gary croton victorian dual diagnosis initiative nebmh- albury wodonga health oct. 2017 ... · 2018....
TRANSCRIPT
Welcometo another
Dual diagnosis
interactive learning resource
Digestible info re mental health-substance use
issues
New Psychoactive Substances – Mental Health
Gary CrotonVictorian Dual Diagnosis InitiativeNEBMH- Albury Wodonga Health
Oct. 2017
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What are NPS?
NPS market places
SCRAs - User profile
SCRAs-Mental Health
SCRAs –Toxicity & Withdrawal
Legislative Responses
NPS-MH Treatment
SCRAs Detection & Assessment
Depressant NPS
Hallucinogenic NPS
Stimulant NPS
Cannabinoid NPS
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Key Messages
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What are NPS?
What are NPSs?
New Psychoactive Substances
• ‘compounds designed to mimic existing established recreational drugs’ 1
AKA:
• ‘Synthetics’ – misnomer as many established drugs are synthetic
• ‘Novel Psychoactive Substances’
• ‘New & Emerging Drugs’ 2 – emerging Australian convention
• ‘Legal highs’ …. ‘Herbal highs’ ……. ‘Party pills’…. ‘Research chemicals’ ……
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What are NPSs?
Most useful typology to date- 1, 36 BMJ Tracy et al 2017Paper
PosterPodcast
Albeit effects of some NPSs overlap categories
What are NPSs?
• Currently > 650 identified NPS 3
• Growing rapidly - c.100 new NPS identified each year 3
• Stimulants & Cannabinoids the most common NPS (though ↑ trend to Opioids)
• Variations ++ in chemical structures, effects & harms even within these categories
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NPS market places
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NPS market places
1. Dark web2. Sex shops / Head shops / Tobacconists
(in Vic till Nov 1 2017)
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1. Dark Web NPS market places
• Uses VPN & the TOR browser for anonymous communication
• eBay look & feel - Bitcoin & escrow payment methods. Traditional postage systems.12
• Silk Road 2011-13 8
• Usually 2 dominant sites – currently Dream Market & Valhalla (volatile marketplace!)
• Exit scams. Regular downtimes- maybe temporary due to hacking attacks from other market operators, law enforcement or maintenance
• Harm minimisation aspects 12
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NPS market places 1. Dark Web
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1. Dark Web NPS market places
Drugs and the Internet, Issue 8, May 2017 Roxburgh et al. Sydney: NDARC- Time period: July–Dec.2016. 8
• 18 marketplaces monitored weekly
• 5 most commonly sold substances:• Cannabis, • Pharmaceuticals, • MDMA, • Cocaine• Methamphetamine
• NPS popularity slightly declined.
• Two NPS appeared for first time in top 10:• U-47700 … (7.5 x potency of morphine 9 )• FuranylFentanyl
• 2016 Global Drug Survey- 9% of Australian respondents reported crypto market purchases
• Bought from Victorian sex shop July 2017
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NPS market places 2. Sex shops / Head shops / Tobacconists
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Legislative Responses
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Legislative Responses
• July 2017: US Justice Dept. announced seizure of AlphaBay ( largest dark web marketplace).
• FBI & Dutch police initially pretended website shutdown was an exit scam - expecting AlphaBaycustomers would move to other popular websites, including Hansa.
• Unbeknownst to users, Dutch police had taken over Hansa a month earlier -were operating the site to collect information and trap people involved in the trade.
• Authorities aimed to break the trust, so that users would not feel safe on a dark market. 11
Dark Web
• Evidence shows that publicity like this actually INCREASES cryptomarket trafficking 11
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Legislative Responses
Ireland:
• ‘blanket ban’ of psychoactive drugs 2011
UK:
• ‘blanket ban’ of psychoactive drugs 2016
Victoria:
• Drugs, Poisons and Controlled Substances Miscellaneous Amendment Bill 2017
• Blanket ban to production, sale & promotion of any substance that has a psychoactive effect.
• Ratified Sept 2017 - effective from Nov 1st
• N.B. Possibility of withdrawal presentations especially amongst people with severe mental illness
2. Sex shops / Head shops / Tobacconists
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Legislative Responses
Ireland:
• NPS now ‘easier to get’ via street dealing.13
UK:
• 2017 indicators 14, 15, 16, 17, 21, 22
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Stimulant NPS
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Stimulant NPS
• One of largest NPS groups 1
• Related to MDMA, cocaine, amphetamines
• Typically powders or pills.
• Neuronal reuptake pump inhibitors or active releasers
• Neurotransmitter releasers = greater addiction & neurotoxicity.
• Cathinone family = enhanced neurotoxicity compared to traditional stimulants.
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Stimulant NPS
• Ratio of serotonin to dopamine: 1
• Serotonergic drugs, (similar to ecstasy) =empathy & openness.
• Dopaminergic drugs, (similar to cocaine) = euphoric and mania-like experiences.
• NBOMe = psychedelic experiences.
• Serotonin syndrome risk with multiple serotonergic recreational drugs, or prescription medication
• Structure of many stimulant NPS similar to amphetamine so OD looks similar
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Hallucinogenic NPS
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Hallucinogenic NPS
Psychedelics
• Not hallucinations, but “psychedelic” effects, perceptual alterations, quasi-mystical experiences
• Some have stimulant properties
• NBOMe =↑risk of OD- dose difficult to measure & small difference between dose to produce a high & OD
• Recreational use of 25I-NBOMe carries significant risk of both pharmacological and behavioraltoxicity.
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Dissociatives
• Euphoric “dissociated” state, absence of time, weightlessness, disconnection from body.
• Spectrum– milder than Ketamine to strong as Phencyclidine.
• Ketamine possible acute hallucinations, anxiety, near-death experience. Regular users can have: mood and personality changes, depression, memory & concentration impairments, psychosis, dependence.
• Methoxetamine = intense, long lasting.
• Users report experiencing ‘M-hole’ (like Ketamine's ‘K-hole’ )
• Physical: abdo pain (‘M cramps’), nausea, vomiting, diarrhoea, arrhythmias, blackouts, ulcerative cystitis, renal damage 1
• Long term: neurocognitive deficits & deterioration in mood 1
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Depressant NPS
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Depressant NPS
• Opioid & Benzodiazepine subcategories 1
• Can be ‘so similar to established recreational drugs that clinicians may not realise an individual has used an NPS’ 1
Benzodiazepines
• Benzodiazepine NPS similar to Diazepam but some have long ½ -lives (Flubromazepam, ½-life of 100 hours!)- risk of OD
• Potentiated by alcohol
• Harms similar to Diazepam
• Addiction & Seizure potential
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Depressant NPS
Opioids
• Some much longer durations than established opioids
• Novel Fentanyls• 50-100 times more potent than morphine
• Carfentanil • GA for elephants - 10,000 times more potent
than morphine,
• Found in Aust since late 2016
• 10 -20 times dose of Naloxone needed
• Lethal dose = ‘weight of a grain of pollen’ 19
• Heroin may be cut with fentanyl or carfentanil 20
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Fatal doses compared: heroin, fentanyl and carfentanil• Image: Bruce Taylor, New
Hampshire State Police Forensic Lab
• From ANEX Bulletin:
Fentanyl And Carfentanyl: What Do I Need To Know?
Depressant NPS
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Cannabinoid NPS
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Synthetic Cannabinoid Receptor Agonists (SCRAs) 1
• >150 different SCRAs
• SCRAS ‘super-stimulators’ of CB1 & CB2 receptors compared to Cannabis 25
• SCRAs lack Cannabidiol (CBD) = antipsychotic & anxiolytic. 27
• In natural cannabis CBD dampens effects of Tetrahydrocannabinol (THC). 23, 25
• Cannabis & SCRAs both stimulating & sedating, anxiogenic & anxiolytic
• Both can cause anxiety, paranoia, psychotic symptoms
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Cannabinoid NPS
• As sprayed onto compounds strength & effects can be unpredictable.
• Side effects more frequent with SCRAs
• EDs SCRAs case reports 40: • Confusion & cognitive impairment,
• Slurred speech & excessive sweating
• Hypertension & tachycardia
• Renal failure, pulmonary damage,
• Myocardial infarction, seizures, stroke.
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Cannabinoid NPS
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SCRAs-Mental Health
Synthetic Cannabinoid Use in a Psychiatric Patient Population: A Pilot Study Welter S. et al
Eur Addict Res. August 2017 24
• n = 332• 10% of psychotic people had used SCRAs• +ve symptoms more severe in SCRAs users• -ve symptoms more severe in Cannabis users.
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Clinical characteristics of synthetic cannabinoid-induced psychosis in relation to schizophrenia: a single-center cross-sectional analysis of concurrently hospitalized patients. Altintas. M et al Neuropsychiatric Disease and Treatment August 2016 26
• n = 81 • Inpatients also • SCRAs induced psychosis ‘associated with remarkable rates of
• Suicidal ideation• Involuntary hospitalisation
The adverse health effects of synthetic cannabinoids with emphasis on psychosis-like effects
van Amsterdam, J. et al Journal of Psychopharmacology. 2015 Review. 27
• Compared with Cannabis, SCRAs cause more frequent, more severe –veeffects.
• Fatal cases recorded but causality not proven
• Most common symptoms SCRA side effects are:• tachycardia, • extreme agitation • hallucinations.
• Psychosis and psychosis-like conditions seem to occur relatively often following SCRAs• High potency • Absence of CBD
• SCRAs lack of CBD= no protection against psychosis (seems to occur often)
• Studies on relative risk of SCRAs compared to Cannabis to induce or evoke psychosis urgently needed.
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Synthetic Cannabinoids—Further Evidence Supporting the Relationship Between
Cannabinoids and Psychosis. Fattore. L. Biological Psychiatry. April 2016 28
• Considers pharmacodynamics & pharmokinetics
• Summarised & described case reports of:• Re-emergence of Psychosis: Psychosis induced by SCRAs in vulnerable individuals• New-Onset Psychosis: Psychosis induced by SCRAs in subjects with no previous
history of psychosis
• SCs dissimilar from THC- undesirable effects like confusion, agitation, anxiety ,altered perception & mental status, paranoia, irritability , depression, suicidality
• Clinicians should: • Be aware that SCs may cause severe health consequences & unexpected adverse
effects not always associated with cannabis• Consider possibility of SC use in patients who use drugs & presenting with SXs &
negative urine toxicology.
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Factors explaining intoxication and psychotropic effects of
synthetic cannabinoids
Traditional marijuana, high-potency cannabis and synthetic cannabinoids:
increasing risk for psychosis Robin M. Murray et al. World Psychiatry. Sept.
2016 29
• Reported a survey 80,000 drug users: SCRAS users 30 x more likely to end up in an emergency unit than users of traditional cannabis
• Over 200 SCRAs available on internet-as each has a slightly different molecular structure → unpredictable side effects.
• Cannabis use- esp high potency & SCRAs increases risk of psychosis… but does it in absence of genetic vulnerability?
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Psychiatric comorbidity associated with synthetic cannabinoid use
compared to cannabis Basirnia et al Journal of Psychopharmacology.
2016 30
• Compared clinical presentations of SC users with cannabis users in a psychiatric inpatient setting (n= 594)
• Outcome: SC use strongly associated with more psychotic presentations & agitation compared to cannabis use.
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Synthetic cannabinoid use in an acute psychiatric inpatient unit. Clancy, R. et al. Int. Journ. Mental Health Nursing. May 2017 31
• NSW acute public MH (DDx) unit (n = 100)
• Developed a simple screening tool based on NSW MH-OAT
• Also 17-item NPS Assessment Instrument
Results:
• 56% reported using at least one type of NPS
• 53.5% reported using SCRAs alone
• 18.8% reported using both SCRAs & other NPS
• SCRAs use not associated with any demographic or diagnostic groups.
• Legality & availability & feeling of intoxication were common reasons for use
Implications:
• High prevalence of NPS adds weight to recommendation that clinicians should routinely screen for substances from time of admission.
• Accurate info about these substances is required for appropriate interventions
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SCRAs Detection & Assessment
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SCRAs Detection & Assessment
• Standard UDS screens are inadequate -multiple false positives & negatives 3
• Great variability, even within SCRAs – some may be detected
• Clancy et al 31 offer to share simple screening tool based on NSW MH-OAT & 17-item NPS Assessment Instrument
• Bright 2 recommends sensitive questioning: • Have you used anything that has been bought online or from adult stores?• Have you taken any herbal supplements, legal highs, party pills, herbal highs,
research chemicals, bath salts or incense?• What chemical or brand have you used?• What were the effects of it (e.g. stimulant, depressant or hallucinogen)?• Was it like any other substance you have used?• Did you experience any negative health effects?
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SCRAs - User profile
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SCRAs - User profile
• Many NPS not detected by urine screens → popular in prisons & professions subject to random drug screening 4
• FIFO, military 2,
• Young males
• Very marginalised & vulnerable people disproportionately involved-homeless, prisons & forensic psych. 3
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SCRAs –Toxicity & Withdrawal
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SCRAs –Toxicity & Withdrawal
Signs and symptoms associated with synthetic cannabinoid toxicity: systematic
review. Courts, J. et al. Australasian Psychiatry. August 2016 32
• n = 3695
• Symptoms of SC toxicity included:• Physiological (tachycardia, hypertension, nausea/vomiting),
• Emotional (agitation, irritability, paranoia),
• Behavioural (drowsiness, aggression)
• Perceptual (hallucinations)
• Most common symptoms: tachycardia (30.2%), agitation (13.5%), drowsiness (12.3%), nausea/vomiting (8.2%) hallucinations (7.6%).
• Death or serious medical complications were uncommon • Death 0.2%,
• Stroke 0.1%,
• Myocardial infarction 0.09%
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SCRAs –Toxicity & Withdrawal
Adverse Effects of Synthetic Cannabinoids: Management of Acute Toxicity and Withdrawal Cooper, ZD. CurrPsychiatry Rep. May 2016 33
• ‘Withdrawal has not been systematically characterized and effective treatments have yet to be elucidated’. Withdrawal from SCs has been reported to occur only in daily users.
• Acute intoxication frequently treated with supportive care & intravenous fluids to treat electrolyte & fluid disturbances. Many adverse effects associated with acute intoxication are identical to some withdrawal symptoms - hence treated similarly.
• Patients who present with irritability, agitation, anxiety, and seizures associated with intoxication or withdrawal are generally administered benzodiazepines as a first-line treatment.
• Neuroleptics are also administered for acute psychosis and agitation and mania with psychotic symptoms
• Although not always effective, antiemetics have been administered for hyperemesis
• Quetiapine was effective in treating withdrawal symptoms in patients who failed to respond to benzodiazepines
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SCRAs –Toxicity & Withdrawal
Useful client resource:
Synthetic Marijuana Withdrawal: Strategies for Coping with Common Symptoms
John Lee. Choose Help.com webpage. June 2014
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NPS-MH Treatment
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NPS-MH Treatment
• Non-judgemental approach 35, 37
• Screening 31 (esp youth 39 / dispossessed)
• Thorough assessment – history MSE, physical 35
• Symptomatic care 6
• Personalised treatment
• Integrated, one-agency, treatment where possible - collaborative treatment where not
• Stepped care
• Complex-needs lens
• Usual range of psychosocial treatments - MI, BIs, CBT… 7
• Motivational Interviewing 35
• Pathways to more specialised support for complex cases 6
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NPS-MH Treatment
Harm minimisation - Grounded info & advice: • Start with a very small dose & increase if necessary to obtain desired effects 1
• Combining with other drugs or alcohol can increase risks• Use with another person 2 - Let someone else go first• Seek urgent medical help if you feel unwell after using a NPS • If seeking help take the compound or any information on it with you• Considerable variation in risks b/t individual NPS & classes of NPS - SCRAs ingredients
vary from packet to packet 25, 38
• Don’t mix drugs 25
• With SCRAS ‘beware the bottom of the bag’ 25
• Older people, people with pre-existing MH conditions or CV issues should avoid NPS 2
• Sudden discontinuation of novel benzoes or opioids could prompt withdrawal 25
• Avoid injecting (Unknown contents / fillers) 2
• Packaging often deceptive 2
See also Harm Reduction for People Who Use or May Encounter Fentanyl/Carfentanil April 2017 20
Guidance on the Clinical Management of Acute and
Chronic Harms of Club Drugs and Novel Psychoactive
Substances 7
Abdulrahim D & Bowden-Jones O. Novel Psychoactive Treatment UK Network NEPTUNE
March 2015
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Stellar resource
NPS-MH Treatment
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Key Messages
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Key messages
• > 650 New Psychoactive Substances (NPS) have now been identified - this list is growing rapidly
• Categories of • Stimulants, • Cannabinoids, • Depressants and • Hallucinogens
are a useful way of classifying NPS
(though can be considerable overlap between categories)
• There remains much to be learned about • nature and effects of NPS• best practice in responding to people who develop NPS-related problems
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Key messages
• UK experience suggests that Cannabinoids (SCRAs) are the category of most concern with people with Severe Mental Illness (SMI)
• It appears that SCRAs may have more harms associated with them than does Traditional Cannabis (TC)
• SCRAs lack the anxiolytic, anti-psychotic CBD component found in TC and bind more tightly to the CB1 & CB2 receptors.
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• To date SCRAs have mainly been sold in sex shops, tobacconists and the dark web
• In Victoria it will be illegal to sell SCRAs over the counter from November 1st
• ED and MH clinicians should be alert to the possibility of people presenting with withdrawal complications at this time
• International experience suggest that SCRAs may continue to be sold via street dealing and the web; particularly to dispossessed people (homeless, SMI, forensic populations)
Key messages
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Implication for Mental Health clinicians:
• Most people who use drugs, including NPS, will not develop problems with their use.
• Be aware that SCs may cause severe health consequences & unexpected adverse effects not always associated with cannabis
• Consider possibility of SC use in patients who use drugs who presenting with symptoms & negative urine toxicology.
• Be alert to possible withdrawal presentations from Nov 1st
Key messages
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Implication for Mental Health clinicians:
• Routinely screen for substance use as close as possible to first contact with a client
• Sensitive questioning probably the most effective way to screen for NPS / SCRAs use
• Non-judgemental, harm-minimisation, motivational approaches are indicated
Key messages
1. Novel psychoactive Substances: types, mechanism of action and effects.
Tracy, DK et al. BMJ. Jan 2017
2. Not for human consumption: New and Emerging Drugs in Australia. Bright,
S. Australian Drug Foundation. 2013
3. Novel Psychoactive Substances: bridging the knowledge gap. Tracy DK. The
Mental Elf. Webpage. Sept 2017
References:Click icon for
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4. Novel Psychoactive Substances: important information for health
professionals. Sumnall, H et al. The Mental Elf. Webpage. March 2017
5. New Psychoactive Substances (NPS) Resource pack for informal educators
and practitioners. Home Office June 2016
6. Health responses to new psychoactive substances. EMCDDA 2016
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7. Guidance on the Clinical Management of Acute and Chronic Harms of Club
Drugs and Novel Psychoactive Substances Abdulrahim D & Bowden-Jones O.
Novel Psychoactive Treatment UK Network NEPTUNE March 2015
8. Drugs and the Internet, Issue 8, May 2017 Roxburgh, A., et al. 2017. Sydney:
National Drug and Alcohol Research Centre.
9. PsychonautWiki U-47700 webpage. Accessed 12/09/2017
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10. PsychonautWiki U-47700 webpage. Accessed 12/09/2017
11. Closing Dark Web Marketplaces Won’t Reduce Drug Use or Trafficking Mira Motani. August 2017 Talking Drugs website
12. Darknet Drug Trading: Australian implications, trends and harm reduction possibilities James Martin. Turning Point Vodcast march 2017
13. Warning over new UK legal high law after Irish ban 'made it easier to buy them BBC webpage. April 2016
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14. 'Zombie Spice addicts plague' caused by everything we warned you about, claim legal highs ban critics Independent. April 2017
15. Spice In Manchester ‘More Potent’ And Less Controlled Since Psychoactive Substances Bill, Experts Warn. Huffington Post April 2017
16. 'It's worse than heroin': how spice is ravaging homeless communities. Guardian April 2017
17. Spice Discussion Professor David Nutt BBC 4 Video April 2017
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18. Fentanyl And Carfentanyl: What Do I Need To Know? ANEX Bulletin. May 2017
19. Weekly Dose: while the media panic about ice, we should worry about carfentanil.
David Caldicott The Conversation March 2017
20. Harm Reduction for People Who Use or May Encounter Fentanyl/Carfentanil
Avinash Tharoor Talking Drugs April 2017
21. How spice, ‘the zombie drug’, is devastating communities. Observer August 2017
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22. Spice ban ‘puts prisoners and homeless at risk’ as street drug goes
underground. The Guardian August 2017
23. Chronic Adolescent Δ9-Tetrahydrocannabinol Treatment of Male Mice Leads
to Long-Term Cognitive and Behavioral Dysfunction, Which Are Prevented by
Concurrent Cannabidiol Treatment. Murphy, M et al Cannabis and
Cannabinoid Research. Sep 2017.
24. Synthetic Cannabinoid Use in a Psychiatric Patient Population: A Pilot Study
Welter S. et al Eur Addict Res. August 2017
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25. SPICE New Psychoactive Substances Briefing for professionals. Manchester H&CC
July 2017
26. Clinical characteristics of synthetic cannabinoid-induced psychosis in relation to
schizophrenia: a single-center cross-sectional analysis of concurrently hospitalized
patients. Altintas. M et al Neuropsychiatric Disease and Treatment August 2016
27. The adverse health effects of synthetic cannabinoids with emphasis on psychosis-
like effects van Amsterdam, J. et al Journal of Psychopharmacology. 2015
References:Click icon for
more info
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28. Synthetic Cannabinoids—Further Evidence Supporting the Relationship
Between Cannabinoids and Psychosis. Fattore. L. Biological Psychiatry. April
2016
29. Traditional marijuana, high-potency cannabis and synthetic cannabinoids:
increasing risk for psychosis Robin M. Murray et al. World Psychiatry. Sept.
2016
30. Psychiatric comorbidity associated with synthetic cannabinoid use compared
to cannabis Basirnia et al Journal of Psychopharmacology. 2016.
31. Synthetic cannabinoid use in an acute psychiatric inpatient unit. Clancy, R et
al. Int. Journ. Mental Health Nursing. May 2017
References:Click icon for
more info
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32. Signs and symptoms associated with synthetic cannabinoid toxicity:
systematic review. Courts, J. et al. Australasian Psychiatry. August 2016
33. Adverse Effects of Synthetic Cannabinoids: Management of Acute Toxicity
and Withdrawal Cooper, ZD. Curr Psychiatry Rep. May 2016
34. Synthetic Marijuana Withdrawal: Strategies for Coping with Common
Symptoms John Lee. Choose Help.com webpage. June 2014
References:Click icon for
more info
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35. Novel psychoactive substances: identifying and managing acute and chronic harmful use. Tracy D. et al BMJ. January 2017
36. Novel psychoactive Substances: types, mechanism of action and effects. Tracy, DK et al. BMJ. Jan 2017
37. Dummies Guide to Spice and Other NPS' - a film about the so-called Legal Highs. Video. WoolfeVISION London June 2017
38. Think before you take - How to take NPS' safely . Video. WoolfeVISION London June 2017
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39. Novel Psychoactive Substances Insight Report: The View from Young People.
Research Summary Report. Addaction. February 2017
40. A systematic review of adverse events arising from the use of synthetic
cannabinoids and their associated treatment. Tait, R.J. Caldicott, D., Hill, S.,
Lenton, S. Clinical Toxicology. 2015
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IF you are a Hume-Border Mental Health or AOD agency AND would like a workshop on this, or another mental health-substance use (dual diagnosis) topic, please contact Gary to arrange this