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Dual diagnosis

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Digestible info re mental health-substance use

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New Psychoactive Substances – Mental Health

Gary CrotonVictorian Dual Diagnosis InitiativeNEBMH- Albury Wodonga Health

Oct. 2017

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What are NPS?

NPS market places

SCRAs - User profile

SCRAs-Mental Health

SCRAs –Toxicity & Withdrawal

Legislative Responses

NPS-MH Treatment

SCRAs Detection & Assessment

Depressant NPS

Hallucinogenic NPS

Stimulant NPS

Cannabinoid NPS


Key Messages


What are NPS?

What are NPSs?

New Psychoactive Substances

• ‘compounds designed to mimic existing established recreational drugs’ 1

AKA:

• ‘Synthetics’ – misnomer as many established drugs are synthetic

• ‘Novel Psychoactive Substances’

• ‘New & Emerging Drugs’ 2 – emerging Australian convention

• ‘Legal highs’ …. ‘Herbal highs’ ……. ‘Party pills’…. ‘Research chemicals’ ……



What are NPSs?

Most useful typology to date- 1, 36 BMJ Tracy et al 2017Paper

PosterPodcast

Albeit effects of some NPSs overlap categories

http://www.bmj.com/content/356/bmj.i6848

http://sandpit.bmj.com/graphics/2017/nps/nps-v40-web.pdf

https://soundcloud.com/bmjpodcasts/expanding-your-mind-about-novel-psychoactives

What are NPSs?

• Currently > 650 identified NPS 3

• Growing rapidly - c.100 new NPS identified each year 3

• Stimulants & Cannabinoids the most common NPS (though ↑ trend to Opioids)

• Variations ++ in chemical structures, effects & harms even within these categories



NPS market places


NPS market places

1. Dark web2. Sex shops / Head shops / Tobacconists

(in Vic till Nov 1 2017)

https://en.wikipedia.org/wiki/Dark_web

https://en.wikipedia.org/wiki/Dark_web


1. Dark Web NPS market places

• Uses VPN & the TOR browser for anonymous communication

• eBay look & feel - Bitcoin & escrow payment methods. Traditional postage systems.12

• Silk Road 2011-13 8

• Usually 2 dominant sites – currently Dream Market & Valhalla (volatile marketplace!)

• Exit scams. Regular downtimes- maybe temporary due to hacking attacks from other market operators, law enforcement or maintenance

• Harm minimisation aspects 12

https://en.wikipedia.org/wiki/Virtual_private_network


NPS market places 1. Dark Web

https://ndarc.med.unsw.edu.au/project/drugs-and-new-technologies-dnet





1. Dark Web NPS market places

Drugs and the Internet, Issue 8, May 2017 Roxburgh et al. Sydney: NDARC- Time period: July–Dec.2016. 8

• 18 marketplaces monitored weekly

• 5 most commonly sold substances:• Cannabis, • Pharmaceuticals, • MDMA, • Cocaine• Methamphetamine

• NPS popularity slightly declined.

• Two NPS appeared for first time in top 10:• U-47700 … (7.5 x potency of morphine 9 )• FuranylFentanyl

• 2016 Global Drug Survey- 9% of Australian respondents reported crypto market purchases


https://psychonautwiki.org/wiki/U-47700

https://en.wikipedia.org/wiki/Furanylfentanyl

https://www.globaldrugsurvey.com/



• Bought from Victorian sex shop July 2017


NPS market places 2. Sex shops / Head shops / Tobacconists



• July 2017: US Justice Dept. announced seizure of AlphaBay ( largest dark web marketplace).

• FBI & Dutch police initially pretended website shutdown was an exit scam - expecting AlphaBaycustomers would move to other popular websites, including Hansa.

• Unbeknownst to users, Dutch police had taken over Hansa a month earlier -were operating the site to collect information and trap people involved in the trade.

• Authorities aimed to break the trust, so that users would not feel safe on a dark market. 11

Dark Web

• Evidence shows that publicity like this actually INCREASES cryptomarket trafficking 11

http://www.talkingdrugs.org/closing-dark-web-marketplaces-wont-reduce-drug-use-or-trafficking




Ireland:

• ‘blanket ban’ of psychoactive drugs 2011

UK:

• ‘blanket ban’ of psychoactive drugs 2016

Victoria:

• Drugs, Poisons and Controlled Substances Miscellaneous Amendment Bill 2017

• Blanket ban to production, sale & promotion of any substance that has a psychoactive effect.

• Ratified Sept 2017 - effective from Nov 1st

• N.B. Possibility of withdrawal presentations especially amongst people with severe mental illness

2. Sex shops / Head shops / Tobacconists

http://www.legislation.vic.gov.au/domino/Web_Notes/LDMS/PubPDocs.nsf/ee665e366dcb6cb0ca256da400837f6b/2a6d5d7b8bbf4ebfca2580dd001475f0/$FILE/581094exi1.pdf

http://www.premier.vic.gov.au/cracking-down-on-synthetic-drugs-and-drug-dealing/

http://www.premier.vic.gov.au/cracking-down-on-synthetic-drugs-and-drug-dealing/





Ireland:

• NPS now ‘easier to get’ via street dealing.13

UK:

• 2017 indicators 14, 15, 16, 17, 21, 22

http://www.bbc.co.uk/newsbeat/article/35946152/warning-over-new-uk-legal-high-law-after-irish-ban-made-it-easier-to-buy-them

http://www.huffingtonpost.co.uk/entry/spice-in-manchester-psychoactive-substances-bill_uk_58efb7b7e4b0da2ff85f09af


https://www.theguardian.com/society/2017/apr/15/its-worse-than-heroin-how-spice-is-ravaging-homeless-communities?CMP=share_btn_tw


http://www.independent.co.uk/news/uk/home-news/spice-legal-highs-zombie-plague-walking-zombies-manchester-legal-highs-ban-psychoactive-substances-a7678931.html


https://www.channel4.com/news/spice-discussion


https://www.theguardian.com/uk-news/2017/aug/06/spice-ban-prisoners-homeless-at-risk-drug-goes-underground


https://www.theguardian.com/society/2017/aug/06/spice-zombie-drug-devastating-communities



Stimulant NPS


Stimulant NPS

• One of largest NPS groups 1

• Related to MDMA, cocaine, amphetamines

• Typically powders or pills.

• Neuronal reuptake pump inhibitors or active releasers

• Neurotransmitter releasers = greater addiction & neurotoxicity.

• Cathinone family = enhanced neurotoxicity compared to traditional stimulants.


Stimulant NPS

• Ratio of serotonin to dopamine: 1

• Serotonergic drugs, (similar to ecstasy) =empathy & openness.

• Dopaminergic drugs, (similar to cocaine) = euphoric and mania-like experiences.

• NBOMe = psychedelic experiences.

• Serotonin syndrome risk with multiple serotonergic recreational drugs, or prescription medication

• Structure of many stimulant NPS similar to amphetamine so OD looks similar

https://adf.org.au/drug-facts/nbomes/

https://en.wikipedia.org/wiki/Serotonin_syndrome


Hallucinogenic NPS


Hallucinogenic NPS

Psychedelics

• Not hallucinations, but “psychedelic” effects, perceptual alterations, quasi-mystical experiences

• Some have stimulant properties

• NBOMe =↑risk of OD- dose difficult to measure & small difference between dose to produce a high & OD

• Recreational use of 25I-NBOMe carries significant risk of both pharmacological and behavioraltoxicity.


Dissociatives

• Euphoric “dissociated” state, absence of time, weightlessness, disconnection from body.

• Spectrum– milder than Ketamine to strong as Phencyclidine.

• Ketamine possible acute hallucinations, anxiety, near-death experience. Regular users can have: mood and personality changes, depression, memory & concentration impairments, psychosis, dependence.

• Methoxetamine = intense, long lasting.

• Users report experiencing ‘M-hole’ (like Ketamine's ‘K-hole’ )

• Physical: abdo pain (‘M cramps’), nausea, vomiting, diarrhoea, arrhythmias, blackouts, ulcerative cystitis, renal damage 1

• Long term: neurocognitive deficits & deterioration in mood 1

https://www.healthdirect.gov.au/ketamine-and-mental-health

https://en.wikipedia.org/wiki/Phencyclidine

https://www.healthdirect.gov.au/ketamine-and-mental-health

https://en.wikipedia.org/wiki/Methoxetamine

http://www.urbandictionary.com/define.php?term=Mhole

https://en.wikipedia.org/wiki/K-hole


Depressant NPS


Depressant NPS

• Opioid & Benzodiazepine subcategories 1

• Can be ‘so similar to established recreational drugs that clinicians may not realise an individual has used an NPS’ 1

Benzodiazepines

• Benzodiazepine NPS similar to Diazepam but some have long ½ -lives (Flubromazepam, ½-life of 100 hours!)- risk of OD

• Potentiated by alcohol

• Harms similar to Diazepam

• Addiction & Seizure potential

https://psychonautwiki.org/wiki/Flubromazepam


Depressant NPS

Opioids

• Some much longer durations than established opioids

• Novel Fentanyls• 50-100 times more potent than morphine

• Carfentanil • GA for elephants - 10,000 times more potent

than morphine,

• Found in Aust since late 2016

• 10 -20 times dose of Naloxone needed

• Lethal dose = ‘weight of a grain of pollen’ 19

• Heroin may be cut with fentanyl or carfentanil 20

https://en.wikipedia.org/wiki/Fentanyl

https://en.wikipedia.org/wiki/Carfentanil

http://www.penington.org.au/overdose-prevention-the-lifesaving-naloxone-injection-for-opioid-overdose/


Fatal doses compared: heroin, fentanyl and carfentanil• Image: Bruce Taylor, New

Hampshire State Police Forensic Lab

• From ANEX Bulletin:

Fentanyl And Carfentanyl: What Do I Need To Know?

Depressant NPS

http://www.penington.org.au/anexbulletin/fentanyl-and-carfentanyl-what-do-i-need-to-know/




Cannabinoid NPS


Synthetic Cannabinoid Receptor Agonists (SCRAs) 1

• >150 different SCRAs

• SCRAS ‘super-stimulators’ of CB1 & CB2 receptors compared to Cannabis 25

• SCRAs lack Cannabidiol (CBD) = antipsychotic & anxiolytic. 27

• In natural cannabis CBD dampens effects of Tetrahydrocannabinol (THC). 23, 25

• Cannabis & SCRAs both stimulating & sedating, anxiogenic & anxiolytic

• Both can cause anxiety, paranoia, psychotic symptoms

https://en.wikipedia.org/wiki/Cannabidiol

https://en.wikipedia.org/wiki/Tetrahydrocannabinol


Cannabinoid NPS

• As sprayed onto compounds strength & effects can be unpredictable.

• Side effects more frequent with SCRAs

• EDs SCRAs case reports 40: • Confusion & cognitive impairment,

• Slurred speech & excessive sweating

• Hypertension & tachycardia

• Renal failure, pulmonary damage,

• Myocardial infarction, seizures, stroke.


Cannabinoid NPS

https://www2.health.vic.gov.au/Api/downloadmedia/235B353B-669F-4FB1-A958-0285EBDC8D02

https://www2.health.vic.gov.au/Api/downloadmedia/235B353B-669F-4FB1-A958-0285EBDC8D02


SCRAs-Mental Health

Synthetic Cannabinoid Use in a Psychiatric Patient Population: A Pilot Study Welter S. et al

Eur Addict Res. August 2017 24

• n = 332• 10% of psychotic people had used SCRAs• +ve symptoms more severe in SCRAs users• -ve symptoms more severe in Cannabis users.


Clinical characteristics of synthetic cannabinoid-induced psychosis in relation to schizophrenia: a single-center cross-sectional analysis of concurrently hospitalized patients. Altintas. M et al Neuropsychiatric Disease and Treatment August 2016 26

• n = 81 • Inpatients also • SCRAs induced psychosis ‘associated with remarkable rates of

• Suicidal ideation• Involuntary hospitalisation

https://www.ncbi.nlm.nih.gov/pubmed/28848170



https://www.dovepress.com/clinical-characteristics-of-synthetic-cannabinoid-induced-psychosis-in-peer-reviewed-fulltext-article-NDT



The adverse health effects of synthetic cannabinoids with emphasis on psychosis-like effects

van Amsterdam, J. et al Journal of Psychopharmacology. 2015 Review. 27

• Compared with Cannabis, SCRAs cause more frequent, more severe –veeffects.

• Fatal cases recorded but causality not proven

• Most common symptoms SCRA side effects are:• tachycardia, • extreme agitation • hallucinations.

• Psychosis and psychosis-like conditions seem to occur relatively often following SCRAs• High potency • Absence of CBD

• SCRAs lack of CBD= no protection against psychosis (seems to occur often)

• Studies on relative risk of SCRAs compared to Cannabis to induce or evoke psychosis urgently needed.





Synthetic Cannabinoids—Further Evidence Supporting the Relationship Between

Cannabinoids and Psychosis. Fattore. L. Biological Psychiatry. April 2016 28

• Considers pharmacodynamics & pharmokinetics

• Summarised & described case reports of:• Re-emergence of Psychosis: Psychosis induced by SCRAs in vulnerable individuals• New-Onset Psychosis: Psychosis induced by SCRAs in subjects with no previous

history of psychosis

• SCs dissimilar from THC- undesirable effects like confusion, agitation, anxiety ,altered perception & mental status, paranoia, irritability , depression, suicidality

• Clinicians should: • Be aware that SCs may cause severe health consequences & unexpected adverse

effects not always associated with cannabis• Consider possibility of SC use in patients who use drugs & presenting with SXs &

negative urine toxicology.


Factors explaining intoxication and psychotropic effects of

synthetic cannabinoids






Traditional marijuana, high-potency cannabis and synthetic cannabinoids:

increasing risk for psychosis Robin M. Murray et al. World Psychiatry. Sept.

2016 29

• Reported a survey 80,000 drug users: SCRAS users 30 x more likely to end up in an emergency unit than users of traditional cannabis

• Over 200 SCRAs available on internet-as each has a slightly different molecular structure → unpredictable side effects.

• Cannabis use- esp high potency & SCRAs increases risk of psychosis… but does it in absence of genetic vulnerability?


https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5032490/



https://en.wikipedia.org/wiki/Robin_Murray

https://en.wikipedia.org/wiki/Robin_Murray

Psychiatric comorbidity associated with synthetic cannabinoid use

compared to cannabis Basirnia et al Journal of Psychopharmacology.

2016 30

• Compared clinical presentations of SC users with cannabis users in a psychiatric inpatient setting (n= 594)

• Outcome: SC use strongly associated with more psychotic presentations & agitation compared to cannabis use.





https://scholar.google.com/citations?user=uNTyURwAAAAJ&hl=en

https://scholar.google.com/citations?user=uNTyURwAAAAJ&hl=en

Synthetic cannabinoid use in an acute psychiatric inpatient unit. Clancy, R. et al. Int. Journ. Mental Health Nursing. May 2017 31

• NSW acute public MH (DDx) unit (n = 100)

• Developed a simple screening tool based on NSW MH-OAT

• Also 17-item NPS Assessment Instrument

Results:

• 56% reported using at least one type of NPS

• 53.5% reported using SCRAs alone

• 18.8% reported using both SCRAs & other NPS

• SCRAs use not associated with any demographic or diagnostic groups.

• Legality & availability & feeling of intoxication were common reasons for use

Implications:

• High prevalence of NPS adds weight to recommendation that clinicians should routinely screen for substances from time of admission.

• Accurate info about these substances is required for appropriate interventions


http://onlinelibrary.wiley.com/doi/10.1111/inm.12341/full



https://www.newcastle.edu.au/profile/richard-clancy




• Standard UDS screens are inadequate -multiple false positives & negatives 3

• Great variability, even within SCRAs – some may be detected

• Clancy et al 31 offer to share simple screening tool based on NSW MH-OAT & 17-item NPS Assessment Instrument

• Bright 2 recommends sensitive questioning: • Have you used anything that has been bought online or from adult stores?• Have you taken any herbal supplements, legal highs, party pills, herbal highs,

research chemicals, bath salts or incense?• What chemical or brand have you used?• What were the effects of it (e.g. stimulant, depressant or hallucinogen)?• Was it like any other substance you have used?• Did you experience any negative health effects?

mailto:'[email protected]'



https://www.ecu.edu.au/schools/medical-and-health-sciences/our-staff/profiles/senior-lecturers/dr-stephen-bright




• Many NPS not detected by urine screens → popular in prisons & professions subject to random drug screening 4

• FIFO, military 2,

• Young males

• Very marginalised & vulnerable people disproportionately involved-homeless, prisons & forensic psych. 3



Signs and symptoms associated with synthetic cannabinoid toxicity: systematic

review. Courts, J. et al. Australasian Psychiatry. August 2016 32

• n = 3695

• Symptoms of SC toxicity included:• Physiological (tachycardia, hypertension, nausea/vomiting),

• Emotional (agitation, irritability, paranoia),

• Behavioural (drowsiness, aggression)

• Perceptual (hallucinations)

• Most common symptoms: tachycardia (30.2%), agitation (13.5%), drowsiness (12.3%), nausea/vomiting (8.2%) hallucinations (7.6%).

• Death or serious medical complications were uncommon • Death 0.2%,

• Stroke 0.1%,

• Myocardial infarction 0.09%

http://journals.sagepub.com/doi/pdf/10.1177/1039856216663733





Adverse Effects of Synthetic Cannabinoids: Management of Acute Toxicity and Withdrawal Cooper, ZD. CurrPsychiatry Rep. May 2016 33

• ‘Withdrawal has not been systematically characterized and effective treatments have yet to be elucidated’. Withdrawal from SCs has been reported to occur only in daily users.

• Acute intoxication frequently treated with supportive care & intravenous fluids to treat electrolyte & fluid disturbances. Many adverse effects associated with acute intoxication are identical to some withdrawal symptoms - hence treated similarly.

• Patients who present with irritability, agitation, anxiety, and seizures associated with intoxication or withdrawal are generally administered benzodiazepines as a first-line treatment.

• Neuroleptics are also administered for acute psychosis and agitation and mania with psychotic symptoms

• Although not always effective, antiemetics have been administered for hyperemesis

• Quetiapine was effective in treating withdrawal symptoms in patients who failed to respond to benzodiazepines






Useful client resource:

Synthetic Marijuana Withdrawal: Strategies for Coping with Common Symptoms

John Lee. Choose Help.com webpage. June 2014

http://m.choosehelp.com/topics/detox/synthetic-marijuana-withdrawal-strategies-for-coping-with-common-symptoms#about-author-anchor




NPS-MH Treatment


NPS-MH Treatment

• Non-judgemental approach 35, 37

• Screening 31 (esp youth 39 / dispossessed)

• Thorough assessment – history MSE, physical 35

• Symptomatic care 6

• Personalised treatment

• Integrated, one-agency, treatment where possible - collaborative treatment where not

• Stepped care

• Complex-needs lens

• Usual range of psychosocial treatments - MI, BIs, CBT… 7

• Motivational Interviewing 35

• Pathways to more specialised support for complex cases 6


NPS-MH Treatment

Harm minimisation - Grounded info & advice: • Start with a very small dose & increase if necessary to obtain desired effects 1

• Combining with other drugs or alcohol can increase risks• Use with another person 2 - Let someone else go first• Seek urgent medical help if you feel unwell after using a NPS • If seeking help take the compound or any information on it with you• Considerable variation in risks b/t individual NPS & classes of NPS - SCRAs ingredients

vary from packet to packet 25, 38

• Don’t mix drugs 25

• With SCRAS ‘beware the bottom of the bag’ 25

• Older people, people with pre-existing MH conditions or CV issues should avoid NPS 2

• Sudden discontinuation of novel benzoes or opioids could prompt withdrawal 25

• Avoid injecting (Unknown contents / fillers) 2

• Packaging often deceptive 2

See also Harm Reduction for People Who Use or May Encounter Fentanyl/Carfentanil April 2017 20

http://www.talkingdrugs.org/harm-reduction-for-people-who-use-or-may-encounter-fentanylcarfentanil

Guidance on the Clinical Management of Acute and

Chronic Harms of Club Drugs and Novel Psychoactive

Substances 7

Abdulrahim D & Bowden-Jones O. Novel Psychoactive Treatment UK Network NEPTUNE

March 2015


Stellar resource

NPS-MH Treatment

http://neptune-clinical-guidance.co.uk/wp-content/uploads/2015/03/NEPTUNE-Guidance-March-2015.pdf




Key Messages


Key messages

• > 650 New Psychoactive Substances (NPS) have now been identified - this list is growing rapidly

• Categories of • Stimulants, • Cannabinoids, • Depressants and • Hallucinogens

are a useful way of classifying NPS

(though can be considerable overlap between categories)

• There remains much to be learned about • nature and effects of NPS• best practice in responding to people who develop NPS-related problems


Key messages

• UK experience suggests that Cannabinoids (SCRAs) are the category of most concern with people with Severe Mental Illness (SMI)

• It appears that SCRAs may have more harms associated with them than does Traditional Cannabis (TC)

• SCRAs lack the anxiolytic, anti-psychotic CBD component found in TC and bind more tightly to the CB1 & CB2 receptors.


• To date SCRAs have mainly been sold in sex shops, tobacconists and the dark web

• In Victoria it will be illegal to sell SCRAs over the counter from November 1st

• ED and MH clinicians should be alert to the possibility of people presenting with withdrawal complications at this time

• International experience suggest that SCRAs may continue to be sold via street dealing and the web; particularly to dispossessed people (homeless, SMI, forensic populations)

Key messages


Implication for Mental Health clinicians:

• Most people who use drugs, including NPS, will not develop problems with their use.

• Be aware that SCs may cause severe health consequences & unexpected adverse effects not always associated with cannabis

• Consider possibility of SC use in patients who use drugs who presenting with symptoms & negative urine toxicology.

• Be alert to possible withdrawal presentations from Nov 1st

Key messages


Implication for Mental Health clinicians:

• Routinely screen for substance use as close as possible to first contact with a client

• Sensitive questioning probably the most effective way to screen for NPS / SCRAs use

• Non-judgemental, harm-minimisation, motivational approaches are indicated

Key messages

1. Novel psychoactive Substances: types, mechanism of action and effects.

Tracy, DK et al. BMJ. Jan 2017

2. Not for human consumption: New and Emerging Drugs in Australia. Bright,

S. Australian Drug Foundation. 2013

3. Novel Psychoactive Substances: bridging the knowledge gap. Tracy DK. The

Mental Elf. Webpage. Sept 2017

References:Click icon for

more info



https://adf.org.au/wp-content/uploads/2017/02/ADF-PreventionResearch-Apr13.pdf

https://www.nationalelfservice.net/mental-health/substance-misuse/novel-psychoactive-substances-bridging-the-knowledge-gap/







4. Novel Psychoactive Substances: important information for health

professionals. Sumnall, H et al. The Mental Elf. Webpage. March 2017

5. New Psychoactive Substances (NPS) Resource pack for informal educators

and practitioners. Home Office June 2016

6. Health responses to new psychoactive substances. EMCDDA 2016


more info


https://www.nationalelfservice.net/mental-health/substance-misuse/novel-psychoactive-substances-important-information-for-health-professionals/

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/544030/6_1845_HO_NPS_Resources_Booklet_June16_v10.pdf

http://www.emcdda.europa.eu/system/files/publications/2933/NPS health responses_POD2016.pdf







7. Guidance on the Clinical Management of Acute and Chronic Harms of Club

Drugs and Novel Psychoactive Substances Abdulrahim D & Bowden-Jones O.

Novel Psychoactive Treatment UK Network NEPTUNE March 2015

8. Drugs and the Internet, Issue 8, May 2017 Roxburgh, A., et al. 2017. Sydney:

National Drug and Alcohol Research Centre.

9. PsychonautWiki U-47700 webpage. Accessed 12/09/2017


more info











10. PsychonautWiki U-47700 webpage. Accessed 12/09/2017

11. Closing Dark Web Marketplaces Won’t Reduce Drug Use or Trafficking Mira Motani. August 2017 Talking Drugs website

12. Darknet Drug Trading: Australian implications, trends and harm reduction possibilities James Martin. Turning Point Vodcast march 2017

13. Warning over new UK legal high law after Irish ban 'made it easier to buy them BBC webpage. April 2016


more info




https://youtu.be/rzY0EKFK-rk










14. 'Zombie Spice addicts plague' caused by everything we warned you about, claim legal highs ban critics Independent. April 2017

15. Spice In Manchester ‘More Potent’ And Less Controlled Since Psychoactive Substances Bill, Experts Warn. Huffington Post April 2017

16. 'It's worse than heroin': how spice is ravaging homeless communities. Guardian April 2017

17. Spice Discussion Professor David Nutt BBC 4 Video April 2017


more info














18. Fentanyl And Carfentanyl: What Do I Need To Know? ANEX Bulletin. May 2017

19. Weekly Dose: while the media panic about ice, we should worry about carfentanil.

David Caldicott The Conversation March 2017

20. Harm Reduction for People Who Use or May Encounter Fentanyl/Carfentanil

Avinash Tharoor Talking Drugs April 2017

21. How spice, ‘the zombie drug’, is devastating communities. Observer August 2017


more info



https://theconversation.com/weekly-dose-while-the-media-panic-about-ice-we-should-worry-about-carfentanil-73270











22. Spice ban ‘puts prisoners and homeless at risk’ as street drug goes

underground. The Guardian August 2017

23. Chronic Adolescent Δ9-Tetrahydrocannabinol Treatment of Male Mice Leads

to Long-Term Cognitive and Behavioral Dysfunction, Which Are Prevented by

Concurrent Cannabidiol Treatment. Murphy, M et al Cannabis and

Cannabinoid Research. Sep 2017.

24. Synthetic Cannabinoid Use in a Psychiatric Patient Population: A Pilot Study

Welter S. et al Eur Addict Res. August 2017


more info



http://online.liebertpub.com/toc/can/2/1

https://www.researchgate.net/publication/318987141_Synthetic_Cannabinoid_Use_in_a_Psychiatric_Patient_Population_A_Pilot_Study







25. SPICE New Psychoactive Substances Briefing for professionals. Manchester H&CC

July 2017

26. Clinical characteristics of synthetic cannabinoid-induced psychosis in relation to

schizophrenia: a single-center cross-sectional analysis of concurrently hospitalized

patients. Altintas. M et al Neuropsychiatric Disease and Treatment August 2016

27. The adverse health effects of synthetic cannabinoids with emphasis on psychosis-

like effects van Amsterdam, J. et al Journal of Psychopharmacology. 2015


more info


https://www.yhne.org.uk/wp-content/uploads/Spice-info-sheetv1.3-high-Final-draft.pdf


https://www.researchgate.net/publication/270966118_The_adverse_health_effects_of_synthetic_cannabinoids_with_emphasis_on_psychosis-like_effects







28. Synthetic Cannabinoids—Further Evidence Supporting the Relationship

Between Cannabinoids and Psychosis. Fattore. L. Biological Psychiatry. April

2016

29. Traditional marijuana, high-potency cannabis and synthetic cannabinoids:

increasing risk for psychosis Robin M. Murray et al. World Psychiatry. Sept.

2016

30. Psychiatric comorbidity associated with synthetic cannabinoid use compared

to cannabis Basirnia et al Journal of Psychopharmacology. 2016.

31. Synthetic cannabinoid use in an acute psychiatric inpatient unit. Clancy, R et

al. Int. Journ. Mental Health Nursing. May 2017


more info


https://www.researchgate.net/publication/293044544_Synthetic_Cannabinoids-Further_Evidence_Supporting_the_Relationship_Between_Cannabinoids_and_Psychosis


https://www.researchgate.net/publication/305671180_Psychiatric_comorbidity_associated_with_synthetic_cannabinoid_use_compared_to_cannabis








32. Signs and symptoms associated with synthetic cannabinoid toxicity:

systematic review. Courts, J. et al. Australasian Psychiatry. August 2016

33. Adverse Effects of Synthetic Cannabinoids: Management of Acute Toxicity

and Withdrawal Cooper, ZD. Curr Psychiatry Rep. May 2016

34. Synthetic Marijuana Withdrawal: Strategies for Coping with Common

Symptoms John Lee. Choose Help.com webpage. June 2014


more info











35. Novel psychoactive substances: identifying and managing acute and chronic harmful use. Tracy D. et al BMJ. January 2017

36. Novel psychoactive Substances: types, mechanism of action and effects. Tracy, DK et al. BMJ. Jan 2017

37. Dummies Guide to Spice and Other NPS' - a film about the so-called Legal Highs. Video. WoolfeVISION London June 2017

38. Think before you take - How to take NPS' safely . Video. WoolfeVISION London June 2017


more info




https://youtu.be/jMfz9yhPyKw

https://youtu.be/kvrchq2vIvI









39. Novel Psychoactive Substances Insight Report: The View from Young People.

Research Summary Report. Addaction. February 2017

40. A systematic review of adverse events arising from the use of synthetic

cannabinoids and their associated treatment. Tait, R.J. Caldicott, D., Hill, S.,

Lenton, S. Clinical Toxicology. 2015


more info


https://www.addaction.org.uk/news/new-research-reveals-young-people%E2%80%99s-views-new-psychoactive-substances

http://www.tandfonline.com/doi/abs/10.3109/15563650.2015.1110590





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