Legal Highs That Work

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					Legal Highs
An Update prepared jointly
with Dieke Stegink,
Clocktower Surgery
Learning aims of legal
highs
Consider legalisation & classification
concepts, internet recruitment
Brief awareness of diversity of drug types
Recognition & knowledge of examples of
opiate & stimulants
 –   Kraton
 –   Khat, Mephedrone
 –   Butylpiperazine
Case Study:primary & secondary stepped
care pathway
Introduction to legalisation
& classification concepts

 Legislation to make illicit
 – Alcohol 1916-munitions risk but repealed
 – Corruption of armed service morals 1917
 Narcotics 1920-international USA led
 Misuse of Drugs Act, 1971
 Introduced Classes for severity of legal
 punishment
 Still no scientific/social harm relative risk
 comparitor for different Criminal Justice
 classes agreed with the politicians in 2009 in
 UK
      Social assimilation depends on
      formulation & familiarity of use




                                     Coco leaf chewers


                                   Sustained mountain
                                   work, poor nutrition
                                   in thin oxygenated air

versus adverse dependence of concentrated forms
Medical
Endorsement
of low potency
product
Alcohol and cocaine ‘tonic’

               Cocktail increases
               harm associated
               intoxication
               Mixed with misogeny
               Leads to illegalisation
               Routes of use also
               determine harm &
               dependence potential
               – iv, snorting,smoking
Illegal highs challenge legislation effectiveness
USA analogue legislation versus UK chemical description
to discourage legal ambivalence for courts




      Methamphetamine                   Mephedrone
What will we cover?
 Briefly “Herbal Ecstasy”
 – covers many drug types
      “Spice” cannabinoids-sedative-hallucinogen
       Salvia Divinorum-hallucinogen
 Briefly “Liquid Ecstacy”
 – GBL(gammabutyrolactone)
      sedative anaesthetic
      GHB (gammahydroxybutrate) precursor
 Most potentially harmful so for your
 awareness
 – Kraton (opioid)
 – Stimulants
      Cathinones: Khat,
      Mephedrone
      BZP (benzylpiperazine)
Some 'Legal highs' not legal
anymore
 Class B:
 – Synthetic             90
                         80
     Cannabinoids        70
     Stimulants:         60
     (mephedrone)        50
                                          East
                         40               West
 Class C:                30               North
                         20
 – Stimulants:BZP and    10
   related piperazines    0
                              1st   3rd
 – Sedative:GBL               Qtr   Qtr
   (Gamma-
   Butyrolactone)
Definition

 Drugscope:
 – Substances that mimic the effects of
   illegal drugs such as ecstasy and speed,
   but are not controlled by the Misuse of
   Drugs Act.
 Wikipedia:
 – substances which are not prohibited by
   the United Nations Single Convention on
   Narcotic Drugs & used to seek
   intoxication.
Kratom
Kratom
• Tree native to Southeast Asia (Mitragyna
  speciosa)-same family as the coffee tree.
• Leaves often chewed in SE Asia; folk
  medical use.
• Illegal in Australia, Malaysia, and
  Thailand.
• Grown widely in Indonesia for worldwide
  trade
Kratom Farm
Kratom
Mu-opioid receptor agonists:
 – mitragynine
 – mitraphylline
 – 7-hydroxymitragynine (which is currently the
   most likely candidate for the primary active
   chemical in the plant).


Kratom also contains:
 – epicatechin (antioxidant found in dark chocolate)
 – Raubasine (antihypertensive)
 – yohimbe alkaloids (aphrodisiac)
Effects   Southeast Asia:
          – Chewed: fresh
            leaves numbing,
            stimulating effect.

          – Oral:
               as a tea,
               tea boiled down a
               tar/resin that is
               swallowed


          – Smoked: uncommon
Form
Effects

 POSITIVE
 – Simultaneous stimulation & sedation
 – Feelings of empathy
 – Feelings of euphoria
 – Aphrodisiac qualities for some people
 – Vivid waking dreams
 – Useful with physical labour
Form
Effects
NEUTRAL
 – Relatively short duration
 – Change in ability to focus eyes
 – Analgesia

NEGATIVE
 – Very bitter taste
 – Dizziness, nausea and/or vomiting
 – Mild depression during and/or after
 – Increase in (perceived?) body
   temperature. (feel hot and sweaty)
 – Hangover similar to alcohol
Effects

 Dose oral (chewed or tea)
 between 2 and 10 grams of died
 leaf

 Onset : 5-15 minutes
 Duration : 2-5 hours
 Normal After Effects : 3-6 hours
Is it Addictive?


 – Withdrawal after frequent use
 – Usually mild
 – Comparable in character to opiate
   withdrawal
      – Flu like symptoms, restlessness, teary eyes,
        insomnia etc.
Price

 Powdered leaves “Premium Grade”
 – 10 grams £ 4.99

 Extract
 – 3 grams £6.99

 Resin
 – 2 grams £12.99


             Source: EveryoneDoesIT.com accessed 26/03/2010
Khat

 Cathinone, stimulant extracted from
 Khat (Catha Edulis)
 Grown in Arabia and Africa
 UK: Somali and Yemeni immigrants
 Khat leaves not banned in UK
 Cathinone is Class C Drug
Khat
Khat
Khat
       The ancient
Khat   Egyptians
       considered the
       khat plant a
       "divine food”.



       11th century:
       first description
       of medicinal use
       relieves
       biliousness (Abū
       Rayhān al-Bīrūnī)
       Swedish Botanist, Peter
       Forskal, studied khat in
Khat   Arabian Peninsula,
       1768.

       "I observed a new
       peculiarity in this city
       — everyone chewed
       leaves as goats chew
       the cud.”
       ‘What benefits are
       there to be gained
       from eating these
       leaves?’ to which they
       replied, ‘None
       whatsoever, it’s just
       another expense for us
       as we’ve grown
       accustomed to it’.
       (Abdullah bin Abdul Kadir
       (Malay writer) in Yemen)
Mephedrone
Mephedrone Duration (Oral)

Total Duration   2 - 5 hrs

Onset            15 - 45 mins
Coming Up        15 - 30 mins
Plateau          15 - 30 mins
Coming Down      30 - 90 mins

After Effects    2 - 4 hrs
Mephedrone

POSITIVE
 – stimulation (mental and physical)
 – euphoria, mood lift
 – feelings of empathy, openness
 – increase in sociability, desire to talk with
   others
 – pleasurable rushing
 – sense of being sped up
Mephedrone

“NEUTRAL”
 – reduced appetite
 – pupil dilation
 – unusual body sensations (facial flushing,
   chills, goosebumps, body energy)
 – change in body temperature regulation
 – sweating
 – increase in heart rate and blood pressure
Mephedrone
NEGATIVE (negative side effects increase
 with higher doses)

  – strong desire to re-dose, craving to recapture
    initial euphoric rush
  – uncomfortable changes in body temperature
    (sweating/chills)
  – palpitations, sense of racing heart
  – impaired short term memory
  – insomnia
Mephedrone
NEGATIVE
 – tightened jaw muscles, grinding teeth (trismus
   and bruxism)
 – muscle twitching
 – nystagmus
 – dizziness, light headedness, vertigo
 – a couple of reports include serious
   vasoconstriction
 – when insufflated: pain and swelling in nose and
   throat, sinusitis
Routes of Administration

 Ingestion
 – Delayed onset of effect
 – Effect lasts longer


 Insufflation (Snorting)
 – more associated with compulsive /
   addictive use patterns
Addiction / Compulsive Use
 Advertised as "non-addictive" alternative to
 methamphetamine, cocaine, and other
 stimulants

 compulsive use patterns are similar to or
 stronger than those of other recreational
 euphoric stimulants

 Dependence Psychological in nature
Piperazines
 Illicit
 – Benzylpiperazine
   contains also
 – Trifluoromethyl-
   piperazine & other
   piperazines
 Prescription
 – Sildenafil (Viagra)
 – Cyclizine
 – Bupropion
Benzylpiperazine [BZP]
 COMMON & BRAND NAMES
  – A2, Frenzy, Nemesis
 EFFECTS CLASSIFICATION
  – Stimulant
 CHEMICAL NAME
  – 1-benzylpiperazine
 BZP is a stimulant which gained popularity
 as a previously legal alternative to amphetamine,
   methamphetamine and MDMA.
    Benzylpiperazine
    BZP
Scientific / Trade or
 Slang Name:
 Piperazine BZP, Herbal E, Per
 Pills


 How long it stays in
 your system:
 Lasting 4-6 hours with
 reports as long as 8 hours
 depending on the dose.
Short-term effects:



 Users report alertness, euphoria and a
 general feeling of well being. The
 perception of certain sensations such
 as taste, colour or music may be
 subjectively enhanced
Long-term effects:

 Seizures,
 Dilated pupils,
 Irregular heart beat, rise in blood pressure,
 fainting,
 Impotence can result in excessive use,
 Piperazine CNS toxicity: seizure, ataxia
 Also mild memory loss reported.

 (Recorded UK May ‘06)
Guess what this is:
Case study-Mephedrone

 Client age 20 yrs-escalating interest in
 drugs but not problematic
 Lost his job because of mephedrone
 intoxication
 Mother & client wanted medical advice
 on management of withdrawal
Their particular concerns were
– Appropriate agency to help
– Medical explanation of symptoms
Gp indicated lacked competency to
advise but did not facilitate referral
– Consequently client & carer were
  distrustful of help available
Improved as accessed Tier 2 but
worker wanted medical assessment of
nature of withdrawal symptoms &
mental health assessment
Symptoms-mixed
withdrawal/intoxication
– Electric shocks
– Muscular spasm of body including in sleep
– Bruxism-jaw grinding [client recognised
  typical of stimulants]
– ‘Formication’ with picking of facial skin
Mental state:
 Suspiciousness
 –   Feeling that others spoke about him
 –   Irritable not usual personality
 –   Pressure of speech & thought/mood↓
 Circumstantiality/rambling when not
 intoxicated
 – Magical thinking (schizotypal pd), but describing
   body energy
 Reliance on peer group for credible
 information
Explanation of Symptoms

Acute Increase in Noradrenaline
(NA), Serotonin(5-HT)), Dopamine
(DA) in an increasing dose sequence

– Arousal (NA),     Alert, agitation and
  aggression
– Euphoria (5-HT))      Manic state
– Interest (DA)     Total paranoia
– Psychotic state (brief chronic
  schizophreniform)
Advice for graduated self reduction,
alieviates rapid changes in serotonin
Consideration of symptomatic
prescribing
– fluoxetine may help serotonin levels
  and gradually withdrawn (general
  evidence base-weak but particular
  symptoms). GP content to prescribe
Awareness of internet exchange of
information on both rapidly
increasing use and managing
withdrawal
    Follow-up
One attendance intoxicated verified stimulant
intoxication
 – Mental
     Loquacious
     Agitated
     Irritable/Paranoid
 – Physical
     Tachycardia
     Hypertension
     Sweating
     Pyrexia
     Dilated pupils
Further secondary specialist
assessment to determine if mental
health symptoms alieviated or required
further follow-up

Tier 2 counselling
Community reinforcement approach

				
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