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

An Internet Snapshot Survey Assessing the sale of Synthetic Cannabinoid Receptor Agonists for use with Electronic Vaping Devices

INTRODUCTION

Synthetic cannabinoid receptor agonists (SCRAs) are associated with significant toxicity and are increasingly used in electronic vaping devices. We assessed the availability of SCRA vaping products to UK purchasers on the surface web.

METHODS

An internet snapshot survey was performed between October 2022 and January 2023 on 'google.com' using the search terms "buy c-liquid vape", "buy herbal incense vape liquid", "buy cannabis vape liquid", "buy hashish vape liquid", "buy K2 vape liquid".

RESULTS

62 websites selling 128 SCRA vaping brands were identified. Most were purportedly based in the USA (41 websites, 66%) and most sold other controlled substances. Purchase incentives offered included discreet packaging (38, 61%), discounts for bulk purchase (34, 55%) and tracked delivery (30, 48%). Many websites stated SCRA products were: not for human consumption (41, 66%), for research purposes only (15, 24%), or legal (28, 45%). Websites sold a median (IQR) of 16 (7-25) SCRA vaping brands. Almost all were bottles of vaping liquid (1220/1225, 99.6%). The most common bottle size was 5mL (60%), the median (IQR) total volume of SCRA liquid per sale was 50mL (10-200mL). Median (IQR) price was £3.39/mL (£2.01/mL- £5.29/mL). Price decreased with increasing volume purchased (£6.58/mL for ≤ 5mL, £1.60/mL for > 200mL).

CONCLUSION

SCRA vaping products are easily obtainable online, in both small and bulk quantities. Information provided to purchasers on safety and legality is lacking or misleading. Further studies are needed to confirm the chemistry of these products. Policymakers should consider steps to limit the potential harm caused by the purchase and use of these products.

The Resurgence of Exogenous Psychosis: A Phenomenological Examination of Substance-Induced Psychopathology

ABSTRACT

The psychopathological manifestations associated with substance use, including induced psychotic experiences, are increasingly relevant but not well-understood within the medical community. Novel psychoactive substances and potentiated old compounds like cannabis and cocaine have emerged as a global concern, especially among adolescents and young adults. Transition rates from substance-induced psychosis (SIP) to persistent psychosis are significant, particularly in cases of cannabis-induced psychosis. Scientific inquiry into induced psychotic phenomena has revealed differences between SIP and primary psychotic disorders, highlighting the risk factors associated with each. The concept of exogenous psychosis, including its toxic variant known as lysergic psychoma, provides valuable insights into the role of external factors in psychosis development. A phenomenological approach characterizes this disruption in perception as a shift in temporal and spatial dimensions, leading to auditory and visual hallucinations. The "twilight state" of consciousness plays a crucial role in the transition from substance use to psychosis, with implications for spatiality, intersubjectivity, and temporality. This complex path to psychosis challenges traditional diagnostic models and underscores the need for a more nuanced understanding of substance-induced psychopathological experiences.

Rethinking Mental Automatism: De Clérambault's Theory in the Age of Novel Psychoactive Drugs: Psychotropic Effects and Synthetic Psychosis

The widespread use of novel psychoactive substances (NPSs)-defined as new narcotic or psychotropic agents not classified under the Single Convention on Narcotic Drugs of 1961 or the Convention on Psychotropic Substances of 1971-poses a significant challenge to contemporary mental health paradigms due to their impact on psychiatric disorders. This study revisits and expands upon the theory of mental automatism as proposed by Gaëtan Gatian de Clérambault, aiming to elucidate the psychopathological mechanisms underlying substance-induced psychoses (SIP) and their distinction from non-induced psychoses (schizophrenia and related disorders). Through a phenomenological and clinical investigation, we explore the relevance of mental automatism in the development of toxic psychoses, drawing upon the historical and contemporary literature. This research highlights the psychopathological distinctions between induced and non-induced psychoses and the transition mechanisms from acute to chronic psychosis states. De Clérambault's theory, supplemented by Janet, Jackson, and Bonhoeffer's contributions, provides a foundational framework for understanding the genesis of SIP. Our findings suggest that NPS consumption, particularly among adolescents and psychiatric patients, significantly correlates with increased risks of SIP, marked by a transition to chronicity influenced by biological lesions triggered by substance use. Furthermore, we propose a comprehensive framework for SIP, integrating mental automatism, psychopathological distinctions, and transition mechanisms. This framework aims to refine diagnostic criteria and therapeutic approaches, addressing gaps in clinical practice and research. The study underscores the need for a nuanced understanding of SIP, advocating for a paradigm shift in psychiatric assessment and treatment approaches to better address the complexities of substance-induced mental health disorders.

A systematic review and meta-analysis of synthetic cathinone use and psychosis

RATIONALE

Synthetic cathinones (SC), commonly referred to as "bath salts", are stimulants resembling the natural alkaloid cathinone found in the khat plant. These substances have the potential to induce serious health risks such as hallucinations, delusions, paranoia and agitation which can lead to substance-induced psychotic disorders. Despite growing concerns, there is a limited understanding of the association between SC consumption and the devolvement of such psychopathologies.

METHODS

We conducted a systematic review to investigate the frequency of substance-induced psychotic disorder (SIPD) and associated conditions in humans following synthetic cathinone consumption. We qualitatively and quantitatively analyzed SC exposure cases.

RESULTS

A total of 32 studies were included, with a diverse range of demographics, synthetic cathinone types, and consumption patterns. The proportion of individuals developing psychotic symptoms was reported at 0.380 (Random-effects model, 95% CI 0.289 - 0.475). Additionally, the significant heterogeneity in diagnostic approaches limited our ability to provide a precise estimate of prevalence.

CONCLUSIONS

Synthetic cathinone consumption is associated with the risk of developing psychotic symptoms as indicated by the prevalence of hallucinations and/or delusions. Due to the lack of information on classifying factors, particularly duration of symptoms, we are unable to conclude synthetic cathinone-induced psychosis. Further research is warranted to elucidate the underlying mechanism linking synthetic cathinone consumption and psychosis. This review underscores the urgency of addressing the growing health risks posed by synthetic cathinone use. Additionally, it highlights the necessity of proper quantification of psychotic symptoms through scales and reporting of classification criteria to accurately diagnose SIPD.

The Loss of Spatiality and Temporality in Twilight Consciousness: The Emergence of Exogenous Psychosis Induced by Novel Psychoactive Substances

BACKGROUND

The state of twilight consciousness is marked by a focused narrowing of awareness, maintaining vigilance and attention while simultaneously experiencing perceptual shifts in the surrounding environment. It is crucial to recognize that this twilight state represents not just a contraction but also an expansion of conscious experience.

SUMMARY

Substances of abuse, particularly new psychoactive substances, play a significant role in inducing this twilight state. They achieve this by deconstructing essential components of consciousness, such as the perception of time and space.

KEY MESSAGE

This paper aimed to explore the phenomenon of the twilight state of consciousness and shed light on how new psychoactive substances can alter the perception of time and space during this twilight phase, potentially triggering exogenous psychosis. This comprehensive inquiry employs a phenomenological approach to the study of consciousness, recognizing it as the primary tool for ascribing significance to this intricate yet often overlooked aspect of psychopathology.

Aberrant salience in cannabis-induced psychosis: a comparative study

Background

Natural Cannabis (NC) and Synthetic Cannabinoids (SCs) use can increase the risk and exacerbate the course of psychotic disorders. These could be influenced by the Aberrant Salience (AS) construct. It refers to an excess of attribution of meaning to stimuli that are otherwise regarded as neutral, thereby transform them into adverse, dangerous, or mysterious entities. This leads the patient to engage in aberrant and consequently incorrect interpretative efforts concerning the normal perception of reality and its relationship with our analytical abilities. AS appears to play a significant role in the onset and perpetuation of psychotic disorders. The internal conflict arising from aberrant attributions of significance leads to delusional thoughts, ultimately culminating in the establishment of a self-sustaining psychosis.

Aims

To examine the differences between psychoses course not associated with cannabis use and those associated with NC-use and SCs-use, in terms of psychotic and dissociative symptoms, AS, global functioning and suicidal ideation.

Methods

A sample of 62 patients with First Episode Psychosis (FEP) was divided into 3 groups: non cannabis users (non-users, N = 20); NC-users or rather Delta-9-tetrahydrocannabinol (THC) users (THC-users, N = 21); SCs-users, commonly referred to as SPICE-users (SPICE-users, N = 20). Each group underwent assessments at the onset of psychotic symptoms, as well as at the 3 months and 6 months marks, utilizing a range of psychopathological scales. These included the Positive and Negative Syndrome Scale (PANSS) for investigating psychotic symptoms, the Global Assessment of Functioning (GAF) scale for assessing overall functioning, the Dissociative Experiences Scale (DES-II) for measuring dissociative symptoms, the Scale for Suicide Ideation (SSI) for evaluating suicidal ideation and the Aberrant Salience Inventory (ASI) scale for gauging AS.

Results

SPICE-users showed more severe and persistent positive symptoms, while negative symptoms were mostly represented among non-users. Non-users showed better recovery than SPICE-users in global functioning. All groups showed a decrease in both ASI scores and subscale scores. SPICE-users exhibited higher global AS scores and less improvement in this aspect compared to other groups.

Conclusion

This study may help understanding the role of AS in both non-substance-related and substance-induced psychosis. This knowledge may lead clinician to a better diagnosis and identify patient-tailored psychopharmacological treatment.

New Psychoactive Substances: Major Groups, Laboratory Testing Challenges, Public Health Concerns, and Community-Based Solutions

Across communities worldwide, various new psychoactive substances (NPSs) continue to emerge, which worsens the challenges to global mental health, drug rules, and public health risks, as well as combats their usage. Specifically, the vast number of NPSs that are currently available, coupled with the rate at which new ones emerge worldwide, increasingly challenges both forensic and clinical testing strategies. The well-established NPS detection techniques include immunoassays, colorimetric tests, mass spectrometric techniques, chromatographic techniques, and hyphenated types. Nonetheless, mitigating drug abuse and NPS usage is achievable through extensive community-based initiatives, with increased focus on harm reduction. Clinically validated and reliable testing of NPS from human samples, along with community-driven solution, such as harm reduction, will be of great importance, especially in combating their prevalence and the use of other illicit synthetic substances. There is a need for continued literature synthesis to reiterate the importance of NPS, given the continuous emergence of illicit substances in the recent years. All these are discussed in this overview, as we performed another look into NPS, from differentiating the major groups and identifying with laboratory testing challenges to community-based initiatives.

Changes in alcohol consumption and the risk of cardiovascular diseases in patients with depression who had not consumed alcohol: A nationwide cohort study

Although numerous studies have examined the association between alcohol consumption and cardiovascular diseases (CVDs) in the general population, such association in patients with depression has not been reported yet. Thus, the objective of this study was to examine the association between changes in alcohol consumption and CVDs in patients with depression who had not consumed alcohol. A national database of medical records in South Korea was used and 375,710 subjects newly diagnosed with depression who had not consumed alcohol within two years after the diagnosis of depression (1st point) were identified. Subjects were categorized into three groups (non-drinkers, mild-to-moderate drinkers, and heavy drinkers) based on the status of alcohol intake within two years after the 1st point (2nd point). Subjects were followed up for the occurrence of CVDs including myocardial infarction (MI), ischemic stroke, and all-cause mortality. Among eligible subjects, 329,802 non-drinkers, 43,659 mild-to-moderate drinkers, and 2,249 heavy drinkers were identified. Compared to non-drinkers, heavy drinkers showed increased risks for MI (aHR, 1.41; 95% CI, 1.08-1.83), ischemic stroke (aHR, 1.49; 95% CI, 1.12-1.99), composite CVDs (aHR, 1.48; 95% CI, 1.21-1.80), and all-cause mortality (aHR, 1.38; 95% CI, 1.13-1.68). Compared to those who maintained abstinence from alcohol, those who started heavy drinking after the diagnosis of depression had increased risks of CVDs and all-cause mortality. These data highlight the need for alcohol consumption limitations for people who are diagnosed with depression in clinical settings.

Towards digital organized crime and digital sociology of organized crime

As technology has changed people's lives, criminal phenomena are also constantly evolving. Today's digital society is changing the activities of organized crime and organized crime groups. In the digital society, very different organized crime groups coexist with different organizational models: from online cybercrime to traditional organized crime groups to hybrid criminal groups in which humans and machines 'collaborate' in new and close ways in networks of human and non-human actors. These criminal groups commit very different organized crime activities, from the most technological to the most traditional, and move from online to offline. They use technology and interact with computers for a variety of purposes, and the distinction between the physical and virtual dimensions of organized crime is increasingly blurred. These radical developments do not seem to be accompanied by a new criminological theoretical interpretive framework, with a definition of organized crime that is able to account for the changes that digital society brings to organized crime and generate modern research hypotheses. This article proposes the concept of digital organized crime and the spectrum theory of digital organized crimes, to be embedded within a current, revised sociological theory of the organization of crime and deviance in digital society (a new theory of digital criminal organizing) and argues that the study of digital organized crime will increasingly require a digital sociology of organized crime. Criminologists are called upon to work in this direction.

The Association of High-Frequency Nut Intake With a Low Risk of Psychological Problems in Female Methamphetamine Users

BACKGROUND

Recent years have witnessed a gradual increase in the number of female methamphetamine users. Meanwhile, female methamphetamine users are more likely to have psychological problems than male methamphetamine users. The association between diet and psychological problems have been found among non-methamphetamine user. The present study aims to investigate the relationship between dietary intake frequency and psychological problems in female methamphetamine users.

MATERIALS AND METHODS

A total of 109 female methamphetamine users, collected from a Compulsory Isolated Drug Rehabilitation Centre in northern China, participated in the study. All participants completed the Symptom Checklist 90 (SCL-90) questionnaire to assess psychological status. The relation of dietary intake frequency with the SCL-90 score was tested in partial correlation analysis. Multivariable regression models were used to calculate odds ratios to evaluate the association of dietary intake frequency with psychological problems.

RESULTS

Of the current female methamphetamine population, 33 participants were diagnosed with psychological problems using SCL-90. In the terms of dietary intake frequency, the frequency of nut intake in the psychiatric symptom group was significantly lower than that in the asymptomatic group. However, there was no difference in the frequency of other food intakes between the two groups. The frequency of nut intake was negatively correlated with the total score of SCL-90 and 8 different symptom clusters of psychopathologies on SCL-90. Logistic regression analysis indicated that the increased frequency of nut intake was associated with a lower risk of psychological problems.

CONCLUSION

In the female methamphetamine population, increasing the frequency of nut intake may reduce the risk of psychological problems for female methamphetamine users.

Pharmacology and adverse effects of new psychoactive substances: synthetic cannabinoid receptor agonists

Over the last decade, new psychoactive substances (NPS) have continuously been the focus of the international society since their emergence on the illicit drug market. NPS can be classified into six groups including; synthetic cannabinoid receptor agonists (SCRAs), stimulants, opioids, dissociatives, sedatives/hypnotics, and classic hallucinogens with psychoactive effects. These are sold as "herbal incense," "bath salts," "legal highs," and "research chemicals". They can be synthesized easily with slight changes in the chemical moieties of known psychoactive substances. NPS are sold worldwide via on- and off-line markets without proper scientific evaluation regarding their safety or harmfulness. Abuse of NPS poses a serious public health issue, and systematic studies on their adverse effects are lacking. Therefore, it would be meaningful to collect currently available data in order to understand NPS and to establish viable solutions to cope with the various health issues related to them. In this article, we reviewed the general pharmacological characteristics, recent findings, and adverse effects of representative NPS; SCRAs. SCRAs are known as the most commonly abused NPS. Most SCRAs, cannabinoid receptor 1 and cannabinoid receptor 2 agonists, are often associated with severe toxicities, including cardiotoxicity, immunotoxicity, and even death, unlike natural cannabinoid Δ⁹-Tetrahydrocannabinol.

Substance-related exogenous psychosis: a postmodern syndrome

There is growing recognition that substance use is associated with the emergence of psychosis.Elements of post-modernity dominate contemporary social contexts and operate as existential background factors that contribute to the emergence of substance-related psychotic phenomena, particularly use of potent and highly rewarding novel psychoactive substances (NPS). About 25% of first-episode psychoses are substance-induced (SIP). DSM-5 SIP diagnosis is based on the assumption that symptoms are transient and disappear after sustained abstinence. This narrowed definition does not consider the issue of persistent SIP. There is a clear need for a new diagnostic framework that provides reliable, unambiguous clinical criteria to differentiate between comorbid conditions (i.e., schizophrenia patients with a substance use disorder) and substance-related psychoses. In the present contribution, we aim to outline a novel and separate clinical entity: substancerelated exogenous psychosis (SREP). Within this diagnostic category, we refer to both transientand persistent psychoses associated with substance use. SREP is conceived as a distinct psychoticdisorder with psychopathological specificities that clearly differentiate it from schizophrenia. We address differences in terms of clinical presentation, epidemiology, etiological models and treatment response. SREP is characterized by altered states of consciousness, persecutory delusions, visual and cenesthetic hallucinations, impulsivity and psychomotor agitation, affectiveand negative symptoms, a pervasive feeling of unreality and intact insight. Delusions are typically secondary to abnormal perception resulting from a characteristic "sensorialization" of the world. Longitudinal studies are warranted to substantiate our hypothesis of a novel diagnostic categoryand support the clinical validity of SREP. This may have important implications in terms of early differential diagnosis and staging (i.e., between comorbid conditions, persistent and transientsubstance-related psychotic states) as well as choice of treatment interventions.

Development and Feasibility of a Spanish Language Version of the Tobacco, Alcohol, Prescription Drug, and Illicit Substance Use (TAPS) Tool

OBJECTIVES

The Tobacco, Alcohol, Prescription drug, and illicit Substance use (TAPS) Tool is a validated two-stage screening and brief assessment in primary care for unhealthy substance use. We developed a Spanish language version of the TAPS Tool and conducted a small study of its feasibility, acceptability, and preliminary validity.

METHODS

Participants were adult primary care patients ages 18 or older with Spanish as their primary language (N = 10 for development/refinement using qualitative congnitive interviewing; N = 100 for the preliminary validation study). The Spanish language TAPS Tool was administered in both interviewer- and selfadministered tablet format (in random order). We examined disclosure of substance use on the TAPS by administration format, and compared it with established measures for identifying substance use and substance use disorders.

RESULTS

The Spanish language TAPS was feasible to use and participants reported high levels of acceptability. The rates of past 12-month substance use were 11% for tobacco, 28% for risky alcohol, 4% for illicit drugs, 1% for nonmedical prescription drugs and substance use disorders rates were 7% for tobacco, 2% for alcohol, and 1% for other substances. The selfadministered TAPS elicited 1, 3, and 1 additional disclosures of tobacco, risky, alcohol, and marijuana use than the interviewer-administered TAPS, respectively. Rates of disclosure on the TAPS were similar to those on established measures for past 12-month and 3-month time frames.

CONCLUSIONS

The current study represents a starting point for expanding the availability of the TAPS Tool beyond its original English language version into Spanish. The Spanish language TAPS Tool could expand options for substance use screening in primary care settings with Spanish-dominant/preferred populations.

TRIAL REGISTRATION

The studies were registered with www.clinicaltrials.gov: NCT03879785, March 19, 2019.

How to ask about the use of new psychoactive substances to increase the validity of results in self-report prevalence surveys

INTRODUCTION AND AIMS

New psychoactive substances (NPS) represent hundreds of novel compounds. However, the general public might not be familiar with the overarching term NPS. This can result in both under- and over-reporting of NPS use.

DESIGN AND METHODS

The study analysed the last-year prevalence of NPS use in an online survey conducted across I-TREND project countries (the Czech Republic, the Netherlands and Poland). Self-reported NPS use was assessed within two types of questions-a generic and a checklist question. We analysed prevalence for each question separately, incorporated the free-text probe 'other' that followed them, and combined the two questions into a conservative and an inclusive estimate.

RESULTS

Including free-text responses to the 'other' categories increased prevalence of NPS use (from 51% to 56% for the checklist question and 25% to 32% for the generic question). Taking an inclusive approach to estimating prevalence (i.e. indicating NPS use in either a generic list or from the checklist) yielded a higher prevalence estimate (60%, 95% confidence interval 58-62%), compared to a more conservative approach in which NPS use had to be affirmed by both questions (27%, 95% confidence interval 26-29%).

DISCUSSION AND CONCLUSIONS

Generic questions might lead to notably lower estimates of self-reported NPS use in comparison to checklists. However, creating relevant checklists is challenging and lengthy survey instruments have limitations. Further surveys might benefit from featuring a combination of the strategies used in this study-a single (generic) question involving a number of locally specific NPSs and a free-text 'other' probe.

Club Drugs: Psychotropic Effects and Psychopathological Characteristics of a Sample of Inpatients

BACKGROUND

Growing evidence supports the possibility of significant psychiatric consequences related to novel and traditional psychoactive substance consumption. The problem of differential diagnosis has hampered research on specific psychopathologies with unclear outcomes. The aim of our study was to report psychiatric and clinical features of subjects admitted to a psychiatric ward in Ibiza, Spain, with a clinical diagnosis of substance abuse or intoxication.

METHODS

A survey was administered to a sample of inpatients hospitalized due to psychiatric symptoms related to recent use of psychoactive substances. The questionnaire investigated sociodemographic factors, familiar and personal anamnesis, substance use habits, general and psychopathological features. Urine samples were collected and analyzed in a toxicology laboratory using gas chromatography and mass spectrometry.

RESULTS

A total of 110 patients were included in the study. Most patients (70%) declared multiple substance use, and 33% of patients reported more than two substances; nevertheless, it was possible to identify 17 (15%) depressor users, 44 (40%) stimulant users and 49 (45%) psychodysleptics users. A positive association with a lifetime diagnosis of bipolar disorder was found (two-tailed Fisher's exact test: p = 0.013). Psychomotor agitation, reference, and paranoid delusions, affective symptoms, consciousness disorders, and aggressiveness represented some of the most frequent symptoms at entry evaluation.

CONCLUSIONS

In this study, we described the acute psychiatric presentations related to recreational drug use in subjects on holiday in Ibiza. The use of psychoactive substances was characterized by poly-use of both traditional and novel substances, with several psychopathological consequences. Future research should focus on a better understanding of the psychopathological effects of specific substances, defining signs and symptoms to help make a differential diagnosis and prospectively examine long-term effects.

New psychoactive substances: challenges for drug surveillance, control, and public health responses

The rapid emergence since the mid-2000s of a large and diverse range of substances originally designed as legal alternatives to more established illicit drugs (pragmatically clustered and termed new psychoactive substances; [NPS]) has challenged traditional approaches to drug monitoring, surveillance, control, and public health responses. In this section of the Series, we describe the emergence of NPS and consider opportunities for strengthening the detection, identification, and responses to future substances of concern. First, we explore the definitional complexity of the term NPS. Second, we describe the origins and drivers surrounding NPS, including motivations for use. Third, we summarise evidence on NPS availability, use, and associated harms. Finally, we use NPS as a case example to explore challenges and opportunities for future drug monitoring, surveillance, control, and public health responses. We posit that the current means of responding to emerging substances might no longer be fit for purpose in a world in which different substances can be rapidly introduced, and where people who use drugs can change preferences on the basis of market availability.

Understanding and managing the new psychoactive substances phenomenon: a holistic approach

The new psychoactive substances (NPS) phenomenon has emerged as a global threat that challenges public health and institutions. There are important qualitative differences between the NPS and traditional drugs phenomena. We discuss these differences and explore the complex structure of the NPS phenomenon. We analyse the entire phenomenon with a global, holistic approach. We present an original framework to help policy makers, healthcare practitioners, and community workers understand the NPS phenomenon's structure and to plan comprehensive policy responses and prevention strategies. We discuss fundamental characteristics, driving forces, routes of information, and social and individual health risks of the phenomenon. We conclude that a holistic approach integrating all aspects of the framework is essential for addressing this emerging threat. We give practical examples of interventions likely to be effective.

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

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

Designer benzodiazepines: a report of exposures recorded in the National Poison Data System, 2014-2017

IMPORTANCE

Exposures to novel psychoactive substances are reported with increasing frequency in both the medical literature and the lay press. While the majority of reports describe synthetic cannabinoids and cathinones, a lesser understood family is the "designer benzodiazepines". The current literature describing human exposures to these compounds is comprised of case reports and small case series.

OBJECTIVE

The primary objectives of this study are to describe epidemiologic trends and clinical effects of designer benzodiazepine use.

METHODS

Data regarding single agent exposures to designer benzodiazepines between 1 January 2014 and 31 December 2017 was obtained from the National Poison Data System. Substances queried include: adinazolam, clonazolam, cloniprazepam, diclazepam, etizolam, flubromazepam, flubromazolam, meclonazepam, nifoxipam, norflurazepam, and pyrazolam. Data was summarized descriptively.

RESULTS

234 single agent exposures in 40 states were reported during the study period. The annual number of exposures increased each year, from 26 in 2014 to 112 in 2017, amounting to a 330% increase. The most common exposures were etizolam (n = 162) and clonazolam (n = 50). The most common clinical effects were drowsiness/lethargy (65%), and slurred speech (17%). 3% required intubation, 36% of cases required hospital admission, 22% to the intensive care unit. There was 1 death in the study population.

CONCLUSIONS

The incidence of exposures to designer benzodiazepines is rising. Clinical effects are generally consistent with a sedative-hypnotic toxidrome. Severe effects, including death, seemed relatively uncommon in the study population.

Sales and Advertising Channels of New Psychoactive Substances (NPS): Internet, Social Networks, and Smartphone Apps

In the last decade, the trend of drug consumption has completely changed, and several new psychoactive substances (NPS) have appeared on the drug market as legal alternatives to common drugs of abuse. Designed to reproduce the effects of illegal substances like cannabis, ecstasy, cocaine, or ketamine, NPS are only in part controlled by UN conventions and represent an emerging threat to global public health. The effects of NPS greatly differ from drug to drug and relatively scarce information is available at present about their pharmacology and potential toxic effects. Yet, compared to more traditional drugs, more dangerous short- and long-term effects have been associated with their use, and hospitalizations and fatal intoxications have also been reported after NPS use. In the era of cyberculture, the Internet acts as an ideal platform to promote and market these compounds, leading to a global phenomenon. Hidden by several aliases, these substances are sold across the web, and information about consumption is shared by online communities through drug fora, YouTube channels, social networks, and smartphone applications (apps). This review intends to provide an overview and analysis of social media that contribute to the popularity of NPS especially among young people. The possibility of using the same channels responsible for their growing diffusion to make users aware of the risks associated with NPS use is proposed.

Hallucinogen Persisting Perception Disorder: Etiology, Clinical Features, and Therapeutic Perspectives

Hallucinogen Persisting Perception Disorder (HPPD) is a rare, and therefore, poorly understood condition linked to hallucinogenic drugs consumption. The prevalence of this disorder is low; the condition is more often diagnosed in individuals with a history of previous psychological issues or substance misuse, but it can arise in anyone, even after a single exposure to triggering drugs. The aims of the present study are to review all the original studies about HPPD in order to evaluate the following: (1) the possible suggested etiologies; (2) the possible hallucinogens involved in HPPD induction; (3) the clinical features of both HPPD I and II; (4) the possible psychiatric comorbidities; and (5) the available and potential therapeutic strategies. We searched PubMed to identify original studies about psychedelics and Hallucinogen Persisting Perception Disorder (HPPD). Our research yielded a total of 45 papers, which have been analyzed and tabled to provide readers with the most updated and comprehensive literature review about the clinical features and treatment options for HPPD.

Characteristics of NPS use in patients admitted to acute psychiatric services in Southeast Scotland: a retrospective cross-sectional analysis following public health interventions

OBJECTIVES

Assess the impact of selective prohibition and seizure of novel psychoactive substances (NPS) supply on NPS use prevalence within psychiatric admissions and evaluate demographic characteristics of current NPS users.

DESIGN

A 6-month retrospective cross-sectional analysis of discharge letters between 1 October 2015 and 31 March 2016.

SETTING

General psychiatry inpatients and intensive home treatment team (IHTT) community patients at a psychiatric hospital in a Scottish city.

PARTICIPANTS

All participants were between the ages of 18 and 65 years. After application of exclusion criteria, 473 discharge letters of general psychiatry patients were deemed suitable for analysis and 264 IHTT patient discharge letters were analysed.

INTERVENTIONS

A nationwide temporary class drug order (TCDO) was placed on 10 April 2015 reclassifying methylphenidate-related compounds as class B substances. On 15 October 2015, local forfeiture orders were granted to trading standards permitting the seizure of NPS supplies.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was to determine the prevalence of NPS use in two cohorts. Second, demographic features of patients and details regarding their psychiatric presentation were analysed.

RESULTS

The prevalence of NPS use in general psychiatry and IHTT patients was 6.6% and 3.4%, respectively. Inpatients using NPS compared with non-users were more likely to be men (OR 2.92, 95% CI 1.28 to 6.66, P=0.009), have a forensic history (OR 5.03, CI 2.39 to 10.59, P<0.001) and be detained under an Emergency Detention Certificate (OR 3.50, CI 1.56 to 7.82, P=0.004). NPS users were also more likely to be diagnosed under International Statistical Classification of Diseases and Related Health Problems, Version 10, F10-19 (OR 9.97, CI 4.62 to 21.49, P<0.001).

CONCLUSIONS

Compared with previous work, psychiatric inpatient NPS use has fallen. NPS continue to be used by a demographic previously described resulting in presentations consistent with a drug-induced psychosis and at times requiring detention under the Mental Health Act. Further research is required to evaluate the effectiveness of the recent prohibition of all NPS.

Psychoactive drugs: occurrence in aquatic environment, analytical methods, and ecotoxicity-a review

This review focused on seven psychoactive drugs being six benzodiazepines (alprazolam, bromazepam, clonazepam, diazepam, lorazepam, and oxazepam) and one antidepressant (citalopram) widely consumed by modern society and detected in different aqueous matrices (drinking water, surface water, groundwater, seawater, estuary water, influent and effluent of wastewater treatment plants). The review included 219 selected scientific papers from which 1642 data/entries were obtained, each entry corresponding to one target compound in one aqueous matrix. Concentrations of all investigated drugs in all aqueous matrices varied from 0.14 to 840,000 ng L^-1. Citalopram presented the highest concentrations in the aqueous matrices. Based on the Wilcoxon-Mann-Whitney test, differences between wastewater influents and effluents were not significant for most wastewater categories, suggesting that conventional wastewater treatment systems as such do not remove or remove partially these compounds. High-income countries showed much lower concentrations in surface water than the group formed by upper-middle-, lower-middle-, and low-income countries. Regarding analytical methods, solid-phase extraction (SPE) was by far the most used extraction method (83%) and performance liquid chromatography (HPLC) (73%) coupled to mass spectrometry (99%) the most common analytical method. Changes in behavior and in survival rates were the most common effects reported on bioindicators (aquatic species) due to the presence of these drugs in water. Concentrations of psychoactive drugs found in surface waters were most of the time within the range that caused measurable toxic effects in ecotoxicity assays.

Body Image and Eating Disorders are Common among Professional and Amateur Athletes Using Performance and Image Enhancing Drugs: A Cross-Sectional Study

The use of performance and image enhancing drugs (PIEDs) is not uncommon in athletes and appears to be associated with several psychopathological disorders of unclear prevalence. In this multicenter, cross-sectional study, we aimed to evaluate the prevalence of body image disorders (BIDs) and eating disorders (EDs) in PIED-using athletes vs. PIED nonusers. We enrolled 84 consecutive professional and amateur athletes training in sport centers in Italy, who underwent semi-structured interviews (SCID-I, SCID-II) and completed the Body Image Concern Inventory (BICI) and the Sick, Control, One, Fat, Food Eating Disorder Screening Test (SCOFF). PIEDs were searched for in participants' blood, urine, and hair. Of these, 18 (21.4%) used PIEDs, the most common being anabolic androgenic steroids, amphetamine-like substances, coffee and caffeine derivatives, synthetic cathinones, and ephedrine. PIED users and nonusers did not differ in socio-demographic characteristics, but differed in clinical and psychopathological features, with PIED users being characterized by higher physical activity levels, higher daily coffee and psychotropic medication use (e.g., benzodiazepines), more SCID diagnoses of psychiatric disorders, especially substance use disorder, body dysmorphic disorder (BDD), EDs, and general anxiety disorder, higher BICI scores (indicating higher risk of BDD), and higher SCOFF scores (suggesting higher risks for BIDs and EDs).

The Novel Psychoactive Substances in the UK Project: empirical and conceptual review work to produce research recommendations

Background

Although illegal drug use has largely been declining in the UK over the past decade, this period has witnessed the emergence of a range of novel psychoactive substances (NPS) (‘legal highs’). These are new, mostly synthetic, substances that mimic the effects of existing drugs). Despite there being many causes for concern in relation to NPS, there has been little prior study of the burden associated with their use in public health terms. Clarity is lacking on research priorities in this rapidly developing literature.

Objectives

To inform the development of public health intervention research on NPS by reviewing existing data on their use, associated problems and potential responses to such problems.

Design

A scoping review and narrative synthesis of selected bodies of evidence was undertaken to summarise and evaluate what is known about NPS use and the related harms of, and responses to, such use. Relevant literature was identified from electronic databases (covering January 2006 to June 2016 inclusive), Google (Google Inc., Mountain View, CA, USA), relevant websites and online drug forums and by contacting experts. Articles were included if they were primary studies, secondary studies involving the analysis and interpretation of primary research or discussion papers. A conceptual framework postulating an evidence-informed public health approach to NPS use in the UK was developed through a pragmatic literature review, the iterative development of concepts and finalisation in light of the results from the empirical review work. The process also involved feedback from various stakeholders. Research recommendations were developed from both strands of work.

Results

A total of 995 articles were included in the scoping review, the majority of which related to individual-level health-related adverse effects attributable to NPS use. The prevalence of lifetime NPS use varied widely between (e.g. with higher prevalence in young males) and within population subgroups. The most commonly reported adverse effects were psychiatric/other neurological, cardiovascular, renal and gastrointestinal manifestations, and there is limited evidence available on responses. In these and other respects, available evidence is at an early stage of development. Initial evidence challenges the view that NPS should be treated differently from other illicit drugs. The conceptual framework indicated that much of the evidence that would be useful to inform public health responses does not yet exist. We propose a systems-based prevention approach that develops existing responses, is multilevel and life course informed in character, and emphasises commonalities between NPS and other legal and illegal drug use. We make 20 recommendations for research, including nine key recommendations.

Limitations

Scoping reviews do not interrogate evidence in depth, and the disjunction between the scoping review and the conceptual framework findings is worthy of careful attention.

Conclusions

Key research recommendations build on those that have previously been made and offer more evidence-based justification and detail, as previous recommendations have not yet been acted on. The case for decision-making on commissioning new research based on these recommendations is both strong and urgent.

Future work

The validity of recommendations generated through this project could be enhanced via further work with research commissioners, policy-makers, researchers and the public.

Study registration

The systematic review element of this study is registered as PROSPERO CRD42016026415.

Funding

The National Institute for Health Research Public Health Research programme.

An insight into the deep web; why it matters for addiction psychiatry?

OBJECTIVE

Nowadays, the web is rapidly spreading, playing a significant role in the marketing or sale or distribution of "quasi" legal drugs, hence facilitating continuous changes in drug scenarios. The easily renewable and anarchic online drug-market is gradually transforming indeed the drug market itself, from a "street" to a "virtual" one, with customers being able to shop with a relative anonymity in a 24-hr marketplace. The hidden "deep web" is facilitating this phenomenon. The paper aims at providing an overview to mental health's and addiction's professionals on current knowledge about prodrug activities on the deep web.

METHODS

A nonparticipant netnographic qualitative study of a list of prodrug websites (blogs, fora, and drug marketplaces) located into the surface web was here carried out. A systematic Internet search was conducted on Duckduckgo® and Google® whilst including the following keywords: "drugs" or "legal highs" or "Novel Psychoactive Substances" or "NPS" combined with the word deep web.

RESULTS

Four themes (e.g., "How to access into the deepweb"; "Darknet and the online drug trading sites"; "Grams-search engine for the deep web"; and "Cryptocurrencies") and 14 categories were here generated and properly discussed.

CONCLUSIONS

This paper represents a complete or systematical guideline about the deep web, specifically focusing on practical information on online drug marketplaces, useful for addiction's professionals.

Pharmaco-toxicological effects of the novel third-generation fluorinate synthetic cannabinoids, 5F-ADBINACA, AB-FUBINACA, and STS-135 in mice. In vitro and in vivo studies

INTRODUCTION

5F-ADBINACA, AB-FUBINACA, and STS-135 are 3 novel third-generation fluorinate synthetic cannabinoids that are illegally marketed as incense, herbal preparations, or research chemicals for their psychoactive cannabis-like effects.

METHODS

The present study aims at investigating the in vitro and in vivo pharmacological activity of 5F-ADBINACA, AB-FUBINACA, and STS-135 in male CD-1 mice, comparing their in vivo effects with those caused by the administration of Δ⁹ -THC and JWH-018. In vitro competition binding experiments revealed a nanomolar affinity and potency of the 5F-ADBINACA, AB-FUBINACA, and STS-135 on mouse and human CB₁ and CB₂ receptors. Moreover, these synthetic cannabinoids induced neurotoxicity in murine neuro-2a cells.

RESULTS

In vivo studies showed that 5F-ADBINACA, AB-FUBINACA, and STS-135 induced hypothermia; increased pain threshold to both noxious mechanical and thermal stimuli; caused catalepsy; reduced motor activity; impaired sensorimotor responses (visual, acoustic, and tactile); caused seizures, myoclonia, and hyperreflexia; and promoted aggressiveness in mice. Behavioral and neurological effects were fully prevented by the selective CB₁ receptor antagonist/inverse agonist AM 251. Differently, the visual sensory response induced by STS-135 was only partly prevented by the AM 251, suggesting a CB₁ -independent mechanism.

CONCLUSIONS

For the first time, the present study demonstrates the pharmaco-toxicological effects induced by the administration of 5F-ADBINACA, AB-FUBINACA, and STS-135 in mice and suggests their possible detrimental effects on human health.

Novel psychoactive substance use among treatment-seeking opiate users: The role of life events and psychiatric symptoms

OBJECTIVE

Over the past 5 years, a shift to the use of novel psychoactive substances (NPS) has been observed among opioid users. The aim of this study was to assess the potential reasons for NPS use among treatment-seeking patients receiving opiate substitution therapy.

METHOD

A structured questionnaire was filled out by a sample of 198 opiate dependent patients of Hungary's National Institute of Psychiatry and Addiction. This questionnaire assessed demographics, treatment characteristics, lifetime substance use, potential reasons for NPS use, negative life events (Life Events Scale), and psychiatric symptoms (Brief Symptom Inventory).

RESULTS

The most frequent reasons for NPS use were curiosity, replacing other drugs, and easy availability. The majority of the respondents used synthetic cathinones and chose practical reasons, not psychopharmacological preferences. A series of binary logistic regressions indicated that lifetime amphetamine use (OR = 4.64, 95% CI [2.16, 9.96]) and more severe psychiatric symptoms (OR = 1.89, 95% CI [1.18, 3.04]) may predict NPS use. Time spent in treatment was a minor protective factor (OR = 0.92, 95% CI [0.86, 0.99]).

CONCLUSION

Synthetic cathinones might still substitute amphetamine-derivatives, although these NPS are no longer legal. There is a need for the regular screening of psychiatric symptoms and the use of family therapy among participants on opioid substitution programs.

From concept(ion) to life after death/the grave: The 'natural' history and life cycle(s) of novel psychoactive substances (NPS)

A range of information needs should be met in order to better understand and predict the longevity/existence of novel psychoactive substances (NPS). This conceptual paper argues that one way of assessing how long a molecule may be around is to document how the life cycles or natural histories of 'traditional' drugs and NPS evolve. The earliest indication of the possible appearance of a new substance might be evidenced on the DeepWeb. However, this means they are less visible, in line with the clandestine nature of drug use and supply. Therefore, monitoring discussion groups/fora needs the development of new methods compared to those used in the Surface Net. Issues needing consideration in establishing NPS life cycles are outlined here, together with the probable outcomes that could result. The approach advocated means that it should be easier to identify which NPS are likely to come up or are emerging in real time, and, therefore, pre-empt/prevent their supply.

Substance-related psychopathology and aggressiveness in a nightlife holiday resort: Results from a pilot study in a psychiatric inpatient unit in Ibiza

OBJECTIVES

We aimed to describe a sample of subjects admitted to a psychiatric unit after the intake of psychoactive substances for recreational purposes.

METHODS

Between June and September 2015, 49 subjects were included. Sociodemographic characteristics and psychopathological aspects were investigated, and urine samples for further analysis were collected. Three subgroups (cannabinoids, stimulants, and depressors users) were identified, according to the structured interview regarding substance use and urinalysis.

RESULTS

Level of aggressiveness was found to be significantly higher (p < .05) in the cannabinoids subgroup. Self-reported symptom severity was comparable among groups, but trends could be identified: SCL-90 results showed a prevalence of anxiety symptoms among depressors users, hostility or aggression in the tetrahydrocannabinol subgroup, and psychoticism in the stimulants subgroup.

CONCLUSIONS

The use of psychoactive substances was be characterised by poly-use of both traditional and novel substances. The presence of aggressiveness emerged as a main feature associated with the use of cannabis and other cannabinoids. Binge drinking and sleep deprivation also represented a relevant component in almost all the evaluated subjects.

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.

1-cyclohexyl-x-methoxybenzene derivatives, novel psychoactive substances seized on the internet market. Synthesis and in vivo pharmacological studies in mice

INTRODUCTION

Among novel psychoactive substances notified to EMCDDA and Europol were 1-cyclohexyl-x-methoxybenzene stereoisomers (ortho, meta, and para). These substances share some structural characteristics with phencyclidine and tramadol. Nowadays, no information on the pharmacological and toxicological effects evoked by 1-cyclohexyl-x-methoxybenzene are reported. The aim of this study was to investigate the effect evoked by each one stereoisomer on visual stimulation, body temperature, acute thermal pain, and motor activity in mice.

METHODS

Mice were evaluated in behavioral tests carried out in a consecutive manner according to the following time scheme: observation of visual placing response, measures of core body temperature, determination of acute thermal pain, and stimulated motor activity.

RESULTS

All three stereoisomers dose-dependent inhibit visual placing response (rank order: meta > ortho > para), induce hyperthermia at lower and hypothermia at higher doses (meta > ortho > para) and cause analgesia to thermal stimuli (para > meta = ortho), while they do not alter motor activity.

CONCLUSIONS

For the first time, this study demonstrates that systemic administration of 1-cyclohexyl-x-methoxybenzene compounds markedly inhibit visual response, promote analgesia, and induce core temperature alterations in mice. This data, although obtained in animal model, suggest their possible hazard for human health (i.e., hyperthermia and sensorimotor alterations). In particular, these novel psychoactive substances may have a negative impact in many daily activities, greatly increasing the risk factors for workplace accidents and traffic injuries.

Influencing Antibody-Mediated Attenuation of Methamphetamine CNS Distribution through Vaccine Linker Design

Active vaccination examining a single hapten engendered with a series of peptidic linkers has resulted in the production of antimethamphetamine antibodies. Given the limited chemical complexity of methamphetamine, the structure of the linker species embedded within the hapten could have a substantial effect on the ultimate efficacy of the resulting vaccines. Herein, we investigate linker effects by generating a series of methamphetamine haptens that harbor a linker with varying amino acid identity, peptide length, and associated carrier protein. Independent changes in each of these parameters were found to result in alterations in both the quantity and quality of the antibodies induced by vaccination. Although it was found that the consequence of the linker design was also dependent on the identity of the carrier protein, we demonstrate overall that the inclusion of a short, structurally simple, amino acid linker benefits the efficacy of a methamphetamine vaccine in limiting brain penetration of the free drug.

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

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

Neuropharmacology of New Psychoactive Substances (NPS): Focus on the Rewarding and Reinforcing Properties of Cannabimimetics and Amphetamine-Like Stimulants

New psychoactive substances (NPS) are a heterogeneous and rapidly evolving class of molecules available on the global illicit drug market (e.g smart shops, internet, “dark net”) as a substitute for controlled substances. The use of NPS, mainly consumed along with other drugs of abuse and/or alcohol, has resulted in a significantly growing number of mortality and emergency admissions for overdoses, as reported by several poison centers from all over the world. The fact that the number of NPS have more than doubled over the last 10 years, is a critical challenge to governments, the scientific community, and civil society [EMCDDA (European Drug Report), 2014; UNODC, 2014b; Trends and developments]. The chemical structure (phenethylamines, piperazines, cathinones, tryptamines, synthetic cannabinoids) of NPS and their pharmacological and clinical effects (hallucinogenic, anesthetic, dissociative, depressant) help classify them into different categories. In the recent past, 50% of newly identified NPS have been classified as synthetic cannabinoids followed by new phenethylamines (17%) (UNODC, 2014b). Besides peripheral toxicological effects, many NPS seem to have addictive properties. Behavioral, neurochemical, and electrophysiological evidence can help in detecting them. This manuscript will review existing literature about the addictive and rewarding properties of the most popular NPS classes: cannabimimetics (JWH, HU, CP series) and amphetamine-like stimulants (amphetamine, methamphetamine, methcathinone, and MDMA analogs). Moreover, the review will include recent data from our lab which links JWH-018, a CB1 and CB2 agonist more potent than Δ⁹-THC, to other cannabinoids with known abuse potential, and to other classes of abused drugs that increase dopamine signaling in the Nucleus Accumbens (NAc) shell. Thus the neurochemical mechanisms that produce the rewarding properties of JWH-018, which most likely contributes to the greater incidence of dependence associated with “Spice” use, will be described (De Luca et al., 2015a). Considering the growing evidence of a widespread use of NPS, this review will be useful to understand the new trends in the field of drug reward and drug addiction by revealing the rewarding properties of NPS, and will be helpful to gather reliable data regarding the abuse potential of these compounds.

Next generation of novel psychoactive substances on the horizon - A complex problem to face

BACKGROUND

The last decade has seen a rapid and continuous growth in the availability and use of novel psychoactive substances (NPS) across the world. Although various products are labeled with warnings "not for human consumption", they are intended to mimic psychoactive effects of illicit drugs of abuse. Once some compounds become regulated, new analogues appear in order to satisfy consumers' demands and at the same time to avoid criminalization. This review presents updated information on the second generation of NPS, introduced as replacements of the already banned substances from this class, focusing on their pharmacological properties and metabolism, routes of administration, and effects in humans.

METHODS

Literature search, covering years 2013-2015, was performed using the following keywords alone or in combination: "novel psychoactive substances", "cathinones", "synthetic cannabinoids", "benzofurans", "phenethylamines", "2C-drugs", "NBOMe", "methoxetamine", "opioids", "toxicity", and "metabolism".

RESULTS

More than 400 NPS have been reported in Europe, with 255 detected in 2012-2014. The most popular are synthetic cannabimimetics and psychostimulant cathinones; use of psychedelics and opioids is less common. Accumulating experimental and clinical data indicate that potential harms associated with the use of second generation NPS could be even more serious than those described for the already banned drugs.

CONCLUSIONS

NPS are constantly emerging on the illicit drug market and represent an important health problem. A significant amount of research is needed in order to fully quantify both the short and long term effects of the second generation NPS, and their interaction with other drugs of abuse.

Following "the Roots" of Kratom (Mitragyna speciosa): The Evolution of an Enhancer from a Traditional Use to Increase Work and Productivity in Southeast Asia to a Recreational Psychoactive Drug in Western Countries

The use of substances to enhance human abilities is a constant and cross-cultural feature in the evolution of humanity. Although much has changed over time, the availability on the Internet, often supported by misleading marketing strategies, has made their use even more likely and risky. This paper will explore the case of Mitragyna speciosa Korth. (kratom), a tropical tree used traditionally to combat fatigue and improve work productivity among farm populations in Southeast Asia, which has recently become popular as novel psychoactive substance in Western countries. Specifically, it (i) reviews the state of the art on kratom pharmacology and identification; (ii) provides a comprehensive overview of kratom use cross-culturally; (iii) explores the subjective experiences of users; (iv) identifies potential risks and side-effects related to its consumption. Finally, it concludes that the use of kratom is not negligible, especially for self-medication, and more clinical, pharmacological, and socioanthropological studies as well as a better international collaboration are needed to tackle this marginally explored phenomenon.

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.

Identification of AKB-48 and 5F-AKB-48 Metabolites in Authentic Human Urine Samples Using Human Liver Microsomes and Time of Flight Mass Spectrometry

The occurrence of structurally related synthetic cannabinoids makes the identification of unique markers of drug intake particularly challenging. The aim of this study was to identify unique and abundant metabolites of AKB-48 and 5F-AKB-48 for toxicological screening in urine. Investigations of authentic urine samples from forensic cases in combination with human liver microsome (HLM) experiments were used for identification of metabolites. HLM incubations of AKB-48 and 5F-AKB-48 along with 35 urine samples from authentic cases were analyzed with liquid chromatography quadrupole tandem time of flight mass spectrometry. Using HLMs 41 metabolites of AKB-48 and 37 metabolites of 5F-AKB-48 were identified, principally represented by hydroxylation but also ketone formation and dealkylation. Monohydroxylated metabolites were replaced by di- and trihydroxylated metabolites within 30 min. The metabolites from the HLM incubations accounted for on average 84% (range, 67-100) and 91% (range, 71-100) of the combined area in the case samples for AKB-48 and 5F-AKB-48, respectively. While defluorinated metabolites accounted for on average 74% of the combined area after a 5F-AKB-48 intake only a few identified metabolites were shared between AKB-48 and 5F-AKB-48, illustrating the need for a systematic approach to identify unique metabolites. HLMs in combination with case samples seem suitable for this purpose.

A novel psychoactive substance poses a new challenge in the management of paranoid schizophrenia

Novel psychoactive substances (NPS), or 'legal highs' are becoming more commonly used as recreational substances in the UK. Their clinical effects are little known and vary considerably between substances. This case discusses a psychiatric inpatient who repeatedly used a stimulant NPS called 'el blanco' while on leave, precipitating relapses of his schizophrenia. The patient initially denied drug use, considering legal highs as different from drugs. The relationship between NPS use and mental state was eventually revealed on careful direct questioning. He recovered and was discharged following treatment with clozapine and education about NPS use. We suggest that specific questioning about NPS usage is added to routine psychiatric history taking and that patients using NPS should be educated about the substances' use.

"Legal Highs"--An Emerging Epidemic of Novel Psychoactive Substances

During the last decade, there has been an increase in the availability and use of novel psychoactive substances (NPS), also known as "legal highs," across the world. They include a wide range of products, from natural plant-originated substances to synthetic compounds, that can be purchased both online and from high street retailers. "Legal highs" mimic psychoactive effects of illicit drugs of abuse. However, they are claimed to consist of compounds that are legal to sell, possess, and use, often labeled as "not for human consumption" to circumvent drug abuse legislation. Based on the spectrum of their actions on cognitive processes, mood, and behavior, "legal highs" can be classified into four basis categories: amphetamine- and ecstasy-like stimulants, synthetic cannabinoids (SCs), hallucinogenic/dissociative, and opioid-like compounds. NPS may, however, exhibit a combination of these actions due to their designed chemical structure. Although the prevalence and pattern of NPS use differ between various countries, the most popular groups are SCs and psychostimulants, described in this chapter. Currently, there is limited information available on the potential acute toxicity (harms) associated with the use of these substances. However, the number of intoxicated people presenting with emergencies is constantly increasing, providing evidence that negative health and social consequences may indeed seriously affect recreational and chronic users.

Unveiling the nature of black mamba (Dendroaspis polylepis) venom through venomics and antivenom immunoprofiling: Identification of key toxin targets for antivenom development

The venom proteome of the black mamba, Dendroaspis polylepis, from Eastern Africa, was, for the first time, characterized. Forty- different proteins and one nucleoside were identified or assigned to protein families. The most abundant proteins were Kunitz-type proteinase inhibitors, which include the unique mamba venom components 'dendrotoxins', and α-neurotoxins and other representatives of the three-finger toxin family. In addition, the venom contains lower percentages of proteins from other families, including metalloproteinase, hyaluronidase, prokineticin, nerve growth factor, vascular endothelial growth factor, phospholipase A2, 5'-nucleotidase, and phosphodiesterase. Assessment of acute toxicity revealed that the most lethal components were α-neurotoxins and, to a lower extent, dendrotoxins. This venom also contains a relatively high concentration of adenosine, which might contribute to toxicity by influencing the toxin biodistribution. ELISA immunoprofiling and preclinical assessment of neutralization showed that polyspecific antivenoms manufactured in South Africa and India were effective in the neutralization of D. polylepis venom, albeit showing different potencies. Antivenoms had higher antibody titers against α-neurotoxins than against dendrotoxins, and displayed high titers against less toxic proteins of high molecular mass. Our results reveal the complexity of D. polylepis venom, and provide information for the identification of its most relevant toxins to be neutralized by antivenoms.

BIOLOGICAL SIGNIFICANCE

The black mamba, D. polylepis, is one of the most feared snakes in the world, owing to the potency of its venom, the severity and rapid onset of clinical manifestations of envenomings, and its ability to strike fast and repeatedly. The present study reports the first proteomic analysis of this venom. Results revealed a complex venom constituted predominantly by proteins belonging to the Kunitz-type proteinase inhibitor family, which comprises the dendrotoxins, and to α-neurotoxins of the three-finger toxin family. The proteins showing highest acute toxicity were α-neurotoxins, which induce post-synaptic blockade of the neuromuscular junctions, followed by dendrotoxins, which inhibit the voltage-dependent potassium channels. The combination of these two types of toxins in the venom underscores the presence of a dual strategy that results in a highly effective mechanism for prey subduction. This complex toxic arsenal is likely to provide D. polylepis with high trophic versatility. The rapid onset and severity of neurotoxic clinical manifestations in envenomings by D. polylepis demand the rapid administration of effective and safe antivenoms. Preclinical tests showed that an antivenom from South Africa and two antivenoms from India were effective in the neutralization of this venom, albeit differing in their potency. Moreover, ELISA immunoprofiling of these antivenoms against all venom fractions revealed that antivenoms have higher titers against α-neurotoxins than against dendrotoxins, thus underscoring the need to develop improved immunization strategies. The results of this investigation identified the most relevant toxins present in D. polylepis venom, which need to be targeted by antivenoms or other type of inhibitors.

The availability and depiction of synthetic cathinones (bath salts) on the Internet: Do online suppliers employ features to maximize purchases?

BACKGROUND

"Bath salts", a derivative of cathinone, a naturally occurring beta-ketone amphetamine analogue found in the leaves of the khat (Catha edulis) plant, is a potent class of designer drugs associated with significant medical and psychiatric consequences. They are commonly used among 20-29 year olds, a group with easy access to the Internet and an inclination to purchase online. Therefore, the Internet has the potential to play a significant role in the distribution and associated consequences of these "legal highs".

METHODS

Google searches were used to determine bath salts availability on retail websites and how different search terms affected the proportion of retail websites obtained. Retail websites were reviewed by two independent raters who examined content with a focus on characteristics that increase the likelihood of online sales.

RESULTS

Of the 250 websites found, 31 were unique retail websites. Most retail website hits resulted when a product name was used as the search term. The top three countries hosting retail websites were registered in the United States (n=14; 45%), Germany (n=7; 23%), and the United Kingdom (n=3; 10%). These online drug suppliers provided considerable information and purchasing choice about a variety of synthetic cathinones, legitimized their sites by using recognizable images, online chat features, and mainstream payment and shipping methods, and employed characteristics that promote online purchases.

CONCLUSION

Online designer drug suppliers use sophisticated methods to market unregulated products to consumers. The international community has taken diverse approaches to address designer drugs: legislative bans, harm reduction approaches, an interim regulated legal market. Multifaceted efforts that target bath salt users, suppliers, and emergency/poison control entities are critical to comprehensively address bath salt ingestion and its consequences.

Drug abuse, relapse, and prevention education in malaysia: perspective of university students through a mixed methods approach

In recent years, there have been increasing accounts of illegal substance abuse among university students and professional groups in Malaysia. This study looks at university students' perceptions about this phenomenon. Students from Malaysian universities were asked for their impressions about drug availability and abuse, as well as factors contributing to drug abuse and relapse. The questionnaire also inquired into their knowledge and views regarding government versus private rehabilitation centers, as well as their exposure to, and views about, school-based drug-prevention education. Participants were 460 university students from five Malaysian states: Penang, Selangor, Kuala Lumpur, Sabah, and Sarawak. Results showed gender differences in perceptions of relapse prevention strategies, as well as factors leading to drug abuse and relapse. Students also believed that drug education would be more effective if initiated between the ages of 11 and 12 years, which is slightly older than the common age of first exposure, and provided suggestions for improving existing programs. Implications of student perceptions for the improvement of current interventions and educational programs are discussed.