Characteristics of Synthetic Cannabinoid and Cannabis Users Admitted to a Psychiatric Hospital: A Comparative Study

Psychotic-Like Experiences and Concurrent Substance Use Among People Who Use New Psychoactive Substances

New psychoactive substances (NPS) are a group of substances that mimic established drugs, e.g., cannabinoids, stimulants, and opioids. NPS use has been associated with psychotic-like experiences, but current research is limited. This study focused on NPS use and psychotic-like experiences in persons attending substance use services in South-West Finland. The primary aim was to evaluate if NPS use associates with psychotic-like experiences, and if the association is independent of comorbid psychotic illness. As a secondary aim, this study evaluated concurrent substance use among people who use NPS.

The study was based on a voluntary and anonymous survey administered on-site for people attending substance use services. The survey was conducted in 17 substance use service centers in South-West Finland in 2019, totaling 219 respondents. Information on substance use, service use due to psychotic episodes, and comorbid psychotic illness was collected. A validated PROD questionnaire was used for information on psychotic-like experiences.

In all, 17% of 219 participants (n = 38) reported NPS use. After adjustments with comorbid psychotic illness, age, and gender, NPS use associated with PROD-screen positivity, i.e., reporting at least three psychotic-like symptoms. NPS use also associated with service use due to substance-induced psychotic episodes, and extensive use of several substances.

In this study, NPS use associated with psychotic-like experiences independently of comorbid psychotic illness. However, as NPS use is also associated with heavy use of several substances, this study implicates concurrent substance use as a confounding factor when studying NPS use, which should be considered in future research.

Examining the Use of Antidepressants for Adolescents with Depression/Anxiety Who Regularly Use Cannabis: A Narrative Review

Depression and anxiety disorders are two of the most common and growing mental health concerns in adolescents. Consequently, antidepressant medication (AD) use has increased widely during the last decades. Several classes of antidepressants are used mainly to treat depression, anxiety, and obsessive-compulsive disorders by targeting relevant brain neurochemical pathways. Almost all randomized clinical trials of antidepressants examined patients with no concomitant medications or drugs. This does not address the expected course of therapy and outcome in cannabis users. Cannabis is the most commonly used illicit substance globally. Substantial changes in its regulation are recently taking place. Many countries and US states are becoming more permissive towards its medical and recreational use. The psychological and physiological effects of cannabis (mainly of its major components, tetrahydrocannabinol (THC) and cannabidiol (CBD)) have been extensively characterized. Cannabis use can be a risk factor for depressive and anxiety symptoms, but some constituents or mixtures may have antidepressant and/or anxiolytic potential. The aim of this literature review is to explore whether simultaneous use of AD and cannabis in adolescence can affect AD treatment outcomes. Based on the current literature, it is reasonable to assume that antidepressants are less effective for adolescents with depression/anxiety who frequently use cannabis. The mechanisms of action of antidepressants and cannabis point to several similarities and conjunctions that merit future investigation regarding the potential effectiveness of antidepressants among adolescents who consume cannabis regularly.

Cognitive behavioral intervention for improving emotion recognition among individuals with substance use disorders: A randomized-controlled pilot study in a naturalistic setting

Individuals with substance use disorders (SUD) experience impaired facial emotion recognition. This pilot study explored the efficacy of a cognitive behavioral therapy (CBT) intervention to improve facial cues interpretation. Twenty-four men with SUD were randomized into an equal-size experimental and control groups and were evaluated by a cognitive-assessment battery at baseline and post-intervention. Post-intervention individuals in the experimental group recognized happy expressions with higher accuracy, and their response times were slower in sadness/disgust/neutral expressions. Interventions focused at improving social cues interpretation may facilitate social interactions and treatment outcomes for SUD population.

A Nationwide Study Comparing Mental Health Professionals' Willingness to Try Hallucinogenic Drugs in Basic Research or Clinical Practice

This study explored whether personal attitudes toward drug users are associated with professional approaches and whether the association between personal and professional attitudes varies across different mental health professions. Participants (N = 347) included medical (psychiatrists and psychiatric nurses) and other (clinical psychologists and social workers) mental health professions from all 13 mental health centers in Israel. They completed questionnaires aimed to assess familiarity with medical usage of hallucinogenic drugs, personal attitudes toward recreational drug users and willingness to use five hallucinogens in research of clinical practice. Hypotheses were tested using multiple-group structural equation modeling (SEM). Psychiatrists reported the highest levels of familiarity with and willingness to use all types of hallucinogenic drugs, as compared to other mental health professionals. Psychiatrists held the strongest belief in the potential utility of hallucinogenic drugs; yet, their personal attitudes toward drug users affected negatively their willingness to try hallucinogenic drugs in clinical practice. This was the only significant association that was found. Future research and treatment programs should address the topic of hallucinogenic drug therapy, and specifically the need to separate between individual beliefs and professional clinical decision-making.

Why Switch? - Motivations for Self-Substitution of Illegal Drugs

Self-substitution is the conscious switch from one drug to another for reasons such as price, availability, desired effect, or perceived benefit of the substitute drug. Purpose/Objectives: This study aimed to describe drug use patterns and motivations associated with substitution. We examined correlates of lifetime substitution among individuals with substance use disorder. Methods: A cross-sectional study of 771 treatment-enrolled individuals. We used self-report for determining the lifetime prevalence, correlates, and motivations for substitution. Results: Of the 771 respondents, 570 (73.9%) reported ever substituting their preferred substance. The main incentives for substitution were availability (23.7%) and curiosity (20.2%). Among heroin or cannabis preferers, improved effects or less adverse effects of the substitute drug, self-medication, and managing withdrawal symptoms were significant substitution incentives. Increased odds for substitution were observed for past 12 months use of cannabis (OR = 1.51, CI = 1.06-4.52), prescription opioids (OR = 2.86, CI = 1.81-4.52), novel psychoactive substances (OR = 2.68, CI = 1.64-4.36), and repeated admission (OR = 1.50, CI = 1.05-2.14). Older age at onset-of-use was negatively associated with substitution (OR = 0.95, CI = 0.93-0.98). Conclusions: Self-substitution of one substance for another is a highly prevalent behavior among treatment-enrolled patients with substance use disorder. Clinicians caring for substance use disorder patients should be aware of substitution patterns involving the use of highly potent substances, which constitutes a risk to patients. Results underscore the benefit of substitution patterns analyses, as they reveal important information on the characteristics of persons who use drugs and their motivations.

Serum endocannabinoid levels in suicide attempters: A pilot study

The search for a biomarker for suicide risk is a longstanding pursuit in clinical psychiatry. Literature addressing the role of endocannabinoids in suicide attempters (SA) is sparse. This cross-sectional study is aimed at comparing 8 AM serum concentrations of 4 endogenous cannabinoids (anandamide, AEA; 2-arachidonoylglycerol, 2-AG; N-palmitoiletanolamida, PEA; and oleoylethanolamide, OEA) in 30 suicide attempters (SA) and 12 psychiatric controls (PC). 8 AM AEA and PEA serum levels were higher in SA compared to PC without controlling for cannabis use (n = 42) (3.58 ± 5.77 vs. 1.62 ± 2.49, F = 3.04, P = 0.089; and 3.31 ± 4.82 vs. 1.21 ± 1.20, F = 6.22, p = 0.017, respectively). Serum ACTH was higher in PC compared to SA (32.11 ± 21.60 vs. 20.05 ± 9.96, F = 9.031, p = 0.0.005). After controlling for cannabis use in the urine test (n = 28), 8 AM AEA and PEA serum levels remained higher in SA compared to PC (4.57 ± 6.38 vs. 0.64 ± 1.11, F = 4.852, P = 0.037; and 4.35 ± 5.46 vs. 1.21 ± 1.25, F = 4.125, p = 0.053, respectively). The present study offers preliminary evidence about the role of AEA and PEA in suicidal behavior (SB). Furthermore, in the context of the mental pain model of SB, our findings suggest that some endocannabinoids may play a role in the pathophysiology of SB. Our pilot study deserves replication by other studies with bigger sample sizes.

Neurological Manifestations Associated with Synthetic Cannabinoid Use- A Case Series

Background:

Synthetic Cannabinoid (SC) use has emerged as a growing public health threat in the United States. Several unexpected cases, presenting with a constellation of unrelated symptoms, but all having toxicity linked to SC use, have been reported in the last decade (2010-2019).

Methods:

We report a cluster of several independent cases where patients were admitted having different neurological manifestations. Extensive and expensive work-ups were performed. Upon further inspection, extended toxicology screens were found to be positive for SC metabolites.

Results:

It is alarming to observe that several reports highlight an increase in the varied and significant morbidity associated after SC use. Various SC compositions have been synthesized and distributed, with new molecules being generated at a staggering rate leading to unexpected manifestations.

Conclusion:

Young people are the most frequent users owing to its recreational effects, its easy accessibility, lower cost and difficulty in being detected in the urine by routine drug screens. From a hospital quality improvement perspective, efforts to characterize the presence of newly generated SC molecules and establish more accessible in-house screening methods will be a starting step in reducing the associated cost-burden. This will also minimize the unnecessary invasive procedures performed on a specific patient. From a socioeconomic viewpoint, solid and systematic crosstalk with increased recognition and reporting mechanism between the healthcare staff and public health personnel is strongly warranted to support state and federal regulatory efforts in combating this ongoing SC epidemic.

Differential Effect of Community Rehabilitation Reform on Hospitalizations of Patients with Chronic Psychotic Disorders With and Without Substance Use Disorder, Israel, 1991-2016

The co-occurrence of schizophrenia and substance use disorder (SUD) is clinically challenging and increasingly prevalent. This study compares trends in hospitalization characteristics of chronic psychotic patients with and without SUD in Israel, before and after introduction of the Community Rehabilitation of Persons with Mental Disability Law in 2000. The National Psychiatric Case Registry provided data on 18,684 adults with schizophrenia/schizoaffective disorders, hospitalized in 1991-2016 (at least once in 2010-2015). Repeated-measures ANOVA was used to measure the effect (and interactions) of group (patients with and without co-occurring disorders (COD)), time-period (Period₁: 1991-2000, Period₂: 2001-2009, Period₃: 2010-2016) and age, on hospitalization measures-average length of stay (LOS), annual number of hospitalizations and hospitalization days. Among non-COD patients hospitalized in all three periods, LOS declined by half from 133.3 days in Period₁ to 63.2 in Period₃, and the annual number of hospitalizations increased slightly from 0.45 to 0.56. Among COD patients, LOS declined moderately from 82.7 days to 58.3 days, while annual hospitalizations increased dramatically from 0.56 to 0.82. The annual average number of hospitalization days/capita declined from 49.7 in Period₁ to 26.3 in Period₃ among non-COD patients, yet remained virtually unchanged among COD patients-39.6 and 37.4 in the two periods, respectively. Since introduction of the law, a significant improvement in hospitalization characteristics of chronic psychotic non-COD patients has been noted, whereas the situation worsened somewhat for COD patients. Community rehabilitation services for COD patients in Israel have yet to develop as a suitable alternative to hospitalization, and additional rehabilitation services are urgently needed.

The switch from one substance-of-abuse to another: illicit drug substitution behaviors in a sample of high-risk drug users

Background

Substitution can be defined as the consciously motivated choice to use one drug, either licit or illicit, instead of another, due to perceptions of cost, availability, safety, legality, substance characteristics, and substance attributions. Substitution represents a potential risk to drug users, mainly when substitutes are of higher potency and toxicity. This study offers a basic conceptualization of illicit substitution behavior and describes substitution patterns among users of two highly prevalent drugs of abuse-heroin and cannabis.

Methods

Here, 592 high-risk drug users undergoing pharmacological and psycho-social treatment were interviewed. Patients were asked questions about current drug use, lifetime substitution, and substitution patterns. Descriptive statistics, chi-square tests of independence, and multinomial logistic regressions were used to identify and test correlates of substitution patterns for heroin and cannabis.

Results

Of the 592 drug users interviewed, 448 subjects (75.7%) reported having substituted their preferred drug for another illicit substance. Interviews yielded a total of 275 substitution events reported by users of cannabis, and 351 substitution events reported by users of heroin. The most frequently reported substitution substances for responders who preferred heroin were illicit non-prescribed "street" methadone (35.9%), followed by oral and transdermal prescription opioids (17.7%). For responders who preferred cannabis, substitution for synthetic cannabinoid receptor agonists (33.5%) followed by alcohol (16.0%) were the most commonly reported. Age at onset-of-use (p < 0.005), population group (p = 0.008), and attending treatment for the first time (p = 0.026) were significantly associated with reported lifetime substitution. Past-year use of stimulants, heroin, hallucinogens, methylenedioxymethamphetamine (MDMA), and novel psychoactive substances were-at the 95% confidence level-also significantly associated with reported lifetime substitution. In multivariate analysis, the odds for methadone substitution among heroin users were significantly affected by age at onset-of-use, type of treatment center, and education. Odds for substitution for synthetic cannabinoid receptor agonists among cannabis users were significantly affected by age, population group, type of treatment center, and education.

Conclusion

Self-substitution behavior should be considered by clinicians and policymakers as a common practice among most drugusers. Substitution for street methadone provides evidence for the ongoing diversion of this substance from Opioid Maintenance Treatment Centers, while the prominence of substitution of synthetic cannabinoids among dual-diagnosis patients should be regarded as an ongoing risk to patients that needs to be addressed by clinicians. Analysis of additional substitution patterns should provide further valuable insights into the behavior of drugusers.

Personality Traits and Psychotic Proneness Among Chronic Synthetic Cannabinoid Users

OBJECTIVE

Chronic use of synthetic cannabinoids (SCs) has been associated with a wide range of negative consequences for health including psychotic and affective disturbances. Accumulating evidence indicates that cannabinoids use may be a risk factor for schizophrenia, and chronic natural cannabis users score higher than non-users on measures of schizotypal personality traits. However, little is known regarding the personality characteristics of SC users, especially in comparison with recreational cannabis users and healthy individuals. This study aimed to examine the differences in personality characteristics and schizotypy between SC users, regular cannabis users, and non-users and to compare these measures between groups.

METHODS

Forty-two chronic SC users, 39 natural cannabis users, and 47 non-using control participants, without history of mental disorder, or current substance use diagnosis (mean age 26± 4.47 years; 23 females, 105 males), completed the Big-Five Factor Inventory (BFI), the Schizotypal Personality Questionnaire-Brief (SPQ-B), substance use history, rating scales of depression and anxiety, and a demographic questionnaire.

RESULTS

On the BFI, SC users scored higher than natural cannabis users and non-users on neuroticism, but lower on agreeableness and extraversion, and endorsed greater schizotypal symptoms on the SPQ-B. In addition, SC users had lower scores on conscientiousness than non-users, and natural cannabis users were more extroverted than non-users. Higher openness and lower conscientiousness predicted schizotypy for both SC and natural cannabis users. Finally, greater neuroticism predicted schizotypy for natural cannabis users, and introversion predicted schizotypy for non-users.

CONCLUSIONS

These results show that chronic SC users differ from natural cannabis users and non-users on dimensions of specific personality traits and schizotypy that may indicate psychotic proneness.

Chronic Use of Synthetic Cannabinoids Is Associated With Impairment in Working Memory and Mental Flexibility

BACKGROUND

We have recently shown that chronic use of Synthetic Cannabinoids (SCs) has been associated with mood disorders and impairments in executive functions. There is also evidence indicating that chronic SC users have higher rates of comorbidity with depression and psychotic symptoms. Here, we investigate performance on executive function and emotional processing tasks in regular SC users and a measure of schizotypal traits.

METHOD

Thirty chronic SC users, 32 recreational cannabis users, and 32 non-using control participants, without history of mental disorder, or current substance abuse diagnosis (mean age 26 ± 4.27 years; 85 males, 9 females), were tested in addiction treatment centers in Israel. Computerized neurocognitive function tests; the N-back task, Go/No-Go task, Wisconsin Sorting Card-like Task (WSCT), and emotional face recognition task and questionnaires of depression, anxiety and schizotypal traits and symptoms were used.

RESULTS

SC users have performed worse than recreational cannabis users and non-cannabis users on the N-back working-memory task (lower accuracy) and the WSCT cognitive flexibility task. SC users showed greater schizotypal traits and symptoms compared with recreational cannabis users and non-user control participants. A positive association was found in cannabinoid-user groups between schizotypal traits and symptoms and cognitive and emotional processing measures. Finally, SC users have scored higher on depression and state-trait anxiety measures than recreational cannabis users or healthy control participants.

CONCLUSIONS

Repeated use of SCs is associated with impairment in executive functions and emotional processing. These alterations are associated with depression and schizotypal traits and symptoms. This adds to existing evidence on the long-term consequences of SC drugs and their risks for mental health.

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.

What are the psychological effects of using synthetic cannabinoids? A systematic review

BACKGROUND

Synthetic cannabinoids are, typically, full agonists at the cannabinoid CB1 receptor, and therefore considerably more potent than natural cannabis and may have correspondingly more serious psychological effects. Despite government sanctions against their production they continue to be available in ever-increasing varieties over the Internet. The psychological consequences of synthetic cannabinoid use are relatively unknown.

AIM

The purpose of this study was to synthesise the available research on the psychological consequences of synthetic cannabinoid use.

METHOD

A literature search of three databases was conducted in February 2018, including the following keywords: Spice, synthetic cannabis, cognition, affect, behaviour, psychosis, depression and anxiety.

RESULTS

Seventeen studies involving a variety of participants were eligible for inclusion: one controlled administration study, seven cross-sectional studies, five Internet surveys and four qualitative studies. The controlled administration study showed that, compared to placebo, synthetic cannabinoids acutely affected some aspects of cognitive functioning and subjective psychological ratings. Non-controlled, cross-sectional studies generally showed that synthetic cannabinoid users had lower performance on cognitive tasks and showed elevated symptomatology (e.g. paranoia) compared to both natural cannabis and non-cannabis users. Methodological limitations were noted across different study designs. There is limited research on how doses, frequency or type of synthetic cannabinoid influence outcomes.

CONCLUSIONS

Acute synthetic cannabinoid use can result in a range of psychological outcomes and, when non-intoxicated, synthetic cannabinoid users appear to differ from natural cannabis and non-users on various affective and cognitive domains. As synthetic cannabinoid use is increasing in at-risk populations there is an urgent need for more and better research to inform users, professionals and policymakers.

Psychopathological symptoms associated with synthetic cannabinoid use: a comparison with natural cannabis

BACKGROUND

Synthetic cannabinoids (SCs) are a class of new psychoactive substances that have been rapidly evolving around the world throughout recent years. Many different synthetic cannabinoid analogues are on the consumer market and sold under misleading names, like "spice" or "incense." A limited number of studies have reported serious health effects associated with SC use. In this study, we compared clinical and subclinical psychopathological symptoms associated with SC use and natural cannabis (NC) use.

METHODS

A convenience sample of 367 NC and SC users was recruited online, including four validated psychometric questionnaires: The Drug Use Disorders Identification Test (DUDIT), Insomnia Severity Index (ISI), Altman Mania Scale (Altman), and Brief Symptom Inventory (BSI). The two groups were compared with analysis of variance (ANOVA) and covariance (ANCOVA), chi² tests, and logistic regression when appropriate.

RESULTS

The SC user group did not differ in age from the NC user group (27.7 years), but contained less females (21% and 30%, respectively). SC users scored higher than NC users on all used psychometric measures, indicating a higher likelihood of drug abuse, sleep problems, (hypo)manic symptoms, and the nine dimensions comprising the BSI, somatization, obsessive-compulsive behavior, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. Odds ratios (95% CI) for the SC user group vs NC user group were, respectively, drug dependence 3.56 (1.77-7.16), (severe) insomnia 5.01 (2.10-11.92), (hypo-)mania 5.18 (2.04-13.14), and BSI psychopathology 5.21 (2.96-9.17).

DISCUSSION

This study shows that SC use is associated with increased mental health symptomatology compared to NC use.

Spicing it up - synthetic cannabinoid receptor agonists and psychosis - a systematic review

Synthetic cannabinoid receptor agonists (SCRAs) are suggested to have increased potential to induce psychosis compared to natural cannabis (NC). In this review we synthesise current knowledge about the association of SCRA use with psychotic symptoms. Following a literature search we identified 2 toxicology reports, 4 case-control studies, 3 cross-sectional studies and 15 case reports. In each of the case reports, we identified the presence or absence of symptoms based on the items of the Postitive and Negative Syndrome Scele (PANSS). The toxicology reports highlighted the main presenting features as being toxic psychosis and delirium (40%), agitation (10%) and hallucinations (4-7%). The median age was 25 years, and around 80% cases were male. Cross-sectional studies reported that SCRA use was present in approximately 10-13% patients presenting to acute psychiatric services, and was often the cause of their presentation, and that psychotic symptoms were present in 15% patients attending emergency departments following SCRA use. Case-control studies reported that SCRA use was significantly associated with psychotic symptoms and that SCRA users had higher levels of positive psychotic symptoms than NC users. The case reports supported the association of SCRA use with a wide range of positive and negative psychotic symptoms as well as with self-harm, agitation and aggressive behaviour. SCRA use is relatively prevalent in patients with psychosis and may lead to psychotic symptoms in individuals with no past psychiatric history. Further work is required to understand the long term risks of SCRA use and optimal management strategies.

Psychosis and synthetic cannabinoids

Synthetic cannabinoid (SC) products have gained popularity as abused drugs over the past decade in many countries. The SCs broadly impact psychological state (e.g., mood, suicidal thoughts and psychosis) and physiological functions (e.g., cardiovascular, gastrointestinal and urinary). This review is about the effects of SCs on psychotic symptoms in clinical settings and the potentially relevant chemistry and mechanisms of action for SCs. Induction of psychotic symptoms after consuming SC products were reported, including new-onset psychosis and psychotic relapses. The role of SCs in psychosis is more complex than any single chemical component might explain, and these effects may not be a simple extension of the typical effects of cannabis or natural cannabinoids.