The challenge of the novel psychoactive substances: How have we responded and what are the implications of this response?
Year: 2020
Type: article
Abstract: The use of illicit drugs is common, with approximately 29% (around 96 million) of adults aged 15-64 years old in the European Union having used an illicit drug in their life.1 The most commonly used illicit drug remains cannabis (lifetime use by 91.2 million [27.4%] European Union adults), followed by cocaine (lifetime use by 18.0 million [5.4%] European Union adults).1 Since the beginning of the 21st century, there has been an increase in the availability and use of a range of drugs known as "novel psychoactive substances," "new psychoactive substances" or "NPS" and more colloquially by users and the lay press as "legal highs" and "herbal highs." By the end of 2018, 730 substances had been detected in Europe and are being monitored by European Monitoring Centre for Drugs and Drug Addiction (EMCDDA).1 These typically enter the drug scene as either legal alternatives to existing illicit drugs or to replace gaps in the market when other illicit drugs are not readily available. An example of the latter is when the piperazines and cathinones replaced the lack of MDMA in the UK drug scene.2 Often, NPS are structurally related to existing illicit drugs, but with small changes to the chemical structure, meaning that at the time that they emerge onto the drug scene, they are not controlled by existing national and international legislation.3 For example, mephedrone (4-methylmethcathinone), which was first detected in 2007 in drug seizures from Scandinavia, is the beta-keto derivative of 4-methylamphetamine and therefore initially was outside of existing drug control legislation in Europe until it was risk assessed by the EMCDDA in June 2010 and recommended for control across Europe by the European Council in December 2010.2, 4 Previous data on the prevalence of use and harms associated with the use of illicit substances have traditionally focused on the frequency and volume of detection of substances in law enforcement and border seizures, drug-related deaths, and utilisation of drug treatment services for drug dependency, along with data from animal and pre-clinical studies.1, 5-7 The exponential rise in the number and range NPS that have been detected and the rapidity by which substances become available has presented significant challenges in relation to our understanding of the prevalence of their use, how NPS are obtained by users, how we can detect the use of these substances, what the acute harms related to their use are, and how we respond to the potential public health risks posed by NPS.6, 8, 9 In addition, clinicians treating patients presenting with acute toxicity and dependence related to the use of NPS often have less confidence in treating those patients compared to those who present with issues related to the use of established illicit drugs, despite the commonality of the issues seen.10-12 In the European Union, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) has developed new monitoring tools alongside their existing indicators with the hope that these will provide a more complete picture on the risks related to NPS. These new monitoring tools include syringe residue analysis, data on hospital emergency presentations from the European Drug Emergency Network Plus (Euro-DEN Plus) project, analysis of wastewater, drug checking services, and expanded web surveys.1 Testing of drugs that users are intending to take in different settings provides more robust information on the different types of illicit drugs and NPS being used in different recreational settings.13, 14 Providing information to users on what is actually in their drugs could be considered a "harm minimisation" strategy, as it enables users to make an informed decision not only whether they use them, but also to reduce the amount that they use thereby reducing the potential risks.14, 15 Data on the prevalence of use of both illicit drugs and NPS have been greatly increased by the development of analysis of wastewater to detect both parent drug and major metabolites at the wastewater treatment level.16, 17 This allows comparison of patterns of use both across different geographical regions and countries across different time periods. Analysis of urine from street level urinals compliments the data from wastewater treatment studies, since it allows detection at a smaller geographical level as well as enabling the detection of illicit drugs and NPS at lower levels without the confounding issues of bacterial metabolism in the wastewater system.18-21 The development of the European Drug Emergencies Network (Euro-DEN) project from the original 16 sentinel centres in 10 European Countries in 2013 to 33 sentinel centres in 22 European and neighbouring countries in the expanded European Drug Emergencies Network Plus (Euro-DEN Plus) project by the end of 2019 has provided a detailed insight into the acute harms and toxicity related to the use of both illicit drugs and NPS.1, 22-25 Through combination of existing traditional indicators with these monitoring tools, we are able to develop a more robust set of information on the use and harms related to the use of both illicit drugs and NPS, which provides a greater understanding of the overall public health risks associated with NPS. The final, and potentially biggest challenge posed by NPS, is how—both nationally and internationally—we respond to their legal status and consider whether control is appropriate to reduce their availability, use, and potential public health and social risks. Previous control mechanisms, both at national and international levels, have required evidence of the availability and use of an NPS together with harm associated with this use, before an individual NPS or class of NPS can be considered for control. These mechanisms are slow to respond when a new NPS is detected, with the required information to implement control taking many months or years, meaning that potential users remain at risk.9 In an attempt to deal with these delays, individual countries have introduced legislation that allows more rapid control of new NPS prior to more formal review and control under their own pre-existing legislation. In the United Kingdom, where substances were traditionally controlled under the Misuse of Drugs Act, 1971, there have been two stepwise approaches. Initially in 2012, there was the introduction of temporary class drug orders which allowed more rapid control of the importation and distribution of an individual NPS or class of NPS once there was evidence of availability, use, and potential harms related to use. However, this still required initial evidence of use and related harms, and so in 2016, the Psychoactive Substance Act came into law which effectively controlled the importation, distribution, and sale of any substance that had potential psychoactive activity.26, 27 The impact of these novel mechanisms of controlling substances is not yet fully understood, but, as demonstrated in this themed issue and data from other sources, there is the potential that the UK Psychoactive Substance Act has reduced the availability, use, and associated harms of NPS.21, 27-29 Unforeseen consequences of the focus on how we deal with the challenges of the emergence of the large number of NPS is the potential increase in the availability and purity of classical illicit drugs,1 which may lead to greater harms from these substances.28-30 It is important that future studies in this field consider drug use in its entirety rather than focusing on just NPS or illicit drugs, which will enable us to truly understand the consequences of our response to the challenge of the NPS phenomenon. D.M.W. is an expert advisor to the UK Advisory Council on the Misuse of Drugs (ACMD), European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), United Nations Office on Drugs and Crime (UNODC) and World Health Organisation (WHO). P.I.D. is a member of the Scientific Committee of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and an expert advisor to the UK Advisory Council on the Misuse of Drugs (ACMD), United Nations Office on Drugs and Crime (UNODC) and World Health Organisation (WHO). D.M.W. wrote the first draft, and both D.M.W. and P.I.D. revised and approved the final submitted manuscript.
DOI: 10.1111/bcp.14236
Authors: David M. Wood, Paul I. Dargan
Language: English
Subfield: Toxicology
Domain: Life Sciences
Open Access status: green
OpenAlex ID: W3010008305