Legal highs and Novel Psychoactive Substances (NPS)- Beyond Cocaine, Ecstasy and Amphetamines

The debate regarding the legislating evolving new drugs persists for Addiction Psychiatry. Whilst ‘Legal Highs’ (so called as they are not yet under legislation and illegal) keep growing, the issue of legislation needs to be carefully balanced by the understanding of scientific effects of these drugs.

The 1st International Conference on Novel Psychoactive Substances in Budapest, Hungary on 12- 13 March 2012 was a very useful conference which highlighted its theme of the rapidly changing world of ‘Legal Highs’. The biggest challenge for Addiction Psychiatry seems to be keeping pace with this rapid developments where newer drugs are coming out along with newer market evolution and the trends that are transgressing national and international borders- an impact of globalisation and the internet becoming a massive global market. Also, the epidemiology of these is not yet clear as the new drugs have been not around with us long enough. Fortunately though, EMCDDA is reporting that there are some prevalence studies coming up which may be reflecting the wide variation of use of these substances in different regions and countries. Other information reported in this conference, that is useful to me as a Private Psychiatrist in Wales, UK is that the Novel Psychoactive Substances are not probably the first preference of drug users and that stimulants- Amphetamines, Cocaine, MDMA & Ketamine remain drugs of preference. From the reported results, it seems that the Mephadrone might be on the decline. From Dr Paul Dargan’s findings, the other challenge that faces us in Addiction Psychiatry is that there are no systematic data on toxicology, the ICD coding takes a long time to code for new drugs and when faced with acute presentations which may be in A&Es, general medical wards, Psychiatry Wards or in Addiction services, the analytic confirmation is still not up to speed to be able to confirm or refute the drug in the body. Whilst most NPS seem to be falling under the categories of Piperazine, Cathinone and Synthetic Cannabinoids- variations in these poses clinical management challenges. Piperadole derivatives like DPMP and D2PM have been on the increase as highlighted in the conference and people after having used these have developed neuropsychiatric syndromes.

Similarly, the  marketing of these has changed a lot and the newer social networking sites have been used a lot for advertising. Another MixMag survey had highlighted that the number of online shops has increased exponentially and the number of head shops have gone up as well. What struck me as well is that the products being sold with the same brand name such as ‘Ivory Wave’ has been found to be having no standardization, therefore the person buying the same brand may never be assured of getting the same drug on repeat orders. And Methoxetamine (Ketamine derivative) is being branded as “Bladder Friendly”.

What effects do these have in the long run is a difficult question to answer at the moment and a collaborative effort by clinicians, researchers, policy makers, criminal justice systems and governments is needed to address this new epidemic!

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Naltrexone in Alcohol Dependence

Alcohol Dependence is still a major cause of concern throughout UK. The issue of ‘minimum pricing’ is up for debate (probably for my next blog) but this post is about the use of Naltrexone in Alcohol Use Disorders. One of the mechanisms that Alcohol gives a pleasurable effect is through our Brain’s Opioid System. Naltrexone is an Opiate Blocker which is used for maintaining abstinence from Opiate Dependence and is licensed in UK in its Oral form. Several studies across the world have been done to demonstrate efficiency of other forms- Depot Naltrexone and Implants as well (most suited for motivated individuals).

Naltrexone has also been used over many years for Alcohol Use disorders for people in recovery, as it blocks the Opioid System, thus causing less pleasurable effects with drinking. The British Association of Pharmacology- Substance Misuse Guidelines have endorsed its use as well. Since it is not licensed in UK for this indication, only specialists in Addiction Psychiatry would generally prescribe this. Naltrexone has beneficial effects- one mechanism of ‘pharmacological extinction’ with Naltrexone and drinking alcohol may be possible but in my experience as a Consultant Psychiatrist in Wales, it has not caused a total extinction of the effects but has certainly helped people with reducing the amounts of alcohol they consume, the number of heavy drinking days and have reported that Alcohol does not affect them the same way as without the Naltrexone. One other effect is that the cravings to drink (which is a significant factor for relapse to heavy drinking) have reduced with Naltrexone.

The Naltrexone depot is a useful formulation which has its effect up to a month and aids concordance along with sustaining its effects. Vivitrol (US Preparation) is already licensed as a treatment for Alcohol Use Disorder in the USA. A similar preparation is available in UK, albeit in the Private Sector only.

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Medico- Legal Psychological Consequences of Trauma- Introduction

In my previous post I had quoted Van der Kolk. But does everyone respond to traumatic events in a similar fashion? The obvious answer is no. And that is the beauty of us Human Beings. Naturally then, one would think of ‘resilience’ factors (what keeps people going without succumbing to trauma), factors related to the intensity & the nature of trauma and equally the duration of the trauma. And since there are always two poles in virtually any concept we may think of in life, there are certain ‘vulnerability’ factors for the nature and degree of response to trauma. From a medico- legal standpoint, our justice system and our society have an equally important role to play in terms of legitimising trauma victims and providing supportive frameworks to deal with clinical and legal issues related to trauma and it’s consequences.

In this little introduction, allow me to restrict myself to a list of Psychiatric sequalae of trauma-

– Initial shock phase
– Delayed shock
– Anger and frustration
– Adaptation reactions- adjustment, reliving the trauma, processing by the brain to establish a meaning of the trauma in our lives to name a few.
– Normality and being back to routine functions
– Psychiatric Syndromes- Adjustment Disorder, Travel Anxieties, Exacerbations of pre- existing conditions, PTSD (Post Traumatic Stress Disorder), Substance Misuse (resorting to drug or alcohol misuse or an exacerbation of pre- existing misuse/dependence).

As a Tier 1 Association of Personal Injury Lawyers (APIL Expert) dealing with psychological trauma and its consequences is a regular part of my medico- legal work. I will cover these issues in more detail in subsequent posts.


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Motivational Interviewing- Addiction Psychiatry and Beyond Part 2

In trying to answer the question- ‘ Are we doing Motivational interviewing or are we doing Motivational Interviewing?”, it is important and only logical to understand what do we actually mean by Motivational Interviewing.

For me, there are a few givens here- that is- what MI is not. And if I were to qualify this, I mean we don’t do MI TO any one but rather do MI WITH someone. The word WITH in my experience is fundamental and crucial to any form of psychotherapy. In our jargon, we call it ‘therapeutic alliance’. Let me put it another way, wouldn’t it be better if I am able to understand and see the world from your perspective and work collaboratively with you to help you achieve your desired change? What is the likelihood of success, if you don’t establish any trust in the therapist?

MI in it’s fundamental approach is seeking to look at you as the sole agent of change and me as the MI practitioner, has the role of recognising that ‘change talk’ & evoking or extracting those internal resources that you have within your own self to facilitate that change.

So in some of the conversations that we may have in sessions, which may be regarding any change- alcohol control or abstinence, smoking cessation, tackling other substance misuse or behavioural addictions to name a few, if you tell me that you WANT to change, then MI will take us through the journey of going from ‘wanting’ to change to ‘willingness’ to change and ‘taking steps’ to change and then maintaining that change.

Of course, when you are talking about Substance Misuse the role of pharmacological options- Naltrexone for Opiates and Alcohol or newer treatments for alcohol as some examples, need to be kept in mind actively as well.

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