α-Pyrrolidinopentiophenone ("Flakka") Catalyzing Catatonia: A Case Report and Literature Review

Catatonia: demographic, clinical and laboratory associations

BACKGROUND

Catatonia, a severe neuropsychiatric syndrome, has few studies of sufficient scale to clarify its epidemiology or pathophysiology. We aimed to characterise demographic associations, peripheral inflammatory markers and outcome of catatonia.

METHODS

Electronic healthcare records were searched for validated clinical diagnoses of catatonia. In a case-control study, demographics and inflammatory markers were compared in psychiatric inpatients with and without catatonia. In a cohort study, the two groups were compared in terms of their duration of admission and mortality.

RESULTS

We identified 1456 patients with catatonia (of whom 25.1% had two or more episodes) and 24 956 psychiatric inpatients without catatonia. Incidence was 10.6 episodes of catatonia per 100 000 person-years. Patients with and without catatonia were similar in sex, younger and more likely to be of Black ethnicity. Serum iron was reduced in patients with catatonia [11.6 v. 14.2 μmol/L, odds ratio (OR) 0.65 (95% confidence interval (CI) 0.45-0.95), p = 0.03] and creatine kinase was raised [2545 v. 459 IU/L, OR 1.53 (95% CI 1.29-1.81), p < 0.001], but there was no difference in C-reactive protein or white cell count. N-Methyl-d-aspartate receptor antibodies were significantly associated with catatonia, but there were small numbers of positive results. Duration of hospitalisation was greater in the catatonia group (median: 43 v. 25 days), but there was no difference in mortality after adjustment.

CONCLUSIONS

In the largest clinical study of catatonia, we found catatonia occurred in approximately 1 per 10 000 person-years. Evidence for a proinflammatory state was mixed. Catatonia was associated with prolonged inpatient admission but not with increased mortality.

Behavioral patterns of people who use synthetic psychostimulants: Results of a qualitative study in St. Petersburg, Russia

BACKGROUND

Russia, like many other places, is currently experiencing a proliferation of new psychoactive substances, many of which are psychostimulants. In St. Petersburg, these appear to be mostly congeners of cathinone. We sought to obtain qualitative data to better understand the impact on the health and behaviors of people who use drugs (PWUD) by recruiting individuals who reported recent use of psychostimulants.

METHODS

In-depth qualitative data on current drug use and its effects were collected through thirty interviews (n=30) and two focus groups (n=10: five male, five female). The interviews and focus groups also provided data on the social contexts of drug use including sexual behaviors and associated medical issues. Secondary data about online drug purchases were obtained from a source that accesses and analyzes darknet purchases. Qualitative data were initially coded using a priori codes developed on the basis of the interview guide, and then data were coded again inductively based on emergent findings from the data. Thematic analysis was carried out using OpenCode 4.0 qualitative data analysis software.

RESULTS

Thematic analysis of the interviews and focus groups identified distinct differences in behavior patterns between older, more experienced PWUD and a "new generation" of PWUD. Routes of initiation of drug use and sexual behaviors associated with drug use differed, but both groups reported high levels of unsafe injection and sexual behaviors. In interpreting the texts and purchasing data, we have attempted to anticipate how the drug use patterns can influence HIV transmission.

CONCLUSIONS

The emergence of a new class of psychostimulant drugs presents new threats to the health of drug users and new opportunities to intervene to reduce those risks. The information obtained may assist HIV/AIDS prevention specialists and drug user support groups in their efforts to decrease unsafe drug use and sexual behaviors.

Effects of α-pyrrolidino-phenone cathinone stimulants on locomotor behavior in female rats

The α-pyrrolidino-phenone cathinone stimulants first came to widespread attention because of bizarre behavior consequent to the use of α-pyrrolidinopentiophenone (α-PVP, "flakka") reported in popular press. As with other designer drugs, diversification of cathinones has been driven by desirable subjective effects, but also by attempts to stay ahead of legal controls of specific molecules. The α-pyrrolidinohexiophenone (α-PHP) and α-pyrrolidinopropiophenone (α-PPP) compounds have been relatively under-investigated relative to α-PVP and provide a key opportunity to also investigate structure-activity relationships, i.e., how the extension of the alpha carbon chain may affect potency or efficacy. Female rats were used to contrast the effects of α-PHP and α-PPP with those of α-PVP in altering wheel activity and effects on spontaneous locomotion, temperature and intracranial self-stimulation reward. The α-PPP, α-PHP and α-PVP compounds (5, 10 mg/kg, i.p.) suppressed wheel activity. Inhalation of α-PHP or α-PVP also suppressed wheel activity, but for an abbreviated duration compared with the injection route. Spontaneous activity was increased, and brain reward thresholds decreased, in a dose-dependent manner by all three compounds; only small decrements in body temperature were observed. These data show that all three of the α-pyrrolidino-phenone cathinones exhibit significant stimulant-like activity in female rats. Differences were minor and abuse liability is therefore likely to be equivalent for all three α-pyrrolidino-phenones.

A Case of Alpha-Pyrrolidinopentiophenone (Flakka)-Induced Ischemic Stroke

Alpha-pyrrolidinovalerophenone (α-PVP) is a designer drug, the mechanism of action of which resembles that of cocaine and amphetamine. New data about the side effects of α-PVP are emerging. We present a case report of an acute ischemic stroke following the recreational use of α-PVP. The ischemic lesions were located in the middle cerebral artery and deep watershed areas of the left cerebral hemisphere. Occupational therapy and physiotherapy were initiated, and the patient was discharged with only a mild right hemiparesis.

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.

Interpol review of toxicology 2016-2019

This review paper covers the forensic-relevant literature in toxicology 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%20.Papers%202019.pdf.

Psychoactive Bath Salts and Neurotoxicity Risk

Synthetic cathinones are new designer drugs that possess hallucinogenic and psychostimulant properties, and are designed to mimic the effects of illegal substances such as cocaine, amphetamines, and 3.4-methylenedioxymethamphetamine (ecstasy) and to produce rewarding effects, circumventing existing laws and penalties. Synthetic cathinones, also referred to as 'bath salts', have become popular particularly among young people since the mid-2000s. Similar to other psychomotor stimulants, synthetic cathinones have the potential to increase monoamine concentration in the synaptic cleft by targeting the plasma membrane transporters of dopamine, norepinephrine, and serotonin. Because of their structural similarities to amphetamines, it has been suggested that synthetic cathinones may have a neurotoxicity profile similar to that of their amphetamine congeners. Therefore, it has been hypothesized that synthetic cathinones may induce neurotoxicity on monoamine nerve endings in the striatum, hippocampus, and cortex. To date, with regard to synthetic cathinone neurotoxicity, parameters such as monoamine depletion, biosynthetic enzyme inhibition, cytotoxicity, generation of reactive oxygen species, pro-oxidation status, and the ability to induce neuroinflammation were investigated in both in vitro and in vivo experimental studies. Compared with amphetamines, synthetic cathinones appear to have more moderate effects than their amphetamine congeners in terms of neurotoxic effects. However, many synthetic cathinone users take these substances simultaneously with other substances such as benzodiazepines, amphetamines, ecstasy, tetrahydrocannabinol, and ethanol and this abuse can modify their neurotoxic effects. Hence, it is important to understand the underlying mechanism of early neurotoxic effects in case of polysubstance use. In this review, we aimed to present up-to-date information on the abuse potential of synthetic cathinones, their legal status, mechanism of action, and particularly their neurotoxic effects.

The Bridge Between Classical and "Synthetic"/Chemical Psychoses: Towards a Clinical, Psychopathological, and Therapeutic Perspective

The critical spread and dissemination of novel psychoactive substances (NPS), particularly among the most vulnerable youngsters, may pose a further concern about the psychotic trajectories related to the intake of new synthetic drugs. The psychopathological pattern of the "new psychoses" appears to be extremely different from the classical presentation. Therefore, clinicians need more data on these new synthetic psychoses and recommendations on how to manage them. The present mini-review aims at deepening both the clinical, psychopathological features of synthetic/chemical NPS-induced psychoses and their therapeutic strategies, according to the different NPS classes implicated, by underlining the main differences with the "classical" psychoses. A comprehensive review was conducted using the PubMed/Medline database by combining the search strategy of free-text terms and exploding a range of MESH headings relating to the topics of novel psychoactive substances and synthetic/chemical psychoses as follows: {(Novel Psychoactive Substances[Title/Abstract]) AND Psychosis[Title/Abstract])} and for each NPS categories as well, focusing on synthetic cannabinoids and cathinones, without time and/or language restrictions. Finally, an overview of the main clinical and psychopathological features between classical versus NPS-induced chemical/synthetic psychoses is provided for clinicians working with dual disorders and addiction psychiatry. Further insight is given here on therapeutic strategies and practical guidelines for managing patients affected with synthetic/chemical NPS-induced psychoses.

Novel complication of Flakka: Stevens-Johnson syndrome/Toxic epidermal necrolysis overlap

Flakka, as the newest member of the synthetic cathinone group, is a substance with serious cardiovascular, neurological, psychiatric, infectious effects and addictive potential. There are only a few case reports and laboratory studies in the literature and there is no dermatological side effects reported yet. We present the first Stevens-Johnson syndrome/Toxic epidermal necrolysis (SJS/TEN) overlap case after Flakka use.