Novel Psychoactive SubstancesRICHARD.STEVENSON@NHS.NET

NPS Background Confusing terminology

“Designer Drugs” “Bath Salts” “Legal Highs” Definition

“Psychoactive drugs, newly available in the UK, which are not prohibited by the United Nations Drug Conventions but which may pose a public health threat comparable to that posed by

substances listed in these conventions”

History of NPS Drugs often developed decades ago

2008 mephedrone identified as clinical concern

Hundreds of drugs identified since

Marked geographical variations

98% users have used controlled substance prior

Supply of NPS “Head shops”, Internet, Dealers ,Mates!

Branding Various compounds branded under the same name e.g. “burst” “Research chemicals” Marked “not for human consumption”

FEWS analysis 61% 2 active drugs 30% 3 active components 88% festival samples contained controlled drugs 2013/2014

Challenges Unknown toxicology

◦ Mechanism of action◦ Duration of action◦ Metabolism◦ Interactions (including prescription drugs)◦ Short term & long term harms

Identification of use◦ Self reporting◦ Post-mortem toxicology◦ Role of urine toxicology screens

Clinical Presentations Concern over health

Extended duration of symptoms

Abnormal behaviours◦ Mild abnormalities◦ Drug induced psychoses◦ Acute behavioural disturbance

Acute drug toxicity

Harm associated with intoxication

Consequences of method of drug use

Local Demographics Ages from 12 to 50

Equal sex distribution

Depends on the substance

Polysubstance use is markedly prevalent◦ Alcohol +++

Approx 44 needle exchange service users NPS

MSM and “slamming”

Synthetic Cannabinoids Sold openly from head shops

Annihilation, Psy-clone, Clockwork Orange, Damnation, Exodus etc

Potent endogenous cannabinoid receptor agonists

Commonly smoked, ? “vaping”

Often present with Nausea +++ Collapse Dissociation, coma Drug induced psychosis

Benzodiazepines Phenzepam, etizolam, diclazepam

1mg = 10mg diazepam

May or may not be detected on urine drug screens

Increasingly responsible for presumed opiate toxicity

Recent study from Abertay Uni & Police Scotland “street blues” found to contain from 8mg to 48mg diazepam Phenazepam & etizolam detected

Ketamine Mimics & Hallucinogens

Methoxetamine, 3-MePCP, methoxphenidine◦ Induce dissociation NMDA receptor antagonists◦ Prolonged duration of action◦ Cerebellar signs

N-BOMe, DOC

Sold on blotters (like LSD)

20 hour duration of action

Drug induced psychosis and threat to life behaviours

Cathinones Mephedrone, methedrone, butylone, MDPV

Meow Meow, bubbles, M-CAT, Meph (not meth or “ma meff!)

Similar mechanism of actions ◦ Catecholamine reuptake inhibitors◦ Dopamine releasers (particularly MDPV)

Commonly ingested, but insufflated, injected, and “bumping”

Predominantly stimulant effects, but some MDMA mimicry

Ethylphenidate Sold as “burst”

Ethylphenidate +/- benzocaine

Responsible for major outbreak of drug induced psychosis in Lothian

Related to methylphenidate but much more potent

Addictive Multiple hits per day (some over 6 times) Risky injecting sites Predominantly ex-heroin users who were stable

Injecting wounds causing significant concerns

Ecstasy Mimics BZP, PMA/PMMA, Benzo Fury, AMT, MDAI

Often sold as Ecstasy, or “legal equivalents” (most now illegal)

Mimic the empathogenic effect

Potent inducers of serotonin toxicity

Serotonin Toxicity Characterised by

Increased muscle activity Abnormal mental status Autonomic instability

Spectrum of toxicity

5-HT2A receptor thought to be responsible

Increased level of serotonin at synaptic level Decreased reuptake Serotonin release MAO – inhibition (direct receptor stimulation)

Acute Behavioural Disturbance

Challenging◦ Potentially life threatening to patient◦ Risk to care providers, police, public

Extremely difficult to manage

May be prolonged (e.g. desoxypipradol)

Resistant to conventional interventions

Doses of benzodiazepines & antipsychotics much greater

Avoid prolonged physical restraint

Emergency anaesthesia may be required

NPS & Mental Health NPS responsible for drug induced psychoses Ethylphenidate has 2 “phases”

◦ Acute florid episode associated with intoxication◦ Protracted symptomology for weeks following abstinence

Changes in neurotransmitters◦ Dopamine reuptake/release/? receptor stimulation◦ Serotonin reuptake/release/receptor stimulation◦ Nor-adrenaline metabolism

Poorly responsive to treatment Implications for treatment & continuation of medications

Summary NPS are here to stay

Challenging area◦ Limitations with identification of use◦ Toxicology◦ Diagnostic coding

Drug induced/related mental illness will rise

Don’t forget “classic” drugs of abuse