Bath salts and recreational creativity, however, were the same as those used for hallucinogen intoxication, although the exact substance was not detected in two individuals. Intoxication for recreational use of these substances might resemble that for experimental hallucinogens. While the use of these drugs for hallucinations was more common among males, the use for other purposes was similar in males and females. The use of these drugs is rapidly increasing worldwide. Physicians, community organizations, emergency departments, and law enforcement organizations need to be more aware of these developments. This study was intended to inform about common intoxicants and common use patterns in a population of intoxicated individuals without co-occurring alcohol, illicit drug use, or psychiatric disorders.
Funding: This study was funded by the Sahlgrenska Academy at the University of Gothenburg (to JH). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
A vast number of new psychoactive drugs are being developed for recreational use. Among them are cathinone (found in Catha edulis and Khat [1]) and 25I-NBOMe (e.g., “rare gas” and “bath salts”) [2]. The development of new compounds has significantly increased since the 1980s [3], although the reasons for this are not completely clear [4]. This may be in part due to technological developments, such as the development of liquid chromatography–mass spectrometry (LC-MS), as well as an increase in the number of compounds that can be synthesized. In addition, the global drug market has grown significantly [5], which in turn may have led to an increased willingness to try new drugs. Recently, a significant increase has also been noted in recreational use of several of the newer substances of abuse, including the synthetic cannabinoid (SC) naphyrone [6], SC α-PVP [7], and synthetic stimulant 25C-NBOMe [8]. A significant increase in use of these drugs has been reported in recent years in Europe and North America [9], and also globally. Some of these drugs have also been detected in biological samples of intoxicated patients, suggesting that they are being used recreationally [10], [11], [12], [13].
The use of hallucinogens and “designer drugs” for other purposes has also increased. Use of recreational psilocybin (hallucinogenic ingredient in “magic mushrooms”) is rapidly increasing and this is sometimes seen as a “gateway drug” to the use of other illicit substances [14]. Also, a “recreational cocktail” was recently described in which drugs were combined by mixing several of them to create a new drug (“cocktailization”), which was suggested to represent a “new form of recreation” [15].
Ingested drugs can lead to a range of psychiatric symptoms [16], which are often difficult to differentiate from those of psychiatric disorders. It is well known that certain substances are also used for the purpose of inducing psychoses, and several groups of drugs can induce a state similar to schizophrenia (e.g., LSD, phencyclidine (PCP), and ketamine). It is also well known that a “hallucinogenic effect” is more common among individuals with pre-existing psychiatric disorders [17]. These drug-induced psychoses and psychotic-like experiences are common in most of the population of individuals who use drugs recreationally, i.e. without the use of alcohol, and in individuals with psychiatric disorders. However, it is not clear what proportion of the use of hallucinogenic drugs is recreational (without alcohol or co-occurring substance abuse or psychotic disorders). One of the most commonly used methods for differentiating recreational use of drugs from drug use for other purposes is through questionnaires or interviews (e.g., [18], [19]).
Alcohol-like and psychedelic effects can also be induced through the consumption of drinks that contain low doses of alcohol mixed with other psychoactive substances (e.g., synthetic stimulants) that increase the effect and intensity of the intoxication. Such drinks are frequently consumed at parties where new designer drugs are often used. Hence, in many clinical settings the intoxicating substances may often be undetermined. The aim of this study was to compare the characteristics of alcohol intoxication and intoxication with recreational psychoactive drugs among young adults from a community sample in Gothenburg, Sweden. We hypothesized that intoxication with recreational psychoactive substances would result in more typical and well-defined psychopathology and could be easier distinguished from alcohol intoxication.
Materials and Methods
The study was performed in Gothenburg, Sweden, during 2009–2010. It was part of a larger study on acute drug intoxication with a longitudinal prospective design. The study was approved by the Regional Ethics Committee in Gothenburg. Participants were students at the university, between 18 and 24 years of age. A total of 250 participants were approached; 219 (88%) agreed to participate, which is in line with previous studies (i.e., [20], [21]). At the initial assessment all participants provided written informed consent and filled out the Alcohol Use Disorders Identification Test (AUDIT) (for details see below). The majority of participants also completed an additional self-reported questionnaire on recreational drug use. This questionnaire included the use of the following drugs: alcohol, cannabis, amphetamine, cocaine, LSD, ecstasy, GHB, ketamine, and psychedelic drugs (mushrooms and mescaline).
Study participants were recruited at four different sites (the university and three large commercial clubs located in the suburbs). Each individual was asked to visit one of these sites and asked to bring all of their drinking partners, if any. The research coordinator went through the group of friends, identifying young individuals that met the inclusion criteria of being between 18 and 24 years of age, and who reported that they were not intoxicated at that time. The initial assessment lasted about 60 minutes. All subjects were asked to take urine samples and then they filled out the AUDIT [22] questionnaire (for details see below). Subjects were paid £ 30 (SEK 340, US $ 45) for their participation. All participants who used amphetamine, ecstasy, ketamine, or mushrooms were excluded from the study due to the ethical problems of performing a study with recreational substances. Alcohol-induced psychoses/psychotic-like experiences were considered a different condition to hallucinations, intoxication, and self-reported drug intoxication, and were thus not included in this study.
To be included in the study, participants had to fulfill the inclusion criteria of: (1) being a university student aged between 18 and 24 years, and (2) having drunk more than six doses of alcohol during the previous week. An alcohol-induced intoxication episode was defined as a situation where the person went to sleep drunk (or fell asleep in an intoxicated state), but who was fully oriented when waking up (also termed “alcohol blackout”). A drug-induced intoxication episode was defined as being intoxicated at the time of filling out the questionnaire and not drinking for a week prior to the initial assessment. In addition, participants were instructed to inform about their smoking habits, consumption of other substances, such as psychoactive drugs (except those used in this study) during the previous week, and history of alcohol and psychoactive drug use prior to the start of the study. Participants who met these criteria for drug or alcohol intoxication were defined as “cases”. This definition is according to previous studies (e.g., [23]).
Participants were excluded from the study if they had any personal psychiatric disorder (bipolar disorder, psychosis, major depression, anxiety disorder, other), serious physical illness, ongoing illicit drug use, or a known medical condition. Participants that had drunk less than six doses of alcohol were also excluded. Participants were informed that they could stop participating in the study at any time or withdraw from the study without further obligation. The participants were also informed that their participation was voluntary and anonymous, and that they could stop participating at
