The fundamental urge to alter our consciousness in significant but controllable ways is, it seems, part of our hard-wiring.28

When considering the issue of drug use in society or the ‘drug problem’, most people tend to think of a relatively small collection of core illicit substances: heroin, cocaine, cannabis, LSD, ecstasy and amphetamine. People rarely include similarly harmful (and potentially addictive) substances such as alcohol and tobacco. They are probably even less likely to call to mind solvents, poppers, nitrous oxide, ‘study drugs’ or even caffeine. However, all of these substances have psychoactive, intoxicating or sense-heightening effects for humans. They are thus, to varying degrees, subject to use, misuse and addiction by individuals seeking to ‘get high’ or get ahead.

Psychoactive substances in society

While our review is focused on new psychoactive substances, one cannot ignore the evolution of drugs and drug use in society. Psychoactive substances have played a role in much of human history. They have provided tonic to pain and disease, played an integral role in social and religious ceremonies in some societies, and fulfilled a desire to alter our consciousness. Researchers have discovered implements for inhaling drug fumes or powders in South America that can be dated back to between 400 BC and 100 BC.29 Beer has been dated as far back to Neolithic times (10,000 BC), and ancient Chinese tools for making wine have been discovered. The benefits and harms associated with alcohol have been debated at least from the ancient Greeks through the 1800s and early 1900s to the present. The use of opiates in various forms also has a long history, from evidence of the consumption of poppy seeds in c 2500 BC, through widespread use in China from the eleventh to the twelfth centuries AD as a medicine and later recreationally, and the introduction of laudanum and other opium products to the practice of medicine in Europe from the sixteenth century onwards in Europe.30 And, of course, the rapidity with which the use of caffeine (in the form of tea and coffee) and nicotine (from tobacco) spread once they were introduced from the New World provides testament to our acceptance of the use of psychoactive substances and of the longterm nature of some of the harms associated with them.

In light of this history, and the persistence (and even increase) in the number of people using a range of psychoactive substances for a variety of reasons, the idea of a ‘drug free’ world, as envisaged by previous drug policy campaigns of the 1980s, seems quixotic, if not unnatural and most certainly unachievable. Nevertheless, to highlight the seemingly basic human desire to ‘alter our consciousness in significant but controllable ways’ should by no means imply that this is something that all humans do, or should do. The number of people who regularly use illicit substances is quite small proportionally. While estimates of drug use are an inexact science, the authoritative numbers suggest that anywhere between 3 per cent and 6 per cent of the world’s population used illicit substances at least once in 2008. The United Nations Office of Drugs and Crime (UNODC) estimates that there are anywhere between 16 million and 38 million problem drug users (who are dependent on drugs, or using the most dangerous drugs such as injected heroin) in the world. The majority of
people who use illicit drugs – approximately 80 per cent – use cannabis, which remains the most widely used illicit substance in Europe and here in the UK.

In many parts of the UK, illicit drug consumption may be perceived as a ‘common’ but not a ‘normal’ activity, at least for most of the population. Of course this differs according to age and locality. By comparison, consumption of licit substances such as tobacco and alcohol is significantly higher and can be said to be a ‘normal’ activity in the UK and abroad.

Alcohol and tobacco: the other ‘legal highs’

Compared with many other European countries, the UK appears to have a particular problem with excessive drinking, especially among young people. Consumption of alcohol in the UK has increased by 19 per cent over the last three decades.31 There are now an estimated 10.5 million adults in England who drink above sensible limits and 1.1 million adults in England have  a level of alcohol addiction.32 These numbers dwarf the number of people in the UK who use (not necessarily in a problematic way) illicit substances. Moreover, while the number of smokers has fallen substantially over the past decade, there are still around 10 1million adults in the UK who smoke cigarettes: approximately one in five men and women smoke. It has been estimated that over 100,000 people a year in the UK die from smoking-related diseases.33

As discussed further below, there has been increasing attention in recent decades on the harms of licit substances such as alcohol and tobacco. According to recent analysis by the Independent Scientific Committee on Drugs, alcohol is the fourth most harmful drug to the user, and the most harmful to society as a whole, making it more harmful than both heroin and cocaine.34 While there is debate about the particular methodology used to reach this assessment there is no doubt that the substantive point about the growing harms of some types of alcohol use is broadly accepted.

New substances and global factors affecting drug use

While the history of psychoactive substances in human society is long and varied, drug use has changed drastically over the past 100 years and more people are using a broader range of substances than ever before. Changes in patterns of drug use are the result of a combination of technological advancements, changing social norms, growing wealth yet widening economic inequalities, civil strife in other parts of the globe along with unscrupulous suppliers and corrupt officials.

Set against these deep undercurrents, we highlight three factors that underpin the emergence of new and varied psychoactive substances and the current dynamism and flux in the drugs market. The result is a difficult problem made significantly more intractable. These trends include:

·    the rise of ‘manufactured drugs’
·    the internet
·    changing cultural norms towards intoxication.

The three trends identified above suggest that the problem of new psychoactive substances will continue to influence patterns of drug use in the coming decades.

The rise of manufactured substances

While the list of ‘legal highs’ presented in the introduction all emerged in the past ten years, the appearance of new synthetic drugs is not an entirely twenty-first-century phenomenon. Alexander Shulgin, an author and influential biochemist in the drugs field, predicted the diversification and increasing number of psychedelic and synthetic substances in the 1960s. There has been considerable growth in the different types of drugs since then: between 1961 (when the UN Single Convention on Narcotic Drugs was first passed) and 1995 the number of prohibited substances rose from 85 to 282.35

Synthetic drugs – manufactured by chemists in laboratories – have risen rapidly in prevalence over the past two decades. Although MDMA and other ecstasy-group drugs were first developed in the early 1900s, recreational use of ecstasy exploded in the 1990s, particularly in Europe and the USA.36 Manufactured amphetamine-group substances, including ecstasy and related drugs, are now the second most used illicit substance behind cannabis. The UNODC predicts that the number of amphetamine-type substance users globally is likely to surpass the number of opiate and cocaine users combined in the near future.37

There are a number of reasons for the growth in the market for these drugs, including changing social norms, youth culture, the manufacturing process, the ease of substituting precursor chemicals and psychoactive substances, and the convenient methods for taking these drugs (pills versus injecting, snorting or smoking).

Additionally, the enforcement strategy against manufactured substances is more complicated. Unlike the cultivation of coca and poppy plants, manufactured drugs can be produced closer to consumer markets with shorter distribution chains.38 They are also impervious to remote sensing, unlike poppy plants, cocoa bushes and indoor cannabis farms.39 Moreover, enforcement efforts must contend with not only the final product, but also the distribution of precursor chemicals. Ecstasy can be manufactured using a variety of precursor chemicals and a variety of manufacturing methods, which makes replacements easy to find, and ensures greater flexibility in the manufacturing process.40

The rise of manufactured drugs has led to an explosion of synthetic drugs designed to mimic the effects of illicit substances. New substances have included synthetic cathinones, synthetic cannabinoids, and new cocaine and amphetamine-like synthetic derivatives, among a variety of other substances. These are the new generation of ‘legal highs’. Coinciding with this is a trend towards increasing levels of deception and confusion in the actual composition of marketed drugs. In the European drugs market, tablets sold as ecstasy increasingly contain other substances, including piperazines like BZP, mCPP and TFMPP.41 Some of these substances are not under domestic or international control, so constitute ‘legal highs’.42 Mephedrone has
increasingly been sold as ecstasy or as a suitable replacement to ecstasy, before and after its control via the EMCDDA and national legislation.

The speed with which this shift has taken place is alarming. UNODC reports that in 2006, 10 per cent of tablets sold as ecstasy in the EU contained mCPP. By the end of 2008 this figure had risen to 50 per cent in countries with large markets for ecstasy.43 This increasing confusion and uncertainty poses a number of challenges to enforcement and public health agencies. It also puts a high premium on quick and easy drug-testing facilities to determine the composition of drugs.

The influence of the internet

The ease with which new drugs can be synthesised and manufactured is matched by the efficient and difficult to regulate distribution methods now provided by the internet. As with every other aspect of life in the twenty-first century, the internet has significantly impacted on the distribution of drugs and drug use. Information about new drugs was previously disseminated through word of mouth or traditional media. Now, information about new drugs can be transmitted to a larger number of people more quickly than ever before.

This is likely to result in a wider range of people being aware of and likely to use an increasingly wide range of substances. Indeed, with ‘legal highs’, groups of people who might be put off using drugs by a lack of contact with drug dealers, can gain access to a drug and purchase it in much the same way they now purchase many other goods over the internet.

The internet has also facilitated the emergence of new manufacturing and distribution centres (most significantly from China and India) by providing them with global reach into the lucrative and seemingly insatiable market for drugs in Europe and North America. Motivated by profit and effectively out of reach of these countries’ drug laws, research chemists and entrepreneurs have emerged to supply the Western world’s demand for drugs. As a result of this change in the supply side of the drug market the frequency and speed with which new drugs can emerge is significantly greater. The same dynamic is at the root of the rise of counterfeit medicines.

Changing cultural attitudes towards intoxication

Reuter suggests there is an increasing tolerance in Western society for ‘altered states of consciousness’.44 However, this does not necessarily mean that use rates of illicit substances like cannabis, cocaine, heroin and ecstasy are rising. Indeed, recent reports suggest that trends in cannabis consumption indicate stable or declining levels of use.45 The UNODC suggests that heroin use is decreasing in most West European countries and although the trend in cocaine use varies between different countries, for the most part use appears stable.

In this context the difference between a ‘good’ high (eg alcohol in moderation) and a ‘bad’ one (eg ecstasy in moderation) is becoming harder to explicate.46 In the USA, as elsewhere, there has been a growing acceptance of marijuana use, particularly for medical purposes. Simultaneously, there has been increased attention to the social and health harms of alcohol consumption. This blurring of the lines has led many experts and members of the public to question why one harmful substance can be purchased in a shop, while possession of the other is punishable by prison and a criminal record.

Such changing attitudes and perceptions may also contribute to the increasing patterns of ‘poly drug’ use (the use of many different kinds of drugs simultaneously), particularly in Europe. According to the EMCDDA, almost all patterns of ‘poly drug’ use include alcohol, and it is likely that a significant proportion also include cannabis.47 In part, such explanations have given rise to new political calls for increased personal responsibility in substance-using behaviours.

Finally, the significant growth in the ‘study drug’ phenomenon – particularly in the USA – means that large numbers of young people are using drugs not only to get high, but also to get ahead. The ‘study drug’ phenomenon is one aspect of a growing problem with the misuse of prescription drugs, including painkillers and antidepressants.

‘Legal highs’: the new generation of manufactured drugs

The rise of new psychoactive substances (aka ‘legal highs’) in the twenty-first century is an extension of these underlying trends. Some of the best-known examples of this new generation of manufactured substances are GBL, BZP (see box 1), Spice, mephedrone (see box 2), NRG-1 (see box 3), Benzo Fury and Ivory Wave. Not all of these substances are new drugs which have just been created by DIY, entrepreneurial chemists. Some of them are manufactured for other industrial uses (eg GBL and other solvents), but have been discovered to have intoxicating effects. A recent article in the International Journal of Drug Policy notes three types of ‘legal highs’: organic plants, synthetic substances and semi-synthetic substances derived from natural oils.48

Box 1    Case study: BZP (1-benzylpiperazine)

BZP became the fourth most widely used drug in New Zealand in the period 2004–2008.49 Originally developed for veterinary purposes, BZP first appeared in ‘party pills’ in 2000.50 Surveys in New Zealand have shown that most users consume BZP with alcohol and other psychoactive substances.
Only a few direct studies have been made on the physiological properties of BZP in humans. Available information derives mainly from indirect sources, for example, from self-reports of users on internet sites, clinical observation of intoxicated patients, or post-mortem material.
In 2006 and 2007, New Zealand’s Expert Advisory Commission on Drugs concluded that the risks to users were moderate. Acute problems largely came from combining BZP with alcohol and other drugs, as well as the variability of potency (the latter may have been mitigated had there been processes for formal regulation). 51 As mentioned above, many BZP tablets and capsules also contain TFMPP (1-(3- trifluoromethylphenyl) piperazine).

How prevalent are new ‘legal highs’?

Reuter’s research into the international experience concluded that the problem of new psychoactive substances (‘legal highs’) has been modest and localised thus far. There have been few instances in which a new psychoactive substance, not covered by existing regulations or laws, has become a significant problem in terms of widespread use on a par with illicit substances like ecstasy and cocaine. The two most prominent examples are BZP in New Zealand and mephedrone in the UK.

Nonetheless, the market for ‘legal highs’ is moving quickly. At the beginning stage of writing this report in December 2010, the issue of ‘legal highs’ and a number of the substances most prominent in Europe were essentially unknown in the USA. A search of the Drug Abuse Warning Network (DAWN), which lists known psychoactive substances in the USA, by Reuter at the end of 2010 found no mention of BZP, Spice, mephedrone or naphyrone, using both street and technical names.52 However, in January and February 2011 there were media reports that the problem is of growing concern in the USA.53 The Washington Post reported recently that cathinone derivatives are being advertised in the USA primarily as ‘bath salts’, rather than ‘plant food’ as in the UK and Europe. In March 2011, the US Government announced that it was using emergency scheduling powers to ban five synthetic cannabinoid chemicals, which can be used to comprise Spice.54

Motivations for using ‘legal highs’

There have only been modest levels of research into the profile of ‘legal high’ users, and their motivations. Who is using these new substances, and why? Do new ‘legal highs’ simply present more choice for those who already use a range of illicit drugs and alcohol, or do they appeal to a new cohort of users who would normally be discouraged from illicit activity?

There is a small but growing body of primary research into use of mephedrone particularly in the UK. There have been three quantitative surveys into mephedrone use. Two were annual Mixmag surveys (online self-selecting surveys of clubbers and festival goers that hence represent a particularly high drug-using group within the population), including the 2010 survey which first revealed that mephedrone had become the fourth most popular drug among the 2,000 people who responded to the survey. The other survey was conducted in Scotland, with over 1,000 school and college or university students responding, showing that one in five had tried mephedrone.55 There has also been a handful of smaller-scale qualitative research studies with mephedrone users.56 This includes research before and following the classification of mephedrone in April 2010, which gives some insight into the effect of classification on changing patterns of use.

Box 2    Case study: mephedrone (4-methylmethcathinone)

Mephedrone is a synthetic cathinone. It is the most recent ‘legal high’ to attract significant media attention, particularly in the UK, which accounted for 88 per cent of European seizures of the drug in 2010.57 Some research suggests that mephedrone emerged in part as the consequence of the declining quality of ecstasy.58

The drug first emerged in the UK in 2008, and grew in prevalence rapidly. Two seizures were reported in 2008, 20 seizures in early 2009 and up to 600 seizures in the latter part of 2009.59 A survey of EU member states found that only the UK and the Netherlands had made substantial seizures; the nine others (Estonia, Finland, Germany, Ireland, Italy, Latvia, Romania, Slovenia and Slovakia) with any seizures reported totals of 2–325 grams. Ireland and the UK reported ‘legal importations’ of mephedrone available for purchase in ‘head shops’ or over the internet advertised as a plant food. Europol and EMCDDA report that there is little evidence of European processing or trafficking in mephedrone. Evidence suggests mainly legal production and distribution from Asia, namely China.

An internet search in December 2009 revealed at least 31 websites selling mephedrone, a majority of which were based in the UK. 60

There is some very limited research into the prevalence of mephedrone within the UK, and the profile of users. The most significant research in scale comes from an annual survey of drug using by the European clubbing magazine, Mixmag. 61 This online survey consisted mainly of self-selecting individuals who are active in the club scene and therefore probably yields figures that show greater levels of drug use, than among even the wider clubbing population. The survey had 2, 220 respondents, of which 65 per cent were male and 81 per cent were employed, mostly aged 18–27. The Mixmag survey revealed that in less than a year, mephedrone had become the fourth most popular drug among those British clubbers sampled, with 42 per cent reporting ever having taken the substance (lifetime prevalence), 34 per cent use in the past month, and 6 per cent use weekly. There has also been a small-scale qualitative study of ten mephedrone users in Middlesbrough, UK. This consisted of nine men and one woman, all of whom were regular or occasional users of other drugs (mainly alcohol, cannabis, ecstasy). Among this sample, mephedrone was mainly a weekend indulgence at parties or nightclubs, with most people mixing the drug with alcohol and/or cannabis. Users describe stimulant and hallucinogenic effects, with negative effects including cravings, skin rashes, vomiting, insomnia and/or amnesia; several respondents experienced some of these effects.

Knowledge of the adverse effects of the substance is slight, as the EMCDDA reported in 2010: ‘there are no published formal studies assessing the psychological or behavioural effects of mephedrone in humans’. 62 As with BZP, much information is based on informal sources such as user reports.

Professor Fiona Measham and colleagues conducted research into the reasons for the growth in popularity of mephedrone in particular.63 People choose to take ‘legal highs’, or any drugs for that matter, for a number of factors including:

·    legality
·    price
·    purity
·    convenience and availability
·    effect

Their research suggests that displacement resulting from fluctuations in the supply of illegal drugs is a key issue in understanding changing patterns of drug use. They argue that there was a ‘growing disillusionment with the quality of street drugs throughout the 2000s’ because of the lack of purity of drugs like cocaine, ecstasy and MDMA. Cocaine purity reportedly dropped from 60 per cent in 1999 to 22 per cent in 2009, while analysis of seized ecstasy pills in 2009 showed that half contained no ecstasy, but rather BZP or caffeine. There have also been decreasing purity levels of MDMA, probably as a result of enforcement successes and stricter security.

Additionally, availability appeared to be a more significant motivation than legality for using mephedrone. Users were less concerned about whether they were doing something illegal than they were about the ease with which the lack of any regulation made these drugs available. Curiosity to experiment with something new was also a cited factor for use.64 Box 3 presents a case study of the drug naphyrone, which emerged around the time of mephedrone and was often marketed by sellers as a replacement following the banning of mephedrone.

Box 3    Case study: NRG-1 (naphyrone)

Naphyrone is a high -potency cathinone. Before it was banned in July 201 0 as a class B drug within the Misuse of Drugs Act (MDA), it was largely sold in the UK through the internet. Its harms are thought to closely equate with those of mephedrone, but it is much more potent; a standard dose of naphyrone is one-tenth that of mephedrone.

The majority of samples of supposed naphyrone actually contain mephedrone and other related compounds. 65 The ACMD speculates that this may be the consequence of mephedrone distributors dumping their product after it was classified in April 2010.66

Naphyrone has significant potential for abuse: according to Reuter, naphyrone is a triple-uptake inhibitor like cocaine (with ten times the potency) rather than a single-uptake like d-amphetamine and MDMA, which means that it affects all
three neurotransmitters linked to depression: serotonin, norepinephrine and dopamine. 67 Moreover, the lack of transparency over its content, and the much smaller difference between safe and lethal dosage compared with mephedrone, could potentially lead to overdoses.

These findings concerning motivations do not necessarily hold for all ‘legal highs’, but depend on the quality of the effect, as well as the quality of illicit substances. For example, Measham et al cite research around the motivations for using Spice, finding that legality was the most significant motivator. Spice is a set of herbs with some synthetic cannabinoids added. It was first identified in Sweden in 2007, though it had been available at least since 2004. Like other ‘legal highs’, Spice has been an internet phenomenon, where it is advertised for purposes other than consumption (eg incense, bath salts). It can contain a large range of cannabinoid substitutes, of which many of the harms are unknown, and often does not contain the materials identified on the package. Once Spice was given comparable status within the MDA, most users reportedly switched back to cannabis. Participants said this was because the effects of Spice were not as pleasurable as cannabis.

The impact of banning ‘legal highs’

Meanwhile, there is evidence to suggest that the use of mephedrone has continued despite its classification. Research by McElrath and O’Neill, based on semi-structured interviews with 23 people in Northern Ireland who used mephedrone, suggests that while distribution over the internet has diminished and prices have risen, mephedrone remains available and sought after.68 While the majority of the sample purchased mephedrone from friends or dealers before the ban, there was still greater reliance on dealers following the ban. Interestingly, those in this sample were reluctant to purchase mephedrone in ‘head shops’ or over the internet before the ban, for fear of stigmatisation. This suggests that legal status was irrelevant to the stigma of purchasing or using the substance, and the perceived harm. As McElrath and O’Neill note, the lack of impact of legality on the perception of harm contrasts with the experience of BZP in
New Zealand. As discussed in the next chapter, the ambiguous legal status of BZP in New Zealand led some to conclude that it was safe. However, this difference may be because the New Zealand research included higher numbers of young people and drug novices, whereas the Northern Ireland research included a range of older people (it included those aged 19–51), most in professional occupations and long-standing recreational drug users.

The latest Mixmag annual survey for 2011 shows a relatively mixed picture of the effect of the ban on use.69 On the one hand, there was a higher proportion (61 per cent) of respondents who had ever tried mephedrone compared with the previous year before the ban (42 per cent). Users this year were also more likely to have used it in the past 12 months, though slightly less likely to have used it in the previous month. Most notably, 75 per cent of those who had ever tried mephedrone had done so since it was banned in April 2010. The survey also suggests a displacement effect as a result of the ban, with 30 per cent of respondents saying they used more ecstasy as a result of the ban, and 19 per cent saying they used more cocaine as a result of the ban.

On the other hand, 56 per cent said their use had decreased or stopped following the ban, while 33 per cent said that the ban had no effect. The ban also appeared to decrease the availability of mephedrone and increase its price. It is perhaps most
worrying that prevalence of use increased while the purity of the drug decreased. Before the ban, 90 per cent of respondents had thought the purity of mephedrone was either good or excellent, while 30 per cent suspected it was cut with something else.
Following the ban, the percentage who suspected mephedrone was cut with other substances rose to 80 per cent.

The ‘legal high’ challenge for policy makers

Unlike cocaine, cannabis, heroin, alcohol and tobacco, we know much less about the impact of this new generation of psychoactive substances. So far, it seems, new psychoactive substances have remained on the fringes of the drug-using community. The two exceptions appear to be mephedrone in the UK and BZP in New Zealand. Nonetheless, the problem appears to be growing and the rise of these new substances presents policy makers with a number of challenges. The next chapter looks at the policy context, and the response to ‘legal highs’ thus far. As seen above, research suggests that the growth of these new substances may stem in part from successes in tackling illicit substances like ecstasy. Moreover, it seems that banning mephedrone has had only a marginal impact on use, and may even increase the harm it causes by decreasing transparency about its content.