What options are you left with once you’ve cycled through all available antidepressants, but your depression remains? Or when your doctor is telling you that you’re not eligible for medication because you didn’t suffer from attention deficit hyperactivity disorder (ADHD) as a child? Some individuals are taking matters into their own hands and using Novel Psychoactive Substances (NPS) – also known as research chemicals or legal highs – to self-medicate their disorders.
What are NPS?
The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) defines NPS as:
‘a new narcotic or psychotropic drug, in pure form or in preparation, that is not controlled by the United Nations drug conventions, but which may pose a public health threat comparable to that posed by substances listed in these conventions’.
Somewhat unhelpfully, this nebulous category spans a diverse array of substances constantly in flux, with new substances included each year. Several different classes of NPS exist, with substances often mimicking ‘classic’ illicit substances. Originally in the UK, this made them popular as they circumvented control by the Misuse of Drugs Act 1971. However, the production, sale, and supply of many of these substances is now controlled by the Psychoactive Substances Act (PSA) 2016. Previous research has tended to focus on their exploratory use by self-proclaimed ‘Psychonauts’, yet new data suggests that they may also be being used to self-medicate a variety of disorders.
Why use NPS to self-medicate?
The practice of self-medication is nothing new. All of us have reached for a paracetamol after developing a headache, or flu medication upon feeling the start of a cold. Self-medication provides obvious benefits such as ease of access and a reduced burden on the healthcare system. However, self-medication also poses risks. For NPS, the limited data on their use in humans magnifies this risk. What is it then that makes them appealing candidates for self-medication? In a recent study by Kings College London, we explored this novel phenomenon.
Anxiety was one of the most commonly self-medicated disorders, usually using a novel benzodiazepine (NBZD). The most discussed of these was clonazolam – a derivative of the legal benzodiazepine alprazolam (Xanax) – and etizolam. These were sometimes used in conjunction with, or instead of, prescription benzodiazepines. These NPS were usually more potent, and cheaper, than prescription ones – clonazolam being 2.5x more potent that alprazolam. This sometimes resulted in individuals reaching doses so high that they were refused help through specialist services, leaving them to source their own benzodiazepines for tapering (the slow reduction of dose) or risk seizure:
“Ironically, I’ve ended up using flubromazolam […] to taper with after getting rejected by local healthcare/addiction “specialists” because they weren’t willing to take me on once they made a benzo conversion”.
NBZD’s were effective in treating acute anxiety, but without the oversight of a healthcare professional often resulted in negative long-term consequences:
“Have had crazy social anxiety my entire life so I started using it more and more [..] soon I was taking probably 50mg of etizolam a day, my usage just kept climbing higher and higher […], right after my birthday last year I got a DUI.”
Despite the National Institute for Health and Care Excellence (NICE) guidelines only recommending the short-term use of benzodiazepines, many find themselves on prescription medication for years. Recently, issues of over prescribing in the US have led to an attempt to reduce prescriptions. With many NPS still readily available we need to consider that this could push some people towards self-medication, potentially a more dangerous outcome than keeping them within the medical system.
ADHD and similar attentional deficit disorders were also among those being self-medicated. The novel stimulants 2-fluromethamphetamine and 4-fluromethylphenidate were the two main candidates for ADHD self-medication. In part, their popularity was due to their structural similarity to the prescription medications Adderall (amphetamine) and Ritalin (methylphenidate). Opting for NPS over prescription medication also meant saving on diagnosis and medication fees.
The adult diagnosis of ADHD remains a contentious issue, with some countries unwilling to recognise ADHD in adults who were not diagnosed as children. This motivated self-medication for some:
“We tried 2fma and she suddenly felt like a normal person. Here in DK[Denmark]/Europe I heard there is reluctance [to diagnose] especially when you do it as an adult as some line of thought says you must have it [ADHD] as a child to have it as an adult.”
A common theme throughout was ‘Functionality’. This encapsulated the idea that a substance should facilitate one’s functioning, not hinder it. NPS were often compared through this lens:
“4f-mph has worked better for me than any other medication I have tried for adhd. I can retain an appetite, don’t get stim stutters, I fall asleep on it quite easily, and it is amazingly functional.”
The prevalence of treatment-resistant depression is increasing. Novel treatments, such as ketamine, appear promising. Although, for many, these treatments remain out of reach due to their experimental nature or high cost. Our research showed a clear desire of some to save on costs and replicate these treatment protocols using NPS:
“Deschloroketamine obliterates my depression for two days after using.”
“From my understanding of the ketamine trials, a low dose of around 30mg […] showed a rather substantial decrease in depressive symptoms […] I would like to attempt something like this. Which of the dissociatives currently available would you consider best for such an experiment?”
Throughout, the willingness to use NPS seemed fuelled by a dissatisfaction and stigma towards modern antidepressant medication, with many experiencing adverse side effects.
The future of NPS and mental health issues
While it is currently unclear how many individuals are self-treating with NPS, it does seem that mental healthcare options globally are lacking, and traditional treatment methods are not working. Additionally, we live in an era where we are incredibly self-aware, with an abundance of information available at our fingertips. While this self-awareness is celebrated, it also likely contributes to individuals identifying psychological symptoms and attempting to self-medicate. With growing mental health issues, self-medication is unlikely to go away. Clearly, unsupervised self-medication with unstudied chemicals is not the answer, but at the same time should we be making more of an effort to pursue alternative pharmacological options instead of introducing more prohibitive legislation, some of which effectively bans substances before they exist (PSA 2016)?
There is currently a convergence between prescription medication and illicit substances occurring and for as long as we have mental health issues lacking treatment options people will be willing to search for alternative options, despite their risks:
“You see, we must walk this very thin line between, on the one hand, having to self-medicate because, having no access to genuinely effective medication, we’re rendered completely dysfunctional and unproductive if we don’t, and, on the other, having to battle the addiction issues […] if you decide to self-medicate ∗every day∗ with extremely addictive substances”
Tayler Holborn is a PhD student at King’s College London and volunteer researcher with The Loop. His recent work focuses on the use of Novel Psychoactive Substances (NPS). Tweets @T_Holborn