Handbook of Novel Psychoactive Substances

What Clinicians Should Know about NPS

Ornella Corazza, Andres Roman-Urrestarazu

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351655521
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Handbook of Novel Psychoactive Substances (NPS) provides a comprehensive overview of the challenges that clinicians face when dealing with NPS and discusses how the profile of patients and their socio-demographic characteristics frame the serious public health concern that NPS pose. It presents various clinical cases, as well as detailed accounts of symptoms, psychopathology, toxicity, and overall clinical management that NPS require. This handbook brings together a unique collection of chapters written by leading experts in the field, who have felt the need to share their knowledge and experience to improve the clinical practice on NPS and the wellbeing of theirpatients.

1 Overcoming the NPS Challenge

An Introduction

Ornella Corazza and Andres Roman-Urrestarazu

We are delighted to present the first clinical handbook on novel psychoactive substances (NPS). It has taken us over a decade to move from some anecdotal evidence of NPS sold on the Internet as ‘legal’ and ‘safer’ alternatives to illicit drugs to this unprecedented collection of chapters written by front-line researchers and health practitioners for clinical practitioners. Our joint effort is not only intended for anyone working in health care, but also for those who might express an interest in understanding what NPS are and how they came to be and became a common substance of misuse in different settings, ranging from nightclubs to emergency rooms and prisons. It comprehensively integrates research, clinical practice, and experiential knowledge as well as provides a common ground of understanding for all those facing NPS.

In a fast-moving environment, even editing or writing a book chapter can become challenging. We cannot express enough our gratitude for the outstanding contributions received from our colleagues, often outside working hours or in between flights, to support this handbook. It is another sign of our willingness to fill the existing clinical gap of knowledge around NPS and to provide informed evidence-based clinical responses locally and globally. Special thanks go to Professor Clare Gerada for writing the foreword and Dr Attilio Negri, who relentlessly helped us during the editorial process. It was a pleasure working in close contact with such a promising clinical fellow at the beginning of his career, who joined our team for an intensive clinical toxicology traineeship.

It was back in 2007 when we detected the first “Spice” products were sold on the Internet as ‘legal’ and ‘safer’ alternatives to cannabis. No scientific paper was yet published at about the ‘mystical incense with the great reviews’, and we struggled to understand the nature of the undisclosed ‘ingredients’ responsible for its psychoactive effects. It was only the first tip of the iceberg. Since then, over 700 NPS have been formally identified worldwide by the European Union (EU) and United Nations Office on Drugs and Crime (UNODC) early-warning systems as well as our ReDNet project, often found outside legal control and with mostly unknown short- and long-term effects on users.

It was after this series of events that NPS were defined as all those substances in a pure form or a preparation that are not controlled by the 1961 Single Convention on Narcotic Drugs or the 1971 Convention on Psychotropic Substances but which may pose a public health threat. Most NPS are synthetic substances produced to mimic the effects of existing, ‘traditional’ drugs, such as cocaine, cannabis, LSD, and heroin. The main groups include aminoindanes; synthetic cannabinoids; synthetic cathinones; α-pyrrolidinopentiophenone, ketamine, and phencyclidine-type substances; phenethylamines, piperazines, and 1-(3-chlorophenyl) piperazine; plant-based substances, such as kratom, ayahuasca, salvia divinorum, and khat; tryptamines; and other substances often related to performance and image enhancement drugs (PIEDs).

The ever-increasing number of these substances over the past decade has radically transformed the landscape of the illicit drug market, leading to a significant shift in the way drugs are manufactured, marketed, and sold, which is driven by rapid changes in both technology and globalization. We see that the online sale has created a swift change from the street sale of substances to the mail order of illicit substances. Motivations and drugs users’ profiles have also dramatically changed, with drugs being increasingly used by individuals who often do not even perceive themselves as drug users and non-regular users, including college students or professionals aiming to boost their performance and gym goers who use a long list of PIEDs.

Despite the fact that not all NPS users need or want to receive professional help, the proliferation of this diverse set of substances has significantly impacted various medical specialities, posing new challenges to clinicians and healthcare professionals. Often unprepared to face the emergency and sudden irruption of NPS in the drug market, they also lack the necessary knowledge base and skills for dealing with patients using NPS. This has led to inappropriate acute and long-term clinical management strategies for both assessment and treatment, leading sometimes to extreme consequences, such as suicides and fatalities.

Although the phenomenon is well-known at least since 2003, it is now a necessity to provide up-to-date reliable information to health professionals working in clinical and research settings, especially in Accident and Emergency Departments, where cases of acute poisonings and serious harm due to NPS consumption are increasingly recorded, sometimes even on a large scale, as in the case of synthetic cannabinoids. It is also important to include here professionals working in the field of substance abuse and more broadly mental health services, such as in prison and probation settings.

The surge of NPS has not only affected clinical practice but also behavioural patterns of substance abuse. There is evidence that NPS are for example driving changes in the patterns of drug injection in some countries. This is particularly apparent with some of the new stimulants and new synthetic opioids that have a shorter half-life than the usual IV mimics and therefore require more frequent administration and injection. In the former case, these changes have been linked to serious drug-related infectious diseases, such as HIV and hepatitis C, as well as bacterial infections due to the more frequent injection required; sometimes these have even manifested as outbreaks, which can place substantial demands on healthcare and healthcare personnel. The lack of effective rapid testing of biological samples makes the task of providing frontline care for people intoxicated with NPS even more difficult. So far interventions have been based on the basis of self-reported history and baseline observation techniques, such as heart rate, blood pressure, temperature, and level of consciousness, rather than on an accurate biological analysis techniques.

Given the ever-increasing number of substances, the overarching aim of this book is to raise clinicians’ knowledge of the effects of NPS. We want to introduce health practitioners to the latest trend of substance use as well provide a better understanding of the clinical management and pathways due to acute toxicity, while giving emphasis to the motivations behind such risky behaviours and encouraging non-judgmental and sympathetic approaches based on a public health methodology and wellbeing.

All the chapters presented here have been written by leading experts in the field, who in most of cases, have been studying and researching the phenomenon since the very beginning and felt the need to share their knowledge and experience with a wider audience.

In order to facilitate consultation, the book has been divided into three parts and twenty interconnected chapters.

In Section One “NPS User Population: Prevalence, Patterns, and Prevention”, our main goal is to make the reader acquainted with the scale of the problem, profile those affected, and highlight the forces that drive the market force and the patterns of consumption across different populations.

In Chapter 1, Dr Ornella Corazza and Dr Andres Roman-Urrestarazu present a overview of the NPS challenge, the complex dynamics behind its upsurge, and how this phenomenon is old and new at the same time. It includes an analysis a different sociodemographic base of users than the usual traditional drugs and how this phenomenon has been handled with the current institutional frameworks available in drug policy. The chapter also provides an overview of the need for clinical management strategies and how the present book aims to help clinicians achieve this. It finishes with a brief summary of the individual chapters and how they are parsimoniously part of the book.

In Chapter 2, Owen Bowden-Jones and Dima Abdulrahim focus on the need for guidance specific to NPS and why existing substance misuse guidance is not sufficient. The chapter introduces the model of NEPTUNE (Novel Psychoactive Treatment: UK Network) clinical guidance and the products developed over time as a response to the current gap in knowledge and experience in the management of NPS in the UK and beyond.

In Chapter 3, Máté Kapitány-Fövény, Zsolt Demetrovics, and Aviv M. Weinstein present a comprehensive overview of user group characteristics, patterns, and the most hidden motives behind NPS consumption among both adolescent and adult populations. It refers to subgroups, according to the substance used, and it shares good practices in terms of research methods and web-based prevention strategies, which the group has extensively studied. We aim here to characterize users and motives behind NPS consumption and how this new trend might not follow the usual channels of substance abuse with the surge of a completely new type of user.

Chapter 4 was written by Shanna Marinnan, Giuseppe Bersani, and Ornella Corazza. It discusses how NPS has become one of the most serious threats to the safety and security of the prison system in the United Kingdom, where over 40,000 cases of self-harm related to NPS have been reported, including a dramatic increase in assaults on prison staff. It analyzes how health professionals working in such secure settings often lack the necessary expertise to tackle the situation. It explores how the NPS prison phenomenon is also spreading in other countries and the urgent need to develop education and prevention programmes in prisons.

Chapter 5, by Neha Ainsworth, Jake Shelley, and Andrea Petroczi, looks at the diffusion of PIEDs among gym goers, exercisers, and athletes. It profiles the main substances of abuse in fitness settings and emphasizes possible motivations behind such use and the best forms of intervention. It discusses the performance and image enhancing drugs (PIEDs) in the framework of NPS and how the two phenomena might be interrelated.

In Section Two, “Clinical Recommendations and Best Practices Across Front-Line Health Professionals”, our main goal is to discuss clinical practice from an evidence-based approach. We aim to present here the main challenges that NPS pose in terms of clinical management, while also providing basic clinical tools to detect and treat those presenting with NPS misuse.

In Chapter 6, Carla Morganti, Attilio Negri, Laura Cazzaniga, Riccardo Carlo Gatti, and Franca Davanzo focus on the challenges faced by clinicians while dealing with NPS in emergency rooms and present a detailed classification and useful advice on how to deal with agitated or aggressive behaviours due to NPS abuse and also provide guidance on different sedation and clinical examinations and treatment approaches. In addition, they discuss toxicology and clinical management of NPS toxicity.

In Chapter 7, Luke De La Rue, David M. Wood, and Paul Dargan explore the challenges that clinicians face in dealing with patients with acute NPS toxicity and the necessity of implementing a systemic collection of data on presentations to hospital emergency departments with acute drug and NPS toxicity at regional, national, and international levels. It presents the pioneering work of the EURO-DEN Plus project, which utilizes sentinels in emergency departments across Europe to collect data on NPS harms. It also shows the benefits to clinicians and how to use and navigate the information that EURO-DEN provides.

In Chapter 8, Giovanni Martinotti, Cristina Marino del Villar, Raffaele Giogetti, Fabrizio Schifano, and Massimo di Giannantonio explore the use of traditional and novel substances in the Balearic island of Ibiza. Original clinical admissions data of the Psychiatric Unit of Ibiza hospital will be presented. Authors also discuss various cases of intoxications due to a wide set of different substances and NPS-related fatalities recorded during the summer period.

In Section 3, “Substances, Adverse Effects, and Clinical Management”, we discuss the misuse of different families of NPS and how they present clinically, including side effects, toxicity, and clinical symptoms. The goal of this part is to introduce healthcare practitioners to the different family types of NPS available and the main issues clinicians should look for when presented with their misuses. We have taken a pragmatic approach to make all the chapters focused on clinical management, symptoms, and the presentations of different NPS families.

In Chapter 9, Duccio Papanti, Laura Orsolini, John M. Corkery, and Fabrizio Schifano look at the evolution of the Spice market since 2004. They explore the epidemiology and use profiles, pharmacology and toxicity, and desired and adverse effects, among other important clinical features. Attention is given to the clinical presentations and management of ‘spiceophrenia’.

In Chapter 10, Mariya Prilutskaya, Justin Yang, and Andres Roman-Urrestarazu discuss synthetic cannabinoids, opioids, and polydrug abuse and their implications for clinical management. They discuss the interaction of synthetic cannabinoids with other drugs in individuals with polydrug substance misuse disorder and how this might be an increasingly prevalent problem in different clinical settings, especially during the management of withdrawal symptoms. They also discuss therapeutic and treatment possibilities, discussing in detail how this might be different to what has traditionally been provided to individuals with polysubstance misuse disorders by clinicians.

In Chapter 11, John M. Corkery, Christine Goodair, and Hugh Claridge present a comprehensive overview of synthetic cathinones, including use, morbidity, and mortality, while providing a comparison with other stimulants when possible. The authors also share unprecedented data on related fatalities in the United Kingdom over an extensive time period.

In Chapter 12, Pierluigi Simonato, Rita Santacroce, and Attilio Negri further discuss synthetic cathinones by presenting in-depth information on two selected clinical cases of “Alice in the Wonderland” and “Marvin the Paranoid Android” and sharing best practices in assessment, intervention, and treatment.

In Chapter 13, Dino Lüthi and Matthias Liechti present a comprehensive overview of methylphenidate abuse as a cognitive enhancer, as well as its similarities with cocaine and other novel stimulants. The chapter aims to bridge the knowledge gaps between NPS; prescription drugs, such as methylphenidate; and illegal drugs, such as methamphetamine. It presents with toxicology analysis and then focuses on clinical presentations and symptoms. It provides a good overview of clinical management and addiction potential.

In Chapter 14, Jessica Neicun, Darshan Singh, and Eduardo Cinosi explore the upsurge of ‘herbal highs’ and how they have resurged once more after their initial peak in the 1960s. Attention has been paid to the case of kratom in terms of both recreational use and therapeutic potential. The authors explore both the clinical presentation and the addictive components of these groups of substances while providing a general overview of kratom use in the scope of the opioid epidemic.

In Chapter 15, Andrew Parrott provides an overview of the evolution of the MDMA market over the years, which has become increasingly more complex and multifaceted with the introduction of products containing very high doses of MDMA or substances passed as MDMA but actually containing a series of different products. A detailed analysis of incidences, dangers, and available treatments has been provided, as well as a review of causes of death and prevention strategies. Andrew Parrott will also discuss the clinical presentation of toxicity and clinical management strategies for clinicians.

In Chapter 16, Esther Papaseit, Clara Pérez-Mañá, Débora González, Francina Fonseca, Marta Torrens, and Magí Farré look at 2C-B, which is one of the most popular synthetic phenethylamines with long-lasting psychedelic effects. The group reviews its pharmacology and provides a detailed analysis of its acute psychedelic effects, both desired and adverse manifestations, and discusses reported cases of acute intoxications, while providing treatment recommendations inclusive of neuropsychiatric and other medical complications. The focus of the chapter is on providing an overview of phenethylamines and how they usually present to clinicians and, more important, when to suspect their use.

In Chapter 17, Attilio Negri and Sulaf Assi look at ketamine and at the latest phencyclidine derivatives. The chapter presents an in-depth analysis in terms of both the recreational use and the uses in medical settings, including a review of the recent research on their antidepressant effect. The chapter also highlights analogies and differences between NMDA antagonists in terms of their chemical structure, desired and adverse effects, and potential clinical applications.

In Chapter 18, Esther Papaseit, Magí Farré, Clara Pérez-Mañá, Adriana Farré, Francina Fonseca, and Marta Torrens discuss the irruption of the new fentanyl derivatives and related opioids as a heterogeneous group of non-therapeutic opioids classified as novel/new synthetic opioids (NSOs), which refers to a category of new psychoactive substances (NPSs) that are either known to be opioids or have opioid-like effects. Authors review the emergence and misuse of fentanyl and NSOs and their clinical pharmacological similitude to classical opioids, the potential for harm, and clinical management and prevention of intoxication/overdose.

In Chapter 19, Peter D. Maskell and Nathan E. Wilson focus on new designer/NPS benzodiazepines, which have been recently detected and caused a series of fatalities in both the United States and the United Kingdom. This chapter provides an overview of benzodiazepine abus...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• Author Biographies
• Foreword
• 1 Overcoming the NPS Challenge: An Introduction
• Section One NPS Users: Prevalence, Patterns, and Prevention
• Section Two Clinical Recommendations and Best Practices Across Front-Line Health Professionals
• Section Three Substances, Adverse Effects, and Clinical Management
• Index