This is the peer-reviewed version of the following article: ‘Captagon: Use and Trade in the Middle East’, which has been published in final form at http://onlinelibrary.wiley.com/doi/10.1002/hup.2548/abstract . This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Self-Archiving.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/hup.2548

Captagon: use and trade in the Middle East

Background Although illegal drug use has largely been declining in the UK over the past decade, this period has witnessed the emergence of a range of novel psychoactive substances (NPS) (‘legal highs’). These are new, mostly synthetic, substances that mimic the effects of existing drugs). Despite there being many causes for concern in relation to NPS, there has been little prior study of the burden associated with their use in public health terms. Clarity is lacking on research priorities in this rapidly developing literature. Objectives To inform the development of public health intervention research on NPS by reviewing existing data on their use, associated problems and potential responses to such problems. Design A scoping review and narrative synthesis of selected bodies of evidence was undertaken to summarise and evaluate what is known about NPS use and the related harms of, and responses to, such use. Relevant literature was identified from electronic databases (covering January 2006 to June 2016 inclusive), Google (Google Inc., Mountain View, CA, USA), relevant websites and online drug forums and by contacting experts. Articles were included if they were primary studies, secondary studies involving the analysis and interpretation of primary research or discussion papers. A conceptual framework postulating an evidence-informed public health approach to NPS use in the UK was developed through a pragmatic literature review, the iterative development of concepts and finalisation in light of the results from the empirical review work. The process also involved feedback from various stakeholders. Research recommendations were developed from both strands of work. Results A total of 995 articles were included in the scoping review, the majority of which related to individual-level health-related adverse effects attributable to NPS use. The prevalence of lifetime NPS use varied widely between (e.g. with higher prevalence in young males) and within population subgroups. The most commonly reported adverse effects were psychiatric/other neurological, cardiovascular, renal and gastrointestinal manifestations, and there is limited evidence available on responses. In these and other respects, available evidence is at an early stage of development. Initial evidence challenges the view that NPS should be treated differently from other illicit drugs. The conceptual framework indicated that much of the evidence that would be useful to inform public health responses does not yet exist. We propose a systems-based prevention approach that develops existing responses, is multilevel and life course informed in character, and emphasises commonalities between NPS and other legal and illegal drug use. We make 20 recommendations for research, including nine key recommendations. Limitations Scoping reviews do not interrogate evidence in depth, and the disjunction between the scoping review and the conceptual framework findings is worthy of careful attention. Conclusions Key research recommendations build on those that have previously been made and offer more evidence-based justification and detail, as previous recommendations have not yet been acted on. The case for decision-making on commissioning new research based on these recommendations is both strong and urgent. Future work The validity of recommendations generated through this project could be enhanced via further work with research commissioners, policy-makers, researchers and the public. Study registration The systematic review element of this study is registered as PROSPERO CRD42016026415. Funding The National Institute for Health Research Public Health Research programme.

The Novel Psychoactive Substances in the UK Project: empirical and conceptual review work to produce research recommendations.

Ibogaine is an indole alkaloid found in the root bark of the Iboga shrub native to west Africa possessing hallucinogenic properties. For centuries it has been used in religious ceremonies and to gain spiritual enlightenment. However, since the early 1960s, its apparent ability to reduce craving for psychoactive substances including alcohol, cocaine, methamphetamine, opiates, and nicotine has led to its use in detoxification treatments. In many instances, clients receive treatment in non-medical settings, with little by way of robust scientific clinical trials. This chapter provides an overview of the potential benefits that could arise from such research. This is balanced against the serious adverse effects that can occur due to undiagnosed health conditions and/or concomitant use of other drugs. A detailed update is provided of the 33 deaths known to have occurred, including 5 in the UK. Looking forward, there is a need to develop better opiate detoxification treatment against a background of increasing opioid-related fatalities. A congener of ibogaine, 18-MC, appears to be safer and is to undergo clinical trials. In the meantime, would-be consumers and treatment providers must make more careful, detailed risk-assessments before using ibogaine. Treatment outcomes, including deaths, need to be accurately recorded and published.

Ibogaine as a treatment for substance misuse: Potential benefits and practical dangers.

Objective An ever-increasing number of novel psychoactive substances are being detected worldwide. These emerging drugs have been demonstrated to cause toxicity in clusters, and deaths have been reported. We urgently need to learn more about their effects. We report the protocol for the Western Australian Illicit Substance Evaluation (WISE) study, a research project investigating illicit drug use in the ED. Methods Patients can be enrolled if the treating clinician strongly suspects they are currently intoxicated with a stimulant, hallucinogenic or cannabinoid drug; and an i.v. cannula or blood tests are required for routine clinical care. Patients are enrolled under a waiver of consent. A single additional blood tube is collected, de-identified and frozen on site. A temporary link between patient identification number and study identification number is retained for up to 10 business days post-hospital discharge to allow for clinical data collection, before this is destroyed and the patients become permanently de-identified. Samples are transported for external liquid chromatography-mass spectrometry analysis in batches once de-identified. Results The key outcome will be identification of any psychoactive drugs present in the blood sample, together with their respective concentration. This will be linked to the clinical effects, as well as being compared with the substance the patient believed they had taken. Conclusion We consider the novel approach outlined forms a template for an early warning system for emerging drugs of concern, while also providing vital and comprehensive information on current drugs of abuse, their clinical effects and their impact on the health system.

An early warning system for emerging drugs of concern in the emergency department: Protocol for the Western Australian Illicit Substance Evaluation (WISE) study.

https://serval.unil.ch/resource/serval:BIB_7A1FD65DBD81.P001/REF.pdf

Analysis of Google Trends to monitor new psychoactive substance. Is there an added value

OBJECTIVE: To determine the feasibility and utility of using media reports and other open-source information collected by the Global Public Health Intelligence Network (GPHIN), an event-based surveillance system operated by the Public Health Agency of Canada, to rapidly detect clusters of adverse drug events associated with 'novel psychoactive substances' (NPS) at the international level. METHODS AND RESULTS: Researchers searched English media reports collected by the GPHIN between 1997 and 2013 for references to synthetic cannabinoids. They screened the resulting reports for relevance and content (i.e., reports of morbidity and arrest), plotted and compared with other available indicators (e.g., US poison control center exposures). The pattern of results from the analysis of GPHIN reports resembled the pattern seen from the other indicators. CONCLUSIONS: The results of this study indicate that using media and other open-source information can help monitor the presence, usage, local policy, law enforcement responses, and spread of NPS in a rapid effective way. Further, modifying GPHIN to actively track NPS would be relatively inexpensive to implement and would be highly complementary to current national and international monitoring efforts. © 2015 The Authors. Human Psychopharmacology: Clinical and Experimental published by John Wiley & Sons, Ltd. Language: en

/pdf/detecting-a-signal-in-the-noise-monitoring-the-global-spread-3u5co9mswo.pdf

Chad Dubeau

Papers

Detecting a signal in the noise: monitoring the global spread of novel psychoactive substances using media and other open‐source information

Detecting a signal in the noise: Results of a pilot project to monitor the global spread of new drugs by monitoring media