Abstract
Background and aims
New psychoactive substances are causing increasing harm across the UK but the use of new psychoactive substance by injecting has become a significant problem within Lothian since the beginning of 2014. Data indicate a rapid rise in the number of existing drug injectors, particularly heroin injectors, moving to new psychoactive substance injecting. This paper reports the experiences within Lothian of a sudden increase in injecting of ethylphenidate over one year. A temporary class drug order was placed on ethylphenidate on 10 April 2015, and as yet the effects of this are unknown.
Methods
Data specifically relating to new psychoactive substance recorded during injecting equipment provision transactions conducted by the NHS are reported. A survey was utilised to gather more detailed data from new psychoactive substance injectors.
Results
Injection of new psychoactive substance, including ethylphenidate has had significant adverse effects on physical and mental health. Risky behaviour such as sharing of equipment is known, and there are risks of transmission of infections.
Conclusion
The rapid increase in injecting ethylphenidate has had a major impact on injecting equipment provision services, health services and public health. More work is required to identify routes to recovery.
Introduction
Within the United Kingdom there are increasing challenges with the use of new psychoactive substances (NPSs), often referred to as ‘legal highs’. These are known to cause health problems and, in some cases, death. 1
NPSs are commonly used by young people, are prevalent within the ‘club scene’ and by men who have sex with men (MSM). 2 There are a wide range of NPS available and despite slight differences in formulations many have similar results, principally the psychological mind-altering effects. However, users may also experience undesirable systemic effects such as tachycardia, dehydration, hyperthermia, insomnia and weight loss.1,3–5
NPSs are sold in packets, usually as a powder and the packaging is often bright, colourful and appealing with names that maybe euphemistic and misrepresentative such as ‘ocean burst’ or ‘white’. 6
NPSs are usually taken orally; however, within Edinburgh and Lothian, there has been an emerging and worrying trend of injecting NPS. Injection of NPS appears to be confined to major conurbations. However, the preference for injecting these substances, as well as the numbers engaged in this activity, is much greater in Edinburgh and Lothian than anywhere else in Scotland, which creates a unique challenge not experienced elsewhere. Most of the NPS injectors in Lothian are previous heroin injectors, who are now reporting that they are no longer using heroin, and many are withdrawing from their opiate replacement prescription.
Ethylphenidate
The most commonly injected NPS in Lothian is sold as ‘Burst’ or ‘Blue stuff’. Both contain the psychoactive compound ethylphenidate which is a stimulant drug closely related to methylphenidate typically known as Ritalin. 7 A temporary class drug order was placed on ethylphenidate by the UK Government on 10 April 2015, prohibiting the sale and distribution of the drug. It is yet unclear how this will affect supply or use 8 but it is likely that there may be a reduced supply.
Ethylphenidate had been easily accessible on the internet, and in some local shops, E-cigarette shops and ‘Head-shops’ (shops that previously sold drug using paraphernalia). ‘Head-shops’ are more prevalent in Lothian than elsewhere in Scotland (SDF, NPS Scottish Drugs Forum, 2015, personal communication). Shops selling NPS may have extended opening times, offer discounts for multiple buying, provide drugs on credit and some have offered loyalty schemes (Figure 1). NPSs are generally cheaper than heroin with a gram of Burst costing £10, compared to £60 for the same quantity of heroin.
Loyalty card.
Ethylphenidate is thought to provide a stronger stimulant effect than cocaine and an empathogenic effect similar to ecstasy and mephedrone.
Little empirical evidence can be found for the physical effects; however, unverified internet sources (e.g. http://psychonautwiki.org/wiki/Ethylphenidate) report that ethylphenidate is highly caustic, particularly to mucous membranes, veins and surrounding tissues. The effects from ethylphenidate include feeling energetic, heightened sociability and increased libido with an increased sexual desire and urgency, but with difficulty ejaculating.9,10
When ethylphenidate is injected, clients report experiencing an extremely intense initial rush. Users of ethylphenidate are ‘chasing’ after this rush; however, the full effects are shorter lasting than they would be if the substance was swallowed. This causes clients to inject frequently, whilst increasing the dosage as they attempt to maintain or increase the intensity of the rush. The subsequent comedown is reported as being severe. People using it can experience symptoms such as restlessness, panic attacks, insomnia, depression, pain and an urge to redoes.9,10 Visual, auditory and tactile hallucinations have been reported with users often seen to be scratching and picking at their skin, and some have presented with neurological symptoms such as tremors, athetoid movements and seizures.
Method
Data are recorded during all injecting equipment provision (IEP) transactions conducted by the NHS Lothian Harm Reduction Team, third sector organisations and pharmacies. Those data specifically relating to NPS are reported here.
In addition, a short rapid survey of local NPS injectors was undertaken in August 2104 to gather more detailed data around injecting history and complications.
Results
Database results
From 1 April 2014 to 31 March 2015, there was 413 NPS injectors registered in Lothian (Figure 2).
Number of clients injecting specific substances. Some clients may be injecting more than one substance.
NPS injectors have accounted for 9239/58,332 of IEP transactions – 16% of the total and second only to opiates (Figure 3). Due to the lower number of users this indicates a high frequency of injecting (Figure 3).
Number of IEP transactions per substance. Some clients may inject more than one substance and therefore adding all the individual substance transactions will be greater than the total transaction number of 58,332. IEP: injecting equipment provision.
There has been a steady increase in the number of monthly NPS IEP transactions, and the numbers have more than doubled between April 2014 and March 2015 (Figure 4).
Total monthly NPS IEP transactions. IEP: injecting equipment provision; NPS: new psychoactive substance.
Seventy-seven per cent (n = 317) males were recorded as NPS users, and 23% (n = 96) were female. The male-to-female ratio of NPS injectors accessing IEP services is just over 3:1.
The highest percentage of NPS injectors in Lothian are within the 30–39 age bracket, followed by the 40–49 age bracket (Table 1).
Twenty-five-year-old male client who had been injecting Burst into leg wound. Age group of NPS injectors. NPS: new psychoactive substance.
The majority of NPS injecting clients report to be injecting intravenously, into lower risk areas such as the arms (Table 2).
This client is a male in their 20 s injecting Burst up to 15 times a day. He had similar wounds in all limbs. Routes of administration of NPS. NPS: new psychoactive substance.
Clients may report a change in their route, and frequency of injecting and therefore totals will differ from the number of registered NPS injectors on the database. A number of clients report injecting four or more times a day with some reporting to be injecting up to 30 times a day (Table 3).
Extensive bruising and track marks in arm of a male in their 40 s. Frequency of injecting by client numbers.
Survey results
A questionnaire was conducted with NPS injectors attending IEP services during one month. Thirty participants (22 males; eight females) were included in the survey (response rate 29%). Ninety-three per cent (n = 28) of NPS injectors were previous opiate injectors.
Sixty-seven per cent (n = 20) of clients reported that they were experiencing negative physical effects. The most common was weight loss 37% (n = 11).
Forty per cent (n = 12) of ethylphenidate injectors experienced wounds.
Twenty per cent (n = 6) experienced cardiac and respiratory problems mostly an abnormally increased heart rate and shallow breathing. Clients reported a feeling that their heart was ‘going to burst out their chest’ and some have experienced endocarditis.
Thirteen per cent (n = 4) clients report difficulty or pain when passing urine, and two of these were experiencing extreme dehydration.
Seventeen per cent (n = 5) were experiencing insomnia.
Fifty-three per cent (n = 16) reported experiencing mental health issues stated as a direct cause of injecting NPS. Seven per cent (n = 2) were experiencing delusional thoughts such as receiving messages from satellites. Twenty-seven per cent (n = 8) were experiencing auditory, visual or tactile hallucinations. Thirty-seven per cent (n = 11) were feeling paranoid. Ten per cent (n = 3) reported to be experiencing anxiety.
Discussion
The male-to-female ratio of NPS injectors accessing IEP services is just over 3:1, similar to opiate injectors. NPS injectors have accounted for 9239/58,332 of IEP transactions – 16% of the total. In August 2014, there was a significant drop in the number of transactions due to a police operation targeting the shop supply of NPS. There was also an unexplained decrease in January and February 2015, followed by the highest total so far in March.
The highest percentage of NPS injectors in Lothian are within the 30–39 age bracket, followed by the 40–49 age bracket This is similar to other injected substances as the drug injecting population in Lothian is believed to be ageing, and the majority of NPS injectors attending IEP services were previous opiate injectors. Clients are known to be switching from stable opiate prescriptions to NPS use.
Most NPS injecting clients who attend IEP services are using the smallest needles to inject with although a significant number are injecting into high-risk sites such as the groin or neck and with some reports of injecting into the tongue and forehead. Although clients should be encouraged not to inject ethylphenidate, rectal administration or insufflation should also be discouraged due to the corrosive nature of the substance which is damaging to the mucous membranes of rectal and nasal tissues.
NPS dissolved in water and drinking is a safer route of administration. Clients are advised to take the smallest dose possible as strength and ingredients can vary from packet to packet, and it is not known how their body will react. Small doses will ensure that the substance is diluted as much as possible in water which will reduce venous damage. Mixing with other drugs should be avoided due to the competing or potentiating effects. Poly-drug use often carries a higher risk due to an increase in side effects which is also dependent on the dosage of both substances.
Wounds
The most obvious physical complication of injecting ethylphenidate appears to be on skin. Users frequently report a burning on injection. When injected, users may become tremulous which can cause the needle to dislodge from the vein and injection into the tissues occurs. The skin can break down rapidly, leaving large, often deep, necrotic ulcers. Veins may only last for two or three injections before enough damage occurs to prevent further use. Due to the frequency of injecting, the body sites used rapidly become unavailable and there are often multiple wounds. Some wounds are used to inject into directly (Figure 5).
Bathroom in NPS injector’s flat. NPS: new psychoactive substance.
These wounds appear to become infected easily, possibly due to the large amounts of necrotic tissue, and there have been reports of limb amputations dueto necrotising infection following injection of ethylphenidate.
Users have commented that the drug burns its way to the skin surface. There may be deposition of micro-emboli causing this sensation. Some wounds are small circular necrotic patches often where small veins have been accessed. Often these present in a multiple number of body sites (Figure 6).
Kitchen within NPS injector’s flat. NPS: new psychoactive substance.
Other wounds are appearing to be deeper and punched out in appearance (Figure 6).
Bruising is a common feature of ethylphenidate use (Figure 7).
There have been frequent reports of groin abscesses, cellulitis and soft tissue infections. Local hospitals are experiencing increased admissions of clients who have injected ethylphenidate and have serious infection (including Group A Streptococcus) or sepsis. Topical antimicrobials, systemic antibiotics and surgical intervention have been required.
When used over long periods and mixed with other substances such as alcohol, Burst carries significant risk to the individual’s mental health. Individuals using Burst may not be sleeping or eating for days at a time whilst repeatedly re-dosing and complex mental health issues may develop including NPS-induced psychosis which has resulted in numerous mental health hospital admissions. 11 The compulsion to use and the intense comedown may lead to severe depression and suicidal thoughts.
Domestic chaos is common, and many users are living in states of self-neglect and this is illustrated in Figures 8 and 9 taken in an NPS injector’s accommodation.
The difficulties in assisting clients who live in this way cannot be underestimated where hygiene and safety are so compromised.
Risk
With reckless and risky practices, lack of inhibitions and a fatalistic attitude from many service users using ethylphenidate-based products, the risks are not only to the user but also the public.
Public injecting of NPS is not unusual and there is open sharing of needles and paraphernalia. There has also been a reported increase in the amount of carelessly discarded injecting equipment.
Harm reduction messages
Much of the advice given is the same given to any drug injector such as fresh equipment for every injection, not sharing and rotating sites. Clients should use the smallest needle possible. This will reduce the damage to the vein and lessen the chances of the needle leaving the vein when vasoconstriction occurs.
However, there are certain issues which are specific for those injecting NPS. The contents of an NPS packet are not clear so clients should be encouraged to ask peers if they have tried the substance and what the experience was like. Clients are encouraged to keep the ‘packet in the pocket’ to help others know what has been ingested. 12
The process of injecting ethylphenidate is different from heroin. It dissolves in water without the need for cooking up; the drug may solidify if heated, causing damage to veins. Other substances such as microcrystalline cellulose may be found in various ethylphenidate products and these will not dissolve which may be a contributory factor to soft tissue infections such as abscesses. Therefore, filtering the injection is essential to reduce unwanted impurities entering the vein. 6 Clients should be deterred from using acidifiers such as citric acid or vitamin C as these are not required and will further enhance corrosion.
Drug use, in particular club drugs and NPS, can lead to disinhibition. 5 Some MSMs are injecting NPS as these substances increase sexual desire and lower inhibitions. Safer sex should be promoted and condoms should be changed every half hour.
Due to the recent change in legal status of ethylphenidate, other NPS may become more prominent and as markets fluctuate there are heightened risks with people who may revert to injecting heroin at previous doses and it is likely that their tolerance will have reduced providing a high risk of overdose. Users who are unable to get their drug of choice may change products and not be aware of the effects of the new product.
Conclusion
The situation in Lothian developed rapidly and remains a situation not seen elsewhere, yet. Within the last year, the injecting of NPS – specifically ethylphenidate – has had a major impact on IEP services, health services and public health. Services are now exploring ways to make appropriate responses in order to support people who are injecting NPS including finding routes into treatment.
Footnotes
Acknowledgments
The authors would like to thank the service users for providing information around their drug use and consent to use photographs; Kathy Evans, South Edinburgh Community Safety Officer at Edinburgh City Council for other photographs; and Jim Sherval and Mairi Simpson for helpful comments on the draft.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.