Not-so-legal 'highs' mess with the mind and may kill

SINGAPORE – Struggling to cope with academic demands, Mike (not his real name), a 21-year-old student took a friend’s advice and obtained “bath salts” off the Internet to help him feel less anxious. He was told the substance was legal and would not do major harm.

What was supposed to help him relax and de-stress ended up worsening his academic performance when he became hooked.

He also started developing bizarre symptoms of paranoia after the first few doses.

“He felt that he was being watched, and suffered poor sleep with increased anxiety. His academic performance deteriorated along with other areas of normal functioning,” said Dr Mohamed Zakir Karuvetil, an associate consultant at the Institute of Mental Health’s (IMH) National Addictions Management Service (Nams) where Mike was referred for treatment by a school counsellor.

They go by many innocent-sounding names such as bath salts, mushroom and spice, and are commonly thought to be harmless. But New Psychoactive Substances (NPS), commonly marketed as “legal highs” or designer drugs that have recently become available on the market, are chemically similar to other strong and addictive psychoactive drugs, said experts.

“These man-made chemicals mimic the psychedelic and mood elevating effects of other controlled substances such as heroin or cannabis. As such, NPS are marketed as cheap substitutes for illicit drugs. They are also perceived to be less harmful than hard drugs, making (them) popular among users,” said Dr Karuvetil.

The number, types and availability of NPS have rapidly increased globally. Over 800 NPS were reported from 2009 to 2017, according to the United Nations Office on Drugs and Crime’s (UNODC) World Drug Report.

In Singapore, an increasing number of NPS are now listed as controlled drugs.

NPS were first reclassified as Class A controlled drugs in Singapore in May 2014, which meant anyone found guilty of trafficking the substances will face at least five years in jail and five strokes of the cane.

Prior to that, the NPS were listed in the Fifth Schedule of the Misuse of Drugs Act, which allowed the authorities to seize them. But the trafficking, manufacture, import, export, possession or consumption of them did not constitute an offence.

TODAY understands that Singapore and some countries where different NPS have emerged have adopted controls on entire substance groups of NPS based on generic chemical similarity of the substance.

There are currently 11 generic NPS groups and 112 individually-listed NPS listed as Class A controlled drugs under the Misuse of Drugs Act, a Central Narcotics Bureau (CNB) spokesperson told TODAY.

The CNB seized 642 tablets and over 3.5 kg of NPS last year.

DAMAGE DONE MAY BE WORSE THAN HARD DRUGS

The composition of NPS are often not known, which places users at high risk, according to the UNODC.

The “damage done is worse” than some hard drugs, as some NPS may contain industrial chemicals, said Mr Robin Tay, head of department for programmes and community services at The New Charis Mission, which runs a halfway house and rehabilitation programme for ex-drug offenders.

“Some heroin users can still have some control over their ‘kick’ (a term that drug abusers use to describe when drugs take effect). But for NPS, a lot of them just lose control after the kick. They may walk around, losing their senses,” said Mr Tay, who has heard of cases of near-fatal NPS overdose in Singapore.

He has also heard of an overseas case involving a 16-year-old NPS user who died on the spot after taking the drug.

“Whatever chemicals that were added into the drug was too much for the body to take. People taking these drugs may think ‘oh it’s okay, I’ll just try once’ but your first time may also be your last,” said Mr Tay.

Every month, approximately one to two patients present at the emergency department at Changi General Hospital (CGH) for adverse health effects suspected to be due to drug abuse. Dr Mong Rupeng, a consultant at CGH’s accident and emergency, estimated that cases related to NPS use are seen once every two months.

Their symptoms are usually not distinguishable from the usual drugs of abuse like methamphetamine, heroin and marijuana, said Dr Mong.

“While most presentations are mild, we have encountered cases with serious toxicity, including extreme agitation and violence, seizures, kidney failure, and rhabdomyolysis (breakdown of damaged muscles),” said Dr Mong.

For such cases, treatment is mostly supportive. There are no specific antidotes, and medical care is aimed at supporting vital organ function, said Dr Mong.

“They usually do well and recover after the drugs are washed out. The only way to confirm that they have taken NPS is to send a urine or blood specimen to Health Sciences Authority (HSA) where the drugs could be specifically tested. As these drugs may be new to HSA too, it may take a longer time for the drugs to be identified and isolated,” said Dr Mong.

Under the Misuse of Drugs Regulations, medical practitioners are required to report suspected drug addicts to the CNB and Ministry of Health, said Dr Karuvetil.

POPULAR AMONG YOUNGER USERS

NPS users are typically from the younger age groups, including teenagers, observed Mr Tay. There are also older adults who use these drugs as substitutes when they cannot get hold of their usual fix, he said.

Mr Tay estimated that the proportion of ex-drug offenders supported at The New Charis Mission who have used NPS is “very low”. This could be due to NPS being new on the market and cases being under-detected, he said.

The IMH does not have numbers related to NPS use as they fall into the broader category of drug addiction in its data collection.

Some users are not aware of its dangers.

“When it comes to NPS, the younger users are not ready to seek help. They don’t think it causes any real damage and think (their drug use) is controllable. Some deceive themselves or justify their drug use as an aid, to help them focus, for example,” said Mr Tay.

According to anecdotal evidence, Singaporeans may also take NPS when they are overseas.

A 28-year-old senior executive, who declined to be named, said she paid around S$20 for a mushroom “smoothie” while vacationing in Bali several years ago. The drug, which was blended with a fizzy drink to mask its strong taste, was readily available in “shroom cafes” near clubs, she said.

“It was actually a really bad experience for me. It heightens your paranoia, and I was suspicious of everything. That was my first and last time taking it,” she said.

SOME EXPERIENCE PARANOIA, HALLUCINATIONS, SUICIDAL TENDENCIES

Like other forms of drugs, regular use of NPS may lead to an addiction. While NPS may appear to have milder physical withdrawal symptoms compared to controlled drugs, their psychological withdrawal symptoms, such as agitation, anger, anxiety and depressed mood, are similar to that of other drugs like cannabis, said Dr Karuvetil.

As the chemicals in NPS vary significantly, there are no typical withdrawal symptoms, which could range from mild to severe, depending on the NPS used and individual vulnerability, said Dr Karuvetil.

Some vulnerable individuals can be more sensitive to the addictive nature of NPS, and may therefore develop medical complications such as extreme paranoia, hallucinations, suicidal tendencies and altered mental status, he said.

Addiction to NPS will also bring with it long-term mental health problems, such as depression, anxiety, psychosis and memory problems, which will affect almost all areas of the person’s life, he said.

Nams (helpline 6-7326837 (6-RECOVER)) offers a voluntary inpatient treatment programme consisting of a detoxification and rehabilitation phase for individuals suffering from an addiction to drugs, including NPS.

The detoxification phase is for those who find it hard to give up their dependence on the drugs due to withdrawal symptoms, or stop using on their own accord, said Dr Karuvetil. This is followed by the second stage of treatment, rehabilitation, which involves the use of pharmacological (for instance, the use of antipsychotics to alleviate psychosis) and psychosocial treatment (such as individual counselling, group therapy, family session and social integration).

Patients who do not require inpatient treatment or are unwilling to be admitted will be offered follow-up on an outpatient basis, said Dr Karuvetil.

“Ideally, the main treatment outcome is complete abstinence. However, as addiction is a chronic relapsing disease, it is important to identify early relapse signs and seek early treatment,” he said.