Risk of emergency medical treatment following consumption of cannabis or synthetic cannabinoids in a large global sample

Assessing rates and predictors of cannabis-associated psychotic symptoms across observational, experimental and medical research

Cannabis, one of the most widely used psychoactive substances worldwide, can give rise to acute cannabis-associated psychotic symptoms (CAPS). While distinct study designs have been used to examine CAPS, an overarching synthesis of the existing findings has not yet been carried forward. To that end, we quantitatively pooled the evidence on rates and predictors of CAPS (k = 162 studies, n = 210,283 cannabis-exposed individuals) as studied in (1) observational research, (2) experimental tetrahydrocannabinol (THC) studies, and (3) medicinal cannabis research. We found that rates of CAPS varied substantially across the study designs, given the high rates reported by observational and experimental research (19% and 21%, respectively) but not medicinal cannabis studies (2%). CAPS was predicted by THC administration (for example, single dose, Cohen's d = 0.7), mental health liabilities (for example, bipolar disorder, d = 0.8), dopamine activity (d = 0.4), younger age (d = -0.2), and female gender (d = -0.09). Neither candidate genes (for example, COMT, AKT1) nor other demographic variables (for example, education) predicted CAPS in meta-analytical models. The results reinforce the need to more closely monitor adverse cannabis-related outcomes in vulnerable individuals as these individuals may benefit most from harm-reduction efforts.

Effects of Δ9-Tetrahydrocannabinol and the Aminoalkylindole K2/Spice Constituent JWH-073 on Cardiac Tissue and Mesenteric Vascular Reactivity

Background: Although use of Cannabis sativa is not associated with serious adverse effects, recreational use of aminoalkylindole (AAI) cannabinoid receptor agonists found in K2/Spice herbal blends has been reported to cause adverse cardiovascular events, including angina, arrhythmia, changes in blood pressure, ischemic stroke, and myocardial infarction. Δ9-Tetrahydrocannabinol (Δ9-THC) is the primary CB1 agonist found in cannabis and JWH-073 is one of the AAI CB1 agonists found in K2/Spice brands sold to the public. Methods: This study used in vitro, in vivo, and ex vivo approaches to investigate potential differences on cardiac tissue and vascular effects betweenJWH-073 and Δ9-THC. Male C57BL/6 mice were treated with JWH-073 or Δ9-THC and cardiac injury was assessed by histology. Effects of JWH-073 and Δ9-THC on H9C2 cell viability and ex vivo mesenteric vascular reactivity were also determined. Results: JWH-073 or Δ9-THC induced typical cannabinoid effects of antinociception and hypothermia but did not promote death of cardiac myocytes. No differences in cell viability were observed in cultured H9C2 cardiac myocytes after 24 h of treatment. In isolated mesenteric arteries from drug-naive animals, JWH-073 produced significantly greater maximal relaxation (96%±2% vs. 73%±5%, p<0.05) and significantly greater inhibition of phenylephrine-mediated maximal contraction (Control 174%±11%KMAX) compared with Δ9-THC (50%±17% vs. 119%±16%KMAX, p<0.05). Discussion: These findings suggest that neither cannabinoid at the concentrations/dose studied caused cardiac cell death, but JWH-073 has the potential for greater vascular adverse events than Δ9-THC through an increased vasodilatory effect.

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.

Rates and correlates of cannabis-associated psychotic symptoms in over 230,000 people who use cannabis

Cannabis, a widely used psychoactive substance, can trigger acute cannabis-associated psychotic symptoms (CAPS) in people who use cannabis (PWUC). To assess rates and correlates of CAPS requiring emergency medical treatment, we analyzed data from an international sample of PWUC (n = 233,475). We found that 0.47% (95%CI 0.42; 0.52) PWUC reported lifetime occurrence of CAPS, defined as the occurrence of hallucinations and/or paranoia requiring emergency medical treatment following the use of cannabis. A range of factors correlated with risk of CAPS in the last year: higher rates were observed in young individuals [risk ratio (RR) 2.66, compared to older PWUC] and those residing in Denmark (RR 3.01, compared to PWUC from other countries). Furthermore, risk was elevated in those using predominantly high-potency resin (RR 2.11, compared to PWUC using herbal cannabis), those mixing cannabis with tobacco (RR 2.15, compared to PWUC not mixing with tobacco) and those with a diagnosis of psychosis (RR 14.01), bipolar (RR 4.30), anxiety (RR 2.92) and depression (RR 2.68), compared to individuals without a mental health diagnosis. Taken together, acute self-limiting psychotic symptoms in the context of cannabis use may occur in about 1 in 200 PWUC's lifetime. Some individuals could be particularly sensitive to the adverse psychological effects of cannabis, such as young individuals or those with pre-existing mental health vulnerabilities. In light of the movements towards legalization of recreational cannabis, more research should focus on the potential harms related to cannabis use, to educate PWUC and the public about risks related to its use.

Similar 5F-APINACA Metabolism between CD-1 Mouse and Human Liver Microsomes Involves Different P450 Cytochromes

In 2019, synthetic cannabinoids accounted for more than one-third of new drugs of abuse worldwide; however, assessment of associated health risks is not ethical for controlled and often illegal substances, making CD-1 mouse exposure studies the gold standard. Interpretation of those findings then depends on the similarity of mouse and human metabolic pathways. Herein, we report the first comparative analysis of steady-state metabolism of N-(1-adamantyl)-1-(5-pentyl)-1H-indazole-3-carboxamide (5F-APINACA/5F-AKB48) in CD-1 mice and humans using hepatic microsomes. Regardless of species, 5F-APINACA metabolism involved highly efficient sequential adamantyl hydroxylation and oxidative defluorination pathways that competed equally. Secondary adamantyl hydroxylation was less efficient for mice. At low 5F-APINACA concentrations, initial rates were comparable between pathways, but at higher concentrations, adamantyl hydroxylations became less significant due to substrate inhibition likely involving an effector site. For humans, CYP3A4 dominated both metabolic pathways with minor contributions from CYP2C8, 2C19, and 2D6. For CD-1 mice, Cyp3a11 and Cyp2c37, Cyp2c50, and Cyp2c54 contributed equally to adamantyl hydroxylation, but Cyp3a11 was more efficient at oxidative defluorination than Cyp2c members. Taken together, the results of our in vitro steady-state study indicate a high conservation of 5F-APINACA metabolism between CD-1 mice and humans, but deviations can occur due to differences in P450s responsible for the associated reactions.

Clinical pattern of synthetic cannabinoids users in Upper Egypt: cross-sectional study

Background

There is an expanding use of new psychoactive substances containing synthetic cannabinoids in the last years. This study was conducted to identify the epidemiologic data of acute and chronic toxicity by synthetic cannabinoids in Upper Egypt patients.

Results

All cases included in the presenting study were fifty males. Most users of synthetic cannabinoids were in the adolescence and middle age group (15–< 35) representing 68%. Curiosity was the most common motivator for using synthetic cannabinoids. Alteration of perception was reported in 68% of subjects after synthetic cannabinoids use. Additionally, dizziness, loss of consciousness, convulsion, and panic attacks were also reported. Cardiovascular adverse effects experienced by users were palpitations (76%) and chest pain (12%). Half of included subjects (50%) reported financial problems and about one-third (32%) got involved in domestic violence. Abnormal routine laboratory findings that were found in included cases were in the form of 12% anemia, 10% leukocytosis, and 6% leucopenia. Also, liver and kidney functions were elevated in 8% and 4% of the cases, respectively. While 22% and 4% of cases were positive for hepatitis C and HIV respectively.

Conclusions

This study can be concluded that adolescence are the most common users of SCs; neuro-psychiatric and cardiovascular side effects were the most experienced by subjects. Violence in many forms, especially domestic violence, was associated with synthetic cannabinoids abuse.

Trial registration

Registered in clinical trial under name syntheticcannabinoidsAssiut and ID NCT03866941 and URL.

Novel Psychoactive Substances: The Razor's Edge between Therapeutical Potential and Psychoactive Recreational Misuse

BACKGROUND

Novel psychoactive substances (NPS) are compounds of natural and synthetic origin, similar to traditional drugs of abuse. NPS are involved in a contemporary trend whose origin lies in a thinner balance between legitimate therapeutic drug research and legislative control. The contemporary NPS trend resulted from the replacement of MDMA by synthetic cathinones in 'ecstasy' during the 2000s. The most common NPS are synthetic cannabinoids and synthetic cathinones. Interestingly, during the last 50 years, these two classes of NPS have been the object of scientific research for a set of health conditions.

METHODS

Searches were conducted in the online database PubMed using boolean equations.

RESULTS

Synthetic cannabinoids displayed protective and therapeutic effects for inflammatory, neurodegenerative and oncologic pathologies, activating the immune system and reducing inflammation. Synthetic cathinones act similarly to amphetamine-type stimulants and can be used for depression and chronic fatigue.

CONCLUSIONS

Despite the scientific advances in this field of research, pharmacological application of NPS is being jeopardized by fatalities associated with their recreational use. This review addresses the scientific achievements of these two classes of NPS and the toxicological data, ending with a reflection on Illicit and NPS control frames.

Therapeutic Potential of Cannabinoids on Tumor Microenvironment: A Molecular Switch in Neoplasia Transformation

The efficacy of chemotherapy depends on the tumor microenvironment. This microenvironment consists of a complex cellular network that can exert both stimulatory and inhibitory effects on tumor genesis. Given the increasing interest in the effectiveness of cannabis, cannabinoids have gained much attention as a potential chemotherapy drug. Cannabinoids are a group of marker compounds found in Cannabis sativa L., more commonly known as marijuana, a psychoactive drug used since ancient times for pain management. Although the anticancer potential of C. sativa, has been recognized previously, increased attention was generated after discovering the endocannabinoid system and the successful production of cannabinoid receptors. In vitro and in vivo studies on various tumor models have shown therapeutic efficiency by modifying the tumor microenvironment. However, despite extensive attention regarding potential therapeutic implications of cannabinoids, considerable clinical and preclinical analysis is needed to adequately define the physiological, pharmacological, and medicinal aspects of this range of compounds in various disorders covered in this review. This review summarizes the key literature surrounding the role of cannabinoids in the tumor microenvironment and their future promise in cancer treatment.

A Comparison of Acute Neurocognitive and Psychotomimetic Effects of a Synthetic Cannabinoid and Natural Cannabis at Psychotropic Dose Equivalence

Due to differences in potency, efficacy, and affinity for CB1 receptors, similarities and differences in psychoactive effect profiles of natural cannabis and synthetic cannabinoids (SCs) cannot reliably be derived from equipotent dose comparisons. Instead, the current study proposes to compare the intrinsic psychoactive effects of natural cannabis (THC) and an SC, JWH-018, at psychotropic dose equivalence. Participants from two placebo-controlled studies were matched for their levels of subjective high to compare neurocognitive and psychotomimetic effects of THC and JWH-018. At equal subjective intoxication levels, both drugs impaired psychomotor, divided attention, and impulse control, with no significant difference between the two drugs. Both drugs also caused significant psychotomimetic effects, but dissociative effects were considerably more pronounced for JWH-018 than THC. We conclude that psychotropic dose equivalence provides a uniform approach for comparing the neurocognitive and psychotomimetic profiles of CB1 agonists, which can also be applied to other drug classes.

Clinical withdrawal symptom profile of synthetic cannabinoid receptor agonists and comparison of effects with high potency cannabis

Synthetic cannabinoid receptor agonists (SCRAs) may be used as an alternative to natural cannabis; however, they may carry a greater risk of problematic use and withdrawal. This study aimed to characterise the withdrawal symptom profile of SCRAs and compare their profile of effect with high-potency herbal cannabis. Global Drug Survey data (2015 and 2016) were used to access a clinically relevant sample of people reporting use of SCRAs >10 times in the past 12-months, a previous SCRA quit attempt, and lifetime use of high-potency herbal cannabis. Participants completed an 11-item SCRA withdrawal symptom checklist and compared SCRAs and high-potency herbal cannabis on their onset and duration of effects, speed of the development of tolerance, severity of withdrawal, and difficulty with dose titration. Participants (n = 284) reported experiencing a mean of 4.4 (95% CI: 4.1, 4.8) withdrawal symptoms after not using SCRAs for >1 day; most frequently reported were sleep issues (59.2%), irritability (55.6%), and low mood (54.2%). Withdrawal symptoms were significantly associated with frequency (>51 vs. 11-50 times per year: IRR = 1.43, 95% CI: 1.16, 1.77, p = 0.005) and quantity (grams per session: IRR = 1.13, 95% CI: 1.05, 1.22, p = 0.001) of SCRA use. Compared to high-potency herbal cannabis, SCRAs were rated as having a faster onset and shorter duration of effects, faster development of tolerance, and more severe withdrawal (p's < 0.001). In conclusion, SCRA withdrawal symptoms are more likely to occur after greater SCRA exposure. The effects of SCRA indicate a more severe withdrawal syndrome and a greater risk of problematic use than natural cannabis.

Analytical findings in a non-fatal intoxication with the synthetic cannabinoid 5F-ADB (5F-MDMB-PINACA): a case report

The case report centres on analytical findings from a spice sample (mixed with tobacco (as a cigarette) for consumption), and its corresponding plasma sample, smoked by a 31-year-old man who was attended by emergency services following collapse. The man was fully conscious and cooperative during initial medical treatment. Suddenly, he suffered a complete loss of self-control, whereupon the police was notified. The man encountered the police officers when exiting the apartment, at which point he threatened them with clenched fists and reached for a plant bucket in order to strike out in the direction of the officers. At the trial, he described himself as confused and as being completely overwhelmed, having lost self-control, suffered a panic attack and “just wanted to get out the situation”. Furthermore, he stated that he had no recollection of the incident. He feared death due to palpitations, heart pain, dizziness and repetitive anxiety states. Routine systematic as well as extended toxicological analysis of the plasma sample, taken approximately 2 h after the incident, confirmed the use of cannabis and spice. Plasma concentrations of THC, OH-THC and THC-COOH were 8.0 μg/L, 4.0 μg/L and 147 μg/L, respectively. Furthermore, analysis confirmed uptake of 5F-ADB (5F-MDMB-PINACA) via detection of both 5F-ADB and the 5F-ADB N-(5-OH-pentyl) metabolite. The spice sample additionally contained 5F-MDMB-PICA, which was not detected in the plasma sample. A differentiation between a possible co-use and a recent use of cannabis was not possible. In summary, this case once more underlines the health risks of spice use.

Mechanisms of cannabis impairment: Implications for modeling driving performance

Past research on cannabis has been limited in scope to THC potencies lower than legally available and efforts to integrate the effects into models of driving performance have not been attempted to date. The purpose of this systematic review is to understand the implications for modeling driving performance and describe future research needs. The risk of motor vehicle crashes increases 2-fold after smoking marijuana. Driving during acute cannabis intoxication impairs concentration, reaction time, along with a variety of other necessary driving-related skills. Changes to legislation in North America and abroad have led to an increase in cannabis' popularity. This has given rise to more potent strains, with higher THC concentrations than ever before. There is also rising usage of novel ingestion methods other than smoking, such as oral cannabis products (e.g., brownies, infused drinks, candies), vaping, and topicals. The PRISMA guidelines were followed to perform a systematic search of the PubMed database for peer-reviewed literature. Search terms were combined with keywords for driving performance: driving, performance, impairment. Grey literature was also reviewed, including congressional reports, committee reports, and roadside surveys. There is a large discrepancy between the types of cannabis products sold and what is researched. Almost all studies that used inhalation as the mode of ingestion with cannabis that is around 6% THC. This pales in comparison to the more potent strains being sold today which can exceed 20%. Which is to say nothing of extracts, which can contain 60% or more THC. Experimental protocol is another gap in research that needs to be filled. Methodologies that involve naturalistic (real world) driving environments, smoked rather than vaporized cannabis, and non-lab certified products introduce uncontrollable variables. When considering the available literature and the implications of modeling the impacts of cannabis on driving performance, two critical areas emerge that require additional research: The first is the role of cannabis potency. Second is the route of administration. Does the lower peak THC level result in smaller impacts on performance? How long does potential impairment last along the longer time-course associated with different pharmacokinetic profiles. It is critical for modeling efforts to understand the answers to these questions, accurately model the effects on driver performance, and by extension understand the risk to the public.

'Synthetic cannabis': A dangerous misnomer

The term 'synthetic cannabis' has been widely used in public discourse to refer to a group of cannabinoid receptor agonists. In this paper we detail the characteristics of these drugs, and present the case that the term is a misnomer. We describe the pharmacodynamics of these drugs, their epidemiology, mechanisms of action, physiological effects and how these differ substantially from delta-9-tetrahydrocannabinol (THC). We argue that not only is the term a misnomer, but it is one with negative clinical and public health implications. Rather, the substances referred to as 'synthetic cannabis' in public discourse should instead be referred to consistently as synthetic cannabinoid receptor agonists (SCRAs), a drug class distinct from plant-derived cannabinoids. SCRAs have greater potency and efficacy, and psychostimulant-like properties. While such terminology may be used in the scientific community, it is not widely used amongst the media, general public, people who use these drugs or may potentially do so. A new terminology has the potential to reduce the confusion and harms that result from the misnomer 'synthetic cannabis'. The constant evolution of this distinct drug class necessitates a range of distinct policy responses relating to terminology, harm reduction, epidemiology, treatment, and legal status.

The use and effects of synthetic cannabinoid receptor agonists by New South Wales cannabis treatment clients

Introduction

Despite decreasing consumption by general populations, use of synthetic cannabinoid receptor agonists (SCRAs) persists in some marginalised groups, including those who use other substances. This article explores SCRA consumption in an Australian cannabis treatment sample, comparing those who report ever using SCRAs with those who have never used SCRAs.

Methods

A questionnaire orally administered in person to a convenience sample of 154 cannabis treatment service clients from New South Wales, Australia (71% male, median age 35) collected information regarding cannabis and SCRA use including motivations, effects and health-related consequences of use, demographics, other substance use and overall health. Demographic profiles and between-group differences were explored. McNemar tests compared effects of SCRA and cannabis. Logistic regression analysis determined predictors of SCRA use.

Results

Half (53%) reported lifetime SCRA use; 20% reported previous-month use. The SCRA + cannabis group displayed greater polysubstance use and psychological distress. Reduced dependence on cannabis but higher levels of other substance use may predict SCRA use. Although curiosity motivated initial SCRA consumption, perceived psychoactive strength drove continued use. SCRAs appear to induce more negative side-effects than cannabis. Of the SCRA + cannabis group, 27% sought medical assistance for SCRA use. Most (90%) preferred cannabis to SCRAs, citing superior safety, effects and consistency of cannabis.

Conclusions

Among clients seeking treatment for cannabis use, SCRA use was relatively common, although not a preferred substance. Hazardous substance use and poor mental health characterised SCRA consumers, highlighting the need for continued monitoring by researchers and treatment providers of SCRA consumption in populations who use substances.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42238-021-00091-z.

Drug-related medical hospital admissions during and after a period of head shop expansion

BACKGROUND

New psychoactive substance (NPS) use can negatively impact health and may result in drug-related hospital admissions (DRHAs). Irish youth reported very high rates of NPS use by international standards, the most common being synthetic cannabinoids and cathinones. There was a rapid expansion in specialist 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 would prove futile. We sought to determine if changes in head shop activity coincided with changes in DRHA.

METHODS

The national database on admissions to general hospitals hospital in-patient enquiry was examined focusing on young adults admitted from 2008 to 2012, and all emergency admissions with an International Classification of Diseases-10 diagnosis of mental disorder related to any drug (F11-F19) were identified. Joinpoint regression analysis was utilized to explore for the presence of trend changes in DRHA.

RESULTS

Joinpoint regression analysis identified a significant downward trend change which occurred in June 2010 (95% CI February 2010 to January 2011). DRHA increased by 0.5% (95% CI 0.1-0.9) per month prior to this and then fell by 2.6% (95% CI -1.4 to -3.8) per month over the next 16 months.

CONCLUSIONS

Cessation of NPS sale by head shops coincided with a reversal in the upward trend of emergency hospital admissions related to drugs. Although correlation does not confirm causation, legislation which successfully curtails the commercial sale of NPS may result in reduced hospitalizations.

Systematic evaluation of a panel of 30 synthetic cannabinoid receptor agonists structurally related to MMB-4en-PICA, MDMB-4en-PINACA, ADB-4en-PINACA, and MMB-4CN-BUTINACA using a combination of binding and different CB1 receptor activation assays. Part III: The G protein pathway and critical comparison of different assays

The present work is the last of a three-part study investigating a panel of 30 systematically designed synthetic cannabinoid receptor agonists (SCRAs) including features such as the 4-pentenyl tail and varying head groups including amides and esters of l-valine (MMB, AB), l-tert-leucine (ADB), and l-phenylalanine (APP), as well as adamantyl (A) and cumyl moieties (CUMYL). Here, we evaluated these SCRAs for their capacity to activate the human cannabinoid receptor 1 (CB₁ ) via indirect measurement of G protein recruitment. Furthermore, we comparatively evaluated the results obtained from three in vitro assays, based on the recruitment of β-arrestin 2 (βarr2 assay) or Gα_i protein (mini-Gα_i assay), or binding of [³⁵ S]-GTPγS. The observed efficacies (E_max ) varied depending on the conducted assay. Statistical analysis suggests that the population means of the relative intrinsic activity (RA_i ) significantly differ for the [³⁵ S]-GTPγS assay and the other two assays, but the population means of the βarr2 and mini-Gα_i assays were not statistically different. Our data suggest that differences observed between the βarr2 and mini-Gα_i assays are the best predictor for 'biased agonism' towards βarr or G protein recruitment in our study. SCRAs carrying an ADB or MPP moiety as a head group tended to produce elevated E_max values in the βarr2 assay, which might result in a tendency of these compounds to cause pronounced tolerance in users-a hypothesis that should be evaluated further by future studies. In general, a comparison of efficacies derived from different assays is difficult and should only be conducted very cautiously.

The emergency department care of the cannabis and synthetic cannabinoid patient: a narrative review

BACKGROUND

Cannabis is the most prevalent illegal drug used and the second most common cause of ED drug-related complaints in the USA. Recently, newer more potent strains, concentrated THC products, and consumption methods have become available.

OBJECTIVE

Our first objective was to define cannabis use in the USA and provide a summary background on its current preparations, pharmacokinetics, vital sign and physical exam findings, adverse effects, and laboratory testing. Our second objective, using the aforementioned summary as relevant background information, was to present and summarize the care and treatment of the most commonly reported cannabis-related topics relevant to ED physicians.

METHODS

We first performed an extensive literature search of peer-reviewed publications using New PubMed and Cochrane Central Register of Controlled Trials to identify the most commonly reported cannabis-related topics in emergency care. Once the six topic areas were identified, we undertook an extensive narrative literature review for each section of this paper using New PubMed and Cochrane Central Register of Controlled Trials from the inception of the databases to September 30, 2020.

RESULTS

The six subject areas that were most frequently reported in the medical literature relevant to cannabis-related ED care were acute intoxication/overdose, pediatric exposure, cannabinoid hyperemesis syndrome, cannabis withdrawal, e-cigarette or vaping product use-associated lung injury (EVALI), and synthetic cannabinoids.

CONCLUSION

As cannabis becomes more widely available with the adoption of state medical cannabis laws, ED-related cannabis visits will likely rise. While cannabis has historically been considered a relatively safe drug, increased legal and illegal access to newer formulations of higher potency products and consumption methods have altered the management and approach to ED patient care and forced physicians to become more vigilant about recognizing and treating some new cannabis-related life-threatening conditions.

Synthetic drugs of abuse

Synthetic drugs of abuse contain various psychoactive substances. These substances have recently emerged as novel drugs of abuse in public; thus, they are known as novel psychoactive substances (NPS). As these compounds are artificially synthesized in a laboratory, they are also called designer drugs. Synthetic cannabinoids and synthetic cathinones are the two primary classes of NPS or designer drugs. Synthetic cannabinoids, also known as "K2" or "Spice," are potent agonists of the cannabinoid receptors. Synthetic cathinones, known as "Bath salts," are beta-keto amphetamine derivatives. These compounds can cause severe intoxication, including overdose deaths. NPS are accessible locally and online. NPS are scheduled in the US and other countries, but the underground chemists keep modifying the chemical structure of these compounds to avoid legal regulation; thus, these compounds have been evolving rapidly. These drugs are not detectable by traditional drug screening, and thus, these substances are mainly abused by young individuals and others who wish to avoid drug detection. These compounds are analyzed primarily by mass spectrometry.

Comparison of the Neurotoxic and Seizure-Inducing Effects of Synthetic and Endogenous Cannabinoids with Δ9-Tetrahydrocannabinol

Introduction: Synthetic cannabinoids (SCs) are commonly found in preparations used as recreational drugs. Although severe adverse health effects are not generally associated with cannabis use, a rising number of studies document seizures and even death after SC use. In this study, a mouse model is used to investigate the hypothesis that SCs are more toxic than Δ⁹-tetrahydrocannabinol (THC), the principal psychoactive constituent of cannabis.

Materials and Methods: Beginning with the SCs, JWH-073 and AM-2201, dose–response curves were generated to find the dose of each drug that was similarly efficacious to 50 mg/kg THC. Mice were given daily intraperitoneal (IP) injections of vehicle, 50 mg/kg THC, 30 mg/kg JWH-073, or 1 mg/kg AM-2201 until tolerance to the antinociceptive and hypothermic effects was complete, and then were assessed for spontaneous and antagonist-precipitated withdrawal and potential organ damage. No differences in tolerance were noted, but AM-2201 showed more rearing in the spontaneous and antagonist-precipitated withdrawal phases than either vehicle or the other two drug treatments. Histopathological examination of these mice revealed no drug-induced lesions. In a subsequent set of experiments, various doses of THC, methanandamide (mAEA), and of a variety of SCs (HU-210, CP55940, JWH-073, AM-2201, and PB-22) were given IP, and convulsions and change in body temperature were quantified.

Discussion: The treatments yielded varying numbers of convulsions and a range of changes in body temperature. JWH-073 and AM-2201 produced significantly more convulsions than THC, HU-210, mAEA, or cannabidiol (CBD) (the latter two producing none). HU-210, CP55940, JWH-073, and mAEA produced greater hypothermia than THC or CBD. Convulsions and hypothermia induced by several agonists were prevented by pretreatment with a CB₁ antagonist, but not a CB₂ antagonist.

Conclusions: In agreement with human studies and case reports, this study found that SCs generally produced more seizures than THC. Of particular significance was the finding that mAEA produced far greater hypothermia than THC (similar to most SCs), but unlike the SCs and THC, produced no seizures.

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.

New psychoactive substances: a review and updates

New psychoactive substances (NPS) are a heterogeneous group of substances. They are associated with a number of health and social harms on an individual and societal level. NPS toxicity and dependence syndromes are recognised in primary care, emergency departments, psychiatric inpatient and community care settings. One pragmatic classification system is to divide NPS into one of four groups: synthetic stimulants, synthetic cannabinoids, synthetic hallucinogens and synthetic depressants (which include synthetic opioids and benzodiazepines). We review these four classes of NPS, including their chemical structures, mechanism of action, modes of use, intended intoxicant effects, and their associated physical and mental health harms. The current challenges faced by laboratory testing for NPS are also explored, in the context of the diverse range of NPS currently available, rate of production and emergence of new substances, the different formulations, and methods of acquisition and distribution.

Cannabinoid1 (CB-1) receptor antagonists: a molecular approach to treating acute cannabinoid overdose

The legalization of cannabis for both recreational and medical use in the USA has resulted in a dramatic increase in the number of emergency department visits and hospital admissions for acute cannabinoid overdose (also referred to as cannabis intoxication and cannabis poisoning). Both “edibles” (often sold as brownies, cookies, and candies) containing large amounts of Δ⁹-tetrahydrocannabinol and synthetic cannabinoids (many possessing higher potencies and efficacies than Δ⁹-tetrahydrocannabinol) are responsible for a disproportionate number of emergency department visits relative to smoked cannabis. Symptoms of acute cannabinoid overdose range from extreme lethargy, ataxia, and generalized psychomotor impairment to feelings of panic and anxiety, agitation, hallucinations, and psychosis. Treatment of acute cannabinoid overdose is currently supportive and symptom driven. Converging lines of evidence indicating many of the symptoms which can precipitate an emergency department visit are mediated through activation of cannabinoid₁ receptors. Here, we review the evidence that cannabinoid₁ receptor antagonists, originally developed for indications ranging from obesity to smoking cessation and schizophrenia, provide a molecular approach to treating acute cannabinoid overdose.

DARK Classics in Chemical Neuroscience: Synthetic Cannabinoids (Spice/K2)

This Review covers the background, pharmacology, adverse effects, synthesis, pharmacokinetics, metabolism, and history of synthetic cannabinoid compounds. Synthetic cannabinoids are a class of novel psychoactive substances that act as agonists at cannabinoid receptors. This class of compounds is structurally diverse and rapidly changing, with multiple generations of molecules having been developed in the past decade. The structural diversity of synthetic cannabinoids is supported by the breadth of chemical space available for exploitation by clandestine chemists and incentivized by attempts to remain ahead of legal pressures. As a class, synthetic cannabinoid products have a more serious adverse effect profile than that of traditional phytocannabinoids, including notable risks of lethality, as well as a history of dangerous adulteration. Most synthetic cannabinoids are rapidly metabolized to active species with prolonged residence times and peripheral tissue distribution, and analytical confirmation of use of these compounds remains challenging. Overall, the emergence of synthetic cannabinoids serves as a noteworthy example of the pressing public health challenges associated with the increasing development of easily synthesized, structurally flexible, highly potent, psychoactive drugs.

Do Toxic Synthetic Cannabinoid Receptor Agonists Have Signature in Vitro Activity Profiles? A Case Study of AMB-FUBINACA

Recreational consumption of synthetic cannabinoid receptor agonists (SCRAs) is a growing crisis in public health in many parts of the world. AMB-FUBINACA is a member of this class of drugs and is responsible for a large proportion of SCRA-related toxicity both in New Zealand and internationally. Strikingly, little is currently known about the mechanisms by which SCRAs exert toxic effects or whether their activity through the CB₁ cannabinoid receptor (the mediator of cannabinoid-related psychoactivity) is sufficient to explain clinical observations. The current study therefore set out to perform a basic molecular pharmacology characterization of AMB-FUBINACA (in comparison to traditional research cannabinoids CP55,940, WIN55,212-2, and Δ⁹-THC) in fundamental pathways of receptor activity, including cAMP inhibition, pERK activation, ability to drive CB₁ internalization, and ability to induce translocation of β-arrestins-1 and -2. Activity pathways were then compared by operational analysis to indicate whether AMB-FUBINACA may be a biased ligand. Results revealed that AMB-FUBINACA is highly efficacious and potent in all pathways assayed. However, surprisingly, bias analysis suggested that Δ⁹-THC, not AMB-FUBINACA, may be a biased ligand, with it being less active in both arrestin pathways than predicted by the activity of the other ligands tested. These data may help predict molecular characteristics of SCRAs. However, more research is required to determine whether these molecular effects manifest in toxicity at tissue/system level.

Sociodemographic and clinical characteristics of synthetic cannabinoid users in a large psychiatric emergency department in Turkey

Synthetic cannabinoid (SC) use is a global concern and is creating new challenges for treatment services. Although some studies have been reported, there is a need for further research regarding the sociodemographic and clinical characteristics of SC users so that general and psychiatric emergency departments can provide more effective treatments. We aimed to investigate the sociodemographic and clinical characteristics in a cohort of patients using SC who presented to the psychiatric emergency department of the University of Health Sciences, Istanbul Erenköy Training and Research Hospital for Psychiatry and Neurology (ERSHEAH) in Istanbul, Turkey. This cross-sectional and retrospective medical record review examined 340 SC users who presented to the emergency department of ERSHEAH in a 3-month period. The mean age of the SC users was 26.8 ± 7.5 years and 92.6% were men. Psychotic symptoms were present in 247 SC users (78.8%). Severe intoxication was diagnosed in 26 SC users (7.6%), although SC was detectable in the samples of only 6 patients (13.6%). Impaired consciousness (42.3%) was the most common reason for referral to the general hospital and increased liver enzyme levels (15.9%) were the most common indication in the laboratory findings. We observed that the SC users in our sample presenting as psychiatric emergencies were mostly young men experiencing psychotic symptoms. Determining the sociodemographic and clinical properties of SC users may provide an important contribution to fast recognition and more effective management of acute symptoms of SC users in emergency departments.

Motives for Classical and Novel Psychoactive Substances Use in Psychedelic Polydrug Users

Novel psychoactive substances (NPS) are compounds designed to mimic the effects of existing recreational drugs (classical psychoactive substances [CPS]), while eluding established legal frameworks. Little is known about their effects and potential harms, rendering the increasing number of NPS a challenge to policy makers and researchers alike. Quantitative studies on the motives underlying NPS use are limited, though understanding them is crucial for the design of effective harm prevention strategies. The present study therefore aimed to compare motivational patterns for NPS, CPS, and legal psychoactive substance (LPS) use. An online survey including questions about lifetime drug use, demographics, and motives for use was completed by 2,319 participants of which 1,967 consented and were 18 years or older. Data on lifetime use and endorsed motives are presented for 12 psychoactive substances classified into LPS (alcohol, nicotine), CPS (cannabis, MDMA/ecstasy, amphetamines, cocaine, psilocybin, LSD, ayahuasca), and NPS (synthetic cannabinoids, stimulant, and hallucinogenic) and compared between classes. Across substances, the most frequently endorsed motives were to feel euphoric (58.0%), enhance an activity (52.3%), and broaden consciousness (48.1%). Motives for use were found to differ by substance and gender, with coping-related reasons being more frequent among female participants compared to males who indicated to use for a broad range of reasons. Motivational patterns of CPS and NPS use were largely similar to their classical analogues, this was not the case for synthetic cannabinoids, which had as main endorsed motive getting intoxicated, indiscriminate of specific qualities. This information can feed into tailoring of educational campaigns and prevention strategies.

Evidence for public health on novel psychoactive substance use: a mixed-methods study

Background

Novel psychoactive substances (NPSs) contribute to the public health impact of substance misuse. This report provides research evidence addressing 11 research questions related to NPSs, covering types, patterns and settings of use; supply sources; and implications for policy and practice.

Methods

The study used a conceptually linked three-phase mixed-methods design with a shared conceptual framework based on multiple-context risk and protective factors. Phase 1 was a quantitative phase involving secondary data analysis of the longitudinal Belfast Youth Development Study (BYDS), a latent class analysis using the 2039 BYDS participants. Phase 2 was an extensive qualitative analysis via narrative interviews with participants, sampled from BYDS, drug/alcohol services and prisons, to explore NPS use trajectories. Phase 3 was the final quantitative phase; generalisability of the shared risk factor part of the model was tested using the manual three-step approach to examine risk factors associated with latent class membership. The quantitative and qualitative analyses were integrated, thus allowing emerging findings to be further explored.

Results

The data suggest that NPSs have a place within a range of polydrug use trajectories. Models showed no distinctive NPS class, with no clear evidence of differential risks for NPS use compared with the use of other substances. From the qualitative analysis, a taxonomy of groups was derived that explored how and where NPSs featured in a range of trajectories. This taxonomy was used to structure the analysis of factors linked to use within a risk and protective framework. Drivers for use were considered alongside knowledge, perceptions and experience of harms. Suggestions about how interventions could best respond to the various patterns of use – with special consideration of synthetic cannabinoids (SCs), including how they relate to the use of heroin and the potential for NPSs to operate as a ‘snare’ to more problem use – were also presented.

Limitations

The study was conducted during 2016/17; generalisability beyond this sample and time point is limited. The level of missing data for some of the BYDS analysis was a limitation, as was the fact that the BYDS data were collected in 2011, so in a different context from the data collected during the narrative interviews. The Psychoactive Substances Act 2016 (Great Britain. Psychoactive Substances Act 2016. London: The Stationery Office; 2016) came into force during qualitative fieldwork and, although not particularly influential in this study, may be influential in future work. It is acknowledged that many of the data related to SCs and mephedrone. Although drug use was measured by self-report, the strength of rapport within interviews, reflective diaries and methodological acceptability checks helped to mitigate self-report bias.

Conclusions

NPSs continue to present significant challenges for legislation and monitoring, researching and developing interventions. Understanding of usage patterns remains poor, with most information based on populations and settings where problems have already occurred. This research contributes to the evidence base by providing much needed further empirical data on the lived experiences of NPS users across a range of settings. In the light of these data, implications for policy and practice are discussed.

Future work

Future research must generate improved epidemiological data on the extent, patterns and motivations for use longitudinally. The uniqueness of the information concerning SC use points to a specific set of findings not evidenced in other literature (e.g. intensity of SC withdrawal). Future research should focus on the symbiotic link between SC and heroin use.

Funding

The National Institute for Health Research Public Health Research programme.

Neuropsychiatric Sequelae in Adolescents With Acute Synthetic Cannabinoid Toxicity

BACKGROUND AND OBJECTIVES

Adolescents represent the largest age group that presents to emergency departments (ED) for synthetic cannabinoid (SC) toxicity; however, the neurotoxic effects of acute SC exposures in this group are understudied. Our aim was to characterize the neuropsychiatric presentation of adolescents with SC-related exposure in the ED compared with those with traditional cannabis exposure.

METHODS

A multicenter registry of clinical information prospectively collected by medical toxicologists (Toxicology Investigators Consortium Case Registry) was reviewed for adolescents presenting to the ED after SC or cannabis exposure from 2010 through 2018. Associations were measured between drug exposures and neuropsychiatric symptoms and/or signs. Exposures were classified into 4 groups: SC-only exposure, SC-polydrug exposures, cannabis-only exposure, and cannabis-polydrug exposures.

RESULTS

Adolescents presenting to the ED with SC-only exposure (n = 107) had higher odds of coma and/or central nervous system depression (odds ratio [OR] 3.42; 95% confidence interval [CI] 1.51-7.75) and seizures (OR 3.89; 95% CI 1.39-10.94) than those with cannabis-only exposure (n = 86). SC-only drug exposure was associated with lower odds of agitation than cannabis-only exposure (OR 0.18; 95% CI 0.10-0.34). In contrast, the group with SC-polydrug exposures (n = 38) had higher odds of agitation (OR 3.11; 95% CI 1.56-7.44) and seizures (OR 4.8; 95% CI 1.80-12.74) than the cannabis-polydrug exposures group (n = 117).

CONCLUSIONS

In this multisite cohort of US adolescents assessed in the ED, SC exposure was associated with higher odds of neuropsychiatric morbidity than cannabis exposure providing a distinct neurospychiatric profile of acute SC toxicity in adolescents.

In vitro metabolic profiling of synthetic cannabinoids by pooled human liver microsomes, cytochrome P450 isoenzymes, and Cunninghamella elegans and their detection in urine samples

As synthetic cannabinoids are extensively metabolized, there is an urgent need for data on which metabolites can be used for successful urine screening. This study examines the in vitro metabolism of EG-018 and its 5F-analogue EG-2201 by means of comparing three different in vitro models: pooled human liver microsomes, cytochrome P450 isoenzymes, and a fungal approach utilizing the filamentous fungus Cunninghamella elegans LENDNER, which is known for its ability to mimic human biotransformation of xenobiotics. In addition, this study includes the screening of two authentic urine samples from individuals with proven EG-018 consumption, for the evaluation of in vitro-in vivo extrapolations made in the study. Incubation with pooled human liver microsomes yielded 15 metabolites of EG-018 belonging to six different metabolite subgroups, and 21 metabolites of EG-2201 belonging to seven different metabolite subgroups, respectively. Incubation with cytochrome P450 isoenzymes incubation yielded a further three EG-018 and five EG-2201 metabolites. With reference to their summed metabolite peak abundancies, the isoenzymes CYP2C9, CYP2C19, CYP2D6, CYP3A4, and CYP3A5 were shown to contribute most to the microsomal metabolism of EG-018 and EG-2201. CYP2B6 was shown to make the lowest contribution, by far. As the phase I metabolism of both synthetic cannabinoids was shown to be distributed over a substantial number of different cytochrome P450 isoenzymes, it was concluded that it is likely to not be significantly affected by co-consumption of other drugs. Although fungal incubation with Cunninghamella elegans yielded an additional three EG-018 and four EG-2201 metabolites not observed after microsomal incubation, metabolites generated by Cunninghamella elegans were in good correlation with those generated by microsomal incubations. The fungal model demonstrated its ability to be an independent in vitro model in synthetic cannabinoid metabolism research. The three tested in vitro models enable sufficient predictive in vitro-in vivo extrapolations, comparable to those obtained from hepatocyte incubation published in the literature. In addition, with regard to the screening of authentic urine samples and comparison with the literature, one monohydroxylated EG-018 metabolite and two monohydroxylated EG-2201 metabolites can be recommended as urinary targets, on the basis of the tested in vitro models. Graphical abstract.

What are the psychological effects of using synthetic cannabinoids? A systematic review

BACKGROUND

Synthetic cannabinoids are, typically, full agonists at the cannabinoid CB1 receptor, and therefore considerably more potent than natural cannabis and may have correspondingly more serious psychological effects. Despite government sanctions against their production they continue to be available in ever-increasing varieties over the Internet. The psychological consequences of synthetic cannabinoid use are relatively unknown.

AIM

The purpose of this study was to synthesise the available research on the psychological consequences of synthetic cannabinoid use.

METHOD

A literature search of three databases was conducted in February 2018, including the following keywords: Spice, synthetic cannabis, cognition, affect, behaviour, psychosis, depression and anxiety.

RESULTS

Seventeen studies involving a variety of participants were eligible for inclusion: one controlled administration study, seven cross-sectional studies, five Internet surveys and four qualitative studies. The controlled administration study showed that, compared to placebo, synthetic cannabinoids acutely affected some aspects of cognitive functioning and subjective psychological ratings. Non-controlled, cross-sectional studies generally showed that synthetic cannabinoid users had lower performance on cognitive tasks and showed elevated symptomatology (e.g. paranoia) compared to both natural cannabis and non-cannabis users. Methodological limitations were noted across different study designs. There is limited research on how doses, frequency or type of synthetic cannabinoid influence outcomes.

CONCLUSIONS

Acute synthetic cannabinoid use can result in a range of psychological outcomes and, when non-intoxicated, synthetic cannabinoid users appear to differ from natural cannabis and non-users on various affective and cognitive domains. As synthetic cannabinoid use is increasing in at-risk populations there is an urgent need for more and better research to inform users, professionals and policymakers.

Cluster randomised controlled trial of an online intervention to prevent ecstasy and new psychoactive substance use among adolescents: final results and implications for implementation

OBJECTIVES

To evaluate the effectiveness of the online Climate Schools: Ecstasy and Emerging Drugs module over 2 years, and examine the impact of intervention dose on outcomes.

DESIGN

Cluster randomised controlled trial.

SETTING

Secondary schools in Australia.

PARTICIPANTS

1126 students (aged 14.9 years) from 11 schools.

INTERVENTION

Five schools were randomly allocated to the four-lesson internet-based Climate Schools: Ecstasy and Emerging Drugs module. This universal intervention uses cartoon storylines to deliver harm-minimisation information about ecstasy and new psychoactive substances (NPS). It was delivered during health education classes over 4 weeks. Six schools were randomised to the control group (health education as usual). Participants were not blinded to intervention allocation.

OUTCOMES MEASURES

Students completed self-report surveys at baseline, post-test, 6, 12 and 24 months post-baseline. Intentions to use ecstasy and NPS (including synthetic cannabis and synthetic stimulants), knowledge about ecstasy and NPS and lifetime use of ecstasy and NPS were assessed. This paper reports the results at 24 months post-baseline.

ANALYSIS

Mixed effects regressions were conducted to analyse intervention effects from baseline to 24 months. Post hoc analyses using Inverse Probability of Treatment Weighting compared controls with students who: i) completed all four lessons ('full dose') and ii) partially completed the intervention (≤three lessons, 'incomplete dose').

RESULTS

Primary analyses found that controls were significantly more likely to intend on using synthetic cannabis compared with intervention group students (OR=3.56, p=0.01). Results from the weighted analyses indicated that controls reported significantly lower knowledge about ecstasy (p=0.001) and NPS (p=0.04) compared with the full-dose group. No significant differences were observed between the incomplete dose and control groups.

CONCLUSIONS

The online intervention was effective in modifying students' intentions to use synthetic cannabis up to 24 months; however, this study highlights the importance of delivering prevention programmes in full to maximise student outcomes.

TRIAL REGISTRATION NUMBER

ACTRN12613000708752.

Cannabinoids: from pot to lab

Cannabis is becoming increasingly present in our society. In recent years, the line between the natural (cannabis) and the synthetic (synthetic cannabinoids), the recreational (cannabis) and the medical (pharmaceutical cannabinoids and medical cannabis) has been crossed. In this paper we review some of the novel aspects of cannabis and cannabinoids in relation to their legal situation, changes in their composition and forms of cannabis use, the concept of medical cannabis, and synthetic cannabinoids as new psychoactive substances (NPS). We have also analyzed serious adverse reactions and intoxications associated with the use of synthetic cannabinoids, as well as the latest developments in the research of pharmaceutical cannabinoids.

Are cannabis-using and non-using patients different groups? Towards understanding the neurobiology of cannabis use in psychotic disorders

A substantial body of credible evidence has accumulated that suggest that cannabis use is an important potentially preventable risk factor for the development of psychotic illness and its worse prognosis following the onset of psychosis. Here we summarize the relevant evidence to argue that the time has come to investigate the neurobiological effects of cannabis in patients with psychotic disorders. In the first section we summarize evidence from longitudinal studies that controlled for a range of potential confounders of the association of cannabis use with increased risk of developing psychotic disorders, increased risk of hospitalization, frequent and longer hospital stays, and failure of treatment with medications for psychosis in those with established illness. Although some evidence has emerged that cannabis-using and non-using patients with psychotic disorders may have distinct patterns of neurocognitive and neurodevelopmental impairments, the biological underpinnings of the effects of cannabis remain to be fully elucidated. In the second and third sections we undertake a systematic review of 70 studies, including over 3000 patients with psychotic disorders or at increased risk of psychotic disorder, in order to delineate potential neurobiological and neurochemical mechanisms that may underlie the effects of cannabis in psychotic disorders and suggest avenues for future research.

New and Emerging Illicit Psychoactive Substances

Several novel psychoactive substances have emerged in recent years. Users are typically young men who use other substances. In the category of stimulants, cathinones ("bath salts") have predominated and can lead to agitation, psychosis, hyperthermia, and death. Synthetic cannabinoids ("spice") are more potent than marijuana and can lead to agitation, psychosis, seizures, and death. There are no rapid tests to identify these substances and general treatment includes benzodiazepines for agitation and supportive therapy. Many Synthetic opioids are potent analogues of fentanyl and carry a high risk of overdose. In addition, there are several designer benzodiazepines that have emerged.

Are ecstasy induced serotonergic alterations overestimated for the majority of users?

BACKGROUND

Neuroimaging studies imply that the regular use of ±3,4-methylenedioxymethamphetamine (MDMA), the major constituent of ecstasy pills, alters the brain's serotonergic system in a dose-dependent manner. However, the relevance of these findings remains unclear due to limited knowledge about the ecstasy/MDMA use pattern of real-life users.

AIMS

We examined the representativeness of ecstasy users enrolled in neuroimaging studies by comparing their ecstasy use habits with the use patterns of a large, international sample.

METHODS

A systematic literature search revealed 10 imaging studies that compare serotonin transporter levels in recreational ecstasy users to matched controls. To characterize the ecstasy use patterns we relied on the Global Drug Survey, the world's largest self-report database on drug use. The basis of the dose comparison were the Usual Amount (pills/session), Use Frequency (sessions/month) and Dose Intensity (pills/year) variables.

RESULTS

Both the average Usual Amount (pills/session) and Use Frequency (sessions/month) of neuroimaging study participants corresponded to the top 5-10% of the Global Drug Survey sample and imaging participants, on average, consumed 720% more pills over a year than the Global Drug Survey participants.

CONCLUSIONS

Our findings suggest that the serotonin brain imaging literature has focused on unusually heavy ecstasy use and therefore the conclusions from these studies are likely to overestimate the extent of serotonergic alterations experienced by the majority of people who use ecstays.

Synthetic and Non-synthetic Cannabinoid Drugs and Their Adverse Effects-A Review From Public Health Prospective

There is a growing use of novel psychoactive substances containing synthetic cannabinoids. Synthetic cannabinoid products have effects similar to those of natural cannabis, yet, these drugs are more potent and dangerous, and have been associated with dangerous adverse effects. Here, we review current literature on the epidemiology, acute, and chronic effects of synthetic and natural cannabinoid-based drugs. Synthetic drugs contain a mixture of psychoactive compounds that mostly bind cannabinoid receptors with high potency. These synthetic drugs replicate the effects of natural cannabis and Δ9-tetrahydrocannabinol but they induce more severe adverse effects including respiratory difficulties, hypertension, tachycardia, chest pain, muscle twitches, acute renal failure, anxiety, agitation, psychosis, suicidal ideation, and cognitive impairment. Chronic use of synthetic cannabinoids has been associated with serious psychiatric and medical conditions and even death. Given the growing popularity in the use of cannabinoid-based drugs and their harmful potential, there is a need for further research in this field.

Polysubstance use and misuse or abuse of prescription opioid analgesics: a multi-level analysis of international data

Increasing mortality and morbidity associated with opioid analgesics has led to concerns about their misuse and abuse, even when obtained through a prescription. These concerns have been most pronounced in the United States, but limited data make it difficult to determine whether it is a problem in other countries. We investigated opioid analgesic misuse and abuse in participants from the Global Drug Survey 2015 resident in the United States (N = 1334), United Kingdom (N = 1199), France (N = 1258), Germany (N = 866), and Australia (N = 1013) who had used at least 1 prescription opioid analgesic medication in the past year. We also investigated the relationship with polysubstance use, one of the most consistent predictors of problematic opioid analgesic use. Data included misuse and abuse of codeine, hydrocodone, oxycodone, and tramadol; ability to obtain a prescription; different sources for obtaining drugs; and past-year use of benzodiazepines and illicit drugs. In multilevel models, country of residence accounted for less than 3% of the variance in opioid analgesic misuse or abuse. Adjusting for country of residence and sociodemographic factors, use of illicit drugs and benzodiazepines was associated with 4-fold greater odds of misuse (odds ratio 4.36, 95% confidence interval 3.29-5.93) and 6-fold greater odds of abuse compared with not using either drug (odds ratio 6.49, 95% confidence interval 4.0-10.48), although the strength of the association with abuse varied by country. Misuse and abuse by those prescribed opioid analgesics seem to be a problem that is not limited to the United States and warrant attention on an international scale.

Analysis of the pharmacological properties of JWH-122 isomers and THJ-2201, RCS-4 and AB-CHMINACA in HEK293T cells and hippocampal neurons

Synthetic cannabinoids are marketed as legal alternatives to Δ⁹-THC, and are a growing worldwide concern as these drugs are associated with severe adverse effects. Unfortunately, insufficient information regarding the physiological and pharmacological effects of emerging synthetic cannabinoids (ESCs) makes their regulation by government authorities difficult. One strategy used to evade regulation is to distribute isomers of regulated synthetic cannabinoids. This study characterized the pharmacological properties of a panel of ESCs in comparison to Δ⁹-THC, as well as six JWH-122 isomers relative to its parent compound (JWH-122-4). Two cell-based assays were used to determine the potency and efficacy of ESCs and a panel of reference cannabinoids. HEK293T cells were transfected with human cannabinoid receptor 1 (CB₁) and pGloSensor-22F, and the inhibition of forskolin-stimulated cyclic adenosine monophosphate (cAMP) levels was monitored in live cells. All ESCs examined were classified as agonists, with the following rank order of potency: Win 55,212-2 > CP 55,940 > JWH-122-4 > Δ⁹-THC ≈ RCS-4 ≈ THJ-2201 > JWH-122-5 > JWH-122-7 > JWH-122-2 ≈ AB-CHMINACA > JWH-122-8 > JWH-122-6 > JWH-122-3. Evaluation of ESC-stimulated Ca²⁺ transients in cultured rat primary hippocampal neurons confirmed the efficacy of four of the most potent ESCs (JWH-122-4, JWH-122-5, JWH-122-7 and AB-CHMINACA). This work helps regulatory agencies make informed decisions concerning these poorly characterized recreational drugs.

Patterns of Acute Toxicity Associated with New Psychoactive Substances

This chapter begins by considering why it is important to understand the clinical patterns of acute toxicity associated with new psychoactive substances (NPS), the challenges associated with gathering these data, the sources of information available and the limitations of each. It describes the data triangulation approach that can be used to combine individual, each inherently limited, data sources to help build the picture of the pattern of acute non-fatal toxicity associated with NPS. The chapter illustrates the data triangulation approach by the use of clinical examples and aims to consider mechanism of action data in conjunction with clinical features to provide an overarching understanding of the clinical presentation. Examples of the most important individual and groups of NPS were identified using multimodal literature searching based on the most relevant terms. The chapter provides descriptive accounts that are a complete reference source on the patterns of acute toxicity.

When good times go bad: managing 'legal high' complications in the emergency department

Patients can use numerous drugs that exist outside of existing regulatory statutes in order to get "legal highs." Legal psychoactive substances represent a challenge to the emergency medicine physician due to the sheer number of available agents, their multiple toxidromes and presentations, their escaping traditional methods of analysis, and the reluctance of patients to divulge their use of these agents. This paper endeavors to cover a wide variety of "legal highs," or uncontrolled psychoactive substances that may have abuse potential and may result in serious toxicity. These agents include not only some novel psychoactive substances aka "designer drugs," but also a wide variety of over-the-counter medications, herbal supplements, and even a household culinary spice. The care of patients in the emergency department who have used "legal high" substances is challenging. Patients may misunderstand the substance they have been exposed to, there are rarely any readily available laboratory confirmatory tests for these substances, and the exact substances being abused may change on a near-daily basis. This review will attempt to group legal agents into expected toxidromes and discuss associated common clinical manifestations and management. A focus on aggressive symptom-based supportive care as well as management of end-organ dysfunction is the mainstay of treatment for these patients in the emergency department.

Do emotions related to alcohol consumption differ by alcohol type? An international cross-sectional survey of emotions associated with alcohol consumption and influence on drink choice in different settings

OBJECTIVES

To examine the emotions associated with drinking different types of alcohol, explore whether these emotions differ by sociodemographics and alcohol dependency and whether the emotions associated with different drink types influence people's choice of drinks in different settings.

DESIGN

International cross-sectional opportunistic survey (Global Drug Survey) using an online anonymous questionnaire in 11 languages promoted through newspapers, magazines and social media from November 2015 to January 2016.

STUDY POPULATION

Individuals aged 18-34 years who reported consumption of beer, spirits, red and white wine in the previous 12 months and were resident in countries with more than 200 respondents (n=21 countries; 29 836 respondents).

MAIN OUTCOME MEASURES

Positive and negative emotions associated with consumption of different alcoholic beverages (energised, relaxed, sexy, confident, tired, aggressive, ill, restless and tearful) over the past 12 months in different settings.

RESULTS

Alcoholic beverages vary in the types of emotions individuals report they elicit, with spirits more frequently eliciting emotional changes of all types. Overall 29.8% of respondents reported feeling aggressive when drinking spirits, compared with only 7.1% when drinking red wine (p<0.001). Women more frequently reported feeling all emotions when drinking alcohol, apart from feelings of aggression. Respondents' level of alcohol dependency was strongly associated with feeling all emotions, with the likelihood of aggression being significantly higher in possible dependent versus low risk drinkers (adjusted OR 6.4; 95% CI 5.79 to 7.09; p<0.001). The odds of feeling the majority of positive and negative emotions also remained highest among dependent drinkers irrespective of setting.

CONCLUSION

Understanding emotions associated with alcohol consumption is imperative to addressing alcohol misuse, providing insight into what emotions influence drink choice between different groups in the population. The differences identified between sociodemographic groups and influences on drink choice within different settings will aid future public health practice to further comprehend individuals' drinking patterns and influence behaviour change.

Synthetic Cannabinoid Use Among High School Seniors

OBJECTIVES

In this study, we examined the prevalence and correlates of current synthetic cannabinoid (SC) use among high school seniors in the United States.

METHODS

Monitoring the Future, an annual nationally representative survey of high school seniors, began querying current (30-day) SC use in 2014. Data were examined from the 2 most recent cohorts (2014-2015; N = 7805). Prevalence of self-reported use was examined and differences in demographics and recency and frequency of other drug use was compared between current marijuana-only users and current SC (plus marijuana) users using χ² and generalized linear model using Poisson.

RESULTS

We found that 2.9% of students reported current SC use; 1.4% of students (49.7% of users) reported using SCs on ≥3 days in the past month. SC users were more likely to report more recent (and often more frequent) use of lysergic acid diethylamide, cocaine, heroin, and/or nonmedical use of opioids compared with marijuana-only users. Compared with current marijuana-only users, SC users were more likely to report lower parent education (P < .05) and current use of a higher number of illegal drugs other than marijuana (Ps < .001). Students using SCs ≥10 times in the past month were more likely to be boys, frequent marijuana users (Ps < .01), African American, and users of multiple other illegal drugs (Ps < .001).

CONCLUSIONS

SC use is typically part of a repertoire of polydrug use, and polydrug use is less prevalent among marijuana-only users. Current SC users are at risk for poisoning from use of the newest generation of SCs and from concurrent drug use.

User characteristics and effect profile of Butane Hash Oil: An extremely high-potency cannabis concentrate

BACKGROUND

Recent reports suggest an increase in use of extremely potent cannabis concentrates such as Butane Hash Oil (BHO) in some developed countries. The aims of this study were to examine the characteristics of BHO users and the effect profiles of BHO.

DESIGN

Anonymous online survey in over 20 countries in 2014 and 2015. Participants aged 18 years or older were recruited through onward promotion and online social networks. The overall sample size was 181,870. In this sample, 46% (N=83,867) reported using some form of cannabis in the past year, and 3% reported BHO use (n=5922).

MEASUREMENTS

Participants reported their use of 7 types of cannabis in the past 12 months, the source of their cannabis, reasons for use, use of other illegal substances, and lifetime diagnosis for depression, anxiety and psychosis. Participants were asked to rate subjective effects of BHO and high potency herbal cannabis.

FINDINGS

Participants who reported a lifetime diagnosis of depression (OR=1.15, p=0.003), anxiety (OR=1.72, p<0.001), and a larger number of substance use (OR=1.29, p<0.001) were more likely to use BHO than only using high potency herbal cannabis. BHO users also reported stronger negative effects and less positive effects when using BHO than high potency herbal cannabis (p<0.001) CONCLUSION: Mental health problems and other illicit drug use were associated with use of BHO. BHO was reported to have stronger negative and weaker positive effects than high potency herbal cannabis.