Novel
Psychoactive
Substances
RICHARD.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