Implications of psychoactive 'bath salts' use during pregnancy

Magnitude of Khat use and associated factors among women attending antenatal care in Gedeo zone health centers, southern Ethiopia: a facility based cross sectional study

Background

Khat (Catha edulis) is a fresh green leave commonly chewed for recreational purpose and its euphoric effect as a result of dopamine activities stimulation effect of Khat. Women may use Khat during their pregnancy to tolerate their pregnancy related distress. Khat has biological, social or psychological complications; adverse pregnancy outcomes and negatively affects the health of the mother and the fetus. However, magnitude, pattern and associated factors of Khat use are not well addressed among pregnant women in Ethiopia. The aim of this study was to address this gap by assessing the magnitude and associated factors of Khat use among women attending antenatal care service at Gedeo zone rural health centers.

Methods

This was a facility based cross-sectional study conducted at rural health centers in Gedeo zone from June 1^st to August 1^st, 2017. The data were collected through structured interview using an interview guide developed from different literatures. A total of 718 pregnant women attending antenatal care service participated in the study using multi stage sampling technique. Bivariable and multivariable analysis were used to identify associated factors of Khat use among women during their current pregnancy period. In the multivariable analysis, variables with P-Values of less than 0.05 were considered as statistically significant correlates of Khat use. The strength of the association was also measured with adjusted odds ratio at a corresponding 95% confidence interval.

Results

The lifetime and current prevalence of khat use among pregnant women were 11.0% (95%CI: 8.8–13.2) and 9.9% (95% CI: 7.7–12), respectively. The odds of being khat user was higher among those who had khat user partner [AOR = 3.450, 95% C.I (1.907–6.244)], respondents with alcohol use behavior [AOR = 3.235, 95% C.I (1.573–6.659)] and mental distress [AOR = 3.575, 95% C.I (2.067–6.189)].

Conclusion

Significant proportions of pregnant women were experiencing khat chewing during pregnancy. Having khat user partner, alcohol use behavior and metal distress were significantly associated with khat use of pregnant women. This demonstrates a need to integrate the prevention, early identification and intervention of Khat use as a component of treatment modality for pregnant women during their antenatal visit.

Bath salts and polyconsumption: in search of drug-drug interactions

BACKGROUND AND RATIONALE

Polydrug use is a widespread phenomenon, especially among adolescents and young adults. Synthetic cathinones are frequently consumed in combination with other drugs of abuse. However, there is very little information regarding the consequences of this specific consumption pattern.

OBJECTIVES

The aim of this review is to introduce this topic and highlight the gaps in the existing literature. In three different sections, we focus on specific interactions of synthetic cathinones with alcohol, cannabinoids, and the stimulants nicotine and cocaine. We then dedicate a section to the existence of sex and gender differences in the effects of synthetic cathinones and the long-term psychophysiological consequences of adolescent and prenatal exposure to these drugs.

MAJOR FINDINGS

Epidemiological studies, case reports, and results obtained in animal models point to the existence of pharmacological and pharmacokinetic interactions between synthetic cathinones and other drugs of abuse. This pattern of polyconsumption can cause the potentiation of negative effects, and the dissociation between objective and subjective effects can increase the combined use of the drugs and the risk of toxicity leading to serious health problems. Certain animal studies indicate a higher vulnerability and effect of cathinones in females. In humans, most of the users are men and case reports show long-term psychotic symptoms after repeated use.

CONCLUSIONS

The co-use of synthetic cathinones and the other drugs of abuse analyzed indicates potentiation of diverse effects including dependence and addiction, neurotoxicity, and impaired cognition and emotional responses. The motivations for and effects of synthetic cathinone use appear to be influenced by sex/gender. The long-term consequences of their use by adolescents and pregnant women deserve further investigation.

Fetal death associated with the use of 3,4-MDPHP and α-PHP

INTRODUCTION

The second largest group of new drugs monitored by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is synthetic cathinones. Substances that are controlled by the law are immediately replaced by new uncontrolled derivatives that cause constant and dynamic changes on the drug market. Some of the most recent synthetic cathinones that have appeared on the "legal highs" market are 3,4-methylenedioxy-α-pyrrolidinohexanophenone (3,4-MDPHP) and α-pyrrolidinohexanophenone (α-PHP).

CASE HISTORY

A 21-year-old woman in the 36th week of pregnancy presented with psychomotor agitation. Fetal demise was demonstrated and a caesarean delivery performed.

METHODS

The analyses were carried out by liquid chromatography with mass spectrometry (LC-MS/MS). The analytes were isolated from the biological material by liquid-liquid extraction with n-butyl chloride.

RESULTS

3,4-MDPHP and α-PHP were detected and quantified in both the fetus' and the mothers blood, as well as in the mothers urine samples. The determined concentrations of 3,4-MDPHP and α-PHP were, 76 ng/mL and 12 ng/mL in the fetal blood sample, 16 ng/mL and traces in the mothers blood, and 697 mg/mL and 136 ng/mL in the mothers urine, respectively.

DISCUSSION

The presented case demonstrates that 3,4-MDPHP and α-PHP transfers from maternal blood to fetal blood. Blood concentrations of these compounds were higher in the fetus than in the mother. Based on the known effects of these substances and the patient's presentation and clinical course, it would seem that these substances contributed to the fetal death.

CONCLUSIONS

The detected substances transfer from maternal to fetal circulation, and synthetic cathinone blood concentration can be higher in the fetus than in the mother. This along with the fact immature metabolic ability makes a fetus more vulnerable to cathinones intoxication than adults.

Gestational Exposure to the Synthetic Cathinone Methylenedioxypyrovalerone Results in Reduced Maternal Care and Behavioral Alterations in Mouse Pups

The member of synthetic cathinone family, methylenedioxypyrovalerone (MDPV), is a frequently used psychoactive drug of abuse. The objective of our study was to determine the effect of MDPV (administered from the 8th to the 14th day of gestation) on the behavior of neonatal and adolescent mice, as well as its effect on maternal care. We measured maternal care (pup retrieval test, nest building), locomotor activity (open field test), and motor coordination (grip strength test) of dams, whereas on pups we examined locomotor activity at postnatal day 7 and day 21 (open field test) and motor coordination on day 21 (grip strength test). On fresh-frozen brain samples of the dams we examined the expression of two important peptides implicated in the regulation of maternal behavior and lactation: tuberoinfundibular peptide 39 (TIP39) mRNA in the thalamic posterior intralaminar complex, and amylin mRNA in the medial preoptic nucleus. We detected decreased birth rate and survival of offspring, and reduced maternal care in the drug-treated animals, whereas there was no difference between the motility of treated and control mothers. Locomotor activity of the pups was increased in the MDPV treated group both at 7 and 21 days of age, while motor coordination was unaffected by MDPV treatment. TIP39 and amylin were detected in their typical location but failed to show a significant difference of expression between the drug-treated and control groups. The results suggest that chronic systemic administration of the cathinone agent MDPV to pregnant mice can reduce birth rate and maternal care, and it also enhances motility (without impairment of motor coordination) of the offspring.

The pharmacokinetic profile of synthetic cathinones in a pregnancy model

In recent years, the abuse of synthetic cathinones or 'bath salts' has become a major public health concern. Although these compounds were initially sold legally and labeled "not for human consumption", the 'bath salts' are psychostimulants, with similar structures and pharmacologic mechanisms to cocaine, the amphetamines, and 3,4 methylendioxymethamphetamine (MDMA, Molly, or Ecstasy). The reported use of these substances by women of child-bearing age highlights the necessity of studies seeking to delineate risks of prenatal exposure. Three popular drugs of this type are methylone, mephedrone, and 3, 4-methylenedioxypyrovalerone (MDPV). Unfortunately, there is currently no information available on the teratogenicity of these compounds, or of the extent to which they cross the placenta. As such, the purpose of this study was to examine the pharmacokinetic profile of the 'bath salts' in a pregnancy model. Pregnant mice (E17.5 gestation) were injected intraperitoneally with a cocktail of 5mg/kg methylone, 10mg/kg mephedrone, and 3mg/kg (MDPV) dissolved in sterile saline. Maternal brain, maternal plasma, placenta, and fetal brain were collected at 30s, 1min, 5min, 10min, 15min, 30min, 1h, 2h, 4h, and 8h following injection. Methylone, mephedrone, and MDPV were extracted from tissue by solid phase extraction, and concentrations were determined using a previously validated liquid chromatography-tandem mass spectrometry (LC-MS/MS) method. Interestingly, all 3 cathinones reached measurable concentrations in the placenta, as well as the fetal brain; in fact, for MDPV, the maximal concentration (Cmax) was highest in fetal brain, while mephedrone's highest Cmax value was achieved in placenta. Additionally, the total drug exposure for all 3 compounds (as represented by area under the curve, AUC) was higher in fetal matrices (placenta and fetal brain) than in maternal matrices (maternal brain and plasma), and the half-lives for the drugs were longer. Given the extensive presence of methylone, mephedrone, and MDPV in the fetal brain following prenatal exposure, fetal risk is definitely a concern. As there are currently no prenatal studies available on the teratogenicity of these agents, pregnant patients should be informed about the potential risks that these substances may have.

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.