The term “legal highs” will soon shed its connotations. The masterminded legal advantages that these novel psychoactive substances (NPS) enjoy over the other commonly abused drugs are expected to be neutralised as our politicians, a bit behind schedule, finalise the EU imposed law that bans this group of chemicals.
‘Spice is available as a mixture of synthetic cannabinoids sprayed on inert herbal material and sold in small bags roughly at €10 per gram, enough to make a couple of joints. Consumers cannot predict the composition, potency or toxicity of the sprayed chemicals.’In the past few years the escalated use of NPS instigated a surge of hospital admissions with gross behavioural disturbance, fuelled by disordered thoughts and labile emotions.
Patients are mostly males, in their teens or early 20s, and present with florid and at times bizarre psychosis that significantly disrupts their mental, social and occupational functioning.
Treatment is challenging in terms of a relatively long timeframe to recovery, partial or poor response to combined medications, and multiple relapses and readmissions following repeated drug use.
Most worrisome is the seemingly irreversible decline in the overall level of functioning, disrupting important aspects of the individual’s life such as enduring relationships and personal and career development.
The main adverse effects are not exclusively psychiatric. Users also present to emergency departments with seriously deranged blood salts, dangerously high body temperatures, epileptic fits and loss of consciousness with sudden collapse. A number of fatal outcomes most probably occurred with the culprit escaping detection.
NPS comprise a mixed group of temporary legal and illegal substances. They are sold online as incense, potpourri, bath salts or plant food with the disclaimer “not meant for human consumption”, thus obscuring their illegitimacy and bypassing safety regulations.
Clandestine chemists strive to revive NPS’s legal status by fabricating hundreds of new and therefore not yet illegal derivatives that are potentially more toxic, powerful, and liable to cause more severe dependence syndromes: the downside of outlawing specific substances and the main reason behind the blanket ban imposed by the new law.
Users are mostly after altering their conscious state and detachment from reality through highs that mimic the effects of the more traditional illicit drugs such as cocaine, marijuana and ecstasy.
NPS consumption grew rapidly as a result of uncontrolled access, mainly among users who may feel uncomfortable with breaking the law and those who limit themselves to incognito and discreet online trading. Locally, it seems that most users still resort to street-level drug dealers for their regular supplies delivered in small transparent plastic bags with nothing printed on them.
Adolescents and young adults are the main targets of the NPS market, perhaps as a result of their dubious legal status, cheap price, widespread availability and easy online access. These factors are also meant to be targeted by the new law.
The most commonly consumed NPS are the synthetic cannabinoids, substances that despite having no structural similarity to THC, the principal psychoactive ingredient of marijuana, attach to and stimulate the same receptors of the endocannabinoid system more intensely and effectively than THC itself. Appetite, mood, memory, pain appreciation, body temperature regulation, orientation to reality and other aspects of psychological functioning are disrupted.
Patients are mostly males, in their teens or early 20s, and present with florid and at times bizarre psychosis…
Spice is available as a mixture of synthetic cannabinoids sprayed on inert herbal material and sold in small bags roughly at €10 per gram, enough to make a couple of joints. The chemical blend varies widely despite being bought under the same label and from the same source. As a result, consumers cannot predict the composition, potency or toxicity of the sprayed chemicals.
Both the sought-after and the adverse effects fluctuate widely, resulting in clusters of similar presentations to hospital over a short period of time. K2, Black Mamba and Aroma are similar products sold worldwide with attractive labels targeting teenagers and young adults.
It is not surprising that a low-cost substance that is nonetheless capable of instigating intense highs attracts the attention of potential users from different walks of life. As a bonus, it is almost invisible as it can be easily dissolved in volatile transparent solvents that can be sprayed on anything including paper and clothes, making traffic to prisons and mental health institutions almost impossible to control.
It is also highly potent, that is low doses are needed for intoxication and is largely undetected by routine drug screening tests. It can be afforded by people with low incomes without the need to engage in risky illegal activities to fund the habit.
The risk averse, or those who are closely scrutinised for drug use, such as those under probation and the inmates of prison or other institutions, are understandably fascinated by the qualities of these drugs. The extension of drug use and altered states of consciousness beyond detection is, for many, irresistible.
Others still prefer the sought-after effects of the traditional illicit drugs but resort to synthetics when their supply is interrupted.
Then there are those who seek the thrill of experiencing a new kind of high, perhaps driven by the boredom and tolerance to other substances and want to test their personal reactions to novel chemicals.
These chemicals produce marijuana-like effects, including mood elation and relaxation, and altered perceptions, though the individual experience may be somewhat different given their stronger effects on the cannabis receptors and other systems.
Unwanted effects are commoner, and more prominent and severe compared to those of THC. Anxiety, extreme agitation and psychosis with hallucinations and paranoia are frequently experienced. Memory problems and decreased attention contribute further to the overall level of impairment.
Driving under the effects of synthetic marijuana is extremely risky due to the more pronounced decreased coordination and delayed-response time.
Users with severe vomiting, metabolic disturbances and kidney failure requiring dialysis present to emergency departments following intoxication with NPS. Serious medical problems such as sudden collapse through palpitations, hypertension, heart attacks, general seizures, brain haemorrhage and stroke can be life-threatening.
Specific, ultra-potent synthetic cannabinoids such as AMB-FUBINACA have been associated with a series of cases presenting with zombie-like behaviours such as staring blankly in space, slurred speech and groaning, and sluggish movements of the limbs.
While acknowledging and highlighting the devastating effects of the synthetic cannabinoids, it would be daft to ignore the fact that a good part of the above harm is induced by the extensive disruption of the endocannabinoid system. Cannabis exerts most of its effects on the same system causing the same sort of harm though less aggressively. The damage that legal highs trigger almost instantly, THC inflames gradually and cumulatively, depending on the total amount used over time and the inherent vulnerability of the individual.
The immediate and significant damage of a soon illegal group of substances is an eye-opener to the delayed ill-effects of a different chemical that attacks the same brain receptors in a more subtle way. To what extent can we remain coherent by banning the first and promoting the second by legalising it for recreational use?
Anthony Dimech is a consultant addiction psychiatrist.