A scoping review of home-produced heroin and amphetamine-type stimulant substitutes: implications for prevention, treatment, and policy

Behavioral patterns of people who use synthetic psychostimulants: Results of a qualitative study in St. Petersburg, Russia

BACKGROUND

Russia, like many other places, is currently experiencing a proliferation of new psychoactive substances, many of which are psychostimulants. In St. Petersburg, these appear to be mostly congeners of cathinone. We sought to obtain qualitative data to better understand the impact on the health and behaviors of people who use drugs (PWUD) by recruiting individuals who reported recent use of psychostimulants.

METHODS

In-depth qualitative data on current drug use and its effects were collected through thirty interviews (n=30) and two focus groups (n=10: five male, five female). The interviews and focus groups also provided data on the social contexts of drug use including sexual behaviors and associated medical issues. Secondary data about online drug purchases were obtained from a source that accesses and analyzes darknet purchases. Qualitative data were initially coded using a priori codes developed on the basis of the interview guide, and then data were coded again inductively based on emergent findings from the data. Thematic analysis was carried out using OpenCode 4.0 qualitative data analysis software.

RESULTS

Thematic analysis of the interviews and focus groups identified distinct differences in behavior patterns between older, more experienced PWUD and a "new generation" of PWUD. Routes of initiation of drug use and sexual behaviors associated with drug use differed, but both groups reported high levels of unsafe injection and sexual behaviors. In interpreting the texts and purchasing data, we have attempted to anticipate how the drug use patterns can influence HIV transmission.

CONCLUSIONS

The emergence of a new class of psychostimulant drugs presents new threats to the health of drug users and new opportunities to intervene to reduce those risks. The information obtained may assist HIV/AIDS prevention specialists and drug user support groups in their efforts to decrease unsafe drug use and sexual behaviors.

Toxic desomorphine encephalopathy due to the use of “Krokodil”: clinical and neuroimaging features

Background: Toxic desomorphine encephalopathy (TDE) is a pathological condition that develops as a result of the intravenous use of a drug called Krokodil containing desomorphine, made in the artisanal conditions using codeine-containing drugs, organic solvents (gasoline), iodine and red phosphorus. This disease is more often observed in the CIS countries. In addition to the acute and chronic pathological conditions with the damage to various organs, the use of Krokodil is characterized by pronounced extrapyramidal manifestations in the form of dystonia, parkinsonism, postural disorders, as well as the occurrence of cognitive and affective disorders. Aims: To find the clinical and neuroimaging features of toxic desomorphine encephalopathy, as well as possible methods of its treatment. Methods: A clinical analysis of the medical documentation of 21 TDE patients (11 women and 10 men) with a history of the use of Krokodil was carried out, the patients had been under observation from 2014 to 2021. All the patients underwent a clinical physical and neurological examination, 14 of them underwent neuroimaging (brain MRI and/or MSCT). The observation of these patients revealed a number of characteristic clinical and neuroimaging features inherent in the majority of drug addicts. Results: The clinical picture of patients with TDE was dominated by movement disorders. All the patients had pronounced postural disorders and gait disturbance. Parkinsonism was observed in 20 of 21 patients. The hyperkinetic syndrome was presented in 17 patients (80.9%) and was manifested by dystonia of various localization with polymorphic manifestations. The brain MRI data taken from the Krokodil users for 3 years were characterized by symmetrical focal changes in the basal ganglia, brainstem, cerebellum and internal capsule of the thalamus in the form of an increase in the intensity of the MR signal in the T1 mode and attenuation in the T2-weighted images mode (7 of 11 cases), with the subsequent regression of these characteristics based on the results of the subsequent MRI studies. Conclusion: The study results have revealed the clinical manifestations characteristic of TDE polymorphic extrapyramidal disorders, as well as neuroimaging changes reflecting these data.

Different phases of ATS use call for different interventions: a large qualitative study in Europe

BACKGROUND

Amphetamine-type stimulants (ATS) are globally widely used. Scientific literature generally defines four phases of substance use (initiation, continuation, increase and decrease); however, there is limited understanding of what influences these different phases of ATS use. The ATTUNE study investigated which factors shape individual phases of use, or ATS use patterns. In this article, we report on these phases into and out of ATS use, and propose a set of recommendations for prevention, harm reduction and treatment of the different phases of ATS use.

METHODS

Qualitative, semi-structured interviews (n = 237) were conducted in five different European countries with participants who had used ATS, varying from a few times in a lifetime to daily.

RESULTS

Amphetamine and MDMA were the most commonly used ATS. Yet, types of ATS used differed between the countries. We found that people who use ATS have various motives for and dynamic patterns of ATS use with alternating phases of increase, continuation, decrease and sometimes dependence. Cessation was pursued in different ways and for diverse reasons, such as mental health problems and maturing out. Availability seemed not an issue, regardless of the type of ATS, phase or country.

CONCLUSIONS

These findings demonstrate that tailor-made interventions are needed for the diverse types of people who use ATS and different phases or patterns of ATS use, to reduce possible harms of use. We recommended a set of interventions for the different ATS phases. These include drug checking services, peer-led information, self-management of ATS use, mental health support to help people cope with stressful life events and prevent uncontrolled use, and follow-up support after treatment.

Representations of Psychoactive Drugs' Use in Mass Culture and Their Impact on Audiences

Drug use has been increasing worldwide over recent decades. Apart from the determinants of drug initiation established in numerous studies, the authors wish to draw attention to other equally important factors, which may contribute to augmenting this phenomenon. The article aims to draw attention to the content of mass culture, especially representations of drug use in mass media, which may influence the liberalization of attitudes towards drugs and their use. The role of mass culture and its impact on the audience is discussed. It presents an overview of drug representations in the content of mass culture, e.g., in film, music, literature, and the occurrence of drug references in everyday products, e.g., food, clothes, and cosmetics. Attention was drawn to liberal attitudes of celebrities and their admissions to drug use, particularly to the impact of the presented positions on the attitudes of the audience, especially young people for whom musicians, actors, and celebrities are regarded as authorities. Indications for further preventive actions were also presented. Attention was drawn to the need to take appropriate action due to the time of the COVID-19 pandemic when many people staying at home (due to lockdown or quarantine) have the possibility of much more frequent contact with mass culture content, which may distort the image of drugs.

A randomized controlled trial of a brief behavioral intervention to reduce skin and soft tissue infections among people who inject drugs

BACKGROUND

People who inject drugs (PWID) are at high risk for skin and soft tissue infections (SSTIs), but few interventions have targeted their reduction. The goal of the current study was to test the effects of a brief skin and needle hygiene behavioral intervention (SKIN) in a two-group randomized controlled trial with 12-month follow-up.

METHOD

PWID (N = 252) were recruited from inpatient hospital units at a single urban medical center site and randomly assigned to an assessment-only (AO) condition or SKIN, which was a two-session intervention that included psychoeducation, behavioral skills demonstrations, and motivational interviewing. Mixed effects generalized linear models assessed the impact of the intervention on frequency of: 1) self-reported SSTIs, 2) uncleaned skin injections, and 3) injection.

RESULTS

Participants were 58.3 % male, 59.5 % White, and averaged 38 years of age. SKIN participants had 35 % fewer SSTIs compared to AO (p = .179), a difference of nearly one infection per year. The mean rate of uncleaned skin injections was about 66 % lower (IRR = 0.34, 95 % CI 0.20; 0.59, p < .001) among SKIN participants compared to AO. Almost one-third of participants reported no injection over follow-up and the mean rate of injection during follow-up was about 39 % lower (IRR = 0.61; 95 % CI 0.36; 1.02, p = .058) among persons randomized to SKIN than AO.

CONCLUSIONS

The SKIN intervention reduced uncleaned skin injections but did not reduce SSTIs significantly more than a control condition. Brief interventions can improve high-risk practices among PWID and lead to clinically meaningful outcomes.

DARK Classics in Chemical Neuroscience: Krokodil

Krokodil is the street name for a homemade mixture that has been used as a cheap substitute for heroin. The main active substance in krokodil is desomorphine, an opioid that is 10 times more potent than morphine. Krokodil use began in Russia and Ukraine but has spread throughout several countries in Europe and North America. Krokodil is produced from codeine tablets in a bootleg reaction performed under clandestine and unsanitary conditions. The toxicity of krokodil is characterized by devastating symptoms that start as black ulcers at the injection site and evolve to gangrene and limb amputation. The dangerous effects of krokodil are associated with its homemade nature and lack of purification prior to use. In this review, we discuss the chemical and pharmacological properties and the metabolism of desomorphine, the preparation of krokodil, and how its homemade nature contributes to its toxicity. The synthesis of krokodil produces several other morphinans in addition to desomorphine that warrant further study as possible analgesic alternatives to morphine.

DARK Classics in Chemical Neuroscience: Heroin and Desomorphine

Opioids are arguably one of the most important pharmacologic classes, mainly due to their rich history, their useful and potent analgesic effects, and also, just as importantly, their "Dark Side", constituted by their reinforcing properties that have led countless of users to a spiral of addiction, biological dependence, tolerance, withdrawal syndromes, and death. Among the most significant abused and addictive known opioids are heroin and desomorphine, both synthetic derivatives of morphine that belong to the 4,5-epoxymorphinan structural chemical group of the opioid family drugs. These agents share not only structural, pharmacological, and epidemiological features but also a common geographical distribution. A drop in Afghan heroin production and its "exports" to Russia gave rise to widespread consumption of desomorphine in ex-Soviet republics during the first decade of the 21st century, representing an economical and accessible alternative for misusers to this sort of derivative. Herein we review the state of the art of history, chemistry and synthesis, pharmacology, and impact on society of these "cursed cousins".

Anabolic-Androgenic Steroid Use in the Eastern Mediterranean Region: a Scoping Review of Extant Empirical Literature

The use of image- and performance-enhancing drugs particularly anabolic-androgenic steroids (AAS) is not a new phenomenon. AAS use is not limited to athletes, with mainstream populations using these drugs for aesthetic purposes. Prevalence has been predominantly in Western countries, with some recent studies indicating a rise in popularity in the Eastern Mediterranean region. A scoping review of extant empirical literature from the Eastern Mediterranean region described and mapped what is known about the extent of AAS in the region. Four themes emerged from the review: (1) profile of AAS users; (2) AAS within gymnasium practice; (3) AAS regimes of use; and (4) knowledge and understanding of the AAS concept and related adverse effects. The review highlights a relatively new phenomenon of AAS use in the Eastern Mediterranean. The review underscores the need to carry out further research, particularly qualitative and quantitative studies with both genders, and cognisant of the complexities of culture and religiosity.

HIV, Drug Injection, and Harm Reduction Trends in Eastern Europe and Central Asia: Implications for International and Domestic Policy

PURPOSE OF REVIEW

Scaling up evidence-based HIV prevention strategies like opioid agonist therapies (OAT), syringe services programs (SSPs), and antiretroviral therapy (ART) to mitigate the harms of drug injection is crucial within Eastern Europe and Central Asia (EECA), the only region globally where HIV incidence and mortality are increasing.

RECENT FINDINGS

Though the proportion of new HIV cases directly attributable to drug injection has recently declined, it remains a critical driver of HIV, especially to sexual partners. Concurrently, scale-up of OAT, SSPs, and ART has remained low, contributing to a volatile HIV epidemic among people who inject drugs (PWID). Despite evidence that drug injection contributes to an evolving HIV epidemic in EECA, coverage of evidence-based harm reduction programs remains substantially below needed targets. Due to a combination of punitive drug laws, ideological resistance to OAT among clinicians and policymakers, and inadequate domestic and international funding, limited progress has been observed in increasing the availability of these programs.

Options for reducing HIV transmission related to the dead space in needles and syringes

BACKGROUND

When shared by people who inject drugs, needles and syringes with different dead space may affect the probability of HIV and hepatitis C virus (HCV) transmission differently.

METHODS

We measured dead space in 56 needle and syringe combinations obtained from needle and syringe programs across 17 countries in Europe and Asia. We also calculated the amounts of blood and HIV that would remain in different combinations following injection and rinsing.

RESULTS

Syringe barrel capacities ranged from 0.5 to 20 mL. Needles ranged in length from 8 to 38 mm. The average dead space was 3 μL in low dead space syringes with permanently attached needles, 13 μL in high dead space syringes with low dead space needles, 45 μL in low dead space syringes with high dead space needles, and 99 μL in high dead space syringes with high dead space needles. Among low dead space designs, calculated volumes of blood and HIV viral burden were lowest for low dead space syringes with permanently attached needles and highest for low dead space syringes with high dead space needles.

CONCLUSION

The dead space in different low dead space needle and syringe combinations varied substantially. To reduce HIV transmission related to syringe sharing, needle and syringe programs need to combine this knowledge with the needs of their clients.

Health and Social Problems Associated with Recent Novel Psychoactive Substance (NPS) Use Amongst Marginalised, Nightlife and Online Users in Six European Countries

Continued diversification and use of new psychoactive substances (NPS) across Europe remains a public health challenge. The study describes health and social consequences of recent NPS use as reported in a survey of marginalised, nightlife and online NPS users in the Netherlands, Hungary, Portugal, Ireland, Germany and Poland (n = 3023). Some respondents were unable to categorise NPS they had used. Use of ‘herbal blends’ and ‘synthetic cannabinoids obtained pure’ was most reported in Germany, Poland and Hungary, and use of ‘branded stimulants’ and ‘stimulants/empathogens/nootropics obtained pure’ was most reported in the Netherlands. Increased heart rate and palpitation, dizziness, anxiety, horror trips and headaches were most commonly reported acute side effects. Marginalised users reported substantially more acute side effects, more mid- and long-term mental and physical problems, and more social problems. Development of country-specific NPS awareness raising initiatives, health and social service needs assessments, and targeted responses are warranted.

Online-to-offline models in HIV service delivery

PURPOSE OF REVIEW

Half the world's population has access to Internet and technologies, and utilization is near-ubiquitous among providers and key populations. Despite being so well connected; identifying, reaching and linking vulnerable populations to HIV clinical services remains a global challenge. This review highlights the emerging online-to-offline (O2O) models, their potential in scaling up services, and evaluating impact, and implications for future research.

RECENT FINDINGS

Globally, four major types of O2O models have been implemented, primarily in the West and Asia, especially among MSM and transgender women. These models have varying levels of impact in terms of reach, engagement, participation, linkage, and ability to track and monitor participants, and assess outcomes. Those integrated with offline sites enable seamless transition, dramatically reduce the O2O linkage time and demonstrate high linkage success (>73%). O2O models are ideal for at-risk, stigmatized, criminalized populations and for scaling-up biomedical prevention interventions such as preexposure and postexposure prophylaxis.

SUMMARY

O2O models represent novel and powerful solutions to reverse the pandemic and could help fill significant programmatic gaps in tracking individuals through HIV cascades. Providers, especially in resource-limited settings, could choose between a variety of current approaches highlighted in this review and employ no-cost or cost-effective technologies to transform their traditional models and leverage O2O models.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Desomorphine (Krokodil): An overview of its chemistry, pharmacology, metabolism, toxicology and analysis

BACKGROUND

"Krokodil" or "Crocodile" is an illegal homemade desomorphine drug obtained from chemical reactions of commercial codeine drugs with several other powerful and highly toxic chemical agents increasing its addiction and hallucinogenic effects when compared with other morphine analogues.

METHODS

This paper summarizes a complete review about an old drug called desomorphine (Krokodil), presenting its chemistry, pharmacology, metabolism, toxicology and analysis.

RESULTS

It is of particular interest and concern because this cheaper injectable semisynthetic opioid drug has been largely used in recent years for recreational purposes in several Eastern European as well as North and South American countries, despite known damage to health that continuous use might induce. These injuries are much stronger and more aggressive than morphine's, infecting and rotting skin and soft tissue to the bone of addicts at the point of injection in less than three years, which, in most cases, evolves to death. On this basis, it is imperative that literature reviews focus on the chemistry, pharmacology, toxicology and analysis of dangerous Krokodil to find strategies for rapid and effective determination to mitigate its adverse effects on addicts and prevent consumption.

CONCLUSIONS

It is crucial to know the symptoms and consequences of the use of Krokodil, as well as METHODS: for identification and quantification of desomorphine, contaminants and metabolites, which can help the forensic work of diagnosis and propose actions to control and eradicate this great danger to public health around the world.