psychotic symptoms. Using privileged access sampling, we recruited 33 healthy male khat chewers and 15 comparable non-chewers. Based on extensive preparatory work, we assessed khat use, khat dependence according to DSM-IV, traumatic experiences, posttraumatic stress disorder (PTSD), and psychotic symptoms using standardized diagnostic instruments that had been adapted to the Somali language and culture. Hazardous use patterns like chewing for more than 24 h without interruption were frequently reported. All khat users fulfilled the DSM-IV-criteria for dependence and 85% reported functional khat use, i.e., that khat helps them to forget painful experiences. We found that the studied group was heavily burdened by traumatic events and posttraumatic symptoms. Khat users had experienced more traumatic events and had more often PTSD than non-users. Most khat users experience khat-related psychotic symptoms and in a quarter of them we found true psychotic symptoms. In contrast, among control group members no psychotic symptoms could be detected. We found first evidence for the existence and high prevalence of severely hazardous use patterns, comorbid psychiatric symptoms, and khat use as a self-medication of trauma-consequences among male Somali refugees in urban Kenyan refugee settlements. There is a high burden by psychopathology and adequate community-based interventions urgently need to be developed.

Recreational drug discovery: natural products as lead structures for the synthesis of smart drugs

Covering: up to December 2013. Over the past decade, there has been a growing transition in recreational drugs from natural materials (marijuana, hashish, opium), natural products (morphine, cocaine), or their simple derivatives (heroin), to synthetic agents more potent than their natural prototypes, which are sometimes less harmful in the short term, or that combine properties from different classes of recreational prototypes. These agents have been named smart drugs, and have become popular both for personal consumption and for collective intoxication at rave parties. The reasons for this transition are varied, but are mainly regulatory and commercial. New analogues of known illegal intoxicants are invisible to most forensic detection techniques, while the alleged natural status and the lack of avert acute toxicity make them appealing to a wide range of users. On the other hand, the advent of the internet has made possible the quick dispersal of information among users and the on-line purchase of these agents and/or the precursors for their synthesis. Unlike their natural products chemotypes (ephedrine, mescaline, cathinone, psilocybin, THC), most new drugs of abuse are largely unfamiliar to the organic chemistry community as well as to health care providers. To raise awareness of the growing plague of smart drugs we have surveyed, in a medicinal chemistry fashion, their development from natural products leads, their current methods of production, and the role that clandestine home laboratories and underground chemists have played in the surge of popularity of these drugs.

Reversible khat-induced hepatitis: two case reports and review of the literature

Recreational chewing of Catha edulis (khat) leaves is part of the ethnic culture of Somali, Yemeni and other East African societies for its stimulant properties. With increasing emigration, khat use has become common in these ethnic groups once they move to other areas such as Europe and the USA; one-third of the UK Somali population report khat use within the last month. Cathinone, the active component of the khat leaves, is controlled under the UK Misuse of Drugs Act, but the use of the khat plant and its leaves remains not subject to control in the UK. There have been several previous reports of acute hepatitis related to chronic use of khat leading to acute liver failure, and resulting in transplantation or death. We report two cases with severe acute khat-related hepatitis that resolved on cessation of khat use initially, but relapsed with further use, reinforcing the importance of permanent khat cessation to prevent progression to liver failure. With reference to the current literature, we also consider the difficult diagnosis of this disorder, then go on to consider the pathophysiology, mechanisms of liver injury and potential future areas of research.

Khat (Catha edulis): A systematic review of evidence and literature pertaining to its harms to UK users and society

The use of khat ( Catha edulis) has been associated with a large number of physiological and societal harms, leading to calls for it to be controlled in the UK. The evidence of these harms is often equivocal, limited by confounding factors, or entirely anecdotal: high-powered, quality-controlled studies are lacking. Regardless, the body of relevant literature indicates that the once socially-regulated use of khat has been eroded. Some individuals have developed excessive consumption patterns, either using khat daily or in binge-sessions, though daily consumption is not necessarily problematic per se. The majority of users seem to use khat in moderation, where the associated harms appear low. For excessive users, harms associated with khat are greater, particularly relating to mental health. Social harms also seem to be largely related to excessive khat use rather than khat use itself. Even in cases of excessive khat use, however, causal relationships between chewing and harms have not been described. More research is required to establish the role of khat in liver disease, coronary problems, cancers of the digestive tract and incidents of domestic violence. Studies should consider the likeliness that certain users are more vulnerable to developing patterns of excessive khat use due to an interwoven set of factors such as social health determinants and pre- and post-migration experiences.

Khat dependence syndrome: a cross sectional preliminary evaluation amongst UK-resident Yemeni khat chewers

ETHNOPHARMACOLOGICAL RELEVANCE

Khat is a natural psychostimulant that has pharmacological effects similar to that of amphetamine. The behaviour of khat chewing is embedded within a cultural context. Meanwhile khat chewing is associated with psychological and physiologically burden, as a 'dependence producing' substance.

AIMS OF THE STUDY

To assess the applicability of the construct of substance dependence syndrome (DSM-IV, 1994) to khat chewing and to examine psychosocial and behavioural correlates of this syndrome including tobacco use.

MATERIALS AND METHODS

A sample of 204 khat chewers was recruited during random visits to khat sale outlets. A face to face interview that assessed socio-demographic, psychosocial dependence, substance dependence syndrome and behavioural characteristics was conducted. Descriptive, exploratory psychometric and multivariate analyses were employed.

RESULTS

Approximately a third (31%) of khat chewers reported symptoms consistent with dependence syndrome including increased khat chewing (13%) and cessation attempts (19%) while 17% reported withdrawal symptoms including depression (61%), increase in appetite (74%) and interrupted sleep (58%). Thirty-eight percent reported continued khat chewing despite impacts on their health. Psychometric assessment of the DSM-IV criteria for khat chewing dependence identified two factors; factor 1 consisted of bio-behavioural items and factor 2 withdrawal items, accounting for 67% of the variance and Cronbach's alpha coefficient at 0.78. In multivariate logistic regression modelling, there was an association between intensity of psychological khat dependence (SDS-Khat) and nicotine dependence with the likelihood of exhibiting khat chewing dependence syndrome (p=0.0005, OR=1.51, 95%CI=1.33-1.71; p=0.043, OR=2.87, 95%CI=1.03-7.98, respectively).

CONCLUSIONS

The substance dependence syndrome criteria are applicable to khat chewing and associated with increased intensity of nicotine and psychological khat dependence. The applicability of khat dependence syndrome and exploration of its dimensions and associated factors should be extended in future research. Concurrent validation of these findings using specific objective measures for self-report khat chewing is also recommended.

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

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

Khat use among Somali mental health service users in South London

PURPOSE

Khat use has been suggested to be associated with psychosis, but its prevalence and associations among mental health service users have not been described in either traditional use countries or countries with immigrant populations from traditional use countries. We aimed to investigate the clinical and demographic associations of khat use in a sample of Somali users of mental health service users in South London.

METHODS

We used an electronic case register of 150,000 mental health patients to investigate the associations of khat use among all 240 Somali patients in the database. We used logistic regression to generate adjusted estimates for a range of exposure variables and used multiple imputation as a principled approach to missing data.

RESULTS

Khat use or non-use was recorded for 172 patients (72% of the total), of whom 80 (47%) were current users. Khat use was very strongly associated with ICD-10 primary diagnosis of schizophrenia, psychosis or drug and alcohol disorder (compared to ICD-10 F43 stress-related disorders and other non-psychotic disorders), male gender, harmful or dependent use of alcohol, and detention under the Mental Health Act.

CONCLUSIONS

Recording and monitoring of khat use need to be more consistent in clinical settings, and further studies are required to investigate the much higher rates of use among those with psychotic disorders compared to non-psychotic disorders.

A pilot study on community-based outpatient treatment for patients with chronic psychotic disorders in Somalia: Change in symptoms, functioning and co-morbid khat use

Background

In Low and Middle Income Countries, mental health services are often poorly developed due to the lack of resources and trained personnel. In order to overcome these challenges, new ways of care have been suggested such as a focus on community-based services. In Somalia, the consumption of the natural stimulant khat is highly prevalent, aggravating mental illness. At the same time, mental health care is largely unavailable to the vast majority of the population. In a pilot project, we tested possibilities for effective measures in community-based out-patient mental health care.

Methods

Thirty-five male patients with chronic psychotic disorders and their carers were involved in a 10-months follow-up study. All of them abused khat. Seventeen outpatients experiencing acute psychotic episodes were recruited from the community and received an intensive six week home-based treatment package. Additionally eighteen patients with chronic psychotic disorders in remission were recruited either following hospital discharge or from the community. In a second phase of the study, both groups received community-based relapse prevention that differed in the degree of the family’s responsibility for the treatment. The treatment package was comprised of psycho-education, low-dose neuroleptic treatment, monthly home visits and counseling. The Brief Psychiatric Rating Scale (BPRS) was applied three times. Additionally, we assessed functioning, khat use and other outcomes.

Results

Of the 35 patients enrolled in the study, 33 participated in the 10-month follow-up. Outpatients improved significantly in the first six weeks of treatment and did not differ from remitted patients at the start of the second treatment phase. In the preventive treatment phase, we find heterogeneous outcomes that diverge between symptom and functioning domains. With the exception of depressive symptoms, symptoms in all patients tended to worsen. The outpatient group had higher BPRS positive and negative symptom scores compared to the remitted group. Levels of functioning in 20 out of 33 patients significantly improved, with small differences between groups. Most patients experienced improvements in basic functioning, such as communication, self-care etc. Khat use could only be reduced in the group of outpatients.

Conclusions

Community-based out-patient mental health treatment for chronic psychotic disorders has demonstrated positive effects in Somalia and is both feasible and practical, despite facing formidable challenges, e.g. controlling khat intake.

Validation of self-reported khat chewing amongst khat chewers: an exploratory study

ETHNOPHARMACOLOGICAL RELEVANCE

Khat chewing amongst the UK communities originating from Yemen and the East African coast is suggested to create dependency through its main stimulant components (cathinone, norephedrine and norpseudoephedrine) on the central nervous system.

AIMS OF THE STUDY

To validate self-reported khat chewing behaviours by measuring levels of cathinone, norephedrine and norpseudoephedrine in saliva and to explore their associations with self-reported khat chewing dependency.

MATERIALS AND METHODS

Face-to-face interviews were conducted amongst 30 male UK-resident khat chewers. Saliva samples were collected from each participant and high-performance liquid chromatography (HPLC) employed to extract and quantify the levels of the biomarkers.

RESULTS

The mean (SD) for cathinone and the composite norephedrine and norpseudoephedrine levels were 33.93 (±39.20) and 29.28 (±26.32)μg/mL respectively. These biomarkers were significantly associated (p≤0.05) with khat chewing dependency.

CONCLUSIONS

Validation of self-reported khat chewing is possible. Khat chewing dependency correlates significantly with biomarker levels in saliva. Replication is required.