Results of an international drug testing service for cryptomarket users

Testing the test strips: laboratory performance of fentanyl test strips

BACKGROUND

The overdose crisis driven by synthetic opioids continues to escalate in the USA. We evaluated the efficacy of multiple manufacturing lots of a fentanyl test strip (FTS) to detect fentanyl and fentanyl analogs and assessed cross-reactivity with possible interferences.

METHODS

Drug standards were dissolved in water in a laboratory setting and serially diluted. Drug dilutions were tested using five different manufacturing lots of BTNX Rapid Response (20 ng/mL cutoff) lateral flow chromatographic immunoassay strips to assess lot-to-lot variability for FTS sensitivity and cross-reactivity for the analytes of interest.

RESULTS

All five manufacturing lots cross-reacted with fentanyl and eleven fentanyl analogs. Diphenhydramine, lidocaine, MDMA, and methamphetamine were found to cause false positives with the strips. There was notable lot-to-lot variability in the sensitivity of the strips for fentanyl, fentanyl analogs, and known interferences.

DISCUSSION

FTS remains an important overdose prevention tool, but lot-to-lot variability in performance complicates robust instructions that balance the prevention of false positives and false negatives. Continued lot-to-lot performance assessment is recommended to ensure health education for FTS remains accurate. More sophisticated drug checking technologies and services are needed in the community landscape to augment personal FTS use to facilitate informed consumption and overdose risk mitigation.

Drug transactions and the dark web: Public perceptions of the locational setting of offenders and support for drug policy outcomes

BACKGROUND

Both legal and extra-legal factors influence judicial and non-judicial opinions about persons who use drugs. Yet, how the locational setting of drug transactions influences public perceptions of drug control policies remains understudied. In particular, the public's view of drug exchanges on the dark web could directly and indirectly influence drug policy, legal decision making, and spending decisions. The study's aim is to identify whether the location of a drug exchange, specifically the dark web, influences public preferences for drug policy and police resourcing.

METHODS

A sample (n = 1359) from the United States of America was recruited and participated in a discrete choice experiment. The participants compared and repeatedly chose across five iterations between two drug offender profiles with nine set features, such as the location of drug transactions, all with randomized levels. The resulting sample included a total of 13,590 contest pairs.

RESULTS

Averaging over the non-locational attributes, respondents indicated that, compared to the dark web, several locational settings for drug exchange (such as the street corner, social media, and an unknown location) needed fewer police resources and offenders were less deserving of longer punishments. No statistically significant difference was found for opinions about harm to communities, and offenders involved in drug exchanges on university campuses were considered more deserving of a substance abuse treatment program than offenders on the dark web.

CONCLUSION

There appears to be a preference for more punitive criminal justice policies for drug transactions occurring on the dark web relative to some other common settings. Such preferences may indicate a novelty effect driven by negative sentiment surrounding the dark web or a perceived deficit in the police's ability to deal with drug crimes on the dark web. These findings suggest that the public may prefer supply-side policing efforts over demand-side policies, which emphasizes harm reduction.

Challenges in Drug Surveillance: Strengthening the Analysis of New Psychoactive Substances by Harmonizing Drug Checking Services in Proficiency Testing

BACKGROUND

Drug checking is a proven harm reduction strategy and provides real-time information on the market of new psychoactive substances (NPS). It combines chemical analysis of samples with direct engagement with people who use drugs (PWUD), giving the ability to increase preparedness and responsiveness towards NPS. Next to that, it supports rapid identification of potential unwitting consumption. However, NPS cause a toxicological battle for the researchers, as factors such as the unpredictability and quick shift of the market complicate the detection.

METHODS

To evaluate challenges posed towards drug checking services, proficiency testing was set up to evaluate existing analytical techniques and investigate the capability to correctly identify circulating NPS. Twenty blind substances, covering the most common categories of substances, were analyzed according to the existing protocols of the existing drug checking services, including several analytical methods such as gas chromatography-mass spectrometry (GC-MS) and liquid chromatography with diode array detector (LC-DAD).

RESULTS

The proficiency test scores range from 80 to 97.5% accuracy. The most common issues and errors are mainly unidentified compounds, presumably due to no up-to-date libraries, and/ or confusion between structural isomers, such as 3- and 4-chloroethcathinone, or structural analogs, such as MIPLA (N-methyl-N-isopropyl lysergamide) and LSD (D-lysergic acid diethylamide).

CONCLUSIONS

The participating drug checking services have access to adequate analytical tools to provide feedback to drug users and provide up-to-date information on NPS.

Drug checking services for people who use drugs: a systematic review

BACKGROUND AND AIMS

Drug checking services provide people who use drugs with chemical analysis results of their drug samples while simultaneously monitoring the unregulated drug market. We sought to identify and synthesize literature on the following domains: (a) the influence of drug checking services on the behaviour of people who use drugs; (b) monitoring of drug markets by drug checking services; and (c) outcomes related to models of drug checking services.

METHODS

Systematic review. A systematic literature search was conducted in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, Scopus, Web of Science and Dissertations and Theses Global. Eligible studies were peer-reviewed articles and conference abstracts or grey literature, published in any language since 1990 and including original data on the domains. We assessed risk of bias for quantitative peer-reviewed articles reporting on behaviour or models of drug checking services using National Institutes of Health tools.

RESULTS

We screened 2463 titles and abstracts and 156 full texts, with 90 studies meeting inclusion criteria. Most (n = 65, 72.2%) were from Europe and used cross-sectional designs (n = 79, 87.7%). Monitoring of drug markets by drug checking services (n = 63, 70%) was the most reported domain, followed by the influence of drug checking services on behaviour (n = 31, 34.4%), including intent to use, actual use and disposal of the drug, and outcomes related to models of drug checking services (n = 17, 18.9%). The most common outcome measures were detection of unexpected substances (n = 50, 55.6%), expected substances (n = 44, 48.9%), new psychoactive substances (n = 40, 44.4%) and drugs of concern (n = 32, 36.5%) by drug checking services.

CONCLUSIONS

Drug checking services appear to influence behavioural intentions and the behaviour of people who use drugs, particularly when results from drug checking services are unexpected or drugs of concern. Monitoring of drug markets by drug checking services is well established in Europe, and increasingly in North America. Concerns about drug contents and negative health consequences facilitate the use of drug checking services; lack of concern; trust in drug sellers; lack of accessibility of drug checking services; and legal and privacy concerns are barriers to use.

Invited Commentary: Drug Checking for Novel Insights Into the Unregulated Drug Supply

Tobias et al. (Am J Epidemiol. 2022;191 (2):241–247) present a novel analysis of time trends in fentanyl concentrations in the unregulated drug supply in British Columbia, Canada. The preexisting knowledge about unregulated drugs had come from law-enforcement seizures and postmortem toxicology. As both of these data sources are subject to selection bias, large-scale drug-checking programs are poised to be a crucial component of the public health response to the unrelenting increase in overdose in North America. As programs expand, we offer 2 guiding principles. First, the primary purpose of these programs is to deliver timely results to people who use drugs to mitigate health risks. Second, innovation is needed to go beyond criminal justice paradigms in laboratory analysis for a more nuanced understanding of health concerns. We provide examples of the role adulterants play in our understanding of drug harms. We also describe the applications and limitations of common laboratory assays, with implications for epidemiologic surveillance. While the research and direct service teams in British Columbia have taken groundbreaking steps, there is still a need to establish best practices for communicating results to sample donors in an approachable yet nonalarmist tone.

Recreational ketamine-related deaths notified to the National Programme on Substance Abuse Deaths, England, 1997-2019

BACKGROUND

Ketamine is a phencyclidine derivative with dissociative anaesthetic properties. Increasing numbers of individuals in England take ketamine recreationally. Information on deaths arising from such use in England is presented.

METHODS

Cases were extracted on 31 January 2020 from the National Programme on Substance Abuse Deaths database, based on text searches of the cause of death, coroner's verdict and positive toxicology results for the terms 'ketamine' or 'norketamine'.

FINDINGS

During 1997-2005, there were <5 deaths p.a. in which ketamine was implicated. Numbers increased until 2009 (21), plateauing until 2016; thereafter, deaths have risen to about 30 p.a. Decedents' characteristics (N = 283): male 84.1%, mean age 31.2 (SD 10.0) years, employed 56.5%, drug use history 79.6% and living with others 60.3%. Ketamine was detected with other substances in most cases. Main (74.6%) underlying cause of death was accidental poisoning. Ketamine may have impaired judgement in other cases.

CONCLUSIONS

Although controlled, recreational ketamine use and related fatalities continue to increase. Consumers need to be more aware of the potentially fatal risks they face.

Safer Tripping: Serotonergic Psychedelics and Drug Checking. Submission and Detection Rates, Potential Harms, and Challenges for Drug Analysis

Purpose of Review

With the continuous emergence of new psychoactive substances, drug checking (DC) services are challenged by an increasingly complex drug market. Considering the resumed scientific and public interest in serotonergic psychedelics (SPs) like LSD, psilocybin, and 2C-B, we present the results of a literature search investigating the presence and proportion of SPs in DC samples.

Recent Findings

In 15 identified reports, submission and detection rates of SPs were comparably low, but increasing. Samples contained considerable amounts of adulterations or analogues, mostly novel SPs with unknown toxicological profiles and in some cases potentially life-threatening effects. The detection of SPs, however, requires advanced analysis techniques currently not available to most DC services.

Summary

Given the substantial proportion of novel SPs in DC samples and the associated risks, DC can be a valuable harm reduction and monitoring tool for SPs if analysis techniques with high sensitivity are employed.

Demystifying the Dark Web Opioid Trade: Content Analysis on Anonymous Market Listings and Forum Posts

Background

Opioid use disorder presents a public health issue afflicting millions across the globe. There is a pressing need to understand the opioid supply chain to gain new insights into the mitigation of opioid use and effectively combat the opioid crisis. The role of anonymous online marketplaces and forums that resemble eBay or Amazon, where anyone can post, browse, and purchase opioid commodities, has become increasingly important in opioid trading. Therefore, a greater understanding of anonymous markets and forums may enable public health officials and other stakeholders to comprehend the scope of the crisis. However, to the best of our knowledge, no large-scale study, which may cross multiple anonymous marketplaces and is cross-sectional, has been conducted to profile the opioid supply chain and unveil characteristics of opioid suppliers, commodities, and transactions.

Objective

We aimed to profile the opioid supply chain in anonymous markets and forums via a large-scale, longitudinal measurement study on anonymous market listings and posts. Toward this, we propose a series of techniques to collect data; identify opioid jargon terms used in the anonymous marketplaces and forums; and profile the opioid commodities, suppliers, and transactions.

Methods

We first conducted a whole-site crawl of anonymous online marketplaces and forums to solicit data. We then developed a suite of opioid domain–specific text mining techniques (eg, opioid jargon detection and opioid trading information retrieval) to recognize information relevant to opioid trading activities (eg, commodities, price, shipping information, and suppliers). Subsequently, we conducted a comprehensive, large-scale, longitudinal study to demystify opioid trading activities in anonymous markets and forums.

Results

A total of 248,359 listings from 10 anonymous online marketplaces and 1,138,961 traces (ie, threads of posts) from 6 underground forums were collected. Among them, we identified 28,106 opioid product listings and 13,508 opioid-related promotional and review forum traces from 5147 unique opioid suppliers’ IDs and 2778 unique opioid buyers’ IDs. Our study characterized opioid suppliers (eg, activeness and cross-market activities), commodities (eg, popular items and their evolution), and transactions (eg, origins and shipping destination) in anonymous marketplaces and forums, which enabled a greater understanding of the underground trading activities involved in international opioid supply and demand.

Conclusions

The results provide insight into opioid trading in the anonymous markets and forums and may prove an effective mitigation data point for illuminating the opioid supply chain.

The Future of Substance Abuse Now: Relationships among Adolescent Use of Vaping Devices, Marijuana, and Synthetic Cannabinoids

Background: Substances that can be vaped include nicotine, marijuana, cocaine, heroin, and a range of synthetic drugs called new psychoactive substances (NPS). Due to the rising popularity of vaping among adolescents, it is crucial to understand the relationships between vaping and illicit drug use. Objectives: This paper examined the prevalence and trends of using vaping devices, marijuana vaping, marijuana products, synthetic cannabinoids and mist contents among youth. Methods: The study utilized 5 sets of public cross-sectional national data from the "Monitoring the Future" surveys during 2014-2018. It employed logistic regression to analyze the data. Results: There was an increase from 10.5% in 2017 to 20.8% in 2018 for the past 30-day use of vaping devices among 12^th graders. Furthermore, there was an increase from 21.6% in 2017 to 34.5% in 2018 for the past 12-month use of marijuana via vaping device among 12^th-grade marijuana users. Additionally, there were significant associations between vaping device use and marijuana vaping, between vaping device use and marijuana use, between vaping device use and synthetic cannabinoids use, and between marijuana use and synthetic cannabinoids use from 2016 to 2018. Conclusions: Vaping emerged as another major route of marijuana administration among youth. Adolescent marijuana users had higher odds of using synthetic cannabinoids. This finding highlighted the importance of understanding what adolescent substance consumption pattern would be where marijuana was legalized. It also supported the hypothesis that vaping devices use correlates with, or is associated with, marijuana and synthetic cannabinoids use.

Suitability of infrared spectroscopy for drug checking in harm reduction centres

Drug checking is a service for people who use drugs that includes product analysis and an individual interview including results feedback and harm reduction counselling. It uses different analytical methods but few studies demonstrate their value in current practice. The main objective of this work is to compare the analytical performance of IR spectroscopy to laboratory reference method in the context of drug checking in a harm reduction centre. The secondary objectives are to carry out a description of the people who use drugs requesting a product analysis, and to compare the assumed compositions of products purchased with their real compositions. During 2018, all requests for drug testing analysis were included for on-site analysis by IR spectrometry in a harm reduction center and verified by the reference method (UPLC-HRMS) at Bordeaux University Hospital Center. Socioeconomic and product data were also collected. One hundred and thirty-six samples were collected. The results obtained with IR and UPLC-HRMS were compared. IR spectrometry results did not match with reference method in 8 % (n=11) of cases, corresponding to blotters, cannabis and some psychoactive substances present in mixture or in small quantities. Among the products collected, only 5.1 % (n=7) did not correspond to the declared product, either alone or with adulterants. The IR spectrometer allows a simple and rapid detection of at least one molecule, most often the one of interest. However, it is limited to powder and tablet type matrices and is not suitable for blotters, cannabis, mixed or low content substances for which high resolution mass spectrometry remains the reference method.

Illicit drug prices and quantity discounts: A comparison between a cryptomarket, social media, and police data

BACKGROUND

Illicit drugs are increasingly sold on cryptomarkets and on social media. Buyers and sellers perceive these online transactions as less risky than conventional street-level exchanges. Following the Risks & Prices framework, law enforcement is the largest cost component of illicit drug distribution. We examine whether prices on cryptomarkets are lower than prices on social media and prices reported by law enforcement on primarily offline markets.

METHODS

Data consists of online advertisements for illicit drugs in Sweden in 2018, scraped from the cryptomarket Flugsvamp 2.0 (n = 826) and collected with digital ethnography on Facebook (n = 446). Observations are advertisements for herbal cannabis (n = 421), cannabis resin, hash (n = 594), and cocaine (n = 257) from 156 sellers. Prices are compared with estimates from Swedish police districts (n = 53). Three multilevel linear regression models are estimated, one for each drug type, comparing price levels and discount elasticities for each platform and between sellers on each platform.

RESULTS

Price levels are similar on the two online platforms, but cocaine is slightly more expensive on social media. There are quantity discounts for all three drug types on both platforms with coefficients between -0.10 and -0.21. Despite the higher competition between sellers on cryptomarkets, prices are not lower compared to social media. Online price levels for hash and cocaine are similar to those reported by police at the 1 g level.

CONCLUSION

Mean prices and quantity discounts are similar in the two online markets. This provides support for the notion that research on cryptomarkets can also inform drug market analysis in a broader sense. Online advertisements for drugs constitute a new detailed transaction-level data source for supply-side price information for research.

New psychoactive substances on dark web markets: From deal solicitation to forensic analysis of purchased substances

The dark web scene has been drawing the attention of law enforcement agencies and researchers alike. To date, most of the published works on the dark web are based on data gained by passive observation. To gain a more contextualized perspective, a study was conducted in which three vendors were selected on the "Dream Market" dark web marketplace, from whom subsequently several new psychoactive substances (NPS) were ordered. All transactions were documented from the initial drug deal solicitation to the final qualitative analysis of all received samples. From the selected vendors, a total of nine NPS samples was obtained, all of which were analyzed by NMR, HRMS, LC-UV, and two also by x-ray diffraction. According to our analyses, four of the five substances offered under already known NPS names contained a different NPS. The selected vendors therefore either did not know about their product, or deliberately deceived the buyers. Furthermore, two of three obtained samples of purportedly novel NPS were identified as already documented substances sold under a different name. However, the third characterized substance sold as "MPF-47700" was a novel, yet uncharacterized, NPS. Finally, we received a single undeclared substance, later identified as 5F-ADB. In addition to chemical analysis of the nine obtained NPS samples, the methodology used also yielded contextual information about the accessibility of NPS on the dark web, the associated purchase process, and the modus operandi of three NPS vendors. Direct participation in dark web marketplaces seems to provide additional layers of information useful for forensic studies.

Interpol review of controlled substances 2016-2019

This review paper covers the forensic-relevant literature in controlled substances from 2016 to 2019 as a part of the 19th Interpol International Forensic Science Managers Symposium. The review papers are also available at the Interpol website at: https://www.interpol.int/content/download/14458/file/Interpol%20Review%20Papers%202019.pdf.

Microdosing psychedelics: Motivations, subjective effects and harm reduction

BACKGROUND

In recent years there has been growing media attention on microdosing psychedelics (e.g., LSD, psilocybin). This refers to people routinely taking small doses of psychedelic substances to improve mental health and wellbeing, or to enhance cognitive performance. Research evidence is currently limited. This paper examines microdosing motivations, dosing practices, perceived short-term benefits, unwanted effects, and harm reduction practices.

METHODS

An international online survey was conducted in 2018 examining people's experiences of using psychedelics. Eligible participants were aged 16 years or older, had used psychedelics and could comprehend written English. This paper focuses on 525 participants who were microdosing psychedelics at the time of the survey.

RESULTS

Participants were primarily motivated to microdose to improve mental health (40%), for personal development (31%) and cognitive enhancement (18%). Most were microdosing with psilocybin (55%) or LSD/1P-LSD (48%). Principal components analysis generated three factors examining perceived short-term benefits of microdosing: improved mood and anxiety, enhanced connection to others and environment, and cognitive enhancement; and three factors examining negative and potentially unwanted effects: stronger-than-expected psychedelic effects, anxiety-related effects, and physical adverse effects. Most participants (78%) reported at least one harm reduction practice they routinely performed while microdosing.

CONCLUSION

Our findings suggest that people microdosing are commonly doing so as a self-managed therapy for mental health, either as an alternative or adjunct to conventional treatments. This is despite psychedelics remaining prohibited substances in most jurisdictions. Recent findings from clinical trials with standard psychedelic doses for depression and anxiety suggest that a neurobiological effect beyond placebo is not unreasonable. Randomised controlled trials are needed, complemented by mixed methods social science research and the development of novel resources on microdosing harm reduction.

Variability in content and dissolution profiles of MDMA tablets collected in the UK between 2001 and 2018 - A potential risk to users?

3,4-Methylenedioxymethamphetamine (MDMA, Ecstasy) tablets are widely used recreationally, and not only vary in appearance, but also in MDMA content. Recently, the prevalence of high-content tablets is of concern to public health authorities. To compare UK data with other countries, we evaluated MDMA content of 412 tablets collected from the UK, 2001-2018, and investigated within-batch content variability for a sub-set of these samples. In addition, we investigated dissolution profiles of tablets using pharmaceutical industry-standard dissolution experiments on 247 tablets. All analyses were carried out using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Our data supported other studies, in that recent samples (2016-2018) tend to have higher MDMA content compared to earlier years. In 2018, the median MDMA content exceeded 100 mg free-base for the first time. Dramatic within-batch content variability (up to 136 mg difference) was also demonstrated. Statistical evaluation of dissolution profiles at 15-minutes allowed tablets to be categorized as fast-, intermediate-, or slow-releasing, but no tablet characteristics correlated with dissolution classification. Hence, there would be no way of users knowing a priori whether a tablet is more likely to be fast or slow-releasing. Further, within-batch variation in dissolution rate was observed. Rapid assessment of MDMA content alone provides important data for harm reduction, but does not account for variability in (a) the remainder of tablets in a batch, or (b) MDMA dissolution profiles. Clinical manifestations of MDMA toxicity, especially for high-content, slow-releasing tablets, may be delayed or prolonged, and there is a significant risk of users re-dosing if absorption is delayed.

Nonmedical prescription psychiatric drug use and the darknet: A cryptomarket analysis

Background

Nonmedical prescription psychiatric drug use (NMPDU) is an increasing global health problem, with recent concern focusing on darknet cryptomarkets as sources of procurement. There is a shortage of evidence regarding comparative worldwide NMPDU trends, due in part to data collection difficulties. This problem is particularly marked for non-opioid drugs, particularly those psychiatric drugs which act on the central nervous system (CNS) and have high misuse potential and are associated with high levels of dependency and fatal overdose. This paper therefore has two goals: 1) to report on the kinds of psychiatric prescription drugs available on cryptomarkets, and 2) to use this data to uncover temporal and geographical trends in sales of these products, potentially informing policy regarding NMPDU more generally.

Method

Digital trace data collected from 31 cryptomarkets in operation between September 2013 and July 2016 was analysed by country of origin descriptively and for trends in the sales for 7 psychiatric drug groupings, based on their main indication or intended use in psychiatric practice.

Results

Sedatives (such as diazepam and alprazolam) and CNS stimulants (mainly Adderall, modafinil and methylphenidate) had the greatest share of sales, but usage and trends varied by location. The UK has high and rising levels of sedative sales, whilst the USA has the greatest stimulant sales and increasing sedative rates. Sales of drugs used in the treatment of opioid dependency are also substantial in the USA. The picture is less clear in mainland Europe with high sales levels reported in unexpected Central and Northern European countries. There is evidence of a move towards the more potent sedative alprazolam – already implicated as a source of problematic NMPDU in the USA – in Australia and the UK. Sales of drugs such as antidepressants, antipsychotics, mood stabilisers and antidementia drugs – all drugs with limited abuse potential – were negligible, indicating minimal levels of online cryptomarket procurement for self-medicating mental health problems.

Conclusion

Predominantly, psychiatric drugs with potent sedative, stimulant or euphoriant effects are sold on cryptomarkets and this varies by country. With some caveats regarding the limitations of cryptomarket digital trace data taken into account, the study of trends of these products sold online over time may offer a novel and increasingly important window onto wider drug purchasing habits.

On-site identification of psychoactive drugs by portable Raman spectroscopy during drug-checking service in electronic music events

INTRODUCTION AND AIMS

Hundreds of new psychoactive substances (NPS) have burst into the marketplace, making both the scientific community and people who use drugs lacking of adequate information about their diffusion and effects. In this scenario, drug-checking services have been recently proposed to assist harm reduction policies and provide a global description of the circulating drugs.

DESIGN AND METHODS

The results obtained by a portable Raman spectroscopy device on 472 alleged drugs within the first formal implementation of drug checking in Italy, are reported. The testing was made through a plastic bag held by the applicant and containing the alleged drug. The substance identification was executed by comparison with a spectral library.

RESULTS

Illicit substances were detected in 304 samples. Findings included MDMA (106 samples), ketamine (87 samples), cocaine (51 samples), amphetamine (47 samples), methamphetamine (two samples), heroin (two samples) and NPS (nine samples). Two samples were identified as precursors of psychoactive substances. Identification of a non-controlled substance occurred in 38 samples. Output of inconclusive result was recorded from 128 samples tested on-site, from which the applicant allowed us to collect a small portion in 68 cases, for a delayed laboratory analysis by GC-MS or LC-MS/MS.

DISCUSSION AND CONCLUSIONS

Drug checking by Raman spectroscopy proved effective to identify psychoactive drugs including NPS and track the drug distribution in various recreational settings. The field testing activity revealed the presence of several NPS in the nightlife scenario, often in replacement of traditional illicit drugs, thus posing a high overdose risk and a life-threatening situation.

Population Survey Data Informing the Therapeutic Potential of Classic and Novel Phenethylamine, Tryptamine, and Lysergamide Psychedelics

INTRODUCTION

The majority of contemporary psychedelic research has focused on ayahuasca, lysergic acid diethylamide, and psilocybin, though there are hundreds of novel psychedelic compounds that may have clinical utility. The purpose of the present study was to evaluate the therapeutic potential of classic and novel phenethylamine, tryptamine, and lysergamide psychedelics via a large, nationally representative population-based survey.

METHODS

We tested the unique associations of lifetime classic and novel phenethylamine, tryptamine, and lysergamide psychedelics with past month psychological distress and past year suicidality among respondents pooled from years 2008-2017 of the National Survey on Drug Use and Health (weighted N = 260,964,827).

RESULTS

Lifetime classic tryptamine use was associated with a decreased odds of past month psychological distress [aOR = 0.76; (0.69-0.83)] and past year suicidal thinking [aOR = 0.79; (0.72-0.87)]. Lifetime novel phenethylamine use, on the other hand, was associated with an increased odds of past year suicidal thinking [aOR = 1.44; (1.06-1.95)] and past year suicidal planning [aOR = 1.60; (1.06-2.41)]. No other significant associations were found.

DISCUSSION AND CONCLUSIONS

These findings, which may be driven by differences in pharmacodynamics, suggest that classic tryptamines may hold the greatest therapeutic potential of the psychedelics, whereas novel phenethylamines may pose risk for harm. The present findings thus support continued research on the clinical application of classic tryptamines. Though the current results caution against the clinical utility of novel phenethylamines, further study of these and other novel psychedelic substances is nonetheless warranted to better understand their potential application.

Levamisole-induced vasculopathy: A systematic review

OBJECTIVE

To characterize levamisole-induced vasculopathy.

METHODS

We performed a systematic review searching MEDLINE for articles published from 1972 to 2016.

RESULTS

We retrieved 357 references and abstracts and selected 111 articles. Levamisole-induced vasculopathy was reported in 192 patients, with a female predominance (n = 122, 63.5%). Median [interquartile range] age was 44 [38-50]. Skin was the most frequently involved organ (n = 182, 94.8%). Cutaneous lesions were mostly on the face (n = 136, 70.8%), especially the ears. Purpura (n = 131, 68.2%) was the most reported cutaneous lesion. Organ involvement included acute renal failure (n = 24, 12.5%), and pulmonary involvement (n = 20, 10.4%). Anti-neutrophil cytoplasmic antibodies (ANCAs) were found in 167/178 patients (93.8%), with both anti-myeloperoxydase and anti-proteinase 3 specificity reported in 51/118 patients (43.2%). Anti-phospholipid (APL) antibodies were found in 93/137 patients (67.9%). Leukopenia was detected in 69/138 patients (50%). Skin biopsies identified vasculitis and thrombotic vasculopathy in 73/148 (49.3%) and 62/148 (41.9%) patients, respectively. The outcome was favourable in 116/134 patients (86.6%), but relapses were reported in 33 (28.4%), mainly on levamisole re-exposure.

CONCLUSION

Levamisole-induced vasculopathy is characterized by a female predominance, skin involvement, ANCA and/or APL antibody positivity, leukopenia, vasculitis or vascular thrombotic histological lesions, and despite possible systemic involvement, a favourable outcome with levamisole interruption.

Will growth in cryptomarket drug buying increase the harms of illicit drugs?

BACKGROUND AND AIM

Cryptomarkets-on-line, anonymous market-places for illicit goods and services that specialize mainly in drugs-account for a small but rapidly growing share of the illicit drug market in many countries. Policy responses so far are based generally on the assumption that their rise will only increase drug harms. In this contribution for debate, we question this assumption.

METHODS

We provide a narrative review of the emerging literature connected to drug cryptomarkets. We use MacCoun & Reuter's formula to understand the effect of population-level increases in use on total harm as depending on the level of harm associated with each unit of use. We then consider the potential for cryptomarkets to increase or decrease the harms and benefits related to each unit of drug use, with specific attention to the quality of drugs sold and the non-drug-related harms and benefits for customers.

RESULTS

It is likely that cryptomarkets will increase both the amount and the range of substances that are sold. However, we argue that the effects on harms will depend upon whether cryptomarkets also increase the quality and safety of products that are sold, provide harm-reducing information to consumers and reduce transactional conflict involved in drug purchasing.

CONCLUSIONS

There is an emerging and rapidly growing evidence base connected to the macro and micro harms and benefits of cryptomarkets for drug users. Future researchers should use appropriately matched comparative designs to establish more firmly the differential harms and benefits of sourcing drugs both on- and off-line. While it is unlikely that the on-line drug trade can be eradicated completely, cryptomarkets will respond to regulation and enforcement in ways that have complex, and sometimes unanticipated, effects on both harms and benefits.

Exploration of the Use of New Psychoactive Substances by Individuals in Treatment for Substance Misuse in the UK

Substance misuse services need to meet the growing demand and needs of individuals using new psychoactive substances (NPS). A review of the literature identified a paucity of research regarding NPS use by these individuals and UK guidelines outline the need for locally tailored strategies. The purpose of this qualitative study was to identify and explore key themes in relation to the use of NPS by individuals receiving community treatment for their substance use. Electronic records identified demographics and semi-structured interviews were undertaken. A thematic analysis of transcripts identified a variety of substance use histories; 50% were prescribed opiate substitutes and 25% used NPS as a primary substance. All were males, age range 26–59 years (SD = 9), who predominantly smoked cannabinoids and snorted/injected stimulant NPS. The type of NPS used was determined by affordability, availability, side-effect profile and desired effects (physical and psychological: 25% reported weight loss as motivation for their use). Poly-pharmacy, supplementation and displacement of other drugs were prevalent. In conclusion, NPS use and associated experiences vary widely among people receiving substance use treatment. Development of effective recovery pathways should be tailored to individuals, and include harm reduction strategies, psychosocial interventions, and effective signposting. Services should be vigilant for NPS use, “on top” use and diversion of prescriptions.

The importance of drug checking outside the context of nightlife in Slovenia

Background

The main purpose of the research was to evaluate the implementation of the drug checking service in Slovenia and to obtain the opinion of users included in harm reduction programmes for high-risk drug users and of drug users in nightlife settings on drug checking, the reasons for drug checking, and their attitude towards adulterants in the drugs that they use.

Methods

The two final unrepresentative research samples included 102 respondents from harm reduction programmes and 554 respondents from the online sample. The questionnaire was designed based on analysis of the interviews conducted with professionals from the programmes, who took part in the drug checking project, and based on previous research on drug use in nightlife.

Results

The main findings related to users’ opinions on the drug checking service are that users from both samples perceive drug checking as a contribution to risk reduction and that they find providing information for them about the harmful adulterants and substances that they use very important. In addition, users from both samples considered accessibility of the drug checking service as very important and would be in favour of brief counselling at the collection of the drug sample. One of the salient differences between samples was that nightlife drug users found it more important to recognise substances in the drugs that they use.

Conclusions

Drug users from two different samples attach a relatively high importance to the drug checking service, and they consider it to be a contribution to risk reduction. As well as drug users in nightlife settings, high-risk drug users also perceive the drug checking service to be important, which is relevant in the phase of planning drug checking services outside the context of nightlife and for the act of incorporating these services into contemporary harm reduction policy.

An island apart? Risks and prices in the Australian cryptomarket drug trade

BACKGROUND

Australia has a reputation as an anomaly with regard to cryptomarket drug trading, with seemingly disproportionately high levels of activity given its relatively small size, high prices and anecdotal accounts of it being a destination where many foreign-based vendors will not sell. This paper aims to investigate these claims from a risk and prices perspective.

METHODS

By analysing data for over 60,000 drug products available for purchase from eight cryptomarkets in January 2016 this work builds a descriptive picture of the Australian online market in comparison to the rest of the world, before moving onto analyse the prices of drugs available to Australian consumers, both online and though conventional drug supply routes.

RESULTS

Results show that the Australian online illicit drugs market is of considerable size, internally isolated and with methamphetamine sales being particularly large by comparison to other countries. Australian cryptomarket vendors sell drugs at significantly higher prices than those listed by their foreign counterparts. Online prices are however broadly comparable to street prices, with the exception of methamphetamine where prices appear to be much lower online.

CONCLUSIONS

These findings indicate that the perceived stringency of Australian border protection inadvertently increases the competitiveness and local market share of domestic cryptomarket vendors via a consumer side 'risk tariff', challenging the traditionally vendor-oriented drugs risk and prices framework.

Forensic drug intelligence and the rise of cryptomarkets. Part I: Studying the Australian virtual market

Analysing and understanding cryptomarkets is essential to become proactive in the fight against the illicit drug trade. Such a research seeks to combine a diversity of indicators related to the virtual (darknet markets) and physical (the traditional "offline" market) aspects of the illicit drug trade to provide information on the distribution and consumption as well as to assess similarities/differences between the virtual and physical markets. This study analysed data that had previously been collected on cryptomarkets from December 2013 to March 2015. In this article, the data was extracted from two marketplaces, Evolution and Silk Road 2, and analysed to evaluate the illicit drug trade of the Australian virtual market (e.g. information about the supply and demand, trafficking flows, prices of illicit drugs and market share) and highlight its specificities. The results revealed the domestic nature of the virtual Australian illicit drug trade (i.e. Australian sellers essentially ship their products to local customers). This may explain the coherence between supply and demand. Particularly, the virtual Australian illicit drug trade is dominated by amphetamine-type substances (ATS), mainly methamphetamine and 3,4-methylenedioxymethamphetamine (MDMA), and cannabis. Australia, as a shipping country, accounts for half of the methamphetamine offered and purchased on Silk Road 2. Moreover, it was observed that the online price fixed by Australian sellers for the considered illicit drugs is higher than for any other shipping countries, which is in line with previous studies. Understanding the virtual and physical drug market necessitates the integration and fusion of different perspectives to capture the dynamic nature of drug trafficking, monitor its evolution and finally improve our understanding of the phenomenon so policy makers can make informed decisions.

Seller's reputation and capacity on the illicit drug markets: 11-month study on the Finnish version of the Silk Road

AIMS

This 11-month study analyzed illicit drug sales on the anonymous Tor network, with a focus on investigating whether a seller's reputation and capacity increased daily drug sales.

DESIGN AND SETTING

The data were gathered from Silkkitie, the Finnish version of the Silk Road, by web crawling the site on a daily basis from (November 2014 to September 2015). The data include information on sellers (n=260) and products (n=3823).

MEASUREMENTS

The measurements include the sellers' reputation, the sale amounts (in euros), the number of available products and the types of drugs sold. The sellers' capacity was measured using their full sales potential (in euros). Fixed-effects regression models were used to estimate the effects of sellers' reputation and capacity; these models were adjusted for the types of drugs sold.

FINDINGS

Overall, illicit drug sales totalled over 2 million euros during the study, but many products were not sold at all, and sellers were active for only a short time on average (mean=62.8days). Among the products sold, stimulants were most widely purchased, followed by cannabis, MDMA, and psychedelics. A seller's reputation and capacity were both associated with drug sales.

CONCLUSION

The Tor network has enabled a transformation in drug sales. Due to the network's anonymity, the seller's reputation and capacity both have an impact on sales.

Naloxone for heroin, prescription opioid, and illicitly made fentanyl overdoses: Challenges and innovations responding to a dynamic epidemic

Community-based overdose prevention programs first emerged in the 1990's and are now the leading public health intervention for overdose. Key elements of these programs are overdose education and naloxone distribution to people who use opioids and their social networks. We review the evolution of naloxone programming through the heroin overdose era of the 1990's, the prescription opioid era of the 2000's, and the current overdose crisis stemming from the synthetic opioid era of illicitly manufactured fentanyl and its analogues in the 2010's. We present current challenges arising in this new era of synthetic opioids, including variable potency of illicit drugs due to erratic adulteration of the drug supply with synthetic opioids, potentially changing efficacy of standard naloxone formulations for overdose rescue, potentially shorter overdose response time, and reports of fentanyl exposure among people who use drugs but are opioid naïve. Future directions for adapting naloxone programming to the dynamic opioid epidemic are proposed, including scale-up to new venues and social networks, new standards for post-overdose care, expansion of supervised drug consumption services, and integration of novel technologies to detect overdose and deliver naloxone.

Silicon to syringe: Cryptomarkets and disruptive innovation in opioid supply chains

Cryptomarkets offer insight into the evolving interplay between online black markets and cartel-based distribution. The types and forms of heroin, fentanyl, and prescription drugs show wide diversification. In this commentary we describe changes in the conceptualizations, technologies and structures of drug supply chains in the 21st Century, with special attention to the role of cryptomarkets as tools, contexts, and drivers of innovation in public health research.

A market on both "sides" of the law: The use of the hidden web for the sale of new psychoactive substances

OBJECTIVE

The hidden Web is used for the anonymous sale of drugs, and with the UK Psychoactive Substances Act, 2016, implemented on May 26th 2016; it could increase as a platform for obtaining new psychoactive substances (NPS). This study aims to describe the NPS market on the visible and hidden Web preban, and assess whether the hidden Web is a likely place for the sale of NPS postban.

METHODS

Data collection of 113 online shops took place in October 2015. Data collection of 22 cryptomarkets took place every 2 months from October 2015 to 2016 as part of the CASSANDRA project.

RESULTS

All online shops with a UK domain location sold NPS that were uncontrolled by the UK Misuse of Drugs Act, 1971, and closed after the ban. Of the cryptomarkets analysed, the total number of vendors selling NPS, number of substances, and listings advertised, all increased over the year. The majority of the NPS advertised on the hidden Web were phenethylamines and cathinones, yet the majority of uncontrolled NPS were synthetic cannabinoids.

CONCLUSIONS

Vendors selling and availability of NPS increased over the 12 months of data collection. Potential displacement from the visible Web to hidden Web should be taken into consideration.

Purity, adulteration and price of drugs bought on-line versus off-line in the Netherlands

BACKGROUND AND AIMS

On-line drug markets flourish and consumers have high expectations of on-line quality and drug value. The aim of this study was to (i) describe on-line drug purchases and (ii) compare on-line with off-line purchased drugs regarding purity, adulteration and price.

DESIGN

Comparison of laboratory analyses of 32 663 drug consumer samples (stimulants and hallucinogens) purchased between January 2013 and January 2016, 928 of which were bought on-line.

SETTING

The Netherlands.

MEASUREMENTS

Primary outcome measures were (i) the percentage of samples purchased on-line and (ii) the chemical purity of powders (or dosage per tablet); adulteration; and the price per gram, blotter or tablet of drugs bought on-line compared with drugs bought off-line.

FINDINGS

The proportion of drug samples purchased on-line increased from 1.4% in 2013 to 4.1% in 2015. The frequency varied widely, from a maximum of 6% for controlled, traditional substances [ecstasy tablets, 3,4-methylenedioxy-methamphetamine (MDMA) powder, amphetamine powder, cocaine powder, 4-bromo-2,5-dimethoxyphenethylamine (2C-B) and lysergic acid diethylamide (LSD)] to more than a third for new psychoactive substances (NPS) [4-fluoroamphetamine (4-FA), 5/6-(2-aminopropyl)benzofuran (5/6-APB) and methoxetamine (MXE)]. There were no large differences in drug purity, yet small but statistically significant differences were found for 4-FA (on-line 59% versus off-line 52% purity for 4-FA on average, P = 0.001), MDMA powders (45 versus 61% purity for MDMA, P = 0.02), 2C-B tablets (21 versus 10 mg 2C-B/tablet dosage, P = 0.49) and ecstasy tablets (131 versus 121 mg MDMA/tablet dosage, P = 0.05). The proportion of adulterated samples purchased on-line and off-line did not differ, except for 4-FA powder, being less adulterated on-line (χ²  = 8.3; P < 0.02). Drug prices were mainly higher on-line, ranging for various drugs from 10 to 23% higher than that of drugs purchased off-line (six of 10 substances: P < 0.05).

CONCLUSIONS

Dutch drug users increasingly purchase drugs on-line: new psychoactive substances in particular. Purity and adulteration do not vary considerably between drugs purchased on-line and off-line for most substances, while on-line prices are mostly higher than off-line prices.