1. Novel Psychoactive Substances

2. 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”

3. 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

4. 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

5. Challenges Unknown toxicology Identification of use
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

7. 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

8. 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”

9. 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

11. 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

12. 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

15. 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

16. 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

18. 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

19. Serotonin Toxicity Characterised by Spectrum of toxicity
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)

21.  DEATH  AGITATION MUSCLE ACTIVITY ALTERED MENTAL STATE HYPERTHERMIA
DEHYDRATION
RHABDOMYOLYSIS
ACIDOSIS
KIDNEY INJURY
HYPERPYREXIA 41+
↑ K
DIC
↓ GLUCOSE
↓ Ca
 DEATH 

22. 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

23. 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

24. 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