Legal and Regulatory Issues Governing Cannabis and Cannabis-Derived Products in the United States

This chapter provides an in-depth discussion of the legal and regulatory frameworks surrounding cannabis in the United States, including federal law-as dictated by the Controlled Substances Act (CSA) and governed by various federal agencies like the FDA and DEA-as well as state law-as regulated by each state's laws and regulations authorizing medical and/or adult use cannabis. First, the chapter discusses the definition and classification of cannabis under the CSA, including scheduling under the CSA as well as the process for and potentiality of removing cannabis from Schedule I. Then, it describes the activities relating to industrial hemp that are permitted under the 2014 and 2018 Farm Bill. Next, the chapter addresses state-level cannabis laws. The chapter also analyzes the question of whether state cannabis laws are invalidated and superseded by federal law. Moreover, this section examines the factors underlying the extent of the Department of Justice's enforcement actions relating to state-authorized cannabis activities. The chapter then turns to CBD (cannabidiol) in particular, discussing CBD's legal status under the CSA; the FDA's role in regulating and approving CBD products for medical purposes; and the steps required to take an investigational CBD product through that approval process. The chapter concludes by contending that, while cannabis has had a long and twisting history, and although cannabis-derived products face daunting obstacles to achieving FDA approval as well as rescheduling under both federal and state law, the recent success of one product (Epidiolex®) should inspire other manufacturers to develop additional cannabis-derived products through the FDA process.

Internet search and krokodil in the Russian Federation: an infoveillance study

BACKGROUND

Krokodil is an informal term for a cheap injectable illicit drug domestically prepared from codeine-containing medication (CCM). The method of krokodil preparation may produce desomorphine as well as toxic reactants that cause extensive tissue necrosis. The first confirmed report of krokodil use in Russia took place in 2004. In 2012, reports of krokodil-related injection injuries began to appear beyond Russia in Western Europe and the United States.

OBJECTIVE

This exploratory study had two main objectives: (1) to determine if Internet search patterns could detect regularities in behavioral responses to Russian CCM policy at the population level, and (2) to determine if complementary data sources could explain the regularities we observed.

METHODS

First, we obtained krokodil-related search pattern data for each Russia subregion (oblast) between 2011 and 2012. Second, we analyzed several complementary data sources included krokodil-related court cases, and related search terms on both Google and Yandex to evaluate the characteristics of terms accompanying krokodil-related search queries.

RESULTS

In the 6 months preceding CCM sales restrictions, 21 of Russia's 83 oblasts had search rates higher than the national average (mean) of 16.67 searches per 100,000 population for terms associated with krokodil. In the 6 months following restrictions, mean national searches dropped to 9.65 per 100,000. Further, the number of oblasts recording a higher than average search rate dropped from 30 to 16. Second, we found krokodil-related court appearances were moderately positively correlated (Spearman correlation=.506, P≤.001) with behaviors consistent with an interest in the production and use of krokodil across Russia. Finally, Google Trends and Google and Yandex related terms suggested consistent public interest in the production and use of krokodil as well as for CCM as analgesic medication during the date range covered by this study.

CONCLUSIONS

Illicit drug use data are generally regarded as difficult to obtain through traditional survey methods. Our analysis suggests it is plausible that Yandex search behavior served as a proxy for patterns of krokodil production and use during the date range we investigated. More generally, this study demonstrates the application of novel methods recently used by policy makers to both monitor illicit drug use and influence drug policy decision making.

Who uses a prescription drug monitoring program and how? Insights from a statewide survey of Oregon clinicians

Prescription drug monitoring programs (PDMPs) are relatively new but potentially useful tools to enhance prudent prescribing of controlled substances. However, little is known about the types of clinicians who make the most use of PDMPs, how these programs are incorporated into clinicians' work flow, or how clinicians and patients respond to the information. We therefore surveyed a random sample of Oregon providers, with 1,065 respondents. Clinicians in emergency medicine, primary care, and pain and addiction specialties were the largest number of registrants, but many frequent prescribers of controlled substances were not registered to use the PDMP. Among users, 95% reported accessing the PDMP when they suspected a patient of abuse or diversion, but fewer than half would check it for every new patient or every time they prescribe a controlled drug. Nearly all PDMP users reported that they discuss worrisome PDMP data with patients; 54% reported making mental health or substance abuse referrals, and 36% reported sometimes discharging patients from the practice. Clinicians reported frequent patient denial or anger and only occasional requests for help with drug dependence. More research is needed to optimize how clinicians use PDMPs across settings and how clinicians and patients respond to the data.

PERSPECTIVE

This study examined differences between PDMP users and nonusers and how clinicians in various specialties use PDMPs in practice. A better understanding of effective PDMP use will facilitate access to treatment for patients with pain while curbing the prescription drug epidemic and may ultimately reduce abuse, misuse, and overdose death.

Forensic Mass Spectrometry

Developments in forensic mass spectrometry tend to follow, rather than lead, the developments in other disciplines. Examples of techniques having forensic potential born independently of forensic applications include ambient ionization, imaging mass spectrometry, isotope ratio mass spectrometry, portable mass spectrometers, and hyphenated chromatography-mass spectrometry instruments, to name a few. Forensic science has the potential to benefit enormously from developments that are funded by other means, if only the infrastructure and personnel existed to adopt, validate, and implement the new technologies into casework. Perhaps one unique area in which forensic science is at the cutting edge is in the area of chemometrics and the determination of likelihood ratios for the evaluation of the weight of evidence. Such statistical techniques have been developed most extensively for ignitable-liquid residue analyses and isotope ratio analysis. This review attempts to capture the trends, motivating forces, and likely impact of developing areas of forensic mass spectrometry, with the caveat that none of this research is likely to have any real impact in the forensic community unless: (a) The instruments developed are turned into robust black boxes with red and green lights for positives and negatives, respectively, or (b) there are PhD graduates in the workforce who can help adopt these sophisticated techniques.

Enantiomeric separations of illicit drugs and controlled substances using cyclofructan-based (LARIHC) and cyclobond I 2000 RSP HPLC chiral stationary phases

Recently a novel class of chiral stationary phases (CSPs) based on cyclofructan (CF) has been developed. Cyclofructans are cyclic oligosaccharides that possess a crown ether core and pendent fructofuranose moieties. Herein, we evaluate the applicability of these novel CSPs for the enantiomeric separation of chiral illicit drugs and controlled substances directly without any derivatization. A set of 20 racemic compounds were used to evaluate these columns including 8 primary amines, 5 secondary amines, and 7 tertiary amines. Of the new cyclofructan-based LARIHC columns, 14 enantiomeric separations were obtained including 7 baseline and 7 partial separations. The LARIHC CF6-P column proved to be the most useful in separating illicit drugs and controlled substances accounting for 11 of the 14 optimized separations. The polar organic mode containing small amounts of methanol in acetonitrile was the most useful solvent system for the LARIHC CF6-P CSP. Furthermore, the LARIHC CF7-DMP CSP proved to be valuable for the separation of the tested chiral drugs resulting in four of the optimized enantiomeric separations, whereas the CF6-RN did not yield any optimum separations. The broad selectivity of the LARIHC CF7-DMP CSP is evident as it separated primary, secondary and tertiary amine containing chiral drugs. The compounds that were partially or un-separated using the cyclofructan based columns were screened with a Cyclobond I 2000 RSP column. This CSP provided three baseline and six partial separations.

New Psychoactive Substances: A Matter of Time

In the last few years, a wide range of new psychoactive substances (NPS) have been produced and marketed to elude the controlled substance lists. These molecules enter the traditional illegal and web market with poor knowledge about their toxicity, mechanism of action, metabolism, abuse potential so that they are directly tested by the consumers. This perspective highlights the main issues connected with NPS: the celerity they enter and leave the market once included in the banning laws to be substituted by new legal analogues; the unavailability of analytical screening tests and certified standards to perform toxicological analyses; the time lag between NPS identification and inclusion in the controlled substances lists. Finally, the authors take a snapshot of the commitment of the Italian Early Warning System in highlighting the recent seizures of NPS as well as the distribution of NPS related intoxication and deaths as an example of what is happening in the European countries and internationally.

Best practices in developing a national palliative care policy in resource limited settings: lessons from five African countries

Given the high unmet need for palliative care in Africa and other resource limited settings, it is important that countries embrace the public health approach to increasing access through its integration within existing healthcare systems. To give this approach a strong foundation that would ensure sustainability, the World Health Organisation urges member states to ensure that policy environments are suitable for this intervention. The development, strengthening, and implementation of national palliative care policies is a priority. Given the lack of a critical mass of palliative care professionals in the region and deficiency in documenting and sharing best practices as part of information critical for regional development, policy development becomes a complex process. This article shares experiences with regard to best practices when advocating the national palliative care policies. It also tells about policy development process, the important considerations, and cites examples of policy content outlines in Africa.

Overview of four prescription monitoring/review programs in Canada

BACKGROUND

Prescription monitoring or review programs collect information about prescription and dispensing of controlled substances for the purposes of monitoring, analysis and education. In Canada, it is the responsibility of the provincial institutions to organize, maintain and run such programs.

OBJECTIVE

To describe the characteristics of four provincial programs that have been in place for >6 years.

METHODS

The managers of the prescription monitoring⁄review programs of four provinces (British Columbia, Alberta, Saskatchewan and Nova Scotia) were invited to present at a symposium at the Canadian Pain Society in May 2012. In preparation for the symposium, one author collected and summarized the information.

RESULTS

Three provinces have a mix of review and monitoring programs; the program in British Columbia is purely for review and education. All programs include controlled substances (narcotics, barbiturates and psychostimulants); however, other substances are differentially included among the programs: anabolic steroids are included in Saskatchewan and Nova Scotia; and cannabinoids are included in British Columbia and Nova Scotia. Access to the database is available to pharmacists in all provinces. Physicians need consent from patients in British Columbia, and only professionals registered with the program can access the database in Alberta. The definition of inappropriate prescribing and dispensing is not uniform. Double doctoring, double pharmacy and high-volume dispensing are considered to be red flags in all programs.

CONCLUSIONS

There is variability among Canadian provinces in managing prescription monitoring⁄review programs.

Prescriber response to unsolicited prescription drug monitoring program reports in Massachusetts

PURPOSE

To describe prescriber response to unsolicited patient reports from the Massachusetts prescription drug monitoring program (PDMP).

METHODS

Prescribers were surveyed upon receipt of unsolicited reports of their patients' prescription history and three months later. We assessed prescribers' awareness of other prescribers listed in the report, their clinical assessment of medical necessity of all prescribed medications, actions taken by prescribers after receiving the report, and usefulness of the report.

RESULTS

Of the 333 respondents to the initial survey, only 28 (8.4%) were aware of most, all, or nearly all other prescribers. A total of 146 (43.8%) reported having sufficient knowledge to determine whether the prescriptions were medically necessary, of whom 102 (69.6%) felt the prescriptions were unwarranted. Of the 163 respondents to the follow-up survey, 31.3% added the report to the patient's file, 22.7% discussed the report with other prescribers on the report, 21.5% took no action, and 6% discussed the report with the patient (representing two-thirds of respondents who saw the patient after receiving the report). Most respondents felt that the report was useful for their practice and easy to understand.

CONCLUSIONS

Unsolicited reporting of PDMP data has the potential to improve clinical practice by alerting providers about patients with multiple prescribers and potentially medically unnecessary prescriptions.

Predicting Opioid Use Following Discharge After Cesarean Delivery

PURPOSE

Although cesarean delivery is the most common surgical procedure in the United States, postoperative opioid prescribing varies greatly. We hypothesized that patient characteristics, procedural characteristics, or both would be associated with high vs low opioid use after discharge. This information could help individualize prescriptions.

METHODS

In this prospective cohort study, we quantified opioid use for 4 weeks following hospital discharge after cesarean delivery. Predischarge characteristics were obtained from health records, and patients self-reported total opioid use postdischarge on weekly questionnaires. Opioid use was quantified in milligram morphine equivalents (MMEs). Binomial and Poisson regression analyses were performed to assess predictors of opioid use after discharge.

RESULTS

Of the 233 patients starting the study, 203 (87.1%) completed at least 1 questionnaire and were included in analyses (86.3% completed all 4 questionnaires). A total of 113 patients were high users (>75 MMEs) and 90 patients were low users (≤75 MMEs) of opioids postdischarge. The group reporting low opioid use received on average 44% fewer opioids in the 24 hours before discharge compared with the group reporting high opioid use (mean = 33.0 vs 59.3 MMEs, P <.001). Only a minority of patients (11.4% to 15.8%) stored leftover opioids in a locked location, and just 31 patients disposed of leftover opioids.

CONCLUSIONS

Knowledge of predischarge opioid use can be useful as a tool to inform individualized opioid prescriptions, help optimize nonopioid analgesia, and reduce opioid use. Additional studies are needed to evaluate the impact of implementing such measures on prescribing practices, pain, and functional outcomes.

Massachusetts Dental Schools Respond to the Prescription Opioid Crisis: A Statewide Collaboration

The prescription opioid crisis has involved all sectors of U.S. society, affecting every community, socioeconomic group, and age group. While federal and state agencies are actively working to deal with the epidemic, medical and dental providers have been tasked to increase their awareness of the issues and consider ways to safely prescribe opioids and, at the same time, effectively treat their patients' pain. The Commonwealth of Massachusetts, under the leadership of Governor Charles D. Baker and his administration, challenged the state's four medical schools and three dental schools to improve their curricula to prepare the next generation of clinicians to deal with this crisis in an evidence-based, effective, and sympathetic way. This Perspectives article outlines the national prescription opioid crisis, details its effects in Massachusetts, and describes the interdisciplinary collaboration among the Commonwealth, the three dental schools, the Massachusetts Dental Society, and a concerned student group. The article also describes the efforts each dental school is undertaking as well as an assessment of the challenges and limitations in implementing the initiative. The authors hope that the Massachusetts model will be a useful resource for dental schools in other states.

Medicinal Cannabis: Policy, Patients, and Providers

Medicinal cannabis is legal in some form in 47 states, 3 United States territories, and the District of Columbia. An estimated three million Americans use cannabis for relief of a variety of illnesses, and this figure is expected to grow based on policy changes. However, cannabis remains illegal at the federal level as a Schedule I drug under the 1970 Controlled Substances Act. Schedule I classification of cannabis has impeded the advancement of research, leaving providers with little evidence-based information to educate their patients. Furthermore, the disparities in individual state laws create significant social and health inequities in gaining access to medicinal cannabis. Conflicting state and federal policies regarding medicinal cannabis create logistical and ethical dilemmas, and all U.S. stakeholders-patients, providers, and health delivery systems-may be impacted by conflicting federal and state policies. This brief addresses the impact of conflicting cannabis policies.

Reducing Opioid Misuse: Evaluation of a Medicaid Controlled Substance Lock-In Program

Opioid misuse, abuse, and overdose are a rapidly growing public health epidemic. Medicaid Lock-In Programs (MLIPs) are designed to prevent overutilization of controlled substances by Medicaid patients. However, despite widespread use, there is little information on their effect. Using North Carolina (NC) Medicaid claims data from October 2008 through June 2013, we examined changes in Medicaid-reimbursed opioid prescriptions by patients enrolled in NC's MLIP. We used mixed effects models to examine the effect of MLIP enrollment on monthly opioid claims, number of pharmacies, total days' supply, total units (ie, pills), and total Medicaid payments for opioids. In our sample of 6,148 MLIP patients, the odds of having any opioid claim in a given month was 84% lower during MLIP enrollment relative to the period before enrollment (odds ratio = .16). MLIP enrollment also corresponded with a reduction in monthly number of opioid prescriptions by 1.13, monthly number of pharmacies by .61, and monthly Medicaid expenditures by $22.78. Although MLIPs may constitute a successful component of comprehensive efforts to reduce the potential overutilization of opioids, care should be taken to ensure that programs such as MLIPs do not constrain patients' legitimate needs for analgesic medications.

PERSPECTIVE

Enrollment in NC's MLIP reduced the likelihood that patients would present a claim for an opioid prescription, and the number of opioid prescriptions patients secured each month. MLIPs may constitute a successful strategy for reducing the misuse, abuse, and diversion of prescription opioids. However, further research is needed to examine the program's potential unintended consequences.

Prescription Drug Monitoring Programs and Pharmacist Orientation Toward Dispensing Controlled Substances

OBJECTIVES

We sought to understand how pharmacists viewed and used a newly implemented prescription drug monitoring program (PDMP). We also sought to understand pharmacist orientation toward dispensing of controlled substances and the people who obtain them.

METHODS

We conducted three mini focus groups. The focus group findings were used to inform the design of a structured survey. We emailed a survey to 160 pharmacists who were employed in one statewide community chain store; we obtained 48 survey responses.

RESULTS

Focus groups findings suggested that, in relation to the dispensing of scheduled prescription medication, pharmacists were either "healthcare" oriented, "law-enforcement" oriented, or an orientation that combined these two perspectives. Surveys suggested that pharmacists found PDMPs easy to use and that they used them frequently - often to contact physicians directly. Surveys suggested that pharmacists were typically either "healthcare" oriented or "mixed" (combined perspectives). Pharmacist orientation was associated with the frequency with which they counseled patients about medication risk and the frequency with which they used the PDMP as the basis for contacting prescribers.

CONCLUSIONS

Ongoing tracking of pharmacists' use of PDMPs is important both at the implementation stage and as PDMPs develop over time. The orientation construct developed here is useful in understanding pharmacist behavior and attitudes towards patients potentially at risk for misuse of controlled substance medications. Further research on this construct could shed light on barriers and incentives for pharmacist PDMP participation and use and provide guidance for pharmacist training, ultimately enhancing patient care.

Opioids and the Internet: Convergence of Technology and Policy to Address the Illicit Online Sales of Opioids

The United States is in the midst of an opioid public health emergency, one that is also influenced by a convergence of Internet-based technology, health policy, and the need for stakeholder collaboration and action around the need to combat the illicit online sales of opioids by illegal online pharmacies and digital drug dealers. This risk is not new, however, with calls to actively reduce online opioid availability as online pharmacies use a growing array of digital channels, including search engines, social media platforms, and the dark Web. In response, the US Food and Drug Administration convened a special June 2018 summit bringing together technology companies, government agencies, researchers, and advocacy groups with the goal of collaboratively developing and implementing solutions to tackle the problem. Yet after this meeting, stakeholders remain fragmented in approaches despite the availability of technology that can detect, classify, and report illicit sellers who are in direct violation of Federal law. Despite ongoing challenges, advances in data science and the resources and expertise technology companies can contribute will be a key factor in ensuring that the Internet helps end and not fuel the public health emergency of opioid abuse.

Advances in prescription drug monitoring program research: a literature synthesis (June 2018 to December 2019)

PURPOSE OF REVIEW

Nearly every U.S. state operates a prescription drug monitoring program (PDMP) to monitor dispensing of controlled substances. These programs are often considered key policy levers in the ongoing polydrug epidemic. Recent years have seen rapid growth of peer-reviewed literature examining PDMP consultation and the impacts of these programs on diverse patient populations and health outcomes. This literature synthesis presents a review of studies published from June 2018 to December 2019 and provides relevant updates from the perspective of three researchers in this field.

RECENT FINDINGS

The analyzed studies were primarily distributed across three overarching research focus areas: outcome evaluations (n = 29 studies), user surveys (n = 23), and surveillance (n = 22). Identified themes included growing awareness of the unintended consequences of PDMPs on access to opioids, effects on benzodiazepines and stimulant prescribing, challenges with workflow integration across multiple specialties, and new opportunities for applied data science.

SUMMARY

There is a critical gap in existing PDMP literature assessing how these programs have impacted psychiatrists, their prescribing behaviors, and their patients. Although PDMPs have improved population-level monitoring of controlled substances from medical sources, their role in responding to a drug epidemic shifting to illicitly manufactured drugs is under scrutiny.

Ensuring safe access to medication for palliative care while preventing prescription drug abuse: innovations for American inner cities, rural areas, and communities overwhelmed by addiction

This article proposes and develops novel components of community-oriented programs for creating and affording access to safe medication dispensing centers in existing retail pharmacies and in permanent or travelling pharmacy clinics that are guarded by assigned or off-duty police officers. Pharmacists at these centers would work with police, medical providers, social workers, hospital administrators, and other professionals in: planning and overseeing the safe storage of controlled substance medications in off-site community safe-deposit boxes; strengthening communication and cooperation with the prescribing medical provider; assisting the prescribing medical provider in patient monitoring (checking the state prescription registry, providing pill counts and urine samples); expanding access to lower-cost, and in some cases, abuse-resistant formulations of controlled substance medications; improving transportation access for underserved patients and caregivers to obtain prescriptions; and integrating community agencies and social networks as resources for patient support and monitoring. Novel components of two related community-oriented programs, which may be hosted outside of safe medication dispensing centers, are also suggested and described: (1) developing medication purchasing cooperatives (ie, to help patients, families, and health institutions afford the costs of medications, including tamper-or abuse-resistant/deterrent drug formulations); and (2) expanding the role of inner-city methadone maintenance treatment programs in palliative care (ie, to provide additional patient monitoring from a second treatment team focusing on narcotics addiction, and potentially, to serve as an untapped source of opioid medication for pain that is less subject to abuse, misuse, or diversion).

Tamper-resistant prescription forms for narcotics in France: Should we generalize them?

In France, prescription of narcotics must be written on a tamper-resistant prescription form with specific technical particularities. Dosage and daily dose of medicines shall be written out entirely in letters. These prescription forms are also mandatory for buprenorphine, clorazepate, clonazepam, tianeptine, buccal midazolam and zolpidem owing to traffic, abuse or diversion. In 2012, to assess the use of standard and tamper-resistant prescription forms and the acceptability of the generalization of the latter to all medicines, a national opinion survey was performed, with a postal questionnaire, within three randomized samples of 1500 prescribers (physicians, dentists and midwives). Of the 403 participating prescribers (participation rate of 26.8%), 373 were physicians, 14 dentists and 16 midwives. Tamper-resistant prescription forms were used by 76.2% of prescribers, but only by 5.1% in a computerized version, whereas for standard prescription forms, 61% used computer assisted prescription software. The main reason was the inability of the prescription software to print these forms or to respect the mandatory prescription rules for narcotics. Theft and falsification of prescriptions had ever occurred (working life). Most prescribers (62.5%) were against the generalization of tamper-resistant prescription forms. Those in favour were for a generalization to all medicines (65%) and not only to psychotropic agents. Generalization of tamper-resistant prescription forms is not a consensual solution to prevent medicines' diversion. Some prescribers alluded to the possibility of dematerialization and electronic transmission of prescription forms, which could avoid theft, forgery or falsification.

The Psilocin (4-hydroxy-N,N-dimethyltryptamine) and Bufotenine (5-hydroxy-N,N-dimethyltryptamine) Case: Ensuring the Correct Isomer has Been Identified

Psilocin (4-hydroxy-N,N-dimethyltryptamine, 4-HO-DMT) and bufotenine (5-hydroxy-N,N-dimethyltryptamine, 5-HO-DMT), which are both naturally occurring compounds, are classified as controlled substances in numerous countries due to their pharmacological activities and recreational usage. There are two other benzene ring regioisomers, 6-hydroxy-N,N-dimethyltryptamine (6-HO-DMT) and 7-hydroxy-N,N-dimethyltryptamine (7-HO-DMT), which are not classified by name as controlled substances, and which were synthesized for this current work. The four isomers were analyzed using routine methodologies employed by the Israel's Police Division of Identification and Forensic Science (DIFS) Laboratory, namely thin layer chromatography (TLC), Fourier transform infrared spectroscopy (FTIR), and gas chromatography mass spectroscopy (GC-MS). It was found possible to differentiate the four isomers. Forensic specimens that were suspected to be psilocybe mushrooms were examined, confirming that it is now possible to unequivocally identify the presence of psilocin and rule out the presence of its other isomers.

Preventing large-scale controlled substance diversion from within the pharmacy

Large-scale diversion of controlled substances (CS) from within a hospital or heath system pharmacy is a rare but growing problem. It is the responsibility of pharmacy leadership to scrutinize control processes to expose weaknesses. This article reviews examples of large-scale diversion incidents and diversion techniques and provides practical strategies to stimulate enhanced CS security within the pharmacy staff. Large-scale diversion from within a pharmacy department can be averted by a pharmacist-in-charge who is informed and proactive in taking effective countermeasures.

Prescription patterns of benzodiazepines in the Lebanese adult population: a cross-sectional study

This study assessed the profile of benzodiazepine (BDZ) users in Lebanon. Adult patients visiting the pharmacies with prescriptions of BDZs were included in the study. Seven hundred and eighty-six current BDZ users were included, of whom 54.2% were females. Twenty-three percent reported being alcohol consumers and were mostly males. The two most commonly used BDZs were alprazolam (34.6%) and bromazepam (33.6%). The indication for use was mainly anxiety (44.4%), insomnia (22.5%), and depression (15.9%). The prescribing physicians were primarily psychiatrists (43.2%), followed by general practitioners (29.7%). Forty percent had been taking the drug for more than a year. Among those using BDZs for at least 1 month, 35.5% increased the dose with time. Thirty-three percent reported having experienced side effects. Eighteen patients (2.3%) reported taking more than one BDZ concomitantly, while 18.3% were taking drugs that should not be prescribed along with BDZs. In conclusion, the use of BDZs is highest among females, especially for the treatment of anxiety. Moreover, continuous use of the drugs for more than a year as well as significant potential drug interactions was identified.

Perceptions and experiences of laws and regulations governing access to opioids in South, Southeast, East and Central Asia: A systematic review, critical interpretative synthesis and development of a conceptual framework

BACKGROUND

Opioids are essential medicines. Despite international and national laws permitting availability, opioid access remains inadequate, particularly in South, Southeast, East and Central Asia.

AIM

To review evidence of perceptions and experiences of regulatory enablers and barriers to opioid access in South, Southeast, East and Central Asia.

DESIGN

Systematic review of post-2000 research according to PRISMA guidelines. Data were subjected to critical interpretive synthesis. International, national and sub-national barriers were organised developing a conceptual framework of opioid availability.

DATA SOURCES

PsycINFO, Medline, Embase, The Cochrane Library. CINAHL, Complete and ASSIA from 2000 until 20th May 2019.

RESULTS

21/14097 studies included: quantitative n = 15, qualitative n = 3 and mixed-methods n = 3. Four barrier/enabler themes were developed: Legal, regulatory, socio-political; lack of laws explicitly enabling opioid access, restrictive international controls and clinician prescribing concerns. Opioid availability; limited availability, poor policymaker and clinician education regarding opioid benefits, poor continuity of supply. Opioid Accessibility; medicine costs, distance to prescribing centres. Prescribing; extensive bureaucratic barriers, lack of human resources for prescribing. We present a novel framework of a self-perpetuating model of inadequate opioid provision. The Single Convention on Narcotics provides the context of restrictive laws and negative attitudes amongst policymakers. A consequent lack of prescribers and clinicians' negative attitudes at sub-national levels, results in inadequate access to and use of opioids. Data of inadequate consumption informs annual requirement estimates used by the International Narcotics Control Board to determine future opioid availability.

CONCLUSIONS

Regulatory and socio-political actions unintentionally limit opioid access. International and national laws explicitly enabling opioid access are required, to assuage concerns, promote training and appropriate prescribing.

Evaluating novel silica hydride-based stationary phases for the analysis of phytocannabinoids and other psychoactive drugs

Three silica hydride based novel chromatographic phases chemically-bonded with allyloxy-DL-alpha-tocopherol, allylpentafluorophenyl, and 1-eicosene moieties were evaluated as separation media for selected phytocannabinoids and other substances of abuse. In order to assess column selectivity, a series of reference standards was analyzed and detected by using liquid chromatography with mass spectrometry. Further, quantitative detections of cannabidiol and tetrahydrocannabinol were attempted for the extracts of cannabis plants and cannabidiol gummy formulation. For potential bioanalytical applications, the columns were evaluated for substance screening in a human urine matrix. In summary, the newly developed columns are functional and effective for the analysis of phytocannabinoids and various psychoactive drugs with or without the presence of biological matrices.

Identification of 1-(2,3-dihydro-1H-inden-5-yl)-2-(ethylamino)pentan-1-one (bk-IVP) in a Seized Drug Exhibit

To circumvent the law by evading regulation and obscuring their identities in routine analyses, numerous substituted cathinones have entered the illicit drug market. These compounds have been coined "bath salts" by users. In the described case, the laboratory received an unknown white powder for controlled substances identification. The sample could not be immediately identified using standard methods and procedures. Ultimately, the structure was elucidated using GC-MS, NMR, FTIR, GC-SPIR, UV, and color tests to be 1-(2,3-dihydro-1H-inden-5-yl)-2-(ethylamino)pentan-1-one (bk-IVP), a cathinone analog with a rarely observed nonoxygenated bicyclic ring system. Features of spectra and chemical tests are reported that distinguish this class of cathinones from heterocyclic analogs.