The Flip Side of “Spice”: The Adverse Effects of Synthetic Cannabinoids as Discussed on a Swedish Internet Forum

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

BACKGROUND

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

METHODS

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

RESULTS

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

"Spice Was Made, by the Devil Himself": A Thematic Analysis of the Experience of an Addiction to Synthetic Cannabinoids

Synthetic cannabinoids (SC) are the most common type of new psychoactive substances used predominantly as a replacement for cannabis. There is a wealth of literature on the negative effects experienced by users of SC. However, there is a paucity of research on the experience of addiction to SC from the users' perspectives. The present study qualitatively explored the experience of addiction to SC. Online blog entries detailing the experience of SC addiction were analyzed using thematic analysis. Users reported being stuck in a cycle of addiction which was composed of addiction hallmarks. They also experienced a range of significant physical, mental health and psychosocial problems. Suicidal ideation was also reported, with potential for its occurrence during withdrawal, due to shame of being addicted, and as the only way to stop the addiction cycle. Additionally, both psychotic and cognitive symptoms were reported to persist following cessation, enhancing current understanding of long-term SC effects. Therefore, users require both clinical and psychosocial support for these issues, most notably suicidal ideation.

“The junkie abuses, the psychonaut learns”: a qualitative analysis of an online drug forum community

Purpose

Drug-related web forums have been argued to be an effective way to investigate the latest generation of drug users. The purpose of this paper is to explore discussions about drugs and new psychoactive substances (NPS) on an Italian psychonauts’ online community in order to gain a better understanding of the psychonauts’ profiles by scrutinising their main motives for consumption, which is mainly addressed to psychedelic drugs.

Design/methodology/approach

To collect data, a keywords list was used in the forum search engine. The first five most recent conversations (threads) for each of ten most frequently mentioned substances were selected. In addition, ten posts written by new forum members to introduce themselves were added to the data set, bringing the total number of threads to 60. The data were coded using Atlas.ti 7 applying a template model analysis (King, 1998).

Findings

The forum members present themselves as well-educated, informed drug users, and connoisseurs of the pharmacological properties of chemical compounds: accordingly, they claim to be aware of drug effects and possible risks. The analysis of the motives for using psychedelic drugs substantially confirms previous studies, indicating that the main reasons include spiritual needs, self-exploration and self-treatment. The shift from a recreational use towards more “committed” aims such as self-development is seen as a step forward in a drug user’s career. A generalised interest in harm reduction suggests that the psychonauts’ attitude may be a protective factor against adverse consequences of drug use. The most problematic users represented in the data are those who use drugs for self-treatment, since their discourse focusses on suffering rather than on pleasure.

Originality/value

Most efforts to analyse and monitor drug-related forums have focussed on “leading edge” English-language international websites. No studies have dealt with Italian forums. Furthermore the study address a misleading use of the term e-psychonauts recently introduced by some scholars whose’s studies were focussed on NPS.

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.

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.

The value of unsolicited online data in drug policy research

We alert readers to the value of using unsolicited online data in drug policy research by highlighting web-based content relevant to drug policy generated by distinct types of actor: people who consume, supply or produce illicit drugs, online news websites and state or civil society organisations. These actors leave 'digital traces' across a range of internet platforms, and these traces become available to researchers to use as data - although they have not been solicited by researchers, and so have not been created specifically to fulfil the aims of research projects. This particular type of data entails certain strengths, limitations and ethical challenges, and we aim to assist researchers in understanding these by drawing on selected examples of published research using unsolicited online data that have generated valuable drug policy insights not possible using other traditional data sources. We argue for the continued and increased importance of using unsolicited online data so that drug policy scholarship keep pace with recent developments in the global landscape of drug policies and illicit drug practices.

Psychopathological symptoms associated with synthetic cannabinoid use: a comparison with natural cannabis

BACKGROUND

Synthetic cannabinoids (SCs) are a class of new psychoactive substances that have been rapidly evolving around the world throughout recent years. Many different synthetic cannabinoid analogues are on the consumer market and sold under misleading names, like "spice" or "incense." A limited number of studies have reported serious health effects associated with SC use. In this study, we compared clinical and subclinical psychopathological symptoms associated with SC use and natural cannabis (NC) use.

METHODS

A convenience sample of 367 NC and SC users was recruited online, including four validated psychometric questionnaires: The Drug Use Disorders Identification Test (DUDIT), Insomnia Severity Index (ISI), Altman Mania Scale (Altman), and Brief Symptom Inventory (BSI). The two groups were compared with analysis of variance (ANOVA) and covariance (ANCOVA), chi² tests, and logistic regression when appropriate.

RESULTS

The SC user group did not differ in age from the NC user group (27.7 years), but contained less females (21% and 30%, respectively). SC users scored higher than NC users on all used psychometric measures, indicating a higher likelihood of drug abuse, sleep problems, (hypo)manic symptoms, and the nine dimensions comprising the BSI, somatization, obsessive-compulsive behavior, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. Odds ratios (95% CI) for the SC user group vs NC user group were, respectively, drug dependence 3.56 (1.77-7.16), (severe) insomnia 5.01 (2.10-11.92), (hypo-)mania 5.18 (2.04-13.14), and BSI psychopathology 5.21 (2.96-9.17).

DISCUSSION

This study shows that SC use is associated with increased mental health symptomatology compared to NC use.

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.

Psychoactive substances as a last resort-a qualitative study of self-treatment of migraine and cluster headaches

BACKGROUND

Treatment resistant cluster headache and migraine patients are exploring alternative treatments online. The aim of this study was to improve comprehension regarding the use of non-established or alternative pharmacological treatments used by sufferers of cluster headaches and migraines.

METHODS

A qualitative thematic analysis of the users' own accounts presented in online forum discussions were conducted. The forum boards https://shroomery.org/ , http://bluelight.org , and https://clusterbusters.org/ met the inclusion criteria and were used for the study.

RESULTS

The analysis resulted in six themes: a desperate need for effective treatments; the role of the forum-finding alternative treatments and community support; alternative treatment substances; dosage and regimens; effects and treatment results; and adverse effects. The results provide an insight into why, how, and by which substances and methods sufferers seek relief from cluster headache and migraines.

CONCLUSIONS

These patients are in a desperate and vulnerable situation, and illicit psychoactive substances are often considered a last resort. There appeared to be little or no interest in psychoactive effects per se as these were rather tolerated or avoided by using sub-psychoactive doses. Primarily, psilocybin, lysergic acid diethylamide, and related psychedelic tryptamines were reportedly effective for both prophylactic and acute treatment of cluster headache and migraines. Treatment results with cannabis were more unpredictable. No severe adverse events were reported, but it was observed how desperation sometimes spurred risky behavior when obtaining and testing various treatment alternatives. The forum discourse mainly revolved around maximizing treatment results and minimizing potential harms.

The Novel Psychoactive Substances in the UK Project: empirical and conceptual review work to produce research recommendations

Background

Although illegal drug use has largely been declining in the UK over the past decade, this period has witnessed the emergence of a range of novel psychoactive substances (NPS) (‘legal highs’). These are new, mostly synthetic, substances that mimic the effects of existing drugs). Despite there being many causes for concern in relation to NPS, there has been little prior study of the burden associated with their use in public health terms. Clarity is lacking on research priorities in this rapidly developing literature.

Objectives

To inform the development of public health intervention research on NPS by reviewing existing data on their use, associated problems and potential responses to such problems.

Design

A scoping review and narrative synthesis of selected bodies of evidence was undertaken to summarise and evaluate what is known about NPS use and the related harms of, and responses to, such use. Relevant literature was identified from electronic databases (covering January 2006 to June 2016 inclusive), Google (Google Inc., Mountain View, CA, USA), relevant websites and online drug forums and by contacting experts. Articles were included if they were primary studies, secondary studies involving the analysis and interpretation of primary research or discussion papers. A conceptual framework postulating an evidence-informed public health approach to NPS use in the UK was developed through a pragmatic literature review, the iterative development of concepts and finalisation in light of the results from the empirical review work. The process also involved feedback from various stakeholders. Research recommendations were developed from both strands of work.

Results

A total of 995 articles were included in the scoping review, the majority of which related to individual-level health-related adverse effects attributable to NPS use. The prevalence of lifetime NPS use varied widely between (e.g. with higher prevalence in young males) and within population subgroups. The most commonly reported adverse effects were psychiatric/other neurological, cardiovascular, renal and gastrointestinal manifestations, and there is limited evidence available on responses. In these and other respects, available evidence is at an early stage of development. Initial evidence challenges the view that NPS should be treated differently from other illicit drugs. The conceptual framework indicated that much of the evidence that would be useful to inform public health responses does not yet exist. We propose a systems-based prevention approach that develops existing responses, is multilevel and life course informed in character, and emphasises commonalities between NPS and other legal and illegal drug use. We make 20 recommendations for research, including nine key recommendations.

Limitations

Scoping reviews do not interrogate evidence in depth, and the disjunction between the scoping review and the conceptual framework findings is worthy of careful attention.

Conclusions

Key research recommendations build on those that have previously been made and offer more evidence-based justification and detail, as previous recommendations have not yet been acted on. The case for decision-making on commissioning new research based on these recommendations is both strong and urgent.

Future work

The validity of recommendations generated through this project could be enhanced via further work with research commissioners, policy-makers, researchers and the public.

Study registration

The systematic review element of this study is registered as PROSPERO CRD42016026415.

Funding

The National Institute for Health Research Public Health Research programme.

The slippery slope of flubromazolam: Experiences of a novel psychoactive benzodiazepine as discussed on a Swedish online forum

Aim

The purpose of this qualitative study was to investigate the effects experienced by users of a novel psychoactive substance, the benzodiazepine flubromazolam, by analysing users' own accounts on the Swedish forum Flashback.org.

Method

A thematic analysis of anonymous self-reports published on the forum was performed and generated five general themes describing effects and experiences by flubromazolam users.

Results

The themes which emerged were: Onset and duration, Desired effects, Adverse effects and addiction, Loss of control, General estimations and evaluations. The main reported characteristics of flubromazolam were heavy hypnotic and sedative effects, long-lasting amnesiac effects and the rapid development of tolerance. Flubromazolam was also anxiolytic and acted as a muscle relaxant for many users. Some users experienced euphoria or intense wellbeing. Other prominent characteristics were loss of control (leading to poor choices and actions, with unpleasant consequences) and long-lasting, often severe withdrawals. There were also serious incidents where users had been admitted to hospital, acute psychiatric treatment or taken into custody by the police.

Conclusion

Flubromazolam appears to be a highly addictive and precarious benzodiazepine with many, possibly severe, side effects. The substance is generally described as very potent and with long-lasting effects. Memory loss and loss of control are common adverse effects, and withdrawals appear to be severe for many users.

The effects of synthetic cannabinoids on executive function

BACKGROUND AND AIMS

There is a growing use of novel psychoactive substances (NPSs) including synthetic cannabinoids. Synthetic cannabinoid products have effects similar to those of natural cannabis but the new synthetic cannabinoids are more potent and dangerous and their use has resulted in various adverse effects. The purpose of the study was to assess whether persistent use of synthetic cannabinoids is associating with impairments of executive function in chronic users.

METHODS

A total of 38 synthetic cannabinoids users, 43 recreational cannabis users, and 41 non-user subjects were studied in two centers in Hungary and Israel. Computerized cognitive function tests, the classical Stroop word-color task, n-back task, and a free-recall memory task were used.

RESULTS

Synthetic cannabinoid users performed significantly worse than both recreational and non-cannabis users on the n-back task (less accuracy), the Stroop task (overall slow responses and less accuracy), and the long-term memory task (less word recall). Additionally, they have also shown higher ratings of depression and anxiety compared with both recreational and non-users groups.

DISCUSSION

This study showed impairment of executive function in synthetic cannabinoid users compared with recreational users of cannabis and non-users. This may have major implications for our understanding of the long-term consequences of synthetic cannabinoid based drugs.

Synthetic cannabinoids 2015: An update for pediatricians in clinical practice

Synthetic cannabinoids are a group of substances in the world of designer drugs that have become increasingly popular over the past few years. Synthetic cannabinoids are a chemically diverse group of compounds functionally similar to THC. Since first appearing on the world market a few years ago these compounds have evolved rapidly. Newer more potent analogues have been developed. Identifying youth who abuse these substances can be difficult. Newer forms of consumption have also evolved. These products are now manufactured in products that look like natural cannabis resin and in liquid cartridges used in electronic cigarettes. Synthetic cannabinoids appear to be associated with potentially dangerous health effects that are more severe than that of marijuana. Some synthetic cannabinoid compounds have been associated with serious physical consequences, such as, seizures, myocardial infarction and renal damage. In addition, psychoactive effects, such as aggression, confusion, anxiety and psychosis have also been reported. The diagnosis remains primarily clinical with toxicological confirmation difficult due to manufacturers constantly developing new analogues to avoid detection. Pediatricians are urged to familiarize themselves with these drugs and the typical presentations of patients who use them.

"Chasing the high" - experiences of ethylphenidate as described on international internet forums

Ethylphenidate is a novel psychoactive substance with undocumented effects, risks, and motivation for use. In this study, we investigated the experience of ethylphenidate by analyzing self-reports published on Internet forums, which revealed seven overarching themes: (1) compulsive redosing and addiction; (2) impacts on the mental state; (3) bodily agitation; (4) increased sociableness; (5) administration; (6) diverse evaluations based on intention; and (7) safety and precaution. Ethylphenidate appeared as a potent psychostimulant with an imminent abuse potential. It was mainly used for recreational purposes. The effects included not only pleasurable stimulation, euphoria, and cognitive enhancement but also indecisiveness, anxiety, and cognitive fragmentation. The users reported an increase in body temperature, heart rate, and blood pressure, but they also experienced profuse sweating and muscle tension. Ethylphenidate acted as a social lubricant, enhancing intimacy, communication, and social skills. Two opposing user mentalities were uncovered: (1) pleasure seeking and risk neglecting, and (2) safety-first orientation. This information could be of importance to legislators, public health personnel, and prevention strategists.