The unseen cloud: a survey of vaping practices and the acquisition of vaping products within the UK.

BACKGROUND: Vaping of cannabinoid-based products and informal acquisition of vaping products were associated with the outbreak of E-cigarette or vaping associated lung injury (EVALI) in the USA. Current prevalence of cannabinoid-based vaping within the UK is not known and literature regarding the acquisition of vaping products is limited. AIM: To estimate the prevalence of nicotine-based, nicotine-free and cannabinoid-based product vaping within the UK and to determine where vaping products are acquired. DESIGN AND METHODS: A voluntary online survey of individuals aged 16 and over within the UK was conducted using a convenience sample. Data were collected on respondent demographics, smoking/vaping history and acquisition of e-liquids/products. RESULTS: A total of 2478 responses were included. Median age 45 years (interquartile range 35-57). Prevalence of current vaping of nicotine-based e-liquids, nicotine-free e-liquids and cannabinoid-based products was 14.4%, 11.2% and 5.49%, respectively. Current nicotine-based and nicotine-free vaping was most prevalent in 25-34 years olds (22.4% and 19.2% of respondents). Current cannabinoid-based vaping was most prevalent in 16-24 years olds. The most common 'ever' used cannabinoid-based products were cannabidiol oil/cannabigerol oil and cannabis leaves (4.8%). Specialist vaping stores were the most common source of 'ever' acquisition for all products. 36.8% and 40.5% of respondents who had ever vaped nicotine-based and nicotine-free e-liquids reported prior acquisition from informal sources. CONCLUSION: This survey reported a higher prevalence of current cannabinoid-based vaping within the UK (5.5%) than previously reported in the USA (2.0%). In addition to the informal acquisition of vaping products as demonstrated within the survey, these results highlight potential underestimation of the risk of EVALI within the UK.

The Emerging Cloud: a survey of vapers, their health and utilization of healthcare within the UK.

BACKGROUND: Recent work in the UK estimated the prevalence of current cannabinoid-based vaping to be higher than in the USA, a factor previously associated with e-cigarette or vaping-associated lung injury (EVALI). Research in the USA has demonstrated that attendances to emergency departments relating to e-cigarettes began to rise before the EVALI outbreak, suggesting that vapers also experience milder forms of vaping-related illness. AIM: Quantify symptom prevalence and healthcare utilization amongst current UK vapers. DESIGN: Voluntary online survey of individuals aged 16 and over within the UK. METHODS: Anonymized data were collected on demographics, vaping/smoking status and vaping substances used. Current vapers were asked about the presence of 10 prevalent symptoms from previous US EVALI case series, healthcare attendances and diagnoses given. Risk-ratios were calculated to compare the likelihood of symptoms and attendances between substances. RESULTS: A total of 2477 complete responses were analysed. In all, 397 respondents were current vapers. Symptom prevalence within the previous 12 months ranged from 3.8% to 30.5% (bloody sputum, cough). Healthcare attendances per symptomatic respondent ranged from 0.1 to 1.4 (bloody sputum, shortness of breath). Current vapers of cannabinoid-based products (alone/in combination) had the most attendances per symptomatic respondent for 9/10 symptoms and were more likely to report symptoms aside from 'cough' (nicotine-free e-liquids [risk ratio = 1.7]). Clinicians reportedly never diagnosed vaping-related illness. CONCLUSIONS: UK vapers experience symptoms previously reported in EVALI cases for which they also seek healthcare. Users of cannabinoid-based products were more likely to report symptoms and accounted for a higher healthcare burden. UK vapers may also experience vaping-related illness that does not meet EVALI case criteria.

Isotonitazene, a novel psychoactive substance opioid, detected in two cases following a local surge in opioid overdoses.

BACKGROUND: Isotonitazene is a novel opioid that was first reported in Europe in 2019. There have been no reports of the detection of isotonitazene in patients presenting to the emergency department with acute drug toxicity. AIM: There was an increase in presentations to our emergency department with acute opioid toxicity in August 2021. We aim to describe this outbreak and provide detail on two cases in which isotonitazene was quantified in serum samples. METHODS: Serum samples were available for comprehensive toxicological analysis for two presentations. Written consent was obtained and the samples were analysed through a Thermo XRS ultrahigh-performance liquid chromatography system, interfaced to a Thermo Q Exactive high-resolution accurate mass spectrometer, operating in heated positive ion electrospray mode. Acquired data were processed using Toxfinder software (Thermo) against a regularly updated in-house database. RESULTS: There was an increase in acute opioid presentations to our emergency department from a median of 10 per month to 36 in August 2021. Twenty were treated with naloxone, and 23 were admitted to the hospital for observation and treatment. Serum sample analysis from two patients with acute opioid toxicity responsive to naloxone detected the presence of isotonitazene (0.18 and 0.81 ng/ml). CONCLUSION: We report a cluster of acute opioid toxicity presentations to our Emergency Department with detection of isotonitazene in two cases. Analytical screening is important in determining the presence of novel psychoactive substances (NPS) and to help inform the public health of the implications of NPS use, particularly during clusters of acute recreational drug toxicity presentations.

Doctors' knowledge of the appropriate use and route of administration of antidotes in the management of recreational drug toxicity.

BACKGROUND: Specific antidotes (eg, naloxone, flumazenil, cyproheptadine and benzodiazepines) are available for the management of certain recreational drug-induced toxicities. Some controversies surround the use of some of these antidotes, especially flumazenil in benzodiazepine toxicity. There are no previously published data on doctors' knowledge of the use of these specific antidotes. METHODS: A questionnaire survey was designed to determine internal/emergency medicine doctors' knowledge of the appropriate use of antidotes in the management of clinical scenarios of acutely poisoned patients. For nine simulated clinical scenarios of acute toxicity from recreational drugs (benzodiazepines, cocaine, N-methyl-L-(3,4-methylene-dioxyphenyl)-2-aminopropane (MDMA)-induced serotonin toxicity and opioids), they were asked to indicate whether the suggested antidote and route of administration were correct. RESULTS: 42 physicians of all grades completed the questionnaire. The mean correct score was 5.4 (SD 1.1) (median 6, interquartile range 5-7). The percentages correct for the various clinical scenarios were 68.3% for opioid toxicity, 81% for benzodiazepine toxicity, 28.6% for MDMA-induced serotonin toxicity and 70.2% for cocaine toxicity. Doctors were more likely to record an answer of "unsure" for the use of cyproheptadine in ST serotonin toxicity (28.6%) compared with the use of the other antidotes (1.4%; p<0.001). CONCLUSION: Knowledge of the appropriate use of antidotes in recreational drug toxicity is not consistent, with poorer knowledge on the use of newer antidotes such as cyproheptadine in serotonin toxicity. Education is required both to increase overall knowledge on the use of specific antidotes in the management of recreational drug-induced toxicity, as well as focusing on newer antidotes such as cyproheptadine.

Analysis of anonymized pooled urine in nine UK cities: variation in classical recreational drug, novel psychoactive substance and anabolic steroid use.

BACKGROUND: Analysis of anonymous pooled urine samples from street urinals has been used to demonstrate time-trends in the detection of classical recreational drugs and novel psychoactive substances (NPS). AIM: This study aimed to expand this to undertake a geographical trend analysis of classical recreational drugs/NPS across UK. METHODS: Samples of anonymous pooled urine were collected from street urinals that had been in place for one night in April 2014 in nine cities across the UK. Collected samples were then analysed for the presence of recreational drugs, NPS anabolic steroids using high-performance liquid chromatography coupled to high-resolution accurate mass full-scan mass spectrometry and gas chromatography coupled to electron impact ionization mass spectrometry operating in selected ion monitoring and full-scan modes. RESULTS: Ten classical recreational drugs, nine NPS and four anabolic steroids were detected across the nine cities; the range of detection was from 1 in Leeds to 14 in London. The most common classical drugs were cocaine (9 cities) and 3,4-methylenedioxy-methamphetamine (8 cities); the most common NPS was 4-methylmethcathinone (5 cities). In addition there was variation in the detection of NPS, with methylhexaneamine detected only in Bristol and London, piperazines (3-trifluoromethylphenylpiperazine and 1-benzylpiperazine) and pentedrone only detected in Birmingham and the cathinone methylone only detected in London. CONCLUSIONS: There is variability in the detection of classical recreational drugs, NPS and anabolic steroids across UK, likely reflecting variation in their use. This technique can be used to supplement drug use surveys to determine geographical and time trends in the use of these substances. This is important to ensure appropriate targeting of drug-related interventions.

Trend analysis of anonymised pooled urine from portable street urinals in central London identifies variation in the use of novel psychoactive substances.

CONTEXT: There is increasing interest in the analysis of waste water at sewage treatment plants to monitor recreational drug use. This technique is limited for novel psychoactive substances (NPS) due to limited knowledge on their human and bacterial metabolism and stability in waste water. Small studies have reported the detection of NPS using pooled anonymous urine samples, which eliminates some of these potential confounders. OBJECTIVE: To determine patterns of recreational drug, including NPS, use by confirming their presence in analysis of pooled urine from portable street urinals across a wide geographical area in central London over a 6-month period. MATERIALS AND METHODS: Pooled anonymous urine samples were collected from 12 four-bay stand-alone portable urinals distributed once a month across central London for six consecutive months. Samples were analysed using high-performance liquid chromatography coupled to high-resolution accurate mass spectrometry (LC-HRAM-MS); acquired data were processed against target compound databases. RESULTS: With regards to Classical Recreational Drugs, there was consistency of detection of cathine, cocaine, morphine, MDMA over the 6 months, with variability of detection of amphetamine, ketamine and cannabis. With regards to NPS, a total of 13 NPS were detected during the six months. Mephedrone and methylhexaneamine were detected consistently each month. Other commonly detected NPS included methiopropamine (5 months), pipradrol (4 months), cathinone (4 months), 5-(2-aminopropyl)benzofuran (3 months) and 4-methyethcathinone (3 months). Of note, methoxetamine and the synthetic cannabinoid receptor agonists were not detected in any samples. DISCUSSION: Previous studies using the same method detected three and five NPS in a nightclub and pissoir setting, respectively, on a single night. The longer sampling time of 6 months has allowed detection of 13 NPS. Of note, mephedrone showed the least month-to-month variation in detection over the 6-month sampling period. With regards to classical recreational drugs, those detected were consistent with use-data from UK population surveys. The only exception is amphetamine which these surveys have shown a steady decline in use since 1996 but our study showed some variation in the frequency of its detection. However, the sampling period was too short and a longer study is needed to detect the trend in decreasing use. CONCLUSION: This study demonstrates that analysis of anonymous pooled urine samples from stand-alone urinals can be used to detect and monitor trends in the use of classical recreational drugs and NPS in a large city centre over time. This technique has the potential to be a novel key indicator alongside other existing indicators to provide a more robust picture of the use of recreational drugs including NPS.

An Internet snapshot study to compare the international availability of the novel psychoactive substance methiopropamine.

CONTEXT: With the increased use of novel psychoactive substances, there is an increasing availability of these substances from Internet-based suppliers. Methiopropamine, first reported in 2011, is a recreational drug available over the Internet. The aim of this study was to investigate availability and cost of methiopropamine in three different countries: the UK, France, and Canada. METHODS: Using the European Monitoring Centre for Drugs and Drug Addiction Internet snapshot methodology, this study, conducted in June 2013, was undertaken in two different languages: in English (the UK and Canada) and in French (France and Canada), using three Internet searching engines: " google.co.uk ", " google.fr " and " google.ca ". RESULTS: A total of 62 sites were found, most of them were found from the English searches. 45% of the suppliers seemed to originate from the UK. The prices of methiopropamine were comparable between suppliers, no matter which search engine or language was used. The cost of a unit of methiopropamine was inversely related to the purchased quantity, going from 19.49 ± 0.15 GBP per gram for a purchase amount of 500 mg to 3.54 ± 0.13 GBP per gram for a purchase amount of 1 kg. DISCUSSION: The results of the present study demonstrate that the sale of methiopropamine has the potential to reach users across the world. It also appears to support that snapshot studies could be used for toxicovigilance across different countries, by studying the Internet market of novel psychoactive substances. CONCLUSION: To date, snapshot studies, used to monitor the Internet novel psychoactive substances market, have only been undertaken in Europe. We have shown that the flexibility of this methodology enables comparison of the online activity of drug sellers between different countries and continents and that, at least for methiopropamine, the UK is the predominant source for Internet supply.

Analysis of urine from pooled urinals - a novel method for the detection of novel psychoactive substances.

Current data on the epidemiology of recreational drug use is largely based on population and self-population surveys of drug use. In addition, increasingly, particularly for novel psychoactive substances, data collected from web monitoring systems is used to collect information on early trends in the use of NPS and the drugs available to users. All of these indicators rely on users self-report of the drug(s) that they are using, or more accurately the drugs that they perceive they are using. Numerous recent studies have demonstrated significant variation in the content of both classical recreational drugs and novel psychoactive substances. The technique of waste-water analysis has allowed estimation of population level use of a number of established recreational drugs such as cocaine and MDMA. However this technique is limited for novel psychoactive substances because of limitations in the knowledge of the stability and metabolism of these compounds. Our group has developed a technique that involves the collection and analysis of pooled-urine from standalone portable urinals and demonstrated that this technique can be used to detect the use of both classical, established recreational drugs and novel psychoactive substances. We discuss this technique in this paper and the ways in which this can be further developed to allow detection of use of new NPS and trends in use of these substances over time and across geographical regions.

Analysis of anonymous pooled urine from portable urinals in central London confirms the significant use of novel psychoactive substances.

AIM: Analysis of urine samples collected across a city centre, for the detection of novel psychoactive substances (NPS). DESIGN: Cross-sectional study of anonymized urine samples used for the analysis of classical recreational drugs, NPS and metabolites. METHODS: Pooled urine samples collected from portable stand-alone four-person urinals across a city centre were analysed using full-scan accurate-mass high-resolution liquid chromatography coupled to tandem mass spectrometry. Data were processed against compound databases containing >1700 drug compounds and metabolites. RESULTS: Seven established recreational drugs (3,4-methylenedioxyamphetamine, cocaine, cannabis, ketamine, 3,4-methylenedioxy-N-methylamphetamine, methamphetamine and amphetamine) and six potential NPS [hordenine (all 12 urinals), cathine (11), methylhexaneamine (9), 4-methylmethcathinone (6), methiopropamine and metabolites (2) and methoxetamine and metabolites (1)] were detected. Methylhexaneamine, methiopropamine and hordenine are currently uncontrolled in the UK, whereas methoxetamine is currently subject to a Temporary Class Drug Order. Metabolites of the anabolic steroid nandrolone were found in two urinals and trenbolone metabolites and clenbuterol in one urinal. CONCLUSION: Analysis of pooled urine samples collected anonymously from stand-alone urinals in a large inner city can detect the use of recreational drugs, NPS and anabolic steroids. Metabolite detection indicates actual drug use, metabolism and elimination rather than simply discarded drugs in the urinals. This technique by confirming the actual drug(s) used has the potential to be additive to currently used datasets/key indicators providing more robust information for healthcare authorities, legislative and law enforcement on the drugs actually being used.