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

Perceived harms and protective behavioural strategies among khat chewers: a qualitative study in Jimma, Ethiopia

BACKGROUND

While there have been many previous studies focusing on the adverse effects of khat chewing, attempts to investigate the protective behavioural strategies (PBS) employed by the khat using population are rare. PBS are strategies that substance users employ to minimize or alleviate the possible negative consequences related to the behaviour. This study focuses on the harms that chewers associate with khat use, and the behavioural strategies they practise to prevent or minimize these harms.

METHODS

A community-based qualitative study was conducted using a snowball sampling technique to recruit a diverse sample of khat chewing participants (N = 102) in Jimma city, Ethiopia. Face-to-face in-depth interviews were carried out with the participants.

RESULTS

Participants identified a variety of harms likely to result from chewing khat. These include impacts on their finances, work, social life and health. The PBS that participants employed to avoid or minimize the risks were classified into four themes based on their temporal sequence with khat chewing sessions: prior to chewing, during chewing, after chewing and general PBS covering the whole of their khat chewing career. The PBS enable khat chewers to prevent or minimize the adverse health consequences of chewing, socialize and work without or with fewer difficulties and manage their economy successfully.

CONCLUSION

The study participants believe that khat-related harms are avoidable if khat users implement appropriate strategies prior to, during and after chewing, and if they apply PBS to khat-related factors (e.g. type, amount and frequency), set factors (e.g. reason for using and health behaviour) and setting factors (e.g. place of use, when used, with whom used and social norms) covering the whole of their khat chewing career.

Reducing Khat use among Somalis living in Kenya: a controlled pilot study on the modified ASSIST-linked brief intervention delivered in the community

BACKGROUND

During recent decades, the consumption of the stimulant khat (catha edulis) has profoundly changed in countries around the Horn of Africa, and excessive use patterns have emerged-especially evident among displaced Somalis. This is related to the development of severe somatic and psychiatric disorders. There are currently no preventive or interventional studies targeting khat use. This study's aim was to test screening and brief intervention (SBI) to reduce khat use among urban Somali refugees living in Kenya with limited access to public healthcare.

METHODS

In this controlled study, 330 male Somali khat users from the community were either assigned to SBI (161) or an assessment-only control condition (AC; 169); due to field conditions a rigorous experimental design could not be implemented. The World Health Organization's (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)-linked brief intervention was adapted to khat and Somali culture. Trained local counselors administered the intervention. The amount and frequency of khat use was assessed using the time-line-follow-back method. We compared the month before the intervention (t1) to the two months after it (t2, t3). Baseline differences in khat use frequency were corrected by partial matching and mixed effect models used to evaluate intervention effects.

RESULTS

SBI was well accepted and feasible for khat users. Over the complete observation period and from t1 to t2, khat use amount and frequency decreased (p < .001) and the intervention group showed a greater reduction (group x time effects with p ≤ .030). From t2 to t3, no further reduction and no group differences emerged.

CONCLUSION

The results provide preliminary evidence that khat use amount and frequency can be reduced in community settings by SBI, requiring little resources. Thorough assessment alone might have intervention-like effects. The non-treatment-seeking community sample and the non-professional counselors are distinct from SBI studies with other substances in other countries, but support the feasibility of this approach in khat use countries and especially in Somali populations with limited access to healthcare. Future studies that employ rigorous experimental design are needed.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02253589. Date of first registration 01/10/2014, retrospectively registered https://clinicaltrials.gov/ct2/show/NCT02253589 . First participant 16/09/2014.

An updated review on synthetic cathinones

Cathinone, the main psychoactive compound found in the plant Catha edulis Forsk. (khat), is a β-keto analogue of amphetamine, sharing not only the phenethylamine structure, but also the amphetamine-like stimulant effects. Synthetic cathinones are derivatives of the naturally occurring cathinone that largely entered the recreational drug market at the end of 2000s. The former "legal status", impressive marketing strategies and their commercial availability, either in the so-called "smartshops" or via the Internet, prompted their large spread, contributing to their increasing popularity in the following years. As their popularity increased, the risks posed for public health became clear, with several reports of intoxications and deaths involving these substances appearing both in the social media and scientific literature. The regulatory measures introduced thereafter to halt these trending drugs of abuse have proved to be of low impact, as a continuous emergence of new non-controlled derivatives keep appearing to replace those prohibited. Users resort to synthetic cathinones due to their psychostimulant properties but are often unaware of the dangers they may incur when using these substances. Therefore, studies aimed at unveiling the pharmacological and toxicological properties of these substances are imperative, as they will provide increased expertise to the clinicians that face this problem on a daily basis. The present work provides a comprehensive review on history and legal status, chemistry, pharmacokinetics, pharmacodynamics, adverse effects and lethality in humans, as well as on the current knowledge of the neurotoxic mechanisms of synthetic cathinones.

Depression, Anxiety, Stress, and Associated Factors among Khat Chewers in Amhara Region, Northwest Ethiopia

Individuals with substance use disorder are prone to develop different psychiatric disorders. Substance abuse and associated problems are of current global concern that leads to mental health disorders which contributed about 14% of the global burden of the disease. It has become an epidemic in some parts of the African region with adolescents being the main victims of the ill health and social effects of substance use. This study is aimed at assessing the prevalence of depression, anxiety, and stress and associated factors among khat chewers in the Amhara region, 2019. A community-based cross-sectional study was done from February 14 to April 15, 2019. A purposive sampling technique was used to enroll the subjects. Data was collected using the face-to-face interview technique using the Depression Anxiety Stress Scale 21 (DASS-21) questionnaire. Descriptive statistics and bivariate and multivariate logistic regression were used to summarize the results. p value < 0.05 was considered statistically significant. A total of 478 participants were enrolled in the study with a response rate of 94.1%. The overall prevalence of depression, anxiety, and stress was 27.4%, 40.6%, and 18.8%, respectively. Around 43% of the respondents develop dependency from khat chewing. Working in a private sector, being self-employed, being jobless, spending 90 to 180 minutes and more, chewing 51-100 g and more, and chewing khat more than once per week were positively associated with stress. On the other hand, being a private sector worker, being jobless, completing secondary education, earning 1001-5000 ETB per month, chewing khat more than once per week, being khat dependent, and the presence of chronic illness were positively associated with anxiety. History of chronic illness and being khat dependent were positively associated with depression. The prevalence of depression, anxiety, and stress was high among khat chewers in the Amhara region. Special attention has to be given to khat chewers since khat chewing will double the burden of mental illness. Proper awareness and evaluation activities will reduce the impact of the problem.

The Experiences of People Who Quit Khat and the Health Care Professionals Who Support them

Background

This study aimed to explore the barriers and enablers to quitting khat from the perspective of users and the barriers and enablers to supporting users to quit from the perspective of healthcare professionals (HCPs).

Methods

The present qualitative study was conducted using semi-structured interviews and the Theoretical Domains Framework (TDF) to collect and analyse data.

Findings

Overall, 10 khat users and 3 professionals were interviewed. Beliefs about the consequences of continued use facilitated user’s decisions to quit. Social influences were both a barrier and an enabler. For professionals, the social influence of other colleagues and working together was key in enabling them to support clients. Social/professional role and identity was also an important enabler, as professionals saw supporting users to quit as an integral part of their role. A range of behaviour change techniques was identified as potential ways in which quitting attempts could be more successful, from the perspective of users and professionals.

Conclusion

The study reveals the complexity of khat chewing and quitting from the perspective of khat users, such as the varied influence of family and friends. It also identifies the many barriers and enablers that professionals experience when supporting individuals to quit, such as working with other professionals. There is little evidence for the effectiveness of current services provided for quitting khat or little information outlining how they were developed. Current services would benefit from evaluating the effectiveness of the interventions using established methodology. Recommendations have been provided for practice in the field of substance misuse.

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.

Knowledge and Attitudes on Khat Use among Yemeni Health Sciences Students

Background: Khat chewing has a negative impact on an individual's life. Objectives: The study was execute to assess health sciences students' knowledge and attitudes regarding khat use in Yemen. Methods: This survey involved health sciences students from Aden University. Approximately 500 participants were selected through convenience sampling. The data were collected using a structured and validated self-administered questionnaire. The data were tabulated and descriptively analyzed. Results: The total number of respondents was 500. Almost half of the students reported that they chewed khat (n = 239, 48%). Approximately 66% (n = 330) of the students spent 2000 Yemeni riyals or less (USD1 = YER249.9) per day on khat. The main reasons for chewing khat were 'it is a social habit' (n = 155, 31%), followed by 'it improves my concentration when studying or working' (n = 140, 28%). Students knew that the effects of khat are similar to those of amphetamines (n = 210, 42.0%) and that khat is addictive (n = 254, 50.8%). Additionally, they knew that cathinone is the dependence-producing constituent of khat leaves (n = 269, 53.8%). The students agreed with the following statements: 'I will advise people to cease khat use'; 'Khat chewing is harmful to health'; 'Children and adolescents should not chew khat'; 'Khat chewing helps people stay awake'; and 'Health professionals serve as role models for patients and the public'. Conclusions: Khat chewing is prevalent among Yemeni university health sciences students. Only about half of the students recognized health risks associated with khat use. Also, among those who used khat, students endorsed positive benefits such as improved concentration.

Psychometric properties of the severity of the dependence scale for Khat (SDS-Khat) in polysubstance users

BACKGROUND

Current evidence suggests that the addiction on one substance may underpin or affect addiction on another in polysubstance users. However, there is no tool that has been shown to have psychometric validation for assessment of the severity of khat addiction in polysubstance users.

METHODS

Polysubstance users with khat chewing habit (n = 178, age = 25.8 ± 3.6, BMI = 23.3 ± 2.8 kg/m2) were recruited from randomly selected houses for a cross-sectional study in Mizan, Ethiopia. The survey including severity of dependence scale for khat (SDS-khat), a brief metacognition questionnaire, and a semi-structured socio-demographics tool were administered by trained interviewers.

RESULTS

There was no ceiling effect or floor effect in the SDS-Khat scores. Internal consistency was moderate (Cronbach's alpha = 0.58). Internal homogeneity was adequate (Item-total correlations of the SDS-Khat; r ≥ 0.55). Significant negative correlations between the SDS-Khat and the metacognition (r = -.19 to -.34, p < 0.05 or p < 0.01) indicated convergent validity. The findings of exploratory factor analysis were non-unanimous with a suggestion of two models, i.e., a 2-factor and a 1-factor model, while the confirmatory factor analysis favored 1-Factor model.

CONCLUSION

The SDS-Khat has adequate psychometric validity for the assessment of psychological severity of khat addiction in the polysubstance users.

Effects of Khat (Catha edulis) use on catalytic activities of major drug-metabolizing cytochrome P450 enzymes and implication of pharmacogenetic variations

In a one-way cross-over study, we investigated the effect of Khat, a natural amphetamine-like psychostimulant plant, on catalytic activities of five major drug-metabolizing cytochrome P450 (CYP) enzymes. After a one-week Khat abstinence, 63 Ethiopian male volunteers were phenotyped using cocktail probe drugs (caffeine, losartan, dextromethorphan, omeprazole). Phenotyping was repeated after a one-week daily use of 400 g fresh Khat leaves. Genotyping for CYP1A2, CYP2C9, CYP2C19, CYP2D6, CYP3A5 were done. Urinary cathinone and phenylpropanolamine, and plasma probe drugs and metabolites concentrations were quantified using LC-MS/MS. Effect of Khat on enzyme activities was evaluated by comparing caffeine/paraxanthine (CYP1A2), losartan/losartan carboxylic acid (CYP2C9), omeprazole/5-hydroxyomeprazole (CYP2C19), dextromethorphan/dextrorphan (CYP2D6) and dextromethorphan/3-methoxymorphinan (CYP3A4) metabolic ratios (MR) before and after Khat use. Wilcoxon-matched-pair-test indicated a significant increase in median CYP2D6 MR (41%, p < 0.0001), and a marginal increase in CYP3A4 and CYP2C19 MR by Khat. Repeated measure ANOVA indicated the impact of CYP1A2 and CYP2C19 genotype on Khat-CYP enzyme interactions. The median MR increased by 35% in CYP1A2*1/*1 (p = 0.07) and by 40% in carriers of defective CYP2C19 alleles (p = 0.03). Urinary log cathinone/phenylpropanolamine ratios significantly correlated with CYP2D6 genotype (p = 0.004) and CYP2D6 MR (P = 0.025). Khat significantly inhibits CYP2D6, marginally inhibits CYP3A4, and genotype-dependently inhibit CYP2C19 and CYP1A2 enzyme activities.

Anger, anxiety, and depressive affect as predictors of stress-induced cortisol production in khat and tobacco users

INTRODUCTION

Glucocorticoid activity is disrupted in substance users including khat chewers who also use tobacco. Anger, dysphoria, and anxiety can mediate this relationship. The aim of this study was to contrast emotion dysregulation and substance use variables as predictors of post-stress cortisol output.

MATERIALS AND METHODS

Comparable numbers of males (n = 90) and females (n = 85) including controls, khat only, and concurrent khat and tobacco users participated in a stress study. Depressive affect, anxiety, anger, substance use patterns, and saliva samples were collected following a standardized laboratory stress manipulation.

RESULTS

Regression analysis showed that high depression and low anxiety was associated with high post-stress cortisol, but only in co-users of tobacco and khat. Males, but not females, showed a significant association between co-use of khat and tobacco and cortisol, which appears to be mediated by frequency of use. The link between anxiety and post-stress cortisol in the co-users remained significant after controlling for nicotine dependence and substance use frequency.

CONCLUSION

Anxiety predicted the neuroendocrine consequences of concurrent use of tobacco and khat above and beyond sex, nicotine dependence, anger, and substance use frequency. Sex differences, however, are related to differences in nicotine dependence.

Prevalence and predictors of khat chewing among Ethiopian university students: A systematic review and meta-analysis

Background

Khat chewing has become a common practice among university students in developing countries like Ethiopia. It has a potential effect on physical, mental, social and cognitive aspects of student functioning. In Ethiopia, study findings regarding the prevalence of khat chewing were highly dispersed and inconsistent. Therefore, this systematic review and meta-analysis estimates the pooled prevalence of khat chewing and its predictors among Ethiopian university students.

Method

A systematic review and meta-analysis was conducted to assess the prevalence and predictors of khat chewing among university students in Ethiopia. We searched literature from the databases of PubMed, Google Scholar, Science Direct, and the Cochrane Library. A total of 24 Ethiopian studies reporting the prevalence of khat chewing among university students were included. Data were extracted using a standardized data extraction format prepared in Microsoft Excel and the analysis was done using STATA 14 statistical software. To assess heterogeneity, the Cochrane Q test statistics and I² test were used. Since the included studies exhibit high heterogeneity, a random effect meta-analysis model was computed to estimate the pooled prevalence of khat chewing. Moreover, the association between predictor variables, and khat chewing practice were examined.

Results

The meta-analysis of 24 studies revealed that the pooled prevalence of khat chewing among university students in Ethiopia was 23.22% (95% CI: 19.5, 27.0). In the subgroup analysis, the highest prevalence was observed in Oromia region (31.6%; 95CI: 21.2, 41.9) whereas the lowest prevalence was observed in Amhara region (18.1%; 95%CI: 12.4, 23.8). Being male OR: 2.76 (95% CI 1.64, 4.63), family khat chewing practice OR: 2.91 (95% CI 1.06, 7.98), friend khat chewing habit OR: 4.74 (95% CI 3.48, 13.06), alcohol drinking OR: 7.06 (95% CI 5.65, 8.82) and cigarette smoking habit OR: 15.11 (95% CI 8.96, 25.51) were found to be predictors of khat chewing.

Conclusion

The study found that the prevalence of khat chewing among university students was quite common, with slightly more than 1 in 5 students engaging in the use of this substance. Being male, family khat chewing practice, friend’s khat chewing habit, alcohol drinking, and cigarette smoking were found to be predictors of khat chewing practice among university students.

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.

Khat Use is Associated with Tobacco, Alcohol, and Illicit Drug Use: A Cross-Sectional Examination in the United States

No study has systematically examined khat (Catha edulis) use and its linkages with other substance use in the United States. This study provides novel findings related to the associations of khat with other substance use among immigrants in metropolitan areas of Minnesota where large East African communities reside. Using a convenience sampling, a total of 261 individuals completed a brief face-to-face interview during which demographic information and substance use were assessed. The proportion of lifetime and current use were 30% and 6.6% for khat, 35% and 18% for tobacco, 35% and 21% for alcohol, and 13% and 10% for other illicit drugs. Self-report history of khat use was associated with tobacco, alcohol, and other drug use. Tobacco use was related to alcohol and use of other drugs. The results suggest that a history of khat use is useful in identifying individuals who are vulnerable to substance-use-related problems. The findings indicate the need for more research on khat in the U.S.

New psychoactive substances of natural origin: A brief review

Plant-based drugs of abuse are as old as recorded human history. Although traditional addictive substances, such as opium, cannabis and coca, have been controlled by the United Nations anti-drug conventions, many, if not most, natural plants with addictive or abuse liability remain elusive. Therefore, the United Nations Office on Drugs and Crime (UNODC) has warned the emerging threat from new psychoactive substances (NPS), which are mostly derived or modified from the constituents of natural origin. For example, synthetic cannabinoids and synthetic cathinones are derived from the cannabis and khat plant, respectively. In this review, we briefly discussed the chemistry, pharmacology and toxicology of five common NPS of natural origin, i.e., khat, kratom, salvia, magic mushroom and mandrake. Through the review, we hope that professionals and general public alike can pay more attention to the potential problems caused by natural NPS, and suitable control measures will be taken.

What constitutes problematic khat use? An exploratory mixed methods study in Ethiopia

Background

Khat is a psycho-stimulant herb, which has been in use in traditional societies in East Africa and the Middle East over many centuries. Although khat is reported to cause various health problems, what constitutes problematic khat use has never been systematically investigated. This study explored the acceptable and problematic uses of khat from the perspective of users.

Methods

The study used a mixed methods design (exploratory sequential) in which qualitative (emic) data were collected to develop a framework to define problematic khat use. The qualitative data were gathered through in-depth interviews (N = 13) and focus group discussions (N = 34). By supplementing the emic experiences considered to constitute problematic khat use with an etic definition, DSM-5 criteria for stimulant related disorders, a structured questionnaire was developed. Subsequently a cross-sectional evaluation of 102 respondents was carried out. Respondents both for qualitative and quantitative study were selected through purposive sampling and snowballing methods. Qualitative data were transcribed and subjected to thematic analysis whereas quantitative data were analyzed using descriptive and nonparametric statistics.

Results

Khat use was acceptable socio-culturally and for functional purposes. However, even in these acceptable contexts there was a restriction to the amount, frequency and type of khat used, and in relation to the experience of the individual using khat and other personal characteristics. More specifically, khat use was considered problematic if there was: 1) Impairment (in social and occupational functioning); 2) loss of control in the use of khat; and 3) withdrawal symptoms when not using khat. Among the participants who use khat (n = 102), 45.1% (n = 46) used khat on a daily basis. The commonest indicators of problematic khat use endorsed by the khat users were loss of control over chewing (73.5%), continuing use of khat despite harm (72.5%) and efforts to avoid withdrawal from khat (61.8%).

Conclusion

Despite reported religious, sociocultural and functional benefits to the use of khat, those with defined problematic khat use have impaired mental health, and social and occupational performance. Comparison of these respondent defined indicators of problem behavior matched almost completely to the DSM-5 (etic-defined) understanding of problematic stimulant use. Although the findings have relevant clinical, research and policy implications, the study focused on users purposively identified. Future larger scale definitive studies are required to make concrete policy recommendations.

Is khat use disorder a valid diagnostic entity?

AIMS

This study aimed to validate the presence of a khat use disorder syndrome using DSM-5 criteria and to examine its relationship with increased experience of harms.

DESIGN

Cross-sectional, purposive sample of current khat-chewers, recruited from khat markets and cafes.

SETTING

Participants were recruited from the general community and from Adama Science and Technology University in Ethiopia.

PARTICIPANTS

A total of 400 current khat consumers aged 16 and above were recruited between September 2014 and January 2015 MEASURES: Survey comprising current clinical symptoms (using a modified Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV), and validated measures of health, psychological distress, quality of life and academic functioning.

FINDINGS

A third [35.5% 95% confidence interval (CI) = 31.0-40.3] of respondents reported daily khat use and a quarter (25.4% 95% CI = 21.4-30.0) using three times or more per week. Using DSM-5 criteria, 10.5% (95% CI = 7.9-13.9) were categorized as experiencing mild, 8.8% (95% CI = 6.4-12.0) moderate and 54.5% (95% CI = 49.6-59.3) severe khat use disorder. Confirmatory factor analysis demonstrated a good fit of symptoms to a single underlying construct, consistent with other substance use disorders. Individuals categorized as experiencing khat use disorder demonstrated significantly greater frequency [odds ratio (OR) = 45.29; 95% CI = 10.97-19.01) and quantity of khat use (OR = 2.35; 95% CI = 1.29-4.29). They also demonstrated increased financial problems associated with use, greater problems with academic functioning and higher rates of self-reported mental health problems, higher psychological distress and poorer quality of life. Treatment access was poor, with only one-third (32.9%) of individuals with khat use disorder reporting life-time access, near-exclusively related to help-seeking from friends and relatives.

CONCLUSION

The construct of a substance use disorder syndrome for khat using DSM-5 criteria appears valid and performs in a manner consistent with other substances of dependence. Individuals with khat use disorder experience substantial problems in association with khat use. Despite this, there are low levels of help-seeking for these problems.

Khat-induced liver injuries: A report of two cases

Khat is consumed for recreational purposes in many countries, including Yemen, where >50% of adults chew khat leaves regularly. A wide spectrum of khat-induced liver injuries has been reported in the literature. Herein, we report two patients with khat-induced liver injury. Both patients clinically presented with acute hepatitis, one of whom showed radiological evidence of hepatic outflow obstruction. Based on the histological tests, both patients had acute hepatitis, which indicated drug-induced liver injury (DILI) on a background of chronic hepatitis and portal fibrosis; of the two, one presented with symptoms of immune-mediated liver injury.

Khat Dependency and Psychophysical Symptoms among Chewers in Jazan Region, Kingdom of Saudi Arabia

BACKGROUND

Khat chewing is highly prevalent in Africa, Yemen and Jazan region, southwest of Saudi Arabia. Most of Jazani Khat chewers consider khat session as a social activity and do not consider khat dependency. The aim of this study was to explore khat dependency and its relationship with the psychophysical symptoms among chewers.

METHODS

Cross-sectional study on seventy Saudi male khat chewers living in Jazan area. Psychological dependence to khat chewing was evaluated using the Severity of Dependency Scale (SDS). The participants filled in a self-administrated assisted structured questionnaire designed to collect data about their medical history, neurological symptoms, and their chewing behavior.

RESULTS

Half (52.2%) of khat chewers showed psychological dependency. Those having longer khat sessions (≥6 hours) were more liable for dependency. Physical and psychological symptoms were more prevalent among khat dependent chewers.

CONCLUSIONS

khat has a psychological dependence effect that can be measured by the SDS, even in low doses and with irregular use. SDS scale is a useful tool to expect the burden of either physical or psychological symptoms on khat chewers.

The Psychostimulant Khat (Catha edulis) Inhibits CYP2D6 Enzyme Activity in Humans

The use of khat (Catha edulis) while on medication may alter treatment outcome. In particular, the influence of khat on the metabolic activities of drug-metabolizing enzymes is not known. We performed a comparative 1-way crossover study to evaluate the effect of khat on cytochrome P450 (CYP)2D6 and CYP3A4 enzyme activity. After 1 week of khat abstinence, baseline CYP2D6 and CYP3A4 metabolic activities were determined in 40 Ethiopian male volunteers using 30 mg dextromethorphan (DM) as a probe drug and then repeated after 1 week of daily use of 400 g fresh khat leaves. Urinary concentrations of cathinone and cathine were determined to monitor the subjects' compliance to the study protocol. Genotyping for CYP2D6*3 and CYP2D6*4 was done. Plasma DM, dextrorphan and 3-methoxymorphinan concentrations were quantified. CYP2D6 and CYP3A4 enzyme activities were assessed by comparing plasma log DM/dextrorphan and log DM/methoxymorphinan metabolic ratio (MR) respectively in the presence and absence of khat. Cytochrome 2D6 MR was significantly increased from baseline by concurrent khat use (paired t test, P = 0.003; geometric mean ratio, 1.38; 95% confidence interval [95% CI], 1.12-1.53). Moreover, the inhibition of CYP2D6 activity by khat was more pronounced in CYP2D6*1/*1 compared with CYP2D6*1/*4 genotypes (P = 0.01). A marginal inhibition of CYP3A4 activity in the presence of khat was observed (P = 0.24). The mean percentage increase of CYP2D6 and CYP3A4 MR from baseline by khat use was 46% (95% CI, 20-72) and 31% (95% CI, 8-54), respectively. This is the first report linking khat use with significant inhibition of CYP2D6 metabolic activity in humans.

Before the ban--an exploratory study of a local khat market in East London, U.K

BACKGROUND

Khat is a green leaf with amphetamine-like effects. It is primarily used among people in Africa, the Middle East and in the diaspora communities from these countries. Prior to the prohibition of khat in the UK on 24 June 2014, there was almost no information available on key aspects of the local khat market.

METHODS

A cross-sectional study was conducted in 2012 using snowball sampling, Privileged Access Interviewing and area mapping in order to identify khat sale establishments. Data was collected via face-to-face interviews using mixed methods for data collection. This included information about the establishments selling khat, khat pricing and its use among different ethnic minority groups, in addition to the potential sale of khat to children and risk assessment (e.g., use of pesticides on khat).

RESULTS

Five out of seven sellers identified agreed to participate. Sellers described their khat sale establishments as 'community centres' which included, for example, a restaurant basement. The sellers' history of selling khat ranged between 1-15 years and khat's sale took place between 2pm-10pm. Miraa (e.g., Lara) from Kenya was the most popularly used khat variety, sold in pre-wrapped bundles of approximately 250 g costing £3 each and delivered four days a week. Harari (e.g., Owdi) from Ethiopia was sold in 200 g, 400 g and 1 kg bundles, priced between £5 and £20 and delivered two days a week. The primary benefit of khat use was reported to be social interaction. The customers were predominantly adult males of Somali origin. Most sellers claimed a self-imposed ban on sales to children under 18 years old. Khat bundles had no labelling describing variety or weight and sellers had no knowledge of the use of pesticides on khat and did not advertise the risks associated with khat use.

CONCLUSIONS

Khat selling establishments were businesses that did not adhere to trade standards regulations (e.g., labelling khat bundles). They claimed to provide a community service (facilitating social interaction) to their predominately Somali customers. Without a better understanding of the dynamics of the khat market there is a risk that both health and social needs of the vulnerable populations involved in the market continue to go unaddressed. Future research should track changes in the now illicit khat market in order to evaluate the social and public health implications following the recent changes to the current U.K. regulatory environment regarding khat.

Khat chewing and acculturation in East-African migrants living in Frankfurt am Main/Germany

ETHNOPHARMACOLOGICAL RELEVANCE

Khat (Catha edulis, Forsk) is a drug widely used in countries around the Red Sea (East-Africa and Arabian Peninsula). In Germany khat chewing is illegal but nevertheless an often observed habit in immigrants from this region. This study investigates the interrelation between immigrants acculturation processes and traditional khat chewing habits.

MATERIALS AND METHODS

Sixty-one khat chewers (14 female) from East-African countries were interviewed about their khat chewing habits and acculturation strategy using standardized questionnaires.

RESULTS

Results indicate that immigrants׳ khat chewing behaviors are similar to what is common in countries with traditional khat use. But khat chewing tended to be less among immigrants who were relatively more oriented towards their cultures of origin. Chewing khat was subjectively considered to help coping with problems, to forget bad memories and to concentrate better.

CONCLUSIONS

It was concluded that khat chewing serves a functional use of coping with stressful events in the present or in the past within this sample.

"Natural Amphetamine" Khat: A Cultural Tradition or a Drug of Abuse?

Khat, Catha edulis Forsk, is among the most widely used plant-based psychoactive substance in the world. Grown in Eastern Africa, Horn of Africa, and southwestern part of the Arabian Peninsula, its fresh young leaves and twigs are used daily by over 20 million people for the psychostimulatory effects it produces in the user, a practice deeply rooted in the history, tradition, and culture of the indigenous population. Once hardly known outside the regions where it is grown and used, khat use has now spread to other countries. This review will cover the, phytochemistry, pharmacokinetics of the active ingredients-cathinone, cathine, norephedrine, neurochemistry, effects on cognitive and executive functions as well as its ability to produce dependency in the user. Whether it is an innocuous cultural practice or a drug of abuse is debatable as the preclinical and clinical data needed to arrive at an authoritative conclusion is lacking.

Prevalence of and factors associated with regular khat chewing among university students in Ethiopia

Purpose

Khat (Catha edulis) is commonly chewed for its psychostimulant and euphorigenic effects in Africa and the Arabian Peninsula. Students use it to help them study for long hours especially during the period of examination. However, how regularly khat is chewed among university students and its associated factors are not well documented. In this article we report on the prevalence of and factors associated with regular khat chewing among university students in Ethiopia.

Methods

We did a cross-sectional study from May 20, 2014 to June 23, 2014 on a sample of 1,255 regular students recruited from all campuses of Hawassa University, southern Ethiopia. The data were collected using self-administered questionnaires. We analyzed the data to identify factors associated with current regular khat chewing using complex sample adjusted logistic regression analysis.

Results

The prevalence of current regular khat chewing was 10.5% (95% confidence interval [CI]: 6.1%–14.9%). After controlling for sex, religion, year of study, having a father who chews khat, cigarette smoking and alcohol drinking in the adjusted logistic regression model, living off-campus in rented houses as compared to living in the university dormitory (adjusted odds ratio [95% CI] =8.09 [1.56–42.01]), and having friends who chew khat (adjusted odds ratio [95% CI] =4.62 [1.98–10.74]) were found to significantly increase the odds of current regular khat use.

Conclusion

Students living outside the university campus in rented houses compared to those living in dormitory and those with khat chewing peers are more likely to use khat. A multipronged prevention approach involving students, the university officials, the surrounding community, and regulatory bodies is required.

Khat chewing among Ethiopian University Students--a growing concern

Background

Khat has amphetamine like effect. Students chew khat to stay alert. It has various negative physical, mental, social and cognitive effects. Poor academic performance has been associated with khat. The purpose of this study was to determine the prevalence and identify factors associated with khat chewing among Ethiopian University students.

Methods

A cross sectional study was conducted on Bahir Dar University Students. A self-administered questionnaire was completed by 3268 students. Proportion was calculated to estimate prevalence of khat chewing. Logistic regression was used to identify factors associated with khat chewing.

Results

Lifetime prevalence of khat chewing was 24% (95% Confidence Interval: 22.5%, 26.6%). Half of these are current khat users with a prevalence of 12.7% (95% Confidence Interval: 11.5%, 13.9%). Male students Adjusted Odds Ratio (AOR) = 3.3 (95% Confidence Interval: 1.8, 6.0), students living in off campus housing AOR = 3.0 (95% Confidence Interval: 1.5, 6.0), students who have khat user friends AOR = 4.2 (95% Confidence Interval: 2.6, 6.9), and students who perceive khat use improves academic performance AOR = 6.6 (95% Confidence Interval: 4.6, 9.5) are more likely to use khat.

Conclusions

Prevalence of current use of khat reported in this study is higher than recent study done on university students in Ethiopia and heavily influenced with peer practice.

Severity of khat dependence among adult khat chewers: the moderating influence of gender and age

ETHNOPHARMACOLOGICAL RELEVANCE

The escalating use of khat (Catha edulis) in East Africa and Arabia is a major concern for public health. Yet little is known about the impact of khat on behavior. There has been no study in the region to assess the extent to which dependence syndrome is associated with khat use in this population.

AIM OF THE STUDY

To examine psychometric properties of the Severity of Dependence Scale-Khat (SDS-khat), gender differences in patterns of khat use and dependence, and the extent to which age moderated the link between gender and khat dependence.

MATERIALS AND METHODS

Two-hundred and seventy khat chewers recruited in two Yemeni cities completed face-to-face interviews asking about demographics and patterns of khat use. Validity of SDS-khat was examined by the principle component analysis and reliability of the scale was tested by Cronbach׳s alpha. A series of chi-square tests and analysis of variances (ANOVAs) were conducted to examine gender differences in khat use variables.

RESULTS

The results indicated that the mean age of khat chewers was 30.52 years (95% CI: 29.34, 31.70) and 52% of them were males. The SDS-khat was found to have two factors with moderate reliability. This pattern was consistent when the analysis was conducted in the entire sample and in each gender. Male khat chewers reported more symptoms related to khat dependence than female chewers. A significant gender by age interaction in SDS-khat levels (p=0.013) revealed a positive association between age and khat dependence in women only.

CONCLUSION

These results provide initial support for the use of SDS-khat in the assessment of khat dependence in Yemen. Gender differences in khat use patterns and dependence observed in this study call the need for more studies carefully examining the role of gender in khat research.

Prevalence and predictors of harmful khat use among university students in ethiopia

Comprehensive assessment of harmful khat use is lacking because often researchers rely on a simple tool for studying it. The aim of this study was to determine the prevalence and predictors of harmful khat use among Ethiopian university students by developing a comprehensive scale based on Alcohol Use Identification Test, Severity of Dependency Syndrome scale, and International Classification of Diseases definition of harmful substance use. Logistic regression was performed to identify predictors of harmful khat use. One in five current khat user students were identified as harmful khat users [20.6% (95% CI: 14.3-22.3)]. Harmful khat use in this study was strongly associated with chewing at commercial places [adjusted odds ratio (AOR) = 2.32 (95% CI: 1.01-5.33)], and having non-student friends accompanying the khat-chewing ceremony [AOR = 3.77 (95% CI: 1.09-13.03). Students who started chewing khat at the age of 20 years or later [AOR = 0.19 (95% CI: 0.07-0.55)] and those who preferred to study in the library [AOR = 0.31(95% CI: 0.12-0.81)] were less likely to be harmful khat users. The university authorities, in addition to provision of student guidance on substance-use prevention, need to work in collaboration with the surrounding community and responsible public authorities in order to reduce harmful use of khat by their students.

The likelihood of khat chewing serving as a neglected and reverse 'gateway' to tobacco use among UK adult male khat chewers: a cross sectional study

BACKGROUND

Chewing khat leaves is often accompanied by tobacco use. We assessed aspects of tobacco use and explored factors associated with tobacco use patterns (frequency of use per week) among khat chewers who used tobacco only when chewing khat ("simultaneous tobacco and khat users", STKU).

METHODS

A sample of 204 male khat chewers was recruited during random visits to khat outlets. Data collected included socio-demographic items, tobacco use and khat chewing behaviours. Both psychological and physical dependence on khat were assessed using the Severity of Psychological Dependence on Khat (SDS-Khat) Scale, the Diagnostic Statistical Manual IV (DSM-IV) and adapted items from the Fagerström Test for Nicotine Dependence (chewing even when ill, and difficulty in abstaining from khat chewing for an entire week). Descriptive statistics and non-parametric analyses were conducted.

RESULTS

Of the 204 khat chewers, 35% were khat chewers only, 20% were STKU, and the remainder were daily cigarette smokers. The mean age of STKU was 38.12 (±14.05) years. Fifty seven percent of STKU smoked tobacco and chewed khat for two days per week and 43% smoked and chewed more frequently (three to six days: 33%, daily: 10%). Three quarters (74%) were former daily tobacco users. Khat chewing initiated tobacco smoking among 45% of STKU and 71% reported attempts to quit tobacco smoking during khat chew. Among STKU, smoking tobacco for more than two days per week was significantly associated (p < 0.05) with psychological dependence (increased levels of SDS-Khat), physical dependence (increased levels of DSM-IV symptoms, chewing even when ill, difficulty in abstaining from chewing for an entire week and self-reported health conditions) and behavioural factors (e.g. amount of khat chewed in typical khat session).

CONCLUSIONS

Khat chewing may promote different patterns of tobacco smoking, initiate and sustain tobacco smoking, and trigger tobacco cessation relapses among STKU. Increased frequency of tobacco smoking among STKU was linked to psycho-physical and behavioural factors. Further investigation within large and representative samples of both sexes of STKU in different contexts should be considered for health research and policy development. Khat chewing should be considered when designing tobacco prevention uptake, cessation interventions and relapse prevention programmes.

Daytime Sleepiness, Circadian Preference, Caffeine Consumption and Khat Use among College Students in Ethiopia

OBJECTIVES

To estimate the prevalence of daytime sleepiness and circadian preferences, and to examine the extent to which caffeine consumption and Khat (a herbal stimulant) use are associated with daytime sleepiness and evening chronotype among Ethiopian college students.

METHODS

A cross-sectional study was conducted among 2,410 college students. A self-administered questionnaire was used to collect information about sleep, behavioral risk factors such as caffeinated beverages, tobacco, alcohol, and Khat consumption. Daytime sleepiness and chronotype were assessed using the Epworth Sleepiness Scale (ESS) and the Horne & Ostberg Morningness /Eveningness Questionnaire (MEQ), respectively. Linear and logistic regression models were used to evaluate associations.

RESULTS

Daytime sleepiness (ESS≥10) was present in 26% of the students (95% CI: 24.4-27.8%) with 25.9% in males and 25.5% in females. A total of 30 (0.8%) students were classified as evening chronotypes (0.7% in females and 0.9% in males). Overall, Overall, Khat consumption, excessive alcohol use and cigarette smoking status were associated with evening chronotype. Use of any caffeinated beverages (OR=2.18; 95%CI: 0.82-5.77) and Khat consumption (OR=7.43; 95%CI: 3.28-16.98) increased the odds of evening chronotype.

CONCLUSION

The prevalence of daytime sleepiness among our study population was high while few were classified as evening chronotypes. We also found increased odds of evening chronotype with caffeine consumption and Khat use amongst Ethiopian college students. Prospective cohort studies that examine the effects of caffeinated beverages and Khat use on sleep disorders among young adults are needed.