The price of ecstasy pills is on the rise and there is increasing belief that the quantity of MDMA in pills is increasing, but this deadly seizure reminds us that pills vary widely in composition – and there are pills out there you do not want to try.

If only ecstasy pills were as consistent as a Big Mac!

PMA closely related to PMMA, has been connected to a number of deaths over the last decade in Canada, the US, Europe and Australia. While PMA was initially thought to be a by-product created in the production of MDMA, this is unlikely given the different precursors that each requires for their production.

A delayed onset of effect (often more than 2 hours) can lead to inadvertent overdosing – thinking ‘these pills are crap, better take another one of two and see if we get something’. However it can lead to muscle spasms, burred vision, overheating (hyperthermia), and increases in pulse and blood pressure.

Nausea and vomiting can lead to loss of potassium leading to hypokalemia (low potassium levels) which combined with hyperthermia can lead to irregular heart rhythms, seizures and death – see more on taking new pills here.

So if someone offers you a pill with the Macca’s logo on it – believe use you won’t be ‘lovin it’.

Interestingly, smokers from around the world seem to adopt different styles of rolling. While spending time working for Time Out Amsterdam, engaging in the privileged task of writing Coffee shop reviews courtesy of the expense account, I had a chance to observe these various techniques, as demonstrated by pot-smoking tourists burning time in the ‘global-village’. I wouldn’t like to comment on what it says about the various cultural identities, but it’s interesting all the same.

The Dutch

Lets start with the Dutch style, well planned, serious, and big. Using the whole roach card to make a sturdy filter, notable for the folded Z-shape in the middle, these spliffs are chunky and coned. They are also filled with twice as much weed as you need, mixed with cigarette tobacco to help it burn longer.

Any pre-rolled joint you will find in a Dutch coffeeshop is rolled like this and if you do get lucky and spot a Dutch person actually in one, then you’ll find them rolling theirs the very same way. You could say it’s a design classic.

The American Pure

Quite the other end of the spectrum is the American style. A lot less tidy, and usually rolled with pure cannabis, there’s a reason they call them ‘doobs’. These often don’t even use roaches and instead are twisted up at each end like a sweet-wrapper. They resemble a kind of chubby slug rather than a cone. On the plus side they use up a lot more paper, but you end up wasting a fair amount of weed too as its pretty tricky to smoke it right down to the end with out burning your lips, or choking on the roach (Big Lebowski style). However, the purity does mean it’s fairer on your lungs.

The Slim British

Then of course there’s the UK style, which is similar to the Dutch, as in it uses a roach and is coned, but they tend to be a lot thinner. Like a polite, respectable version of the Dutch one, in line with the Brits’ sensibilities. In the UK, smokers seem to prefer rolling tobacco instead of cigarette flakes, which makes it easier to roll thinly and neater.

Slightly Spanish…?

The weirdest style, however, has to be one a Spanish couple was spotted rolling, although it was so bad that it is unlikely that many people actually do this. Instead of using a roach for a filter they had just snapped off about an inch of a cigarette and used that instead, rolling a wide tubular spliff around it that was on the brink of falling apart as they smoked. This was a seriously botched job, but you can kind of see the twisted logic in it…

Bad Boy Blunts

For the champagne smoker, blunts are the only way. These are thick, brown rolling papers made out of tobacco, and a lot pricier than king-skins as you only buy one or two in a pack. Of course, when in Amsterdam, tourists like to treat themselves, and you can buy blunt wraps in abundance at the various shops selling googly eyed cannabis paraphernalia about the city. These are quite a bit harder to roll, as the paper is less sticky. They are also probably the worst for your chest as it’s a bit like smoking a cigarette and a spliff at the same time. Not to mention that they are generally pretty damn big. Still, nothing beats a novelty smoke….cough….tulip!

Of course, there’s no right or wrong in the world of weed – sort of – but the ritual of rolling, and the time and energy put into preparing your smoke seems to be an integral part of cannabis culture the world over. Unless you like vaporizers, in which case, you’re on your own…

Will Coldwell is a freelance writer and journalist based in London who writes for publications including Time Out, The Independent and The Guardian. (Twitter- @will_coldwell)

Try our new cannabis app here. Follow us on twitter @drugsmeter

Today we are launching our unique and exclusive ‘cannabis app’ for all smart phones and with cannabis being the most common illicit drug used around the world- what better way to begin?

drugs meter was launched last month and since then over 3,000 people have taken the drugs meter, bringing our comparison database to over 15,000 people! Like all drugs meters, the cannabis app provides you with immediate, objective and personalised feedback and lets you compare your cannabis use with thousands of other current cannabis users. So far around 5,000 cannabis users have examined their use against others on drugs meter….and wouldn’t it be interesting for you to anonymously compare your cannabis use to others within the community- well now you can.

drugs meter allows you to work out how much you smoke, and if you don’t know we have pictures- we spent 9 hours in a lab rolling and photographing joints, just so you can have a more ‘visual perspective’. It allows you to judge how much you spend in a year (and your lifetime) and adjust your use based on your unique personal characteristics. There are safer using tips, like trying a vaporizer as an alternative to spliffs, and if you want to, you can assess the impact of your use on your overall well-being.

drugs meter is not funded by any government. It places no judgment. It does not tell a person what to do. So if you are reading this, smoke dope or know someone who does, here’s what to do:
-From a smart phone- go to www.drugsmeter.com/
- click on the cannabis icon for the cannabis
- A pop-up will appear asking if you want to add it to your home screen as an app

-Click Yes and download it directly to your smart phone

It’s that simple!!

We have 8 more apps coming in the next month- so please, share, like, follow and tweet (@drugsmeter) but more importantly- see how you measure up!

[If you would like promotional flyers, stickers and cards or a icon with embedded link for your website please contact me at adam@globaldrugsurvey.com]

It’s common knowledge that students have been labelled as Britain’s biggest binge drinkers. The government have launched numerous ‘youth orientated’ campaigns- with a hefty price tag no doubt but, according to this year’s Global Drug Survey, in partnership with Mixmagand the drugs meter

Driving while under the influence of cannabis

Dear Editor
I read with interest the editorial by Wayne Hall and the systematic review by Abridge et al in the BMJ, highlighting the increased risk of fatal road collision while driving under the influence of cannabis. As part of a wider survey on drug use patterns and harms conducted at the end of 2011 by Global Drug Survey (www.globaldrugsurvey.com) in partnership with Mixmag and the Guardian newspaper, we asked current cannabis smokers about the risk of being identified as intoxicated with cannabis (without alcohol) whilst driving, if they got pulled over by the police within 2 hours of smoking a joint.
Data from over 10,000 last year cannabis users from around the world was obtained. The results from the UK, USA and Australia are outlined in table 1. The findings tend to support the cautious view put forward by Wayne Hall regarding the likely impact that roadside drug testing would have upon drug driving. For any drug driving policy to be an effective deterrent, drugged drivers must consider the risk of being stopped and subsequently detected as being under the influence as a real possibility.
Our results suggest that only a minority of current cannabis users think they would be detected as driving stoned using the present detection approaches utilised in their countries. The full results of the 2012 Global drug Survey are published exclusively in the Guardian and Mixmag on March 15 2012.

Table 1- BMJ- UK, US and Australia sample

Adam R Wintock, Consultant Addiction Psychiatrist

Mixmag has launched their coverage of the Global Drug Survey data today with a massive 10 pages of coverage on all things drugs! Mixmag have been at the forefront of making drugs a media issue for the last decade and Global Drug Survey is proud to be working with them. Check out their beautiful coverage here.

Global Drug Survey will be releasing our own exclusive coverage later today – want to see what drugs are the most popular? Watch this space!

Dr Adam Winstock is involved in some rather exciting projects connected to new psychoactive substances, namely the Global Drugs Survey published in Mixmag in March of every year and the brand new drugs meter app, more info can be found at http://globaldrugsurvey.com/ You can even catch him speaking at Crew’s national event CREWSUS in Perth later this month!

The paper explores interventions in primary care settings with Winstock and Mitcheson suggesting “a guiding communication style based on motivational interviewing”. This is certainly an approach we would advocate at Crew. As the paper describes “A good starting point is to assume that the patient might be ambivalent about change.” In Crew’s experience this is often the case. The very term “legal highs” which many users still apply, could arguably suggest use of these kind of substances is ‘safer’ than illicit substances to users. Teamed with a greater level of social acceptance for psychostimulants generally, it’s easy to see why a user may be ambivalent about change.

The key elements of motivational interviewing are its person centred and non judgemental approach which elicits motivation for change by providing feedback and rolls with any resistance encountered. As the paper explains “The key to motivational interviewing is to ascertain the patient’s concerns and respond accordingly; hold back from advocating change until a clearer picture is obtained”. The starting point for this is assessment, where it is crucial to establish the service users perception of the issues and most importantly what they wish to do about it. Depending on what setting you are working, one might expect if they have come forward to talk to you about it at all they may have at the very least a tiny seed of motivation for change. Of course it is possible the substance issue is not the key issue why that person has been referred and motivation for change may not be as immediately apparent. In these cases the recommended approach by Winstock and Mitcheson would be very effective:

(Winstock and Mitcheson, 2012).

In my own experience, the majority of clients would be willing to discuss substance use when it is introduced in this way. Where a client is completely resistant to talking about substance use as a problem, it may be that it is more appropriate to revisit at a later date rather than pursue at that time. Having introduced the topic and communicated to the client that any further discussions will move at their own pace, backing off is often very powerful and will make them far more likely to come to you when they do feel ready to discuss their use. The paper suggests ending any such interaction by seeking permission to review it again in the future. By doing this, you are making clear you are respecting the clients wishes not to discuss at this time but at the same time communicating that you are aware there may be a problem worthy of addressing.

Brief Interventions

MI techniques fit very well within brief interventions, something which the NHS has been applying to alcohol for a long time. Much of the NHS resources for alcohol brief interventions are transferable and adaptable to new psychoactive substances. There are many available at the Health Scotland website here. There’s also lots of good information available via SAMHSA in their Treatment Improvement Protocols collection, the brief intervention protocol is available here.

The paper goes on to highlight some useful techniques found in brief interventions including providing information and advice, feedback on risk, offering choices (menu of options) and signposting or referring. Where we have established problems related to drug use with a client, the paper suggests service users are more likely to be receptive to “expert information”. This could be described by specialist information given by the staff member gleaned from their knowledge and experience. It goes on to give an example: “When people use stimulants over a weekend and don’t get any sleep, it can lead to a reduction in the chemicals in your brain that help keep our mood stable and feeling happy”. Again this fits with Crew’s experience, through our client work we find the majority are very receptive to specialist information and often ask more detailed questions once rapport has been built. It is vital that the rapport is kept intact at this stage and it doesn’t fall into the “expert trap”, which is to be avoided within MI. The paper makes an excellent yet simple suggestion for this by suggesting “eliciting the patient’s response to that information (“How does that fit with your experience?”)” This simple open question communicates value and is likely to open up the interaction to change talk.

Another useful tool is the decisional balance. This is basically looking at reasons for and against change. This is done by exploring the costs of change against the benefits of change and then the costs of staying the same against the benefits of staying the same. You can talk this through with a client or you may find it useful to use a worksheet within the session so that you can compare the costs and benefits.

The paper also outlines some useful ways of broaching the subject of change:

“We’ve spoken about some of the concerns you have and how your drug use might be related to this̶, where do we go from here?” A direct question might be: “Would you like to do something about your drug use?”

If change is indeed established as a goal in accordance with the brief intervention structure, we must be clear of an exit strategy for the intervention, can we follow up with the client directly ourselves or is it more appropriate to signpost or refer on?

(If you are coming to CREWSUS, George Burton from STRADA will be joining me for the Legal HIghs & Emerging Trends plenary. STRADA also offer courses on MI & brief interventions. In Edinburgh, try NHS training.)

Harm Reduction

Where the client is more ambivalent to change, harm reduction advice (as the paper also identifies) is often an effective alternative. One of the key issues with new psychoactive substances is the lack of specialist knowledge, much of the knowledge base being taken from anecdotal reports. In these cases, we must refer to general safety tips and advice from other related substances. The paper describes this as ‘common sense advice”. Typical practical harm reduction advice for those determined to use may be around:

• Administration route- are there ways they can use more safely? E.g use rolled up card rather than money as tooter (snorting equipment) and don’t share with anyone else

• Test dosing- taking a very small amount and waiting an adequate amount of time before re-dosing. (some of the new psychoactives have delayed onsets so people should ideally be waiting 2 hours before re-dosing)

• Limit the amount they take in a drug using session

Other sensible advice as described in the paper is “reviewing the progression of any health concerns with a period of cessation, and total avoidance of the drug for people in high risk groups, such as those with pre-existing mental health issues.” Encouraging users to research the substance they are going to take is something we certainly do at Crew but as the paper correctly highlights, there are issues with user reports from Internet forums. They can be unreliable and are only one part of the picture.

Establishing Goals

Another approach I have found effective with this users group is solution focused therapy: there is a good article exploring its elements and uses here. The idea of focusing on solutions rather than problems is, again, very motivational. Techniques such as the miracle question and scaling questions are great at establishing goals both short and long term. In my experience, where someone is in the grips of problematic use, they can find it hard to establish aspirations and their self-efficacy may be non-existent. They are often not accustomed to being asked about their aspirations so this can be the start of a really powerful interaction.

The key for me is linking some of the more aspirational and long term goals into smaller and achievable goals. Again scaling questions can be used within this, for example “If 10 is where you want to be and 2 is where you are now, what things could you do to get you to move towards 3”. SMART goals are often effective here, so goals that are specific, measurable, achievable, realistic and time-based. If goal setting is applied correctly, it can be incredibly motivational. Where goals have not been achieved, it’s always worth reviewing them using the SMART framework as often it could be a case of simply moving too fast.

Though working with users of new psychoactives or legal highs can seem daunting for workers, the tools and techniques above can provide a framework for working effectively with a user of any substances.

Our drug counseling team will be providing some useful insights into other effective techniques in their workshop at the National event CREWSUS. Be sure to book your place now before you miss out! I’m also doing open workshop training in Aberdeen with the Incite team, April 24 & 25, please take a look.

Katy MacLeod,
Crew Training & Outreach Coordinator, CREW.

Want to book a ticket for CREWSUS online? Check here.

Up to a quarter of users may experience such problems and it appears that this is related to both the quantity used and the duration that it is taken for.

These symptoms are not to be taken lightly. Symptoms may have a big impact on the quality of life. When extreme, there are reports of needing to pass urine up to 20 times an hour, incontinence and severe pain. Some users have such severe problems that they may even develop kidney failure. Others may need a catheter (tube into the bladder) and some have needed their bladders removed: a major operation that is irreversible.

Bladder problems may mimic common conditions such as urine infections. It may be difficult to diagnose ketamine associated bladder problems, partly because this is such a new condition and GP’s may not have seen it before but also because suffers may not be forthcoming with information about their ketamine use even though they may be well aware themselves that their problems are related.

On a positive note however, problems may improve if ketamine use is stopped and may even be reversible. A team approach may be required to address pain, ketamine use and urinary symptoms to achieve an improvement. As ketamine related bladder problems are such a new entity, further work is needed to determine how ketamine affects the bladder and what the long term health effects are on the body.