‘Bundle of fun’ or ‘bunch of problems’? Case series of khat-related deaths in the UK

Fatalities Involving Khat in Jazan, Saudi Arabia, 2018 to 2021

Interpreting fatalities involving khat is challenging due to a lack of data on cathinone and cathine reference concentrations in postmortem tissues. This study investigated the autopsy findings and toxicological results of fatalities involving khat in Saudi Arabia's Jazan region from 1 January 2018 to 31 December 2021. All confirmed cathine and cathinone results in postmortem blood, urine, brain, liver, kidney, and stomach samples were recorded and analyzed. Autopsy findings and the manner and cause of death of the deceased were assessed. Saudi Arabia's Forensic Medicine Center investigated 651 fatality cases over four years. Thirty postmortem samples were positive for khat's active constituents, cathinone and cathine. The percentage of fatalities involving khat was 3% in 2018 and 2019 and increased from 4% in 2020 to 9% in 2021, when compared with all fatal cases. They were all males ranging in age from 23 to 45. Firearm injuries (10 cases), hanging (7 cases), road traffic accident (2 cases), head injury (2 cases), stab wounds (2 cases), poisoning (2 cases), unknown (2 cases), ischemic heart disease (1 case), brain tumor (1 case), and choking (1 case) were responsible for the deaths. In total, 57% of the postmortem samples tested positive for khat only, while 43% tested positive for khat with other drugs. Amphetamine is the drug most frequently involved. The average cathinone and cathine concentrations were 85 and 486 ng/mL in the blood, 69 and 682 ng/mL in the brain, 64 and 635 ng/mL in the liver, and 43 and 758 ng/mL in the kidneys, respectively. The 10th-90th percentiles of blood concentrations of cathinone and cathine were 18-218 ng/mL and 222-843 ng/mL, respectively. These findings show that 90% of fatalities involving khat had cathinone concentrations greater than 18 ng/mL and cathine concentrations greater than 222 ng/mL. According to the cause of death, homicide was the most common fatality involving khat alone (77%). More research is required, especially toxicological and autopsy findings, to determine the involvement of khat in crimes and fatalities. This study may help forensic scientists and toxicologists investigate fatalities involving khat.

Cathine and cathinone disposition kinetics and neurotransmitter profile in several organs of rats exposed to a single dose of Catha edulis (Vahl) Forssk. ex Endl. extract

OBJECTIVES

Catha edulis (Vahl) Forssk. ex Endl. (Khat) is a stimulant plant that contains cathine and cathinone, which its abuses induce euphoria, alertness, and motor activity. Since the toxicokinetics of these substances remain unclear, this study was carried out to investigate the disposition kinetics of cathine and cathinone, the neurotransmitter profile, following a single dose of C. edulis extract in rats.

METHODS

Twenty-four adult male Wistar albino rats (250-300 g) were randomly selected and divided into six groups of four rats each. All groups received a single oral dose of 2,000 mg/kg body weight, and blood and tissue samples from the brain, lung, heart, liver, and kidney were obtained at intervals of 0.5, 1, 2.5, 5, 12, and 24 h. The cathine and cathinone concentrations were identified and quantified using ion trap ultra-high performance liquid chromatography (HPLC-IT/MS). The neurotransmitter profile was detected using the quadrupole time of flight UPLC-QTOF/MS method.

RESULTS

The lung, liver, and heart tissues attained the highest levels of cathine, while the highest level of cathinone was determined in the heart. Cathine and cathinone concentrations in the blood and heart peaked at 0.5 h. The concentrations peaked in the brain 2.5 h later, indicating that the heart had an immediate effect, whereas the brain had a longer-lasting one. They have longer half-lives (2.68 and 5.07 h, respectively) and may remain in the brain for longer durations (3.31 and 2.31 h, respectively). The neurotransmitters epinephrine, dopamine, norepinephrine, and serotonin were detected in a delayed, prolonged and organ-specific manner.

CONCLUSIONS

Cathine and cathinone were deposited in considerable concentrations in all tissues analyzed, with the highest C_max in the lung and T_max in the heart tissues but not in the brain. In addition, neurotransmitters such as adrenaline, dopamine, norepinephrine, and serotonin were differentially detected in all tested samples in a organ-specific fashion. More study is needed to identify cathine and cathinone's effects on neurotransmitter profiles. Nevertheless, these findings provided a further basis for experimental, clinical, and forensic investigations.

Synthetic Cathinone-Induced Myocarditis and Psychosis: A Case Report

Psychoactive substances are a diverse group of chemical substances that are ever-evolving structurally. Novel psychoactive substances are being reported in and are becoming increasingly popular in East and Southeast Asia, with synthetic cathinones becoming the drugs of choice. The use of synthetic cathinones has increased significantly over the years. However, the easy accessibility of these substances and their potentially damaging health effects have raised many concerns. Herein, we present the case of a patient who ingested mixed synthetic cathinones and eventually developed acute myocarditis and subsequent psychotic symptoms. The delayed presentation of psychosis coupled with initial cardiovascular symptoms was a unique phenomenon, making differential diagnosis challenging. The association between the use of synthetic cathinones and psychosis and myocarditis should be explored in view of the lack of relevant clinical data and potentially dire outcomes.

The impact of khat chewing on heart activity and rehabilitation therapy from khat addiction in healthy khat chewers

Khat is a flowering plant whose leaves and stems are chewed for excitement purposes in most of east African and Arabian countries. Khat can cause mood changes, increased alertness, hyperactivity, anxiety, elevated blood pressure, and heart diseases. However, the effect of khat on the heart has not been studied exclusively. The purpose of this study was to investigate the impact of khat chewing on heart activity and rehabilitation therapy from khat addiction in healthy khat chewers. ECG signals were recorded from 50 subjects (25 chewers and 25 controls) before and after chewing session to investigate the effect of khat on heart activity. In addition, ECG signals from 5 subjects were recorded on the first and eightieth day of rehabilitation therapy for investigating the effect of rehabilitation from khat addiction. All the collected signals were annotated, denoised and features were extracted and analysed. After chewing khat, the average heart rate of the chewers was increased by 5.85%, with 3 subjects out of 25 were prone to tachycardia. 1.66% QRS duration and 23.56% R-peak amplitude reduction were observed after chewing session. Moreover, heart rate variability was reduced by 19.74% indicating the effect of khat on suppressing sympathetic and parasympathetic nerve actions. After rehabilitation therapy, the average heart rate was reduced by 11.66%, while heart rate variability (HRV), QRS duration, and RR interval were increased by 25%, 3.49%, and 12.53%, respectively. Statistical analysis results also confirmed that there is a significance change (p < 0.05) in ECG feature among pre- and post-chewing session. Our findings demonstrate that, khat chewing raises heart rate, lowers heart rate variability, or puts the heart under stress by lowering R-peak amplitude and QRS duration, which in turn increases the risk of premature ventricular contraction and arrhythmia. The results also show that rehabilitation therapy from khat addiction has a major impact on restoring cardiac activity to normal levels.

Substance use and substance use disorders in Africa: An epidemiological approach to the review of existing literature

The relationship between man and substances that have abuse potentials, and whose use has been associated with the development or progression of substance use disorders has continued to evolve in terms of geography, economic implications, and time. History shows that local plants with psychoactive constituents can get exported worldwide through global travel, commerce, or even conquest. Time and globalization also change people’s relationship with substances of abuse; hence, an area that was initially alien to certain substances might evolve to becoming a trafficking hub, and then a destination. A case in point is Africa where a rapidly increasing prevalence of substance use/abuse and substance use disorder among adolescents and young adults is putting enormous strain on the economy, healthcare system, and society at large. However, there appears to be a paucity of scientific literature and data on the epidemiology, risk assessment, and contributing factors to substance use and the development of substance use disorders across Africa. In this narrative review, we examine extant literature (PubMed, Google scholar, Medline) for information on the prevalence, trends, and influencers of substance use and the development of substance use disorders. This is with a view of understanding the determinants of substance use and factors that influence the development of substance use disorders in the region, and how this information can be channeled towards developing a comprehensive intervention and treatment program.

An updated review on synthetic cathinones

Cathinone, the main psychoactive compound found in the plant Catha edulis Forsk. (khat), is a β-keto analogue of amphetamine, sharing not only the phenethylamine structure, but also the amphetamine-like stimulant effects. Synthetic cathinones are derivatives of the naturally occurring cathinone that largely entered the recreational drug market at the end of 2000s. The former "legal status", impressive marketing strategies and their commercial availability, either in the so-called "smartshops" or via the Internet, prompted their large spread, contributing to their increasing popularity in the following years. As their popularity increased, the risks posed for public health became clear, with several reports of intoxications and deaths involving these substances appearing both in the social media and scientific literature. The regulatory measures introduced thereafter to halt these trending drugs of abuse have proved to be of low impact, as a continuous emergence of new non-controlled derivatives keep appearing to replace those prohibited. Users resort to synthetic cathinones due to their psychostimulant properties but are often unaware of the dangers they may incur when using these substances. Therefore, studies aimed at unveiling the pharmacological and toxicological properties of these substances are imperative, as they will provide increased expertise to the clinicians that face this problem on a daily basis. The present work provides a comprehensive review on history and legal status, chemistry, pharmacokinetics, pharmacodynamics, adverse effects and lethality in humans, as well as on the current knowledge of the neurotoxic mechanisms of synthetic cathinones.

Catha edulis Forsk (khat) reduces spontaneous and rewarded alternation in female mice

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Khat is a widely used plant-based psychostimulant.

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Administration of khat leads to disruption of spatial working memory in mice.

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It promotes in mice perseverative behavior rather than alternation behavior.

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Khat treated mice also show right side position preference.

Around 10 million people chew the fresh leaves and twigs of Catha edulis Forsk (khat), which synthesize cathinone, for its psychostimulatory effect. Several studies have reported that regular khat users show executive and cognitive dysfunction, such as impaired inhibitory control and poor performance on memory tests. In this study, the effect of fresh khat extract (100 and 250 mg/kg) on spatial working memory and short-term memory in mice was assessed using spontaneous and rewarded alternation T-maze tests. In the spontaneous alternation test, mice treated with fresh khat extract decreased their spontaneous alternation level to around chance level, and it remained at this level over the 7 days of khat administration and testing. On testing after a 7-day khat free period, the previously khat treated mice showed alternation level above chance but below their pre-khat alternation level. In the rewarded alternation test, acute treatment with khat caused the mice to alternate well below chance level, and then over the next 3 days of khat treatment, the alternation level increased. After a 2 and 9-day khat-free period, the previously khat treated mice alternated above chance level but below their pre-khat level. In both these tests, the mice did not show any position preference before khat treatment; however, during the khat treatment, the mice showed a right side tendency. The results show that khat treatment causes persistent changes in alternation behavior and promotes perseverative behavior, presumably due to its effect on the neural circuits activity and the neurotransmitters and promotion of position preference.

Occupational Exposure to Blood and Body Fluids among Health Care Workers in Gondar Town, Northwest Ethiopia: A Result from Cross-Sectional Study

Background

Health care workers are at the greatest risk of developing blood-borne diseases through occupational exposure to blood and other contaminated body fluids. Occupational exposure to blood and body fluids (BBFs) continues to be the major public health problems and serious concern for the health care force in Ethiopia. Therefore, this study was aimed to determine the prevalence of exposure to blood and other body fluids and its associated risk factors among health care workers.

Methods

The institution-based cross-sectional study design was employed from January 20 to February 30, 2018. A stratified random sampling followed by a simple random sampling technique was used to select 286 study participants. Data were collected using a pretested and structured questionnaire. Bivariate and multivariable logistic regression analyses were performed to identify factors associated with occupational exposure to BBFs. The significance level was obtained at a 95% confidence interval (CI) and p value ≤ 0.05.

Results

The prevalence of occupational exposure to blood and body fluids among health care workers in the last 12 months was 65.3% (95% CI: 59.4, 70.9). Lack of readily available personal protective equipment (adjusted odds ratio (AOR)) = 3.01, 95% CI: 1.56, 5.84), lack of training (AOR = 3.36, 95% CI: 1.1, 11.2), Khat chewing (AOR = 2.74, 95% CI: 1.3, 5.8), and being a medical doctor (AOR = 5.1, 95% CI: 1.68, 15.21) were significantly associated risk factors with occupational exposure to blood and other body fluids.

Conclusions

In this study, occupational exposure to blood and other body fluids among health care workers remains a major health problem. Hence, ensuring the availability of personal protective equipment, developing strategies on banning, and strict monitoring of Khat chewing and training on infection prevention should be emphasized to minimize the problem.

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.

Characteristics of deaths associated with kratom use

BACKGROUND

Kratom (Mitragyna speciosa Korth) use has increased in Western countries, with a rising number of associated deaths. There is growing debate about the involvement of kratom in these events.

AIMS

This study details the characteristics of such fatalities and provides a 'state-of-the-art' review.

METHODS

UK cases were identified from mortality registers by searching with the terms 'kratom', 'mitragynine', etc. Databases and online media were searched using these terms and 'death', 'fatal*', 'overdose', 'poisoning', etc. to identify additional cases; details were obtained from relevant officials. Case characteristics were extracted into an Excel spreadsheet, and analysed employing descriptive statistics and thematic analysis.

RESULTS

Typical case characteristics (n = 156): male (80%), mean age 32.3 years, White (100%), drug abuse history (95%); reasons for use included self-medication, recreation, relaxation, bodybuilding, and avoiding positive drug tests. Mitragynine alone was identified/implicated in 23% of cases. Poly substance use was common (87%), typically controlled/recreational drugs, therapeutic drugs, and alcohol. Death cause(s) included toxic effects of kratom ± other substances; underlying health issues.

CONCLUSIONS

These findings add substantially to the knowledge base on kratom-associated deaths; these need systematic, accurate recording. Kratom's safety profile remains only partially understood; toxic and fatal levels require quantification.

NPS: Medical Consequences Associated with Their Intake

Over the last decade, the 'traditional' drug scene has been supplemented - but not replaced - by the emergence of a range of novel psychoactive substances (NPS), which are either newly created or existing drugs, including medications, now being used in novel ways. By the end of 2014, in excess of 500 NPS had been reported by a large number of countries in the world. Most recent data show, however, that synthetic cathinones, synthetic cannabinoids, and psychedelics/phenethylamines account for the largest number of NPS.The present chapter aims at providing an overview of the clinical and pharmacological issues relating to these most popular NPS categories. Given the vast range of medical and psychopathological issues associated with the molecules here described, it is crucial for health professionals to be aware of the effects and toxicity of NPS. A general overview of the acute management of NPS adverse events is provided as well, although further studies are required to identify a range of evidence-based, index molecule-focused, treatment strategies. The rapid pace of change in the NPS online market constitutes a major challenge to the provision of current and reliable scientific knowledge on these substances.

Novel psychoactive substances: the pharmacology of stimulants and hallucinogens

There are increasing levels of concern relating to the rapidly evolving novel psychoactive substances/NPS and web markets' scenarios. The paper aims at providing an overview of the clinical pharmacological issues related to some of the most popular NPS categories, e.g. stimulants and hallucinogens. NPS intake is typically associated with the imbalance of a complex range of neurotransmitter pathways/receptors, namely: dopamine; cannabinoid/CB1; and 5-HT2A. The intake is almost invariably undetectable with standard screening tests. Hence, it may frequently occur that the acute management of NPS misusers will need to focus on decreasing levels of both self/outward-directed aggression and agitation. Benzodiazepines may be considered as first line treatment. Alternatively, propofol and/or antipsychotics can be administered. Focus will be as well on treatment of possible rhabdomyolysis and hyperthermia. Indeed, future studies should inform better tailored management/treatment strategies.

Bibliometric analysis on global Catha edulis (khat) research production during the period of 1952-2014

BACKGROUND

Publication of scientific articles related to khat (Catha edulis) in peer-reviewed journals is considered a measure of research productivity. The principal objectives of this study were to quantify the research contribution related to khat at the global level, as well as to determine its relative growth rate, collaborative measures taken, productivity at the institutional level, and the most prolific journals publishing on the topic.

METHODS

On the basis of title words related to khat, publications were identified for all data in Scopus bibliographic database's history up to December 31, 2014. The research productivity for the top 10 countries was evaluated in relation to the population size and gross domestic product (GDP) in 2013.

RESULTS

The criteria were met by 651documents published in 51 countries. The largest number of articles associated with khat was from the UK (15.2 %), followed by Yemen (10.3 %), the USA (9.7 %) and Ethiopia (9.1 %). Ethiopia, Yemen, and Kenya had the highest productivity of publications after standardization by population size and GDP. Furthermore, Yemen achieved the highest number of collaborations, by having researchers from 19 countries. Ethiopia followed, having researchers from 16 countries.

CONCLUSIONS

This bibliometric study provides a demonstration for the worldwide research activity regarding khat. The number of articles related to khat has increased rapidly over the last 10 years. The present study is a good starting point to evaluate research activity in the field of khat. Although the data shows a promising increase in the research activity, the quantity of khat-related research is still too little compared to the massive use of khat in certain countries.

Novel psychoactive substances (NPS): clinical and pharmacological issues

Purpose

– The purpose of this paper is to provide health professionals with novel psychoactive substances (NPS) clients with up to date information relating to the background, clinical pharmacology and, when possible, clinical management for each of these categories.

Design/methodology/approach

– The world of NPS is complex and diverse, including a range of different molecules such as: psychedelic phenethylamines; synthetic cannabinoids, cathinone derivatives; novel stimulants; synthetic opiates/opioids; tryptamine derivatives; phencyclidine-like dissociatives; piperazines; GABA-A/GABA-B receptor agonists; a range of prescribing medications; psychactive plants/herbs; and a large series of performance and image-enhancing drugs. These molecules are sought by users for their psychactive effects.

Findings

– The NPS categorization and classification provided here is an attempt to identify and better understand some of these substances. Given the vast range of medical and psychopathological issues associated with the NPS described it is crucial for health professionals to be aware of the effects and toxicity of NPS. The EU-MADNESS project aims to both better understand the pharmacology of the available/forthcoming NPS and to disseminate the most current NPS-related information to practising and training health professionals.

Research limitations/implications

– Further studies are required to identify a range of evidence-based, NPS-focused, clinical management and treatment strategies.

Social implications

– The rapid pace of change in the NPS online market constitutes a major challenge to the provision of current and reliable scientific knowledge on these substances.

Originality/value

– The present review will provide an overview of the clinical and pharmacological issues related to a few hundred NPS.

Novel psychoactive substances of interest for psychiatry

Novel psychoactive substances include synthetic cannabinoids, cathinone derivatives, psychedelic phenethylamines, novel stimulants, synthetic opioids, tryptamine derivatives, phencyclidine-like dissociatives, piperazines, GABA-A/B receptor agonists, a range of prescribed medications, psychoactive plants/herbs, and a large series of performance and image enhancing drugs. Users are typically attracted by these substances due to their intense psychoactive effects and likely lack of detection in routine drug screenings. This paper aims at providing psychiatrists with updated knowledge of the clinical pharmacology and psychopathological consequences of the use of these substances. Indeed, these drugs act on a range of neurotransmitter pathways/receptors whose imbalance has been associated with psychopathological conditions, including dopamine, cannabinoid CB1, GABA-A/B, 5-HT2A, glutamate, and k opioid receptors. An overall approach in terms of clinical management is briefly discussed.

Khat and synthetic cathinones: a review

For centuries, 'khat sessions' have played a key role in the social and cultural traditions among several communities around Saudi Arabia and most East African countries. The identification of cathinone as the main psychoactive compound of khat leaves, exhibiting amphetamine-like pharmacological properties, resulted in the synthesis of several derivatives structurally similar to this so-called natural amphetamine. Synthetic cathinones were primarily developed for therapeutic purposes, but promptly started being misused and extensively abused for their euphoric effects. In the mid-2000's, synthetic cathinones emerged in the recreational drug markets as legal alternatives ('legal highs') to amphetamine, 'ecstasy', or cocaine. Currently, they are sold as 'bath salts' or 'plant food', under ambiguous labels lacking information about their true contents. Cathinone derivatives are conveniently available online or at 'smartshops' and are much more affordable than the traditional illicit drugs. Despite the scarcity of scientific data on these 'legal highs', synthetic cathinones use became an increasingly popular practice worldwide. Additionally, criminalization of these derivatives is often useless since for each specific substance that gets legally controlled, one or more structurally modified analogs are introduced into the legal market. Chemically, these substances are structurally related to amphetamine. For this reason, cathinone derivatives share with this drug both central nervous system stimulating and sympathomimetic features. Reports of intoxication and deaths related to the use of 'bath salts' have been frequently described over the last years, and several attempts to apply a legislative control on synthetic cathinones have been made. However, further research on their pharmacological and toxicological properties is fully required in order to access the actual potential harm of synthetic cathinones to general public health. The present work provides a review on khat and synthetic cathinones, concerning their historical background, prevalence, patterns of use, legal status, chemistry, pharmacokinetics, pharmacodynamics, and their physiological and toxicological effects on animals and humans.

Khat (Catha edulis): A systematic review of evidence and literature pertaining to its harms to UK users and society

The use of khat ( Catha edulis) has been associated with a large number of physiological and societal harms, leading to calls for it to be controlled in the UK. The evidence of these harms is often equivocal, limited by confounding factors, or entirely anecdotal: high-powered, quality-controlled studies are lacking. Regardless, the body of relevant literature indicates that the once socially-regulated use of khat has been eroded. Some individuals have developed excessive consumption patterns, either using khat daily or in binge-sessions, though daily consumption is not necessarily problematic per se. The majority of users seem to use khat in moderation, where the associated harms appear low. For excessive users, harms associated with khat are greater, particularly relating to mental health. Social harms also seem to be largely related to excessive khat use rather than khat use itself. Even in cases of excessive khat use, however, causal relationships between chewing and harms have not been described. More research is required to establish the role of khat in liver disease, coronary problems, cancers of the digestive tract and incidents of domestic violence. Studies should consider the likeliness that certain users are more vulnerable to developing patterns of excessive khat use due to an interwoven set of factors such as social health determinants and pre- and post-migration experiences.

Cardiovascular complications of Khat

This article reviews current knowledge in khat (cathinone) research and its health impacts and toxicity in the cardiac system of khat chewers based on current evidence. The authors describe the process by which khat is postulated to induce multiple cardiac abnormalities by illustrating multiple case reports as described from around the world. The role of free radicals in inducing cardiac disease is also discussed. Future research areas are proposed to enhance our understanding of the mode of action of this toxicological drug.