Effects and risks associated with novel psychoactive substances: mislabeling and sale as bath salts, spice, and research chemicals

Abuse of Synthetic Cannabinoids and Cathinones in a Patient on Buprenorphine-Naloxone Treatment: A Case Report

The rise of novel synthetic drugs, such as cathinones in "bath salts" and synthetic cannabinoids, poses serious health risks due to their severe side effects and unpredictable interactions with other substances, and their evasion of routine drug screenings poses additional challenges in managing opioid agonist treatments. We present a case of an Indian male in his thirties with a history of opiate dependence who was treated with buprenorphine/naloxone. Six months into the treatment, he presented with symptoms of sedation, agitation, and paranoia. Initial toxicological screenings using enzyme-linked immunosorbent assay (ELISA) failed to detect synthetic substances, but subsequent analysis with gas chromatography-mass spectrometry (GC-MS) identified the presence of synthetic cannabinoids and cathinones. The patient admitted to using a K2 blend, unaware of its harmful constituents. This case underscores the crucial significance of meticulous monitoring in the treatment of addiction, taking into account potential interactions with synthetic substances such as K2/spice and bath salts. It highlights the necessity for individualized patient education and enhanced access to specialized toxicology testing, advocating for comprehensive strategies in addiction clinics to better identify and mitigate the risks associated with designer drugs.

Pattern of novel psychoactive substance use among patients presented to the poison control centre of Ain Shams University Hospitals, Egypt: A cross-sectional study

Background

Novel psychoactive substances (NPSs) are relatively new substances in the illicit drug market, not previously listed in the United Nations Office on Drugs and Crime (UNDOC). Strox and Voodoo are considered some of the most popular blends of NPS in the Egyptian drug market.

Objectives

The current study was conducted to assess NPS's use pattern: Voodoo and Strox among acutely intoxicated patients presented to the poison control center of Ain Shams University Hospitals (PCC- ASUH).

Methods

A single center based cross-sectional study was carried out in the PCC-ASUH among acutely intoxicated patients presenting to the emergency department (ED) over four months (from January–April 2019. using a previously adopted and validated Fahmy and El-Sherbini socioeconomic scale (SES). Data were presented as mean, median and range as appropriate. Both smoking and crowding indexes were calculated and presented as previously reported.

Results

Fifty-one patients were presented to the ED of PCC-ASUH during the study period. A total of 96.1% (n = 49) were males. The mean age was 25 ± 7.5 years. The most common NPS used was Strox: 54.9% (n = 28), followed by Voodoo: 27.4% (n = 14). Neurological and gastrointestinal (GI) symptoms were the most frequent presentations. The most common motive behind NPS use was the desire to give a trial of new psychoactive substances. The mean SES score was 35.1 ± 13.17. Most patients have the preparatory as the highest education 36.0% (n = 18).

Conclusions

NPS use is common among young males in preparatory education from different social classes, starting it most commonly as a means to experiencing a new high. Neurological and GI manifestations are the most common presenting symptoms of NPS intoxication.

In Vitro Metabolic Study of Four Synthetic Cathinones: 4-MPD, 2-NMC, 4F-PHP and bk-EPDP

The use of illicit drugs is exceedingly prevalent in society, and several of them can be illegally purchased from the internet. This occurrence is particularly augmented by the rapid emergence of novel psychoactive substances (NPS), which are sold and distributed as “legal highs”. Amongst NPS, the class of synthetic cathinones represents stimulant substances exhibiting similar effects to amphetamine and its derivatives. Despite potentially being less psychoactive than amphetamine, synthetic cathinones are harmful substances for humans, and little or no information is available regarding their pharmacology and toxicology. The present study investigated the in vitro metabolism and metabolites of four recent synthetic cathinones, namely, 1-(4-methylphenyl)-2-(methylamino)-pentanone (4-MPD), 1-(4-methylphenyl)-2-dimethylamino-propanone (2-NMC), 1-(4-fluorophenyl)-2-(pyrrolidin-1-yl-hexanone (4F-PHP) and 1-(1,3-benzodioxol-5-yl)-2-(ethylamino)-1-pentanone (bk-EPDP). Our in vitro metabolism study resulted in 24 identified metabolites, including both phase I and phase II metabolites. All metabolites were detected and identified using liquid chromatography–high-resolution mass spectrometry and may serve as additional markers of abuse of these NPS in toxicological analyses.

Early Warning System for Illicit Drug Use at Large Public Events: Trace Residue Analysis of Discarded Drug Packaging Samples

Inspired by Locard's exchange principle, which states "every contact leaves a trace", a trace residue sampling strategy has been developed for the analysis of discarded drug packaging samples (DPS), as part of an early warning system for illicit drug use at large public events including music/dance festivals. Using direct analysis in real time/mass spectrometry and tandem mass spectrometry, rapid and high-throughput identification and characterization of a wide range of illicit drugs and adulterant substances was achieved, including in complex polydrug mixtures and at low relative ion abundances. A total of 1362 DPS were analyzed either off-site using laboratory-based instrumentation or on-site and in close to real time using a transportable mass spectrometer housed within a mobile analytical laboratory, with each analysis requiring less than 1 min per sample. Of the DPS analyzed, 92.2% yielded positive results for at least one of 15 different drugs and/or adulterants, including cocaine, MDMA, and ketamine, as well as numerous novel psychoactive substances (NPS). Also, 52.6% of positive DPS were found to contain polydrug mixtures, and a total of 42 different drug and polydrug combinations were observed throughout the study. For analyses performed on-site, reports to key stakeholders including event organizers, first aid and medical personnel, and peer-based harm reduction workers could be provided in as little as 5 min after sample collection. Following risk assessment of the potential harms associated with their use, drug advisories or alerts were then disseminated to event staff and patrons and subsequently to the general public when substances with particularly toxic properties were identified.

Pharmacology and adverse effects of new psychoactive substances: synthetic cannabinoid receptor agonists

Over the last decade, new psychoactive substances (NPS) have continuously been the focus of the international society since their emergence on the illicit drug market. NPS can be classified into six groups including; synthetic cannabinoid receptor agonists (SCRAs), stimulants, opioids, dissociatives, sedatives/hypnotics, and classic hallucinogens with psychoactive effects. These are sold as "herbal incense," "bath salts," "legal highs," and "research chemicals". They can be synthesized easily with slight changes in the chemical moieties of known psychoactive substances. NPS are sold worldwide via on- and off-line markets without proper scientific evaluation regarding their safety or harmfulness. Abuse of NPS poses a serious public health issue, and systematic studies on their adverse effects are lacking. Therefore, it would be meaningful to collect currently available data in order to understand NPS and to establish viable solutions to cope with the various health issues related to them. In this article, we reviewed the general pharmacological characteristics, recent findings, and adverse effects of representative NPS; SCRAs. SCRAs are known as the most commonly abused NPS. Most SCRAs, cannabinoid receptor 1 and cannabinoid receptor 2 agonists, are often associated with severe toxicities, including cardiotoxicity, immunotoxicity, and even death, unlike natural cannabinoid Δ⁹-Tetrahydrocannabinol.

Extended Stability Evaluation of Selected Cathinones

Understanding the stability of drugs in a forensic toxicology setting is critical for the evaluation of drug concentrations. Synthetic cathinones are new psychoactive substances structurally derived from cathinone, the psychoactive component of Catha edulis ("khat"), a shrub that is indigenous to the Middle East and East Africa. Previous research has evaluated the stability of synthetic cathinones in biological matrices, including blood preserved with the combination of NaF and K2C2O4 used in gray-top tubes. However, it does not assess their stability in blood preserved with Na2EDTA, used for some clinical samples. Further, stability in unpreserved urine samples was only studied for two weeks. This research evaluates the stabilities of four Schedule I synthetic cathinones: mephedrone, MDPV (3,4-methylenedioxypyrovalerone), naphyrone, and α-PVP (alpha-pyrrolidinopentiophenone) at 20°C (room temperature), 4°C (refrigerator), and -20°C (freezer). Stability was assessed in methanolic and acetonitrile solutions, as well as in Na2EDTA-preserved blood and unpreserved urine. Solutions (1 mg/L) of each drug in each matrix stored in aliquots (100 μL, solvents; 1.2 mL, biological samples; n = 12) at each of the three temperatures for triplicate analysis on days 3, 7, 14, and 30. On day 0 of each study, three additional aliquots of each solution were analyzed. Biological samples underwent solid-phase extraction before analysis. All samples were analyzed in full-scan by gas chromatography-mass spectrometry (GC-MS). The results of this study show that under room temperature and refrigerator storage conditions, mephedrone, naphyrone, and MDPV will degrade in methanol. This degradation starts are early as day 3. Additionally, all four drugs will degrade in Na2EDTA-preserved human whole blood samples in at least one evaluated storage environment. However, when in acetonitrile-based working solutions and unpreserved urine samples, they proved to be more stable. Methanolic working solutions and samples of Na2EDTA-preserved blood containing these cathinones should be stored in the freezer and used or tested with urgency to ensure that quantitative sample analysis is as accurate as possible in forensic casework.

Designers Drugs—A New Challenge to Emergency Departments—An Observational Study in Poland

Background and Objective: In the last decade, the phenomenon of using new psychoactive substances (NPS), called designer drugs, has been on rise. Though their production and marketing in Poland is prohibited, reports of the Supreme Audit Office noted that young people are increasingly reaching for new intoxication agents in the form of designer drugs. There is a significant increase in the number of patients with NPS abuse admitted to the emergency departments. As NPS cannot be detected by standard tests for the presence of psychoactive substances, it is difficult to choose the appropriate therapeutic intervention. Therefore, the aim of the present study was to evaluate the patient characteristics in the population of adults and children suspected of using NPS and formulate the protocol for diagnosis and treatment. Materials and Method: The paper is based on a retrospective analysis of medical records of hospitalized patients in the Clinical Emergency Department of The Regional Specialist Hospital in Olsztyn (SKOR WSS, emergency department (ED)) and the Pediatric Emergency Department of the Provincial Specialist Children′s Hospital in Olsztyn (SORD WSSD, pediatric emergency department (PED)) between years 2013 to 2018. The patient records related to their general symptoms at admission, mental state and laboratory diagnostic tests were evaluated. Results: The majority of patients hospitalized due to the suspected use of NPS were adolescents in 2013–2016 and a reversal of this trend was observed in 2017–2018 when number of adults admitted to the emergency department (ED) due to NPS use was higher. The NPS abuse was significantly higher among male patients, alcoholics, people using other psychoactive substances, patients suffering from mental disorders and teenagers in difficult socio-economic family situations. Whereas, the most common symptoms among pediatric patients were co-ordination disorder and aggression, in adults mainly tachycardia and aggression was observed. The laboratory tests in significant number of adult patients showed leukocytosis and ketonuria. Conclusions: In the present study, no unambiguous toxidrome or biochemical pattern characteristic for using NPS was observed. However, evaluation of blood morphology, coagulation parameters, liver and kidney function can be helpful in the diagnostic and therapeutic process. Symptomatic treatment of patients, fluid therapy and sedation was sufficient in most cases to resolve the patient symptoms in 48 h.

Substance Use in Adolescents Presenting to the Emergency Department

Background:

Adolescent substance use is a dynamic public health problem. Adolescence is a unique developmental period involving overlapping biological, psychological, and social factors which increase the rates of initiation of substance use. The developing adolescent brain is particularly susceptible to the effects of substances and most adults with substance use disorders began to have symptoms and problems in their adolescent years. Yet, for various reasons, most adolescents who use, misuse, abuse, or are addicted to substances do not perceive the need for treatment.

Objective:

Drug and alcohol use among adolescents is a common presentation in hospital Emergency Departments (EDs) and presents in different forms including in association with intoxication, withdrawal states, or trauma associated with drug-related events. For many adolescents with substance use, the Emergency Department (ED) is the first point of contact with medical personnel and thus also serves as a potential entry point into treatment.

Methods:

This article reviews the common ways drug and alcohol problems present in the ED, clinical assessment of the patient and family, screening, laboratory testing, brief interventions in the ED, and referral to treatment beyond the ED.

Conclusion:

Guidelines on how to manage the shifting terrain of adolescent substance use presenting in EDs across the nation continue to evolve. We highlight that considerable further research is needed to inform effective ED protocols to address this important individual and public health safety concern. Systems of care models which include collaborative teams of diverse stake holders are needed to effectively manage adolescents with substance use disorders.

The Consumption of New Psychoactive Substances and Methamphetamine

BACKGROUND

The abuse of new psychoactive substances (NPS) and methamphetamine has severe adverse effects. Here we provide the first report of regional patterns in NPS and methamphetamine consumption in Germany, on the basis of epidemiologic data from six federal states (Bavaria, Hamburg, Hesse, North Rhine-Westphalia, Saxony, and Thuringia).

METHODS

Data were derived from the 2015 Epidemiological Survey of Substance Abuse (Epidemiologischer Suchtsurvey) and supplemented with additional cases from the federal states that were studied. The numbers of persons included in the representative samples of persons aged 18 to 64 in each state were 1916 (Bavaria), 1125 (Hamburg), 1151 (Hesse), 2008 (North Rhine-Westphalia), 1897 (Saxony), and 1543 (Thuringia). Potential risk factors for the lifetime prevalence of consumption were studied by logistic regression.

RESULTS

The lifetime prevalence of methamphetamine consumption in the individual states ranged from 0.3% (North Rhine-Westphalia) to 2.0% (Saxony). Thuringia and Saxony displayed values that were significantly higher than average. For NPS, the figures ranged from 2.2% (Bavaria) to 3.9% (Hamburg), but multivariate analysis revealed no statistically significant differences between the states. Higher age and higher educational level were associated with lower consumption of NPS and methamphetamine, while smoking and cannabis use were each associated with higher consumption.

CONCLUSION

NPS consumption is equally widespread in all of the federal states studied. Methamphetamine is rarely consumed; its consumption appears to be higher in Saxony and Thuringia. The risk factor analysis reported here should be interpreted cautiously in view of the low case numbers with respect to consumption.

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.

Assessment of rimonabant-like adverse effects of purported CB1R neutral antagonist / CB2R agonist aminoalkylindole derivatives in mice

BACKGROUND

Cannabinoids may be useful in the treatment of CNS disorders including drug abuse and addiction, where both CB1R antagonists / inverse agonists and CB2R agonists have shown preclinical efficacy. TV-5-249 and TV-6-41, two novel aminoalkylindoles with dual action as neutral CB1R antagonists and CB2R agonists, previously attenuated abuse-related effects of ethanol in mice.

PURPOSE

To further characterize these drugs, TV-5-249 and TV-6-41 were compared with the CB1R antagonist / inverse agonist rimonabant in assays relevant to adverse effects and cannabinoid withdrawal.

PROCEDURES AND FINDINGS

The cannabinoid tetrad confirmed that TV-5-249 and TV-6-41 were devoid of CB1R agonist effects at behaviorally-relevant doses, and neither of the novel drugs induced rimonabant-like scratching. Generalized aversive effects were assessed, and rimonabant and TV-5-249 induced taste aversion, but TV-6-41 did not. Schedule-controlled responding and observation of somatic signs were used to assess withdrawal-like effects precipitated by rimonabant or TV-6-41 in mice previously treated with the high-efficacy CB1R agonist JWH-018 or vehicle. Rimonabant and TV-6-41 dose-dependently suppressed response rates in all subjects, but TV-6-41 did so more potently in JWH-018-treated mice than in vehicle-treated mice, while rimonabant equally suppressed responding in both groups. Importantly, rimonabant elicited dramatic withdrawal signs, but TV-6-41 did not.

CONCLUSIONS

These findings suggest differences in both direct adverse effects and withdrawal-related effects elicited by rimonabant, TV-5-249, and TV-6-41, which could relate to neutral CB1R antagonism, CB2R agonism, or a combination of both. Both mechanisms should be explored and exploited in future drug design efforts to develop pharmacotherapies for drug dependence.

Polysubstance use profiles among electronic dance music party attendees in New York City and their relation to use of new psychoactive substances

BACKGROUND

Electronic Dance Music (EDM) party attendees are often polysubstance users and are at high risk for use of new psychoactive substances (NPS). We sought to identify patterns of use of common illegal drugs among EDM party attendees, sociodemographic correlates, and use of NPS as a function of patterns of use of more common drugs to inform prevention and harm reduction.

METHOD

Using time-space-sampling, 1045 individuals aged 18-40 were surveyed entering EDM parties in New York City. We queried past-year use of common illegal drugs and 98 NPS. We conducted latent class analysis to identify polysubstance use profiles of use of eight common drugs (i.e., ecstasy, ketamine, LSD, mushrooms, powder cocaine, marijuana, amphetamine, benzodiazepines). Relationships between drug classification membership and sociodemographics and use of drugs within six NPS categories were examined.

RESULTS

We identified four profiles of use of common drugs: non-polysubstance use (61.1%), extensive polysubstance use (19.2%), moderate polysubstance use/stimulants (12.8%), and moderate polysubstance use/psychedelics (6.7%). Those in the moderate/psychedelic group were at higher odds of using NPS with psychedelic-type effects (2C, tryptamines, and other "new" psychedelics; Ps<0.05). Extensive polysubstance users were at increased odds of reporting use of 2C drugs, synthetic cathinones ("bath salts"), tryptamines, other new (non-phenethylamine) psychedelics, new dissociatives, and synthetic cannabinoids (Ps<0.05).

CONCLUSION

NPS preference is linked to the profile of use of common drugs among individuals in the EDM scene. Most participants were identified as non-polysubstance users, but findings may help inform preventive and harm reduction interventions among those at risk in this scene.

A synthetic cannabinoid JWH-210 reduces lymphoid organ weights and T-cell activator levels in mice via CB2 receptors

The problem of new psychoactive substances (NPS) is emerging globally. However, the immunotoxicity of synthetic cannabinoids is not evaluated extensively yet. The purpose of the present study was to investigate whether synthetic cannabinoids (JWH-210 and JWH-030) induce adverse effects on lymphoid organs, viability of splenocytes and thymocytes, and immune cell activator and cytokines in mice. JWH-210 (10 mg/kg, 3 days, i.p.) is more likely to have cytotoxicity and reduce lymphoid organ weight than JWH-030 of ICR mice in vivo. We also demonstrated that JWH-210 administration resulted in the decrease of expression levels of T-cell activator including Cd3e, Cd3g, Cd74p31, and Cd74p41, while JWH-030 increased Cd3g levels. In addition, JWH-210 reduced expression levels of cytokines, such as interleukin-3, interleukin-5, and interleukin-6. Furthermore, we demonstrated that a CB₂ receptor antagonist, AM630 inhibited JWH-210-induced cytotoxicity, whereas a CB₁ receptor antagonist, rimonabant did not in primary cultured splenocytes. These results suggest that JWH-210 has a cytotoxicity via CB₂ receptor action and results in decrement of lymphoid organ weights, T-cell activator, and cytokine mRNA expression levels.

Synthetic Cannabinoid-Induced Immunosuppression Augments Cerebellar Dysfunction in Tetanus-Toxin Treated Mice

Synthetic cannabinoids are one of most abused new psychoactive substances. The recreational use of abused drug has aroused serious concerns about the consequences of these drugs on infection. However, the effects of synthetic cannabinoid on resistance to tetanus toxin are not fully understood yet. In the present study, we aimed to determine if the administration of synthetic cannabinoids increase the susceptibility to tetanus toxin-induced motor behavioral deficit and functional changes in cerebellar neurons in mice. Furthermore, we measured T lymphocytes marker levels, such as CD8 and CD4 which against tetanus toxin. JWH-210 administration decreased expression levels of T cell activators including cluster of differentiation (CD) 3ε, CD3γ, CD74p31, and CD74p41. In addition, we demonstrated that JWH-210 induced motor impairment and decrement of vesicle-associated membrane proteins 2 levels in the cerebellum of mice treated with tetanus toxin. Furthermore, cerebellar glutamatergic neuronal homeostasis was hampered by JWH-210 administration, as evidenced by increased glutamate concentration levels in the cerebellum. These results suggest that JWH-210 may increase the vulnerability to tetanus toxin via the regulation of immune function.

Synthetic Pot: Not Your Grandfather's Marijuana

In the early 2000s in Europe and shortly thereafter in the USA, it was reported that 'legal' forms of marijuana were being sold under the name K2 and/or Spice. Active ingredients in K2/Spice products were determined to be synthetic cannabinoids (SCBs), producing psychotropic actions via CB1 cannabinoid receptors, similar to those of Δ9-tetrahydrocannabinol (Δ9-THC), the primary active constituent in marijuana. Often abused by adolescents and military personnel to elude detection in drug tests due to their lack of structural similarity to Δ9-THC, SCBs are falsely marketed as safe marijuana substitutes. Instead, SCBs are a highly structural diverse group of compounds, easily synthesized, which produce very dangerous adverse effects occurring by, as of yet, unknown mechanisms. Therefore, available evidence indicates that K2/Spice products are clearly not safe marijuana alternatives.

Synthetic cannabinoid, JWH-030, induces QT prolongation through hERG channel inhibition

The problem of new psychoactive substance (NPS) abuse, which includes synthetic cannabinoids, is emerging globally, and the cardiotoxicity of these synthetic cannabinoids has not yet been evaluated extensively. In the present study, we investigated the effects of synthetic cannabinoids on the cytotoxicity, human Ether-à-go-go-related gene (hERG) channel, action potential duration (APD), and QT interval. The 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay showed that JWH-030 was more cytotoxic than JWH-210, JWH-250, and RCS4 in H9c2 cells at 0.1 μM. In addition, the cytotoxicity was associated with its pro-apoptotic effects as evidenced by the increase in caspase-3 levels. We demonstrated that a cannabinoid receptor type 2 (CB2) antagonist, AM630, inhibited JWH-030-induced cytotoxicity, whereas a CB1 antagonist, rimonabant, did not. Furthermore, fluorescence polarization assay showed JWH-030 to block the hERG channel (half-maximal inhibitory concentration, IC₅₀ was 88.36 μM). JWH-030 significantly reduced the APD at 90% repolarization (APD₉₀) in rabbit Purkinje fibers and decreased the left ventricular end diastolic pressure (LVEDP) in Langendorff-perfused Sprague-Dawley (SD) rat hearts at 30 μM. In addition, the electrocardiogram (ECG) measurement revealed that the intravenous injection of JWH-030 (0.5 mg kg^-1) prolonged the QT interval in SD rats. These results suggest that JWH-030 is cytotoxic and its cytotoxicity is mediated by its action on the CB2 receptor; it prolongs the QT interval by regulating ion current channels and APD.

Psychosis associated with acute recreational drug toxicity: a European case series

BACKGROUND

Psychosis can be associated with acute recreational drug and novel psychoactive substance (NPS) toxicity. However, there is limited data available on how common this is and which drugs are most frequently implicated. We describe a European case series of psychosis associated with acute recreational drug toxicity, and estimate the frequency of psychosis for different recreational drugs.

METHODS

The European Drug Emergencies Network (Euro-DEN) collects data on presentations to Emergency Departments (EDs) with acute recreational drug and NPS toxicity at 16 centres in ten countries. Euro-DEN data from October 2013 through September 2014 was retrospectively searched, and cases with psychosis were included. The proportion of cases with psychosis per drug was calculated in the searched Euro-DEN dataset.

RESULTS

Psychosis was present in 348 (6.3 %) of 5529 cases. The median (interquartile range) age was 29 (24-38) years, 276 (79.3 %) were male and 114 (32.8 %) were admitted to psychiatric ward. The drugs most commonly reported were cannabis in 90 (25.9 %) cases, amphetamine in 87 (25.0 %) and cocaine in 56 (16.1 %). More than one drug was taken in 189 (54.3 %) cases. Psychosis was frequent in those ED presentations involving tryptamines (4/7; 57.1 %), methylenedioxypyrovalerone (MDPV) (6/22; 27.3 %), methylphenidate (6/26; 23.1 %), lysergic acid diethylamide (LSD) (18/86; 20.9 %), psilocybe mushrooms (3/16; 18.8 %), synthetic cannabinoid receptor agonists (4/26; 15.4 %) and amphetamine (87/593; 14.7 %), but less common in those involving mephedrone (14/245; 5.7 %), methylenedioxymethamphetamine (MDMA) (20/461; 4.3 %) and methedrone (3/92; 3.3 %). Amphetamine was the most frequent drug associated with psychosis when only one agent was reported, with psychosis occurring in 32.4 % of these presentations.

CONCLUSION

The frequency of psychosis in acute recreational drug toxicity varies considerably between drugs, but is a major problem in amphetamine poisoning. In rapidly changing drug markets and patterns of use, the Euro-DEN sentinel network contributes to measuring the scale of drug-related harms in Europe beyond other more established indicators.

"Trip-Sitting" in the Black Hole: A Netnographic Study of Dissociation and Indigenous Harm Reduction

An array of dissociative novel psychoactive substances, including "methoxetamine," "3-MeO-PCP," and "methoxphenidine," have emerged as substitutes for the illicit substance "ketamine." A netographic research methodology aimed to describe online, dissociative novel psychoactive substance users' perceptions of risk, informed knowledge around use, and indigenous harm-reduction practices as advocated within online drug fora, so as to provide credible information which can be used to inform public online health education and drug prevention. Systematic Internet searches were performed using the terms "synthetic dissociative," "methoxetamine," "methoxphenidine," "diphenidine," "3-MeO-PCP," "4-MeO-PCP," "2-MDP," and "dissociative research chemical" in combination with "forum." Following screening of 3,476 forum threads with removal of duplicates and exclusion criteria, 90 user trip reports and 115 fora threads from seven drug fora websites were analyzed by conducting content analysis. Five themes emerged with 43 categories. The findings illustrated how forum activity within the cyber drug user community disseminated and exchanged "communal folk pharmacology" relating to the use of dissociative novel psychoactive substances. Further research and consistent monitoring of Internet drug fora are advised to explore variations in harm-reduction tactics throughout dissociative NPS populations, and to consider how existing harm-reduction initiatives are influencing these hard-to-reach groups.

Novel psychoactive substances

There has been a significant increase in the number of new intoxicants on the illegal drugs market globally, also in Norway. The substances are given the name NPS: Novel Psychoactive Substances, and are mainly sold over the Internet. Uncertain dosage of potent substances entails a risk of accidental overdose, and therefore serious intoxication and death. In this article we provide an overview of current knowledge with regard to these substances.

Neuropharmacology of New Psychoactive Substances (NPS): Focus on the Rewarding and Reinforcing Properties of Cannabimimetics and Amphetamine-Like Stimulants

New psychoactive substances (NPS) are a heterogeneous and rapidly evolving class of molecules available on the global illicit drug market (e.g smart shops, internet, “dark net”) as a substitute for controlled substances. The use of NPS, mainly consumed along with other drugs of abuse and/or alcohol, has resulted in a significantly growing number of mortality and emergency admissions for overdoses, as reported by several poison centers from all over the world. The fact that the number of NPS have more than doubled over the last 10 years, is a critical challenge to governments, the scientific community, and civil society [EMCDDA (European Drug Report), 2014; UNODC, 2014b; Trends and developments]. The chemical structure (phenethylamines, piperazines, cathinones, tryptamines, synthetic cannabinoids) of NPS and their pharmacological and clinical effects (hallucinogenic, anesthetic, dissociative, depressant) help classify them into different categories. In the recent past, 50% of newly identified NPS have been classified as synthetic cannabinoids followed by new phenethylamines (17%) (UNODC, 2014b). Besides peripheral toxicological effects, many NPS seem to have addictive properties. Behavioral, neurochemical, and electrophysiological evidence can help in detecting them. This manuscript will review existing literature about the addictive and rewarding properties of the most popular NPS classes: cannabimimetics (JWH, HU, CP series) and amphetamine-like stimulants (amphetamine, methamphetamine, methcathinone, and MDMA analogs). Moreover, the review will include recent data from our lab which links JWH-018, a CB1 and CB2 agonist more potent than Δ⁹-THC, to other cannabinoids with known abuse potential, and to other classes of abused drugs that increase dopamine signaling in the Nucleus Accumbens (NAc) shell. Thus the neurochemical mechanisms that produce the rewarding properties of JWH-018, which most likely contributes to the greater incidence of dependence associated with “Spice” use, will be described (De Luca et al., 2015a). Considering the growing evidence of a widespread use of NPS, this review will be useful to understand the new trends in the field of drug reward and drug addiction by revealing the rewarding properties of NPS, and will be helpful to gather reliable data regarding the abuse potential of these compounds.

Rising Threat; Bonsai

OBJECTIVES

In recent years, and especially in the past few months, the number of synthetic cannabinoid (bonsai) users has increased in our country. The aim of this study was to draw attention to the consumption of bonsai among young people and reveal the demographic and basic clinical characteristics of these users.

METHODS

This was a retrospective study conducted at the Ümraniye Training and Research Hospital. All of the adult patients (≥18 year old) with synthetic cannabinoid intoxication who presented to the Emergency Department throughout the two years of the study (July 1(st) 2012-June 30(th) 2014) were enrolled. The frequencies were given as the median and inter-quartile range).

RESULTS

197 patients were included in this study, with 190 male patients (96.4%) and 7 (3.6%) female patients. Two of the four hospitalized patients were exitus, 52 left on their own will and a total of 141 patients were discharged after 6-12 hours of observation in the ED.

CONCLUSIONS

The use of synthetic cannabinoids (bonsai) in the recent years, especially in the summer months of 2014 was investigated in this study. Although these patients can have a benign clinical course, the process can also be fatal. It should especially be noted that patients with depressed respiration, low GCS scores and high PaCO2 values are at higher risk for mortality and the necessity of early intubation should be kept in mind.

Clinical and toxicological findings of acute intoxication with synthetic cannabinoids and cathinones

Aim

Reporting of the analytical and clinical findings of synthetic cannabinoids and cathinones is essential in carrying out a complete clinical assessment of new psychoactive substances.

Methods

From 2012 to 2014, we examined synthetic cathinone and cannabinoid poisoning in six patients aged 22-42 years old. Analyses of these compounds were carried out using liquid chromatography-tandem mass spectrometry.

Results

The observed clinical symptoms were similar to those reported for intoxication with synthetic cathinones and cannabinoids. In cases of intoxication with synthetic cathinones, the psychiatric and neurological symptoms were long-lasting, and these compounds were detected in serum for 15-48 h after use. Although the clinical symptoms induced by the synthetic cannabinoids disappeared within several hours after use, the range of serum concentrations of these compounds was ≤5 ng/mL for 1-3 h after use. In one fatal case, in which high serum concentrations of synthetic cathinones and cannabinoids were detected, the most plausible cause of death was heart failure due to overdose with these drugs. The long-lasting symptoms induced by synthetic cathinones correlated with the long detection window in serum, whereas the early disappearance of symptoms induced by synthetic cannabinoids corresponded to the short detection window in serum.

Conclusions

This study shows that the profiles of synthetic cathinones and cannabinoids in serum are closely related to the duration of the toxic symptoms and that concomitant use of two psychoactive drugs with different pharmacological actions may have the potential for fatal cardiotoxicity.

Intravenous Lipid Emulsion Therapy for Acute Synthetic Cannabinoid Intoxication: Clinical Experience in Four Cases

There is no specific antidote for intoxication with synthetic cannabinoids. In this case series, we considered the efficiency of intravenous lipid emulsion therapy in four cases, who presented to emergency department with synthetic cannabinoid (bonzai) intoxication. The first patient had a GCS of 3 and a left bundle branch block on electrocardiography. The electrocardiography revealed sinus rhythm with normal QRS width after the treatment. The second patient had bradycardia, hypotension, and a GCS of 14. After intravenous lipid emulsion therapy, the bradycardia resolved, and the patient's GCS improved to 15. The third patient presented with a GCS of 8, and had hypotension and bradycardia. After the treatment, not only did the bradycardia resolve, but also the GCS improved to 15. The fourth patient, whose electrocardiography revealed accelerated junctional rhythm, had a GCS of 13. The patient's rhythm was sinus after the treatment. Cardiovascular recovery was seen in all four cases, and neurological recovery was also seen in three of them. Based on the fact that intravenous lipid emulsion is beneficial in patients intoxicated with lipophilic drugs, unstable patients presenting to the emergency department with acute synthetic cannabinoid intoxication may be candidates for intravenous lipid emulsion treatment.

A novel psychoactive substance poses a new challenge in the management of paranoid schizophrenia

Novel psychoactive substances (NPS), or 'legal highs' are becoming more commonly used as recreational substances in the UK. Their clinical effects are little known and vary considerably between substances. This case discusses a psychiatric inpatient who repeatedly used a stimulant NPS called 'el blanco' while on leave, precipitating relapses of his schizophrenia. The patient initially denied drug use, considering legal highs as different from drugs. The relationship between NPS use and mental state was eventually revealed on careful direct questioning. He recovered and was discharged following treatment with clozapine and education about NPS use. We suggest that specific questioning about NPS usage is added to routine psychiatric history taking and that patients using NPS should be educated about the substances' use.