Use and Perceptions of Khat Among Young Somalis in a UK City

Catha edulis Forsk (khat) reduces spontaneous and rewarded alternation in female mice

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Khat is a widely used plant-based psychostimulant.

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Administration of khat leads to disruption of spatial working memory in mice.

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It promotes in mice perseverative behavior rather than alternation behavior.

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Khat treated mice also show right side position preference.

Around 10 million people chew the fresh leaves and twigs of Catha edulis Forsk (khat), which synthesize cathinone, for its psychostimulatory effect. Several studies have reported that regular khat users show executive and cognitive dysfunction, such as impaired inhibitory control and poor performance on memory tests. In this study, the effect of fresh khat extract (100 and 250 mg/kg) on spatial working memory and short-term memory in mice was assessed using spontaneous and rewarded alternation T-maze tests. In the spontaneous alternation test, mice treated with fresh khat extract decreased their spontaneous alternation level to around chance level, and it remained at this level over the 7 days of khat administration and testing. On testing after a 7-day khat free period, the previously khat treated mice showed alternation level above chance but below their pre-khat alternation level. In the rewarded alternation test, acute treatment with khat caused the mice to alternate well below chance level, and then over the next 3 days of khat treatment, the alternation level increased. After a 2 and 9-day khat-free period, the previously khat treated mice alternated above chance level but below their pre-khat level. In both these tests, the mice did not show any position preference before khat treatment; however, during the khat treatment, the mice showed a right side tendency. The results show that khat treatment causes persistent changes in alternation behavior and promotes perseverative behavior, presumably due to its effect on the neural circuits activity and the neurotransmitters and promotion of position preference.

User Experiences of Prescription and Over-The-Counter Drug Abuse in Aden City, Yemen

Khat chewing is commonplace in Yemen, but little else is known about the misuse of other drugs, especially how such misuse may intersect with Khat use. The aim of this study was to investigate misuse of prescription and over-the-counter (OTC) drugs in community pharmacies in Aden city, from the users’ perspective. A qualitative in-depth-interview study was undertaken with fifteen known or suspected drug misusers, recruited through community pharmacies. Thematic analysis was used to identify the main emergent themes around experience of prescription and OTC drug misuse. The majority of interviewees were male (n = 11/15) with an age range of 21–40 years. Benzodiazepines, Tramadol, and Ketoprofen were the most commonly misused drugs. Four main themes were identified: Experience sought with drugs; awareness of problematic drug use; pattern and methods of misuse; and the role of healthcare professionals in responding to misuse. The study highlighted different issues, such as the practice of mixing different OTC and prescription drugs with Khat to heighten the effects or manage associated pain, and drug misuse by females and by health care professionals. The study also suggested that physicians and pharmacists fear counselling such people, probably with the risk of violence as a contributory factor.

Khat Use: What Is the Problem and What Can Be Done?

The chewing of khat leaves is an established tradition in East Africa but is much less prevalent in other areas of the world and is mostly limited to Somali communities. However, our understanding of what constitutes problematic khat use in the Somali community in Victoria, Australia, is limited. The objectives of this study were to better understand the views of Somali community representatives and primary care practitioners regarding problematic khat use, to consider relevant harm minimisation strategies, and to develop resources to assist individuals with problematic khat use and their families. Qualitative research methods were used to investigate the experiences and perceptions of khat use among Somalis and mainstream primary care practitioners. Six focus groups were conducted with 37 members of the Somali community and 11 primary care practitioners. Thematic analysis was used to analyse transcripts. Various indicators of the problematic use of khat were identified, including adverse physical and mental health effects, social isolation, family breakdown, and neglect of social responsibilities. Potential harm minimisation strategies were identified including the adoption of health promotion through education, outreach to the community, and the use of universal harm minimisation strategies specifically tailored to khat use.

"Natural Amphetamine" Khat: A Cultural Tradition or a Drug of Abuse?

Khat, Catha edulis Forsk, is among the most widely used plant-based psychoactive substance in the world. Grown in Eastern Africa, Horn of Africa, and southwestern part of the Arabian Peninsula, its fresh young leaves and twigs are used daily by over 20 million people for the psychostimulatory effects it produces in the user, a practice deeply rooted in the history, tradition, and culture of the indigenous population. Once hardly known outside the regions where it is grown and used, khat use has now spread to other countries. This review will cover the, phytochemistry, pharmacokinetics of the active ingredients-cathinone, cathine, norephedrine, neurochemistry, effects on cognitive and executive functions as well as its ability to produce dependency in the user. Whether it is an innocuous cultural practice or a drug of abuse is debatable as the preclinical and clinical data needed to arrive at an authoritative conclusion is lacking.

Severity of khat dependence among adult khat chewers: the moderating influence of gender and age

ETHNOPHARMACOLOGICAL RELEVANCE

The escalating use of khat (Catha edulis) in East Africa and Arabia is a major concern for public health. Yet little is known about the impact of khat on behavior. There has been no study in the region to assess the extent to which dependence syndrome is associated with khat use in this population.

AIM OF THE STUDY

To examine psychometric properties of the Severity of Dependence Scale-Khat (SDS-khat), gender differences in patterns of khat use and dependence, and the extent to which age moderated the link between gender and khat dependence.

MATERIALS AND METHODS

Two-hundred and seventy khat chewers recruited in two Yemeni cities completed face-to-face interviews asking about demographics and patterns of khat use. Validity of SDS-khat was examined by the principle component analysis and reliability of the scale was tested by Cronbach׳s alpha. A series of chi-square tests and analysis of variances (ANOVAs) were conducted to examine gender differences in khat use variables.

RESULTS

The results indicated that the mean age of khat chewers was 30.52 years (95% CI: 29.34, 31.70) and 52% of them were males. The SDS-khat was found to have two factors with moderate reliability. This pattern was consistent when the analysis was conducted in the entire sample and in each gender. Male khat chewers reported more symptoms related to khat dependence than female chewers. A significant gender by age interaction in SDS-khat levels (p=0.013) revealed a positive association between age and khat dependence in women only.

CONCLUSION

These results provide initial support for the use of SDS-khat in the assessment of khat dependence in Yemen. Gender differences in khat use patterns and dependence observed in this study call the need for more studies carefully examining the role of gender in khat research.

Khat (Catha edulis): A systematic review of evidence and literature pertaining to its harms to UK users and society

The use of khat ( Catha edulis) has been associated with a large number of physiological and societal harms, leading to calls for it to be controlled in the UK. The evidence of these harms is often equivocal, limited by confounding factors, or entirely anecdotal: high-powered, quality-controlled studies are lacking. Regardless, the body of relevant literature indicates that the once socially-regulated use of khat has been eroded. Some individuals have developed excessive consumption patterns, either using khat daily or in binge-sessions, though daily consumption is not necessarily problematic per se. The majority of users seem to use khat in moderation, where the associated harms appear low. For excessive users, harms associated with khat are greater, particularly relating to mental health. Social harms also seem to be largely related to excessive khat use rather than khat use itself. Even in cases of excessive khat use, however, causal relationships between chewing and harms have not been described. More research is required to establish the role of khat in liver disease, coronary problems, cancers of the digestive tract and incidents of domestic violence. Studies should consider the likeliness that certain users are more vulnerable to developing patterns of excessive khat use due to an interwoven set of factors such as social health determinants and pre- and post-migration experiences.

Khat dependence syndrome: a cross sectional preliminary evaluation amongst UK-resident Yemeni khat chewers

ETHNOPHARMACOLOGICAL RELEVANCE

Khat is a natural psychostimulant that has pharmacological effects similar to that of amphetamine. The behaviour of khat chewing is embedded within a cultural context. Meanwhile khat chewing is associated with psychological and physiologically burden, as a 'dependence producing' substance.

AIMS OF THE STUDY

To assess the applicability of the construct of substance dependence syndrome (DSM-IV, 1994) to khat chewing and to examine psychosocial and behavioural correlates of this syndrome including tobacco use.

MATERIALS AND METHODS

A sample of 204 khat chewers was recruited during random visits to khat sale outlets. A face to face interview that assessed socio-demographic, psychosocial dependence, substance dependence syndrome and behavioural characteristics was conducted. Descriptive, exploratory psychometric and multivariate analyses were employed.

RESULTS

Approximately a third (31%) of khat chewers reported symptoms consistent with dependence syndrome including increased khat chewing (13%) and cessation attempts (19%) while 17% reported withdrawal symptoms including depression (61%), increase in appetite (74%) and interrupted sleep (58%). Thirty-eight percent reported continued khat chewing despite impacts on their health. Psychometric assessment of the DSM-IV criteria for khat chewing dependence identified two factors; factor 1 consisted of bio-behavioural items and factor 2 withdrawal items, accounting for 67% of the variance and Cronbach's alpha coefficient at 0.78. In multivariate logistic regression modelling, there was an association between intensity of psychological khat dependence (SDS-Khat) and nicotine dependence with the likelihood of exhibiting khat chewing dependence syndrome (p=0.0005, OR=1.51, 95%CI=1.33-1.71; p=0.043, OR=2.87, 95%CI=1.03-7.98, respectively).

CONCLUSIONS

The substance dependence syndrome criteria are applicable to khat chewing and associated with increased intensity of nicotine and psychological khat dependence. The applicability of khat dependence syndrome and exploration of its dimensions and associated factors should be extended in future research. Concurrent validation of these findings using specific objective measures for self-report khat chewing is also recommended.

Validation of self-reported khat chewing amongst khat chewers: an exploratory study

ETHNOPHARMACOLOGICAL RELEVANCE

Khat chewing amongst the UK communities originating from Yemen and the East African coast is suggested to create dependency through its main stimulant components (cathinone, norephedrine and norpseudoephedrine) on the central nervous system.

AIMS OF THE STUDY

To validate self-reported khat chewing behaviours by measuring levels of cathinone, norephedrine and norpseudoephedrine in saliva and to explore their associations with self-reported khat chewing dependency.

MATERIALS AND METHODS

Face-to-face interviews were conducted amongst 30 male UK-resident khat chewers. Saliva samples were collected from each participant and high-performance liquid chromatography (HPLC) employed to extract and quantify the levels of the biomarkers.

RESULTS

The mean (SD) for cathinone and the composite norephedrine and norpseudoephedrine levels were 33.93 (±39.20) and 29.28 (±26.32)μg/mL respectively. These biomarkers were significantly associated (p≤0.05) with khat chewing dependency.

CONCLUSIONS

Validation of self-reported khat chewing is possible. Khat chewing dependency correlates significantly with biomarker levels in saliva. Replication is required.

Validity and reliability of a Severity of Dependence Scale for khat (SDS-khat)

AIMS OF THE STUDY

(1) To assess psychological khat dependence and (2) to assess the validity and reliability of the Severity Dependence Scale (Gossop et al., 1995) amended for khat use (SDS-khat), in a sample of UK-resident male adult Yemeni khat chewers.

MATERIALS AND METHODS

A cross-sectional study using a face to face structured interview schedule was conducted amongst purposively sampled UK-resident adult Yemeni male khat chewers, aged 18 years and above, selected during random visits to places of khat sale. A factor analysis with principal components extraction was conducted to explore the construct validity of the proposed SDS-khat. Reliability of the proposed scale was assessed using test-retest and internal reliability tests. The concurrent validity of the proposed SDS-khat was assessed in relation to individual measures and a composite index of khat chewing behaviours using univariate analyses.

RESULTS

Two hundred and four Yemeni male adult khat chewers were interviewed. The mean score of the proposed SDS-khat was 5.52 (SD ±4.03). Forty nine percent of respondents (95% CI=43-55%) with ≤5 scores were more likely not psychologically dependent. A single factor, uni-dimensional solution identifying the five items making up the scale accounted for 52.33% of variance. The internal reliability was good (Cronbach's alpha coefficient=0.76) and the test retest intraclass correlation coefficient (ICC) was 0.93 (95% CI=0.80-0.97). Many individual aspects of the khat chewing were significantly related to the scale. Assessment of the proposed SDS-khat's concurrent validity with individual items of khat chewing identified several significant relationships (p≤0.05) whilst the composite index of khat behaviour also identified a significant relationship (OR=14.40, 95% CI=6.71-30.89). The proposed SDS-khat also correlated with self-reported reasons for khat chewing (p≤0.001, OR=3.54; 95% CI=1.80-6.96).

CONCLUSIONS

In this sample of Yemeni khat chewers the SDS-khat is recommended as a valid and reliable research tool for measuring psychological dependence upon khat. Further validation in other samples is indicated.

Khat use and neurobehavioral functions: suggestions for future studies

Although there is a rich body of research available regarding the effect of acute and chronic khat dosing in animal models, research on the behavioral and cognitive effects of khat in human subjects is not extensive and several of the available studies have been done only in the context of observational and single-case studies. In light of the absence of a substantial literature on the neurobehavioral deficits associated with khat use and to provide a context that could be used to identify themes for future research we review previous research that has focused on other stimulant drugs. This review highlights multiple areas of neurocognitive deficit that have been identified in previous studies of individuals who have been chronic users of stimulants, such as amphetamines and methamphetamines. The review highlights a substantial body of evidence demonstrating a wide range of learning and memory impairments including deficits that persist during abstinence from active drug use. This review does not imply a similar khat effect, but due to some similarities pharmacologically between the active components of khat (cathinone and cathine) and amphetamines, future studies examining these same domains of cognitive functioning in chronic khat users and abstinent khat users appears to be warranted, if possible using some of the same or similar laboratory measures.

Motives for khat use and abstinence in Yemen--a gender perspective

Background

Khat consumption is widespread in Yemeni society and causes problems both in economic development and public health. Preventive measures have been largely unsuccessful and the cultivation continues to proliferate. The gender-specific motives for khat use and abstinence were studied to create a toe-hold for more specific interventions.

Methods

In a quota sample with equal numbers of males, females, abstainers and consumers, 320 subjects were interviewed on their specific opinions about khat and its impact on subjective and public health, and on social and community functioning. Strata were compared in their acceptance and denial of opinions. Notions that could predict abstinence status or gender were identified with multivariate logistic regression analysis.

Results

Male khat users had a strong identification with khat use, while females were more ambivalent. The notion that khat consumption is a bad habit (odds ratio (OR) 3.4; p < 0.001) and consumers are malnuorished (OR 2.2; p = 0.046) were associated with female gender among khat users. Among the females worries about health impact (OR 3.2; p = 0.040) and loss of esteem in the family (OR 3.1; p = 0.048) when using khat predicted abstinence. Male abstainers opposed khat users in the belief that khat is the cause of social problems (OR 5.1, p < 0.001). Logistic regression reached an accuracy of 75 and 73% for the prediction of abstinence and 71% for gender among consumers. (All models p < 0.001.)

Conclusions

Distinct beliefs allow a differentiation between males, females, khat users and abstainers when targeting preventive measures. In accordance to their specific values female khat users are most ambivalent towards their habit. Positive opinions scored lower than expected in the consumers. This finding creates a strong toe-hold for gender-specific public health interventions.

Perceptions of the use of khat among Somali immigrants living in Swedish society

AIMS

The aim of this study was to gain a better understanding of Somali immigrants' perceptions of the use of khat when living in Swedish society. Using khat is illegal in Sweden.

METHODS

A phenomenographic design was used to capture different perception of using khat. Fourteen interviews were conducted with both men and women. The information was subjected to phenomenographic analysis.

RESULTS

Perceptions of the habit of chewing khat among Somalis living in Sweden vary. The use of khat is perceived as a kind of food or as a drug. To use khat is perceived as having a physical impact on individual health, as well as an impact on social and family life. Using khat also has an impact on people's time, because time is needed to indulge the habit. Furthermore, using khat is perceived as a medium for cultural and community cohesiveness. The Somalis preferred preventive measures in place to counter the use of khat in Sweden.

CONCLUSIONS

The use of a phenomenographic design which captured the variation in perceptions of the habit of using khat among Somali immigrants' living in Swedish society is helpful in guiding individual strategies in health promotion activities.

Illicit cathinone (“Hagigat”) poisoning

INTRODUCTION

Khat leaves (mainly cathinone and cathine) have been chewed for centuries as stimulants. Hagigat (capsules of 200 mg cathinone) have been marketed in Israel as a natural stimulant and aphrodisiac. The consequences of illicit exposure to cathinone are reported.

METHODS

Prospective observational study of calls to the Poison Center regarding exposure to Hagigat during the course of 10 months. Demographic and clinical data were abstracted from patients' records and telephone follow up was performed.

RESULTS

Data of 34 consecutive patients aged 16-54 years were analyzed. The amount consumed was (1/2)-6 capsules (ingestion-32, sniffing-2). Main clinical manifestations were headache, vomiting, hypertension, nausea, tachycardia, dyspnea, chest pain, and myalgia. Main complications were myocardial ischemia (3), pulmonary edema (2), and intracerebral hemorrhage (1), all in young subjects. Treatment was supportive; one patient underwent neurosurgery.

CONCLUSION

Exposure to illicitly synthesized cathinone is associated with serious cardiovascular and neurological toxicity, even in young subjects.

Risk assessment of khat use in the Netherlands: a review based on adverse health effects, prevalence, criminal involvement and public order

In preparing a decision about the legal status of khat in the Netherlands, the Dutch Minister of Health requested CAM (Coordination point Assessment and Monitoring new drugs) to assess the overall risk of khat in the Netherlands. The present paper is a redraft of a report which formed the scientific basis of the risk evaluation procedure (October 2007). This report reviews the scientific data about khat available in the international literature. In addition, the report contains some information specific for the Netherlands (prevalence, availability of khat and public order aspects). The main psychoactive compounds in khat leaves are cathine and cathinone, which are some 2- to 10-fold less active than amphetamine. Acute health problems are rarely seen, and are usually related with malnutrition, social and financial problems. Khat has a low addictive potential. Chronic toxicity of khat is modest when used in low amounts, whereas at high levels, khat use is associated with adverse effects, like hypertension, heart rhythm disorders, insomnia and loss of appetite. In addition, khat users show a higher prevalence of cancers in the digestive tract. At population level, khat does not lead to specific health risks in the Netherlands, as its use is confined to East-African immigrants. A relationship between khat use and psychiatric disorders has been suggested, but the reports are contradictory, and such studies are presumably heavily confounded by posttraumatic and social stress. In the Netherlands (and other countries), khat use occasionally leads to minor disturbance of civil order in the public domain (loud talking, spitting), but is not related to criminal activities. Following the assessment, CAM estimated the overall risk potential of khat use in the Netherlands as very low. A similar conclusion may be drawn for countries with a comparable prevalence of khat use and khat related public order disturbance.

Research Note: Crime, Chemicals, and Culture: On the Complexity of Khat

In 2006, khat was the object of a federal government operation, which dismantled a Somali trafficking organization and seized five tons of the plant valued at $2 million. Khat is an evergreen tree that grows in Africa. Its leaves are chewed as a stimulant by six million people every day. This paper describes the complexity of khat, beginning with an overview of its international usage and its contradictory portrayals. Primary concern, however, is focused on khat's complexity in terms of its criminal, chemical, and cultural dimensions. According to the FBI, khat is a controlled substance. But others disagree. A khat plant might contain cathinone, a Schedule I drug. But shortly after harvesting, cathinone decomposes. Throughout history, colonizers have used laws against khat to control indigenous Muslim populations. In the U. S., utilization of khat is central to the lives of many members of immigrant communities. Targeting khat can be viewed as targeting members of these communities.

Is miraa a drug?: categorizing Kenyan khat

This article examines the varied perceptions of the substance miraa/khat in Kenya, from strong approval in the Nyambene Hills region where it is cultivated to the strong disapproval evident in its frequent denunciation in various segments of Kenyan society. Perceptions are colored by various local and global discourses, and it is argued that of great importance is "war on drugs" rhetoric, which allows the conflation of miraa with other substances also termed "drugs"; much of the Kenyan miraa debate revolves around just how miraa should be categorized and to whether it can be labeled a "drug." War-on-drugs rhetoric is countered by those more enamored of the substance by discourse in which its use is labeled "traditional," "cool," and an "economic miracle."

Traditional medicines used by Pakistani migrants from Mirpur living in Bradford, Northern England

BACKGROUND

Despite the increasing relevance of trans-cultural healthcare issues in public health policies, knowledge is still very restricted about migrant communities' perceptions and use of traditional medicines (TMs) within multicultural societies in Western countries. In this field study, an in-depth study was carried out of the herbal drugs still in use among Pakistani migrants from Mirpur living in Bradford, in the north of England.

OBJECTIVES

To record TMs known and still used among Pakistani migrants from Mirpur presently living in Bradford; to assess the degree of overlapping between food and medicine in the provision of healthcare within domestic arenas among this community; to analyse how knowledge of TMs is changing among different generations and among the different waves of migrants who have moved from Pakistan to Bradford in the last few decades.

METHODS

Semi-structured and focus-groups interviews with 37 members of the community, as well as other standard techniques of the ethnobiological investigations: free-listing, participant observation, and the collection and identification of the relevant plant material.

RESULTS

TMs are still very popular amongst Pakistani migrants in Bradford, and are regularly delivered in domestic arenas. Two-thirds of the interviewees declared that they prefer TM treatments to conventional Western medicine. Fifty-six different remedies, mainly plant-based, are still used nowadays, and more than half of the recorded remedies represent food-medicines. However, knowledge of Mirpuri TMs is decreasing amongst the younger generations, and the level of knowledge of TMs seems to be dependent on the length of time since the migration from Pakistan took place.

CONCLUSION

Public health policies and strategies aimed at improving migrants' health should take into account the perception and acceptance of plant-based TMs within domestic arenas among Pakistani migrants, and especially their use against diabetes. Concerns about eventual toxicity and side effects of traditional herbal drugs, as well as their interaction with pharmaceuticals, should be carefully considered, since a few of the herbal drugs quoted in this survey are little known in Western herbalism and in modern evidence-based phytotherapy.

Traditional phytotherapy and trans-cultural pharmacy among Turkish migrants living in Cologne, Germany

This article reports on an ethnopharmaceutical field study carried out among Turkish migrants in Cologne, western Germany, which recorded 79 botanical taxa and 115 plant-based preparations, encompassing 167 folk phytotherapeutical uses, as well as a few other biological (animal and mineral derived) remedies. One-fourth of the recorded remedies were represented by food-medicines. Half of the ingredients quoted came originally from Turkey; only a few plants were gathered from the wild or cultivated in the Cologne area. This article discusses the Turkish migrants' frequent use of aerial parts of Sideritis species, the fruits of Pistacia terebinthus and the seeds of Peganum harmala from the perspective of modern phytopharmacology, phytotherapy and toxicology. It considers cultural adaptation related to the use of folk pharmaceuticals by analysing the ingredients of the Turkish folk pharmacopoeia and comparing them with those of the Turkish medical ethnobotany and of the phytotherapy of the host country (Germany). Only one third of the remedies mentioned by Turkish migrants living in Cologne are also known in German evidence-based phytotherapy, and less than 10% of the recorded phytotherapeutic uses are common to both pharmacopoeias. This article concludes by suggesting hypotheses on future changes affecting the knowledge and use of medicinal plants within the Turkish community of Cologne.