Legal highs: staying on top of the flood of novel psychoactive substances
Summary & key facts
This review explains the fast-growing problem of so-called "legal highs", which are better called novel psychoactive substances or NPS. Unknown labs keep making slightly different chemicals to avoid bans, and this led to about 80 new substances being spotted in one year. The paper groups these drugs into five main families, describes how they act and what harms they can cause, and warns that doctors and the public do not yet know enough about many of them. The authors call for more research and for clinicians to learn how to recognize and treat problems linked to these new drugs.
- People and doctors are more aware and concerned about 'legal highs', but these drugs are better called novel psychoactive substances or NPS.
- Manufacturers keep changing chemical formulas to dodge laws, creating a cat-and-mouse situation where new versions appear as soon as old ones are banned.
- About 80 new NPS were identified in 2013 alone, showing how fast the market can change.
- The review sorts NPS into five main groups: stimulants like cocaine and ecstasy, synthetic cannabinoids, benzodiazepine-like drugs, dissociatives like ketamine and PCP, and classic hallucinogen-like drugs such as LSD and psilocybin.
- Some newer NPS look to be more potent than older drugs, which could raise the risk of serious effects or dependence.
- Current information on most NPS is limited, so doctors often rely on what is known about the older, related drugs when they treat patients.
- Clinicians may see NPS through casual reports, emergency cases of intoxication, ongoing substance misuse, or as a factor that worsens long-term physical and mental health.
- The authors say there is a clear need for more research and for health professionals to become better informed about NPS.
Abstract
There has been growing clinical, public, and media awareness and concern about the availability and potential harmfulness of so-called 'legal highs', which are more appropriately called new or novel psychoactive substances (NPS). A cat-and-mouse process has emerged wherein unknown chemists and laboratories are producing new, and as yet nonproscribed, compounds for human consumption; and as soon as they are banned, which they inevitably are, slightly modified analogues are produced to circumvent new laws. This rapidly changing environment, 81 new substances were identified in 2013 alone, has led to confusion for clinicians, psychopharmacologists, and the public at large. Our difficulties in keeping up with the process has had a two-fold negative effect: the danger of ignoring what is confusing; and the problem that some of the newer synthesized compounds appear ever more potent. This review aims to circumscribe a quick moving and growing field, and to categorize NPS into five major groups based upon their 'parent' compounds: stimulants similar to cocaine, amphetamines and ecstasy; cannabinoids; benzodiazepine based drugs; dissociatives similar to ketamine and phencyclidine (PCP); and those modelled after classic hallucinogens such as LSD and psilocybin. Pharmacodynamic actions, subjective and physical effects, harmfulness, risk of dependency and, where appropriate, putative clinical potentials are described for each class. Clinicians might encounter NPS in various ways: anecdotal reportage; acute intoxication; as part of a substance misuse profile; and as a precipitant or perpetuating factor for longer-term physical and psychological ill health. Current data are overall limited, and much of our knowledge and treatment strategies are based upon those of the 'parent' compound. There is a critical need for more research in this field, and for professionals to make themselves more aware of this growing issue and how it might affect those we see clinically and try to help: a brave new world of so-called 'psychonauts' consuming NPS will also need informed 'psychotherapeutonauts'. The paper should serve as a primer for clinicians and interested readers, as well as provide a framework into which to place the new substances that will inevitably be synthesized in the future.