Download NEW WAYS TO BE ADDICTED: LATEST TRENDS IN SUBSTANCE

NEW WAYS TO BE ADDICTED: LATEST
TRENDS IN SUBSTANCE AND
BEHAVIOURAL ADDICTIONS
Dr Giovanni Martinotti
University “G.d’Annunzio” – Chieti (Italy)
email: [email protected]
NEW DRUGS AND NEW ADDICTIVE BEHAVIOURS
AN EVER-CHANGING SCENARIO
This presentation will address two key
areas, which at first sight may not appear
to be particularly related to each other.
Their novelty, however, connects them
tightly.
The appearance of these two issues has,
on one hand, required and promoted a
renewal of the perspective in addiction
science and, on the other hand, could
facilitate the rethinking of practical,
therapeutic and preventive interventions.
THE NEW PSYCHOACTIVE SUBSTANCES
NEW PSYCHOACTIVE SUBSTANCES
A MARKET ON THE MOVE
New Psychoactive Substance (NPS) is
the term used to indicate a new drug or
a new psychotropic substance, either in
pure form or in a preparation, which is
not controlled by the United Nations
Convention on Narcotic Drugs of 1961
or the United Nations Convention of on
Psychotropic Substances 1971, but
which may present public health risks
comparable to those posed by the
substances included in these
conventions
United Nations Office On Drugs And Crime-UNODC World Drug Report 2013
NEW PSYCHOACTIVE SUBSTANCES
A MARKET ON THE MOVE
In this context, the term "new" does not
necessarily refer to new inventions,
since often NPS are the result of the
"recycling" of molecules studied in the
past by official pharmacology, but it
rather refers to substances that have
recently become available in a specific
markets.
The effects of long-term intake, and for
some substances also the short-term
effects, are not known.
United Nations Office On Drugs And Crime-UNODC World Drug Report 2013
MEN AND PSYCHOACTIVE SUBSTANCES
A CHEMICAL LOVE STORY
Looking for altered psychophysical states
is a constant feature in the evolution of
humanity.
Opium, coca leaves, mescaline, and
various other substances have been
used for centuries in various cultures for
therapeutic purposes, for religious
ceremonies and for the improvement or
modification of the physical and mental
abilities.
Even today, the line between socially
acceptable and unlawful use of a variety
of psychoactive products is strictly
culture-bound.
THE PSYCHONAUTS
CROSSING THE DOOR IN THE WALL
The psychonauts (from the Greek ψυχή,
mind, and
ναύτης, navigator) are individuals who
define themselves as "explorers of human
existence," through the achievement of
altered states of consciousness.
Many so-called psychonauts attend forums
and online communities, in which they
exchange opinions and talk about
experiences with psychoactive substances,
often of dubious origin or poorly or not
known at all to scientific community.
NEW PSYCHOACTIVE SUBSTANCES
A MARKET ON THE MOVE
Originally, the most common NPS
belonged to the families of
phenethylamines and tryptamines.
The past five years have instead
witnessed the appearance on the
market of substances from a wider
range of "chemical families", such
as cathinones, synthetic
cannabinoids (Spice),
phencyclidine, benzofurans.
European Monitoring Center for Drugs
and Drug Addiction (EMCDDA) – Annual
Report 2014
SYNTHETIC CANNABINOIDS (SC)
SPICE DRUGS
SC appeared on the illicit market at the
beginning of the millennium. This group
of substances consists of many synthetic
compounds, whose active ingredients
mimic the effects of THC; cannabidiol is
instead not present.
They have a much greater receptor
affinity than natural cannabinoids, and
are not traceable in biological samples
with standard tests.
One of the founders of this class is JWH018, a naphthoylindole agonist of CB1
and CB2, which was synthesized in the
80s by Professor John W. Huffman
during his research for new treatment
options for multiple sclerosis.
SYNTHETIC CANNABINOIDS
A VERY SPICY FAMILY
SYNTHETIC CANNABINOIDS
A VERY SPICY FAMILY
THE “PSYCLONE” CASE
THE “PSYCLONE” CASE
IF YOU GOOGLE “PSYCLONE”…
THEME PARKS RIDES
Canada’s Wonderland Psyclone
URBAN DICTIONARY
Six Flags Magic Mountain (California) Psyclone
PSY-CLONES?
A NAME FOR TWO
PSYCLONE #1
Sold as a “herbal blend not for human
consumption”, it contains 2 different
synthetic cannabinoids: 5F-PB-22 and
AKB48 (APINACA).
The product is priced roughly around 10£
per gram and is commonly smoked in
rolling paper or in pipes, or heated in
aluminium foil and inhaled.
Users refer fast, intense and long lasting
effects, which include euphoria, relaxation,
visual hallucinations and extreme tiredness
SYNTHETIC CANNABINOIDS – 5F-PB-22
5F-PB-22 is a synthetic cannabinoid (quinoline
carboxylated cannabimimetic), and differs from
its parent compound-PB-22 (QUPIC) for the
presence of a fluorine atom in the chain pentyl
terminal.
5F-PB-22 acts as a full agonist for both the
cannabinoid receptors CB1 and CB2, but
showed significantly higher affinity for the CB2
receptors.
Similarly to AKB48, it may be a component of
"smoking incenses" or can be sold as "research
chemical", with the appearance of a pale yellow
powder.
SYNTHETIC CANNABINOIDS – 5F-PB-22
At present, 5F-PB-22 is not controlled in most EU
countries.
It was recently subjected to ban (February 2014)
according to the procedures of the Drug
Enforcement Administration in the United States.
SYNTHETIC CANNABINOIDS – 5F-PB-22
SYNTHETIC CANNABINOIDS – AKB48
AKB48 was identified in Japan in March
2012 as a component of herbal smoking
blends, and has been named after a
popular Japanese girl band.
It acts as a reasonably potent agonist for
the cannabinoid receptors CB1 and CB2; it
has showed to have twice the binding
affinity for CB1 than CB2.
It can be sold in “smoking incenses”,
mixed with other substances, or as a
“research chemical”, as a white to yellow
crystallized powder.
SYNTHETIC CANNABINOIDS – AKB48
AKB48 was added in 2013 in Schedule I of the
Controlled Substances Act in the United States,
and is subject to temporary control in New
Zealand.
It is also illegal in Japan, Germany and Latvia, and
can be regarded as such in Poland, where it is
likely to be included in the general provisions of
national reference.
PSYCLONE #2
Sold as “research chemical not for human
consumption”, Psyclone #2 contains a
mixture of lidocaine, caffeine and
ethylphenidate.
The product is priced roughly around 21£
per gram and appears as a powder.
Common modalities of intake appear to be
inhaling and “bombing” (wrapping the
powder in cigarette paper and
swallowing).
Users report euphoria, boosted energy,
extreme feelings of wellbeing, but also
altered perception of time, insomnia,
anxiety, alternate perception of reality and
a prolonged hangover (an entire day for
“recovery” is suggested).
ETHYLPHENIDATE AND CAFFEINE
IF ONE STIMULANT IS NOT ENOUGH
Ethylphenidate is a strong stimulant acting
on both dopamine and norepinephrine
neurotransmitters in brain.
Its parent compound, methylphenidate, is
a drug approved for the treatment of
ADHD, postural orthostatic tachycardia
syndrome and narcolepsy.
Ethylphenidate appeared on the online
market in December 2010: it is is sold as a
white, sugar-looking powder or as white
crystals.
It is reported to generate a more “euphoric
high” than methylphenidate or cocaine,
probably because of its major activity as a
dopamine reuptake inhibitor.
ETHYLPHENIDATE AND CAFFEINE
IF ONE STIMULANT IS NOT ENOUGH
Caffeine, a xanthine alkaloid retrieved in a
variety of leaves, seeds and fruits, acts as
a CNS and metabolic stimulant.
An overdose of caffeine usually occurs
when there is an excess of about 300
milligrams: symptoms may include
restlessness, excitement, insomnia,
nervousness, flushing, polyuria,
gastrointestinal disturbances, muscle
twitching, increased perspiration, rambling
flow of thought and speech, irritability and
tachycardia or altered cardiac rhythm.
PMA/PMMA
AN ACTUALLY “MORTAL KOMBAT”
Para-methoxyamphetamine (PMA) and paramethoxy-methylamphetamine (PMMA) are
structurally similar to amphetamine and
methamphetamine respectively, but with a
methoxyl group in –para position.
They both have stimulating and
hallucinogenics effects, and are usually
taken orally (in the form of powder, tablets or
capsules) or inhaled, or less commonly,
injected intravenously.
The appearance on the market of PMA dates
back to the 70s: in a decade it has earned
the nickname of "Mr. Death" in the USA and
Canada, for causing dozens of deaths.
PMA/PMMA
AN ACTUALLY “MORTAL KOMBAT”
PMA and PMMA have recently come
back to the fore, often passed off to
buyers as ecstasy tablets. Since their
stimulating effects occur belatedly,
the risk of repeated intake is high.
PMA acts as a serotonergic agent,
with limited effects on the transport of
dopamine and norepinephrine.
Hyperthermia is among the most
common adverse effects from PMA /
PMMA , and is the leading cause of
death for these substances.
KNOWLEDGE OF THE NPS PHENOMENON
AMONG HEALTH PROFESSIONALS
THE FIRST ITALIAN STUDY ON NPS KNOWLEDGE AMONG
HEALTH PROFESSIONALS
A sample of 240 physicians,
residents, nurses and clinical
psychologists (60.5% females, mean
age 40.4 years, mean working
experience 12.7 years, mostly
employed in Mental Health and
Addiction services) has been asked
to fill in a survey aiming at assessing
their knowledge about NPS.
THE FIRST ITALIAN STUDY ON NPS KNOWLEDGE AMONG
HEALTH PROFESSIONALS - RESULTS
Simonato P, Corazza O, Santonastaso P et al. (2013) Novel psychoactive substances as a novel
challenge for health professionals: results from an Italian survey Human Psychopharmacology,
28(4): 324–331
THE FIRST ITALIAN STUDY ON NPS KNOWLEDGE AMONG
HEALTH PROFESSIONALS - RESULTS
More tha 96% of interviewees classified the importance of technical
knowledge of NPS as ”very relevant" for their clinical work.
Conversely, only 31% of the sample received regularly any kind of scientific
information on the subject at the moment of the survey.
Simonato P, Corazza O, Santonastaso P et al. (2013) Novel psychoactive substances as a novel
challenge for health professionals: results from an Italian survey Human Psychopharmacology,
28(4): 324–331
NPS - EPIDEMIOLOGY
EPIDEMIOLOGY OF NPS
A questionnaire has been administered to a
sample of 3023 subjects aged between 16
and 24 years, to investigate the level of
knowledge, sources of information and any
experiences with a group of selected
substances among the most common
currently on the market (herbal highs,
phenethylamines, gammaidrossibutirrato
and derivatives, synthetic cathinones and
cannabimimetics).
Consumption of alcoholic beverages, coffee
and energy drinks, use of "traditional drugs"
and time spent online daily were also taken
into account .
Martinotti et al., in press
KNOWLEDGE OF NPS
USE OF NPS
EPIDEMIOLOGY OF NEW PSYCHOACTIVE SUBSTANCES
- RESULTS
Preliminary results indicate a partial
knowledge of NPS, and a use, albeit
quantitatively small, probably significant
compared to general population.
The most relevant datum is the
percentage of subjects (89.6%) who
practice Binge Drinking among those
who make use of alcoholic beverages
(53.6%).
THE BINGE-DRINKING PHENOMENON
Binge Drinking is a pattern of drinking
that brings a person’s blood alcohol
concentration (BAC) to 0.08 grams
percent or above.
This typically happens when men
consume 5 or more drinks, and when
women consume 4 or more drinks, in
about 2 hours.
Most Binge Drinkers are NOT alcohol
dependent.
NIAAA – US National Institute on Alcohol Abuse and Alcolism, 2013
THE BINGE-DRINKING PHENOMENON – EUROPEAN
DATA
ESPAD, the European School Survey Project on Alcohol and Other Drugs, Report 2011
PATTERNS OF ABUSE – PSYCHIATRIC
PATIENTS VS HEALTHY SUBJECTS
NPS USE IN YOUNG ADULTS WITH AND WITHOUT
PSYCHIATRIC COMORBIDITIES
NPS USE IN YOUNG ADULTS WITH AND WITHOUT
PSYCHIATRIC COMORBIDITIES
A questionnaire designed to investigate
patterns of consumption/abuse of alcohol,
"classic” drugs and NPS was administered to
a sample of 2615 healthy subjects (18-26
years), and to a sample of 206 same-aged
psychiatric patients, diagnosed with a DSM-5
stable diagnosis at the time of testing, and
excluding those with substance use disorder.
Patients were recruited in eight Mental
Health Departments in several Italian cities;
healthy subjects were selected as well
among residents in cities of the north, center
and south of the country.
NPS USE IN YOUNG ADULTS WITH AND WITHOUT
PSYCHIATRIC COMORBIDITIES
NPS USE IN YOUNG ADULTS WITH AND WITHOUT
PSYCHIATRIC COMORBIDITIES - RESULTS
Most abused NPS:
• Synthetic
cannabinoids
• Metamphetamine
• GHB
• Salvia divinorum
a p<0.05
b p<0.001
NPS USE IN YOUNG ADULTS WITH AND WITHOUT
PSYCHIATRIC COMORBIDITIES - RESULTS
BEHAVIOURAL ADDICTIONS
BEHAVIOURAL ADDICTION
INTERNET ADDICTION
GAMBLING
SEXUAL ADDICTION
EXERCISE ADDICTION
COMPULSIVE BUYING
SUBSTANCES – NO SUBSTANCES: COMMON ASPECTS
• Intoxication
• Loss of control
• Abuse
• Impulsivity
• Abstinence
• Compulsivity
• Tolerance
• Obsessiveness
• Craving
• Depression
• Axis I comorbidities
• Victimization
• Axis II comorbidities
• Inadequate money management
• Unsuccessful attempts of
interruption
• Inappropriate use of the body
• Using more than planned
• Communication problems
• Inability to manage the use
• Poor insight
• Distortion of reality
• Recidivism
• Hostility and refusal of medical
care
PSYCHOPATHOLOGY OF PATHOLOGICAL GAMBLING
The formal expansion of the range of addictive
disorders to the direction of addictions not
related to chemical substances has eventually
been brought by the publishing of DSM-5
(American Psychiatric Association, 2013).
In this edition of the manual, the former section
on ’Substance-Related Disorders’ has been
replaced with ’Substance-Related and Addictive
Disorders’.
PSYCHOPATHOLOGY OF PATHOLOGICAL GAMBLING
Repetitive behaviours and presence of recurring
thoughts on the theme of the gaming are factors
that indicate a similarity with OCD, although it is
evident the lack of intrusiveness and aimlessness
typical of obsessions (Pancheri, 1992)
"Blindness" of the subjects towards the family and
of their families towards the subjects (Sylie, 1997)
Tolerance and withdrawal: the need to bet
increasing amounts of money and the experience
of anxiety, irritability and physical distress during
the period of absence from gaming.
Lack of self-esteem that determines an obsessive
search for a better self-image (Cornish, 1978)
PSYCHOPATHOLOGY OF PATHOLOGICAL GAMBLING
Abnormal states of hedonic hypostimulation
(Blaszczynsky and McConaghy, 1989)
Seeking for thrill, experiences, new
environments or events, to be experienced
cognitively or sensitively (Zuckerman, 1999)
Pathological gamblers do not merely pursue for
pleasure, but they search for an altered state of
consciousness (Leisure, 1984)
Susceptibility is caused by boredom,
restlessness is due to the lack of variation of
experience (Zuckerman, 1999)
CONCLUSIONS
A NEW CHALLENGE
The novel psychoactive substance began to spread after the millennium and
have reorganized the apparently stable situation of drug scene.
Since then, new substances have constantly been appearing on the market.
This extremely rapidly changing situation concerning drug use and drug
market set new challenges for professionals.
We have to describe the use of drugs on which we have very limited
knowledge. Not only the chemical description of these substances is often
unavailable, but often we do not even know their street names.
We have to estimate the risks associated with substances without being
familiar even with their most basic characteristics. We have to provide
information to potential users of these and drugs we hardly know anything
about them, or treat unknown side effects or overdoses.
A NEW CHALLENGE
On the other hand, in the past decades, but especially in the past few
years, it has been strengthened the opinion that the range of addictive
disorders should not be reduced to psychoactive substances-related
dependencies.
In line with this, scientific literature on addictions has begun to deal with
a growing number of phenomena, originally not classified as addictive
disorders, but with important psychological and social consequences.
A NEW CHALLENGE
To be inside the social rule: this is how the addict feels himself nowdays
Not using substances, Not binge drinking, Not betting on-line is considered
as an unusual behaviour
Peer exchange is sometimes virtual and not mediated by the body
Both preventions strategies and therapeutical approaches need to be
completely re-thought
We need to improve the knowledge of these issues among health
professionals because we are totally unprepared