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

Becoming a nitrous oxide user on social media: Learning to maximise pleasures and minimise harms

BACKGROUND

In his classic work 'Becoming a marihuana user', Howard Becker (1953) showed how drug use learning occurred in social interactions and settings, which in turn shape drug use. Today, social media offers people opportunities to learn about drugs without physical proximity. In this paper, we identify nitrous oxide (N₂O) users' key concerns about how to maximise pleasures and minimise harms, as expressed on the social media platform Reddit. In doing so, we consider what learning about N₂O online might mean for the provision of drug education in an era of internet technology.

METHOD

Data are drawn from a Reddit page (subreddit) dedicated to N₂O use. We undertook thematic analysis of 655 threads contributed in late-2020. The subreddit is conceptualised as an internet-mediated social world that constitutes drug user knowledges, practices and identities, rather than simply reflecting them.

RESULTS

Our analysis uncovers practices not previously been reported in academic literature or health information on N₂O, such as breathing techniques to maximise the effects and use of filters to reduce exposure to oil residue. While education resources often describe effects as 'mild', users recounted intense pleasures including euphoria, anaesthesia, sensory distortion, hallucination and epiphanies, especially when N₂O was used with other drugs. Subreddit members were deeply concerned to minimise the risk of harms. Yet official health advice regarding N₂O was not referenced, some misinterpretation of scientific literature was apparent and drug treatment was almost never suggested when people recounted harms.

CONCLUSION

In contrast to official health resources, the subreddit offers members practical advice on harm reduction. It provides opportunities for users of N₂O to position themselves as playful, informed and caring curators of drug use pleasures. We highlight the need for those formulating drug education to engage with the knowledge, practices and identities that emerge within internet-mediated social worlds.

Ayahuasca: What Healthcare Providers Need to Know

ABSTRACT

Ayahuasca is a pan-Amazonian botanical hallucinogenic decoction made from a mixture of the bark of the Banisteriopsis caapi plant, containing a monoamine oxidase inhibitor, and Psychotria viridis (Rubiaceae) or Diplopterys cabrerana shrubs containing a serotonergic 2A receptor agonist, N,N-dimethyltryptamine, a powerful psychoactive substance. Ayahuasca is a traditional psychoactive sacrament that has been used for shamanic ceremonies for centuries. Ayahuasca is acclaimed for spiritual and psychotherapeutic benefits and is gaining popularity in the United States. Potential risks involved with usage of this hallucinogenic drug include psychotic episodes related to N,N-dimethyltryptamine and serotonin syndrome, which can be potentially life threatening. The consequences of ayahuasca use remain uncertain because of poor quality control, unpredictability, and polydrug interactions. Nurses, advanced practice nurses, and other healthcare providers working in outpatient settings, hospitals, and treatment centers need to be familiar with the pharmacology, possible drug interactions, and management for ayahuasca ingestion for optimal decision making. Nurses are well positioned to facilitate understanding and to advise and educate the public about the potential risks associated with ayahuasca ingestion.

Abuse or Misuse of OTC Decongestant Produces Serious Adverse Effects

A rising number of cases of misuse and abuse of propylhexedrine (Benzedrex), an over-the-counter nasal decongestant, have been documented. Misuse of this drug can lead to serious and potentially fatal cardiac and psychiatric adverse effects.

Abuse, Toxicology and the Resurgence of Propylhexedrine: A Case Report and Review of Literature

Propylhexedrine, the active ingredient in over-the-counter nasal decongestants, carries significant abuse potential for users seeking psychostimulant effects. Historically, propylhexedrine was perceived to have a good safety profile resulting in endorsement of it replacing the highly abused amphetamine sulfate as the active ingredient in nasal decongestants in 1949. While much of the published literature concerning its psychoactive potential comes from the 1970s and 1980s, we have encountered several recent cases of toxidrome secondary to its abuse. Awareness of the hazards associated with this pharmaceutical should be of interest to physicians of all specialties who are likely to encounter such cases, as well and legislators interested in exerting regulatory control. Here we review all existing literature concerning this pharmaceutical compound.

Intoxication with 3-MeO-PCP alone: A case report and literature review

RATIONALE

3-Methoxyphencyclidine (3-MeO-PCP) is a new psychoactive substance derived from phencyclidine. Although it can lead to severe intoxications, the main manifestations and optimal management have not been well characterized. Here, we report 2 cases of 3-MeO-PCP intoxication in the same patient, and summarize the manifestations of this intoxication reported in literature.

PATIENT CONCERNS

A 17-year-old male purchased a bag of 3-MeO-PCP on the Internet but took an oral dose (200 mg) that corresponds to the less active isomer 4-MeO-PCP. He developed high blood pressure (158/131 mm Hg), tachycardia (100 bpm), and neurological manifestations (confusion, hypertonia, nystagmus, and then agitation). A maculopapular rash appeared, although this may have been related to the administration of midazolam. Hyperlactatemia (2.6 mmol/L) was the main laboratory finding. Seven days later, he returned to the emergency department after sniffing 50 mg of 3-MeO-PCP. High blood pressure, tachycardia, and neurological manifestations (psychomotor impairment and dysarthria) were present but less severe than after the first intoxication.

DIAGNOSIS

In the first intoxication, the blood and urine 3-MeO-PCP concentrations were, respectively, 71.1 ng/mL and 706.9 ng/mL. Conventional toxicity tests were all negative. In the second intoxication, biological samples were not available.

INTERVENTIONS

In the first intoxication, treatment consisted of intravenous hydration and midazolam. The patient was transferred to an intensive care unit for monitoring. After the second intoxication, he was monitored for 12 hours.

OUTCOMES

The patient's condition improved quickly in both cases.

LESSONS

These cases provide additional information on the manifestations of 3-MeO-PCP intoxication. These manifestations are mainly cardiovascular (high blood pressure, tachycardia) and neurological. The fact that second (50 mg) intoxication was less severe than the first (200 mg) is suggestive of a dose-effect relationship for 3-MeO-PCP. The first case also emphasizes the risk of dosing errors caused by the similarity between the names "3-MeO-PCP" and "4-MeO-PCP."

Serotonin Syndrome: Pathophysiology, Clinical Features, Management, and Potential Future Directions

Serotonin syndrome (SS) (also referred to as serotonin toxicity) is a potentially life-threatening drug-induced toxidrome associated with increased serotonergic activity in both the peripheral (PNS) and central nervous systems (CNS). It is characterised by a dose-relevant spectrum of clinical findings related to the level of free serotonin (5-hydroxytryptamine [5-HT]), or 5-HT receptor activation (predominantly the 5-HT_1A and 5-HT_2A subtypes), which include neuromuscular abnormalities, autonomic hyperactivity, and mental state changes. Severe SS is only usually precipitated by the simultaneous initiation of 2 or more serotonergic drugs, but the syndrome can also occur after the initiation of a single serotonergic drug in a susceptible individual, the addition of a second or third agent to long-standing doses of a maintenance serotonergic drug, or after an overdose. The combination of a monoamine oxidase inhibitor (MAOI), in particular MAO-A inhibitors that preferentially inhibit the metabolism of 5-HT, with serotonergic drugs is especially dangerous, and may lead to the most severe form of the syndrome, and occasionally death. This review describes our current understanding of the pathophysiology, clinical presentation and management of SS, and summarises some of the drugs and interactions that may precipitate the condition. We also discuss the newer novel psychoactive substances (NPSs), a growing public health concern due to their increased availability and use, and their potential risk to evoke the syndrome. Finally, we discuss whether the inhibition of tryptophan hydroxylase (TPH), in particular the neuronal isoform (TPH2), may provide an opportunity to pharmacologically target central 5-HT synthesis, and so develop new treatments for severe, life-threatening SS.

Bromo-dragonfly, a psychoactive benzodifuran, is resistant to hepatic metabolism and potently inhibits monoamine oxidase A

Bromo-dragonfly is a benzodifuran derivative known as one of the most potent 5-HT_2A-receptor agonists within this chemical class, with long-lasting effects of up to 2-3 days. In addition to hallucinogenic effects, the drug is a potent vasoconstrictor, resulting in severe adverse effects, such as necrosis of the limbs. In some cases, intoxication has had fatal outcomes. Little is known about the metabolism of bromo-dragonfly. The aims of this study were to investigate the pharmacokinetics of bromo-dragonfly, determine the plasma protein binding, examine the human hepatic metabolism in vitro, and compare with those of its close analogue, 2C-B-fly. Additionally, we assayed the inhibition potency of both compounds on the monoamine oxidase (MAO) A- and B-mediated oxidative deamination of serotonin (5-HT) and dopamine, respectively. Liquid chromatography high-resolution mass spectrometry was used for metabolism studies in pooled human liver microsomes (HLM), pooled human liver cytosol (HLC) and recombinant enzymes. Inhibition studies of the deamination of 5-HT and dopamine were carried out using LC-MS/MS. Bromo-dragonfly was not metabolised in the tested in vitro systems. On the other hand, 2C-B-fly was metabolised in HLM by CYP2D6 and in HLC to some extent, with the main biotransformations being monohydroxylation and N-acetylation. Furthermore, MAO-A metabolised 2C-B-fly, producing the aldehyde metabolite, which was trapped in vitro with methoxyamine. Inhibition experiments revealed that bromo-dragonfly is a competitive inhibitor of MAO-A with a K_i of 0.352 μM. The IC₅₀ value for bromo-dragonfly indicated that the inhibition of MAO-A may be clinically relevant. However, more data are needed to estimate its impact on the increase of 5-HT in vivo.