A critical first assessment of the new pre-market approval regime for new psychoactive substances (NPS) in New Zealand

Clinical Presentations and Predictors of In-Hospital Mortality in Illicit Drug Users in the New Psychoactive Substances (NPS) Endemic Era in Taiwan

Predictors of mortality in illicit drug users involving Novel Psychoactive Substances (NPS) and multiple substances have not been elucidated. We aimed to define predictors of mortality in the NPS endemic era’s illicit drug users to strengthen patient care in emergency treatment. This was a retrospective study. LC-MS/MS-confirmed positive illicit drug users who visited the emergency departments (ED) of six medical systems were enrolled. Demographic information, physical examinations, and laboratory data were abstracted for mortality analysis. There were 16 fatalities in 355 enrolled patients. The most frequently used illicit drugs were amphetamines, followed by opioids, cathinones, and ketamine. The most frequently detected cathinones among the 16 synthetic cathinones were eutylone, followed by mephedrone. The combined use of cathinones and ketamine was most commonly observed in our results. Univariate analysis revealed that the mortality patients were older, with deep coma, faster heart rate and respiratory rate, lower blood pressures and O2 room air saturation, more seizures, abnormal breath sounds, and had urine incontinence compared to the survivor patients. The mortality patients also had acute kidney injury, higher potassium, blood sugar, liver function test, and lactate level. The results of multiple logistic regression demonstrated that SBP < 90 mmHg, dyspnea, blood sugar > 140 mg/dl, and HCO3 < 20.6 mmHg were independent predictors of in-hospital mortality. Regardless of the pattern of the use of illicit drugs, the predictors allow for risk stratification and determining the optimal treatment.

Does cannabis testing in the military drive synthetic cannabinoid use? Self-reported use motivations among justice-involved veterans

BACKGROUND

Though synthetic cannabinoid receptor agonists (SCRAs) were controlled after being introduced as a 'legal high,' SCRAs likely remain appealing to individuals subject to routine drug screens as not all testing programs consistently include SCRAs. Military populations have been linked to SCRAs due to the unconfirmed supposition that testing protocols led many to substitute SCRAs for cannabis. This study aimed to explore SCRA use prevalence, correlates, and use motivations among veterans, with a particular focus on whether United States military personnel substituted SCRAs for cannabis to subvert testing protocols.

METHODS

All veterans appearing in one of eight civilian criminal courts in three U.S. states were invited to answer questionnaire items related to military service, court functionality, and substance use. Of the 579 veterans eligible, 54.9% chose to participate, yielding a cross-sectional sample of 318 veterans charged with a criminal offense by civilian authorities.

RESULTS

Sixty-five (21.3%) justice-involved veterans reported lifetime SCRA use. Use while within the military was reported by 15.0% of veterans enlisting after 2008. Only eight (12.3%) reported SCRAs were used as a substitute for cannabis. Boredom (36.9%), experimentation (27.7%), and social aspects of SCRA use (32.3%) were more commonly reported motives. Logistic regression models indicated that use of cannabis (aPR=2.06, p<.05), hallucinogens (aPR=2.50, p<.01), and SCRAs (aPR=2.49, p<.05) while in the military were risk factors for SCRA use after leaving the military, whereas older age at time of military exist was a protective factor (aPR=.87, p<.01) CONCLUSIONS: Drug testing programs within the military do not appear to have the unintended consequence of routing individuals to more risky drugs; however, SCRAs appear to have been an underappreciated problem within the military. Further, use extends beyond the military with many only initiating use after discharge, suggesting SCRA use may jeopardize the health of veterans post-service.

The Illicit Supply of New Psychoactive Substances Within and From China: A Descriptive Analysis

Although China has played a significant role in the emergence and expansion of new psychoactive substances (NPS) worldwide, little research has specifically focused on the illicit supply of NPS within China and smuggling from China. In this study, data were extracted from sentencing files obtained from closed criminal cases to develop an objective understanding of the NPS supply chain in China. The sample consisted of 341 major cases concerning the illicit supply of three groups of NPS (ketamine, synthetic cathinone, and fentanyl) and five categories of offense, including manufacturing, distributing, retailing, transporting, and manufacturing-retailing. Significant differences between these categories of offense in terms of offenders' profiles, behaviors, and supply patterns were observed. Our results suggest the existence of a dynamic and complex supply network both in China and in terms of smuggling routes from China.

Legislation targeting head shops selling new psychoactive substances and changes in drug-related psychiatric admissions: A national database study

AIM

New psychoactive substance (NPS) use can negatively impact mental health and may result in drug-related psychiatric admissions (DRPA). Irish youth reported very high rates of NPS use by international standards, the most common being synthetic cannabinoids and cathinones. This occurred in the context of a rapid expansion in specialist high street shops, called head shops, selling NPS in 2010. Government responded to public protests about head shops by enacting legislation in May and August 2010 to end this trade. Many academics argued that such actions were futile. We sought to determine if changes in head shop activity coincided with changes in DRPA.

METHOD

The national database on psychiatric admissions was examined focusing on young adults admitted from 2008 to 2012. Joinpoint regression analysis was utilized to examine for the presence of trend changes in DRPA.

RESULTS

The monthly rate of DRPA was higher in 2010 than 2008, 2009 and 2012 (P < 0.01). Joinpoint regression analysis identified a significant downward trend change which occurred in July 2010 (95% CI Feb 2010 to April 2011). Young males aged 18 to 24 years showed evidence of greatest change, DRPA falling by 1.4% per month (95% CI 0.7 to 3.7% decline) from May 2010 to December 2012.

CONCLUSIONS

Cessation of NPS sale by head shops coincided with a reversal in the upward trend of DRPA, this change being most evident in young men. While correlation does not imply causation, legislation which successfully targets the sale of NPS may result in reduced drug-related mental disorders.

How deaths can help clinicians and policy-makers understand the risks of novel psychoactive substances

Novel psychoactive substances (NPS), especially those newly created, are largely an unknown quantity, particularly in terms of their potential serious adverse effects. This means that policy-makers and clinicians are under-informed about appropriate responses. Collation of detailed information on deaths related to NPS use can help in providing knowledge and understanding these aspects of the NPS phenomenon. The purpose of this review is to outline the role(s) which such evidence-based data can play in this respect. UK NPS-related cases demonstrate differences in definitions used by the General Mortality Registers, and differences between countries, not only in terms of the type of NPS implicated in deaths, but the number and extent of such deaths over time. NPS deaths are continuing to increase numerically and as a proportion of all drug-poisoning deaths. In order to better understand how specific molecules contribute to and/or cause death, detailed information collected by Special Mortality Registers can provide examples of substances' modes of action, adverse effects, symptomatology, treatment interventions, mechanisms of death, etc. This information can provide clinicians and policy-makers with objective information on the serious harms from such emerging molecules. Such evidence-based advice informs public health interventions, service provision and policy decisions on regulation and control of NPS. However, without reliable, accurate and complete information that is correctly collated, scientifically analysed and disseminated in a timely manner, an understanding of the phenomenon of what deaths can be ascribed to NPS, their characteristics and nature will remain unachieved, and thus limit what can be done to reduce them.

Combined NMDA Inhibitor Use in a Patient With Multisubstance-induced Psychotic Disorder

: Novel psychoactive substance use is a major social concern. Their use may elicit or uncover unpredictably as yet undescribed clinical pictures. We aimed to illustrate a multisubstance use case indistinguishable from paranoid schizophrenia, so to alert clinicians on possibly misdiagnosing substance-induced psychotic disorders.

CASE REPORT

We describe a case of a 32-year-old man who started at 18 years with cannabinoids and ketamine, and is currently using N-methyl-D-aspartate (NMDA) antagonists. At age 23, he developed social withdrawal after being assaulted by a stranger, but did not consult psychiatrists until age 26; during this period, he was using internet-purchased methoxetamine and ketamine, and was persecutory, irritable, suspicious, and insomniac and discontinued all received medical prescriptions. He added dextromethorphan to his list of used substances. At age 31, while using phencyclidine, and, for the first time, methoxphenidine, he developed a religious delusion, involving God calling him to reach Him, and the near-death experiences ensured by NMDA antagonists backed his purpose. He received Diagnostic and Statistical Manual of Mental Disorders, 5th Edition diagnosis of multisubstance-induced psychotic disorder and was hospitalized 8 times, 6 of which after visiting the emergency room due to the development of extreme anguish, verbal and physical aggression, and paranoia. He reportedly used methoxphenidine, methoxyphencyclidine, ethylnorketamine, norketamine, and deschlorketamine, to achieve near-death experiences, and eventually to reach God in heavens.

CONCLUSIONS

This case points to the need for better control of drugs sold on the internet. It also illustrates that people using NMDA antagonists may present clinical pictures indistinguishable from those of major psychoses and are likely to be misdiagnosed.

Understanding the development of a regulated market approach to new psychoactive substances (NPS) in New Zealand using Punctuated Equilibrium Theory

BACKGROUND AND AIMS

The short-lived regulated legal market for new psychoactive substances (NPS) in New Zealand marked a radical departure from the traditional prohibition-based approach to drugs. This paper aimed to enhance understanding of this policy change using Punctuated Equilibrium Theory (PET).

METHODS

The analysis draws on 3 years of evaluative research, including interviews with key stakeholders, analysis of legislation and policy documents and academic and grey literature.

RESULTS

The reframing of the NPS issue from one of drug control to the need for stricter market regulation was achieved by the efforts of strategic policy entrepreneurs, including the legal high industry, drug law reform advocates, influential politicians and an independent legal advisory institution. This reframing was aided by the perceived saliency of the NPS problem and ineffectiveness of previous prohibition-based responses. In the absence of any political opposition to the regulatory approach, the Psychoactive Substances Act rapidly progressed through the Parliament. However, once the interim legal market was established, portrayal of the issues shifted away from experts and lobbyists to critique from local communities, local government, animal rights activists and the media, who viewed the new regime as a source of social and health problems. The mobilization of criticism ('Schattschneider mobilization') drew on ideas of animal welfare and community safety. With a looming national election, the government responded by ending the interim market with the urgent passage of amendment legislation.

CONCLUSIONS

Punctuated Equilibrium Theory (PET) helps explain how New Zealand's Psychoactive Substances Act (PSA) policy first emerged on the political agenda and how the initial positive tone of expert support for reform shifted to a tide of popular criticism during the interim regime. However, with its emphasis on explaining agenda-setting, PET does not account for the legislative design shortcomings of the PSA.

The future of the international drug control system and national drug prohibitions

A major impediment to any nation abandoning the policy of drug prohibition has been the fact that international drug treaties to which the majority of United Nations (UN) member states are signatory prohibit the non-medical use of amphetamines, cannabis, cocaine and heroin. The future of these treaties is now uncertain because of decisions by Uruguay, eight US states and Canada to legalize cannabis use. This paper: (1) provides a brief account of the international drug control treaties; (2) outlines the major criticisms of the treaties; (3) analyses critically proposals for treaty reform; and (4) provides a personal view on policies that nation states could adopt to minimize the harms from the use of cannabis, party drugs and hallucinogens, opioids, stimulants and new psychoactive substances. It is argued that: a major risk of cannabis legalization in the United States is promotion of heavy use and increased harm by a weakly regulated industry; some cautious national experiments with the regulation of party drugs and hallucinogens would be informative; a strong case remains for prohibiting the nonmedical use of opioids while mitigating the adverse effects that this policy has on opioid-dependent people; stimulant legalization will probably increase problem use but prohibition is difficult to enforce, highlighting the urgency of finding better ways to reduce demand for these drugs and respond to problem users; and that it is unclear what the best approach is to reducing possible harms that may arise from the use of new psychoactive substances.

The long tail of a demon drug: The 'bath salts' risk environment

Using the case of synthetic cathinones (commonly referred to as 'bath salts' in the US context), this paper analyses structural factors surrounding novel psychoactive substances (NPS) as contributing to the unique risk environment surrounding their use. Drawing on interviews with 39 people who use bath salts from four U.S. cities and analysis of the infrastructural, social, economic, and policy contexts, we document the unique harms related to changing contexts for illicit drug regulation, manufacture, and consumption. Findings suggest that NPS and designer drug markets, which are highly reliant upon the internet, share characteristics of the entertainment industry which has come to rely more heavily upon profits derived from the 'long tail' of myriad lesser-known products and the diminished centrality of 'superstars' and 'hits'. Findings point toward increased theoretical and policy attention to changing drug market structures, more rigorous evaluations of drug 'analogues' legislation and greater involvement with NPS education and testing by harm reduction agencies.

Worldwide legislative challenges related to psychoactive drugs

Abstract

The discovery of a “new” psychoactive substance is a relatively exceptional event, while the regulatory response usually involved the assessment of risks to public health and inclusion of the novel substance in the national list of controlled substances. However, in recent years we have witnessed the rapid emergence of new chemical substances, which elude international control and pose a challenge to existing processes and a threat to the credibility of control systems. We currently review and present characteristics of these legal and illegal new substances and issues regarding their global monitoring and regulatory measures already taken, or in the process of being taken, for their control. The concept of prohibition applied in active substance-related legislation is rather hazard ridden as balance is required between the ban on substances of potential therapeutic use and the access on the market of high-risk substances.

Graphical Abstract

Current and future laws regarding psychoactive compounds.

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.

High prevalence of quasi-legal psychoactive substance use among male patients in HIV care in Japan: a cross-sectional study

Background

Syndemics of illicit drug use and HIV remain as significant public health issues around the world. There has been increasing concern regarding the rapidly growing market of new psychoactive substances, particularly in Asia. In response, the Japanese government has increasingly banned such substances in recent years. We sought to identify the prevalence and correlates of use of quasi-legal psychoactive substances among people living with HIV/AIDS (PLHIV) in Japan.

Methods

Data were derived from a nationwide survey of PLHIV conducted at nine leading HIV/AIDS care hospitals between July and December 2013. The prevalence and correlates of the use of quasi-legal psychoactive substances (e.g., synthetic cannabinoids, cathinone derivatives, etc. that had not been prohibited from using at the time of survey) among male participants were examined using multivariate survey logistic regression.

Results

Among 963 study participants, the majority (95.3%) were male. The most commonly used drug among men was quasi-legal psychoactive substances (55.3% ever and 12.8% in the previous year). In multivariate analysis, the lifetime use of tryptamine-type derivatives (i.e., 5-MeO-DIPT or N,N-diisopropyl-5-methoxytryptamine) (adjusted odds ratio [AOR]: 2.42; 95% confidence interval [CI]: 1.36–4.28) and methamphetamine/amphetamine (AOR: 3.59; 95% CI: 2.13–6.04) were independently associated with recent quasi-legal psychoactive substance use.

Conclusions

In our sample of male PLHIV in Japan, quasi-legal psychoactive substances were the most commonly used drugs. Individuals who had ever used tryptamine-type derivatives or methamphetamine/amphetamine were more likely to report recent quasi-legal psychoactive substance use, suggesting a potential shift in drug use patterns from regulated to unregulated substances among this population. These findings indicate a need for further research to examine implications for HIV care.

Can new psychoactive substances be regulated effectively? An assessment of the British Psychoactive Substances Bill

The regulation of new psychoactive substances (NPS) has confounded governments throughout the western world. In 2014 the UK government convened an NPS Review Expert Panel to consider a range of approaches. Ultimately the Panel recommended that the government ban all new psychoactive drugs and allow only psychoactive substances specifically exempted, such as alcohol, tobacco and those allowed as medicines. The government introduced the Psychoactive Substances Bill (PSB) in response to that recommendation. Passed in 2016, the Bill has attracted a torrent of criticism from scientists and experts. The Bill could be improved with revision, but the problems of the total ban, as envisioned by the PSB, with respect to the NPS, may be inherent: (1) defining psychoactivity is conceptually fraught, with great consequence for the scope of the prohibition; (2) operationalizing psychoactivity as a usable concept for legal control purposes is extremely difficult, perhaps impossible; and (3) the detachment of penalties for violating a total ban from establishing the harmfulness of a substance is normatively troubling. Given the uncertainties about the effects of a total ban, it is appropriate at this time for other governments to assess more fully the nature of the NPS problem, and the potential control approaches.

Synthetic Cathinone and Cannabinoid Designer Drugs Pose a Major Risk for Public Health

As part of an increasing worldwide use of designer drugs, recent use of compounds containing cathinones and synthetic cannabinoids is especially prevalent. Here, we reviewed current literature on the prevalence, epidemiology, bio-behavioral effects, and detection of these compounds. Gender differences and clinical effects will also be examined. Chronic use of synthetic cathinone compounds can have major effects on the central nervous system and can induce acute psychosis, hypomania, paranoid ideation, and delusions, similar to the effects of other better-known amphetamine-type stimulants. Synthetic cannabinoid products have effects that are somewhat similar to those of natural cannabis but more potent and long-lasting than THC. Some of these compounds are potent and dangerous, having been linked to psychosis, mania, and suicidal ideation. Novel compounds are developed rapidly and new screening techniques are needed to detect them as well as a rigorous regulation and legislation reinforcement to prevent their distribution and use. Given the rapid increase in the use of synthetic cathinones and cannabinoid designer drugs, their potential for dependence and abuse, and harmful medical and psychiatric effects, there is a need for research and education in the areas of prevention and treatment.

Do police arrestees substitute legal highs for other drugs?

BACKGROUND

Some commentators have suggested legal highs (LH) might reduce existing illegal drug use and contribute to lower drug-related harm. However, no studies have specifically investigated substitution between LH and other drugs.

AIMS

To explore the extent to which police detainees substitute LH for illegal drugs.

METHOD

A total of 848 detainees at four central police stations were interviewed about their drug and LH use. Detainees were asked what impact their LH use had on their other drug use (i.e., 'no change', 'more', 'less' or 'stopped'). The detainees were placed into four groups: (i) no LH use; (ii) LH use and 'no change' in drug use; (iii) LH use and 'more' drug use; (iv) LH use and 'less' or 'stopped' drug use. Demographics and levels of drug use in the past month were compared between groups.

RESULTS

Ninety-six percent of the LH using detainees had used synthetic cannabinoids (SC), and, of those who reported substituting a drug, 94% had substituted (natural) cannabis. Overall, 54% of the detainee sample had not used SC, 34% had used SC but not changed their cannabis use, 9% had used SC and used 'less' or 'stopped' cannabis use, and 3% had used SC and used 'more' cannabis. The SC users were more likely to have recently been in drug treatment. All those who used SC had higher cannabis consumption regardless of substitution behaviour. The SC users who used 'more' cannabis also used more methamphetamine and ecstasy.

CONCLUSION

Twenty percent of those who used SC and cannabis reported reducing or stopping their cannabis use while 6% increased their cannabis use, suggesting a modest overall reduction in cannabis use. Further research is required to quantify the magnitude of substitution changes, the impact on drug-related harm, and extent to which substitution occurs for other LH and other populations.

The impact of the prohibition of benzylpiperazine (BZP) "legal highs" on the availability, price and strength of BZP in New Zealand

BACKGROUND

Legal highs containing benzylpiperazine (BZP) were widely sold in New Zealand until BZP was prohibited in 2008. We examined the impact the prohibition had on the availability and price of BZP over following years.

METHODS

Two national population surveys of BZP use were conducted in 2006 and 2009. Four annual targeted surveys of frequent drug users (FDU) were conducted from 2007-2010. Availability and price measures were obtained. Inflation-adjusted real retail prices were calculated. Other drug markets were monitored as quasi-controls.

RESULTS

The proportion of BZP users from the general population who considered the availability of BZP to be 'very easy' declined from 76% in 2006 to 21% in 2009. The proportion who thought BZP had become 'harder' to obtain increased from 5% in 2006 to 71% in 2009. The proportion who reported the price of BZP was 'higher' increased from 27% in 2006 to 51% in 2009. FDU who considered the availability of BZP to be 'very easy' declined from 98% in 2007 to 15% in 2008, and then increased to 42% by 2010. The real retail price of a BZP tablet increased from $9.86 in 2007 to $15.83 in 2010. The proportion who considered the price of BZP to be 'increasing' rose from 3% in 2007 to 47% in 2010.

CONCLUSIONS

The availability of BZP declined immediately following its prohibition. Availability recovered in subsequent years, but not to the pre-prohibition legal level. The price of BZP increased slowly over a number of years following the prohibition.