Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health (Swansea University, 2011) more

Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health Ashleigh Cullen 529596 Date of submission: 01/04/2011 Supervisor: Andy Parrott Degree Scheme: BSc Psychology (Hons.) Word count: 12985 1 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health Table of Contents Abstract p. 3 Introduction pp. 4-13 Method pp. 14-21 Results pp. 22-31 Discussion pp. 32-47 References pp. 48-57 2 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health Abstract Mephedrone is a new recreational drug on the illicit market. Although it was centre of media attention for some time, there is little research pertaining to its use and effects. The intention of this study was to examine the association between mephedrone, cannabis and alcohol and mental health and well-being with regard to depressive symptoms. A total of 115 participants were sourced from social networking websites and drug related forums to complete a three part online questionnaire. The first stage investigated lifestyle and drug use, the second required completion of the Center of Epidemiological Studies Depression Scale (CES-D), and finally reasons and opinions for mephedrone and other drug use were questioned. The data pertaining to lifestyle, drug use and was compared against CES-D depression scores in a one way ANOVA. There were no observed differences between mephedrone and alcohol use on depression scores, however, there was an observable difference between cannabis and mephedrone. Results illustrate that use of mephedrone has a higher potential for causing depressive symptoms than the use cannabis and alcohol, but not alcohol alone, and that mephedrone users also use a wide variety of other drugs. Percieved benefits and increase in feelings of happiness were associated with consumption. The findings support the theory that users of mephedrone may suffer similar neurochemical depletion to users of ecstasy, but it remains unclear whether this is due to mephedrone, or whether it is contribution from other drugs of use. This study has gathered a fair amount of additional qualitative research surrounding the use of mephedrone that may be of use to future larger-scale studies. 3 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health In the past few decades, researchers have dedicated much time to investigating the harmful effects of drugs in promotion of public health, safety, and well-being. Amongst the literature, alcohol and cannabis appear to be the most common drugs of use, and their detriments have been widely researched (Ashton, 1999). However, there is a new type of recreational drug available on the market, known as mephedrone (4methylmethcathinone), which has similar effects to cocaine, ecstasy/MDMA and amphetamine (Dyer, 2010; Winstock, Mitcheson, Deluca, Davey, Corazza, & Schifano, 2010; Winstock, Marsden, & Mitcheson, 2010). Also known as M-Kat and Meow-Meow, mephedrone poses many new complications to the understanding of modern drug risks, as there is little known about the risks to physical and mental health (Gibbons & Zloh, 2010; Morris, 2010). In effort to promote health and safety advice surrounding the use of mephedrone, in the same way as other illicit drugs, a vast amount of thorough scientific investigation is necessary. Although Mephedrone and its related synthesised compounds have had a relatively new appearance on the drug market, it has a familiar origin. Mephedrone is a synthesised keto-amphetamine taken from the plant alkaloids of the Khat plant Catha edulis, and is part of the cathinone (norpseudoephedrine) family (Measham et al., 2010; Sammler, Foley, Lauder, Wilson, Goudie, & O‟Riordan, 2010). The Khat plant is typically found in Africa and Eastern countries, where locals chew the leaves for their stimulant effects (Wood et al., 2010). The Khat leaf and mephedrone relationship appears to be similar to coca leaves and cocaine, as natives chew coca leaves for energy and focus. Although the use of Khat leaves amongst immigrants is familiar, the synthesised substances such as mephedrone are not, and if the 4 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health relationship between Khat leaves and mephedrone is similar to that of coca leaves and cocaine, mephedrone could illustrate to have stronger addiction and danger potential, than chewing Khat leaves. Mephedrone was legally available to purchase in the UK until prohibition in April 2010 and studies have illustrated that prohibition has had only a slight effect on its availability and widespread use (Winstock et al., 2010). It was originally sold on the internet and marketed as a plant fertiliser, which allowed distributors to avoid legal responsibility and made it fairly difficult to prohibit (Dyer, 2010; Wood, Davies, Puchnarewicz, Button, Archer, Ovaska, Ramsey, Lee, Holt, & Dargan, 2010). The success of this marketing scheme was mainly due the warning attached to the packet, which clearly stated that the substance was not for human consumption (Dyer, 2010; Winstock et al., 2010). This allowed the recreational drug to exist, as it was intended for plant fertilisation not human use, without attention from authorities for some time (Dyer, 2010). This marketing scheme did not allow for safety or dosage instructions for human consumption, and accompanied with little scientific knowledge of the substance, it posed and still poses, a significant risk to recreational users (Measham, Moore, Newcombe, & Welch, 2010; Morris, 2010; Winstock et al., 2010). The legality of the substance allowed for easy access, online availability, discreet delivery, and avoidance of street dealers, however, the substance is now a class B. The prohibition of mephedrone may have affected its recreational use only slightly, as it is still available from illicit dealers, for almost double the price (Winstock et al., 2010). The present substantial research on mephedrone explains that it is similar in structure and offers similar effects to ecstasy/MDMA. However, it is also described to share a likeness with cocaine and amphetamines. These effects include elation and euphoria, grinding of the teeth, dilated pupils, rising body heat, and resulting low 5 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health mood in the following days, which is suggested to be worse than the „midweek blues‟ observed in ecstasy/MDMA users (Winstock et al., 2010). It is purchased as a crystal like substance, for around £10/15 per gram, and is ingested orally or nasally in the method of „snorting‟, and is described as smelling like a cross between vanilla and bleach (Measham et al., 2010; Winstock et al., 2010). Due to its chemical structure, it is suspected that mephedrone stimulates release of and subsequently inhibits the reuptake of monoamine neurotransmitters (Winstock et al., 2010). Current research describes mephedrone as being a very dangerous and addictive drug, detrimental to physical and psychological health, and promises no medicinal value (Gibbons & Zloh, 2010). It has been mainly adopted amongst the clubbing sub-culture but has also been reported being used by other groups of adults and older adolescents. The negative effects of mephedrone can also include nose burn and bleeds, shrinking of the genitals in males, blurry vision, and alternating body temperature (Measham et al, 2010). On a more extreme scale, some users have experienced negative physical complaints of poor circulation in fingers and toes, leaving their digits feeling cold and sometimes turning blue (Winstock et al., 2010). Some studies have suggested that mephedrone causes similar „come-down‟ after-effects to other stimulants such as ecstasy/MDMA, cocaine and amphetamines. This includes fatigue and symptoms of depression. It has been noted that users of mephedrone may experience more severe symptoms of depression with prolonged or long-term use, due to serotonergic and dopaminergic neurochemical dysregulation (Psychonaut WebMapping Research Group (PWRG), 2009; Schifano, Albanese, Fergus, Stair, Deluca, Corazza, Davey, Corkery, Siemann, Scherbaum, Farre‟, Torrens, Demetrovics, Ghodse, Psychonaut Web Mapping, & ReDNet Research Groups, 2011). Serotonin depletion is typically observed with users of 6 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health ecstasy/MDMA, and results in feelings of anxiety, irritability and depression. It is thought poor quality of sleep and related lifestyle choices of this type of drug user, contributes to the negative feeling presented by serotonin dysregulation (Dinges, Pack, Williams, Gillen, Powell, Ott, Aptowicz, & Pack, 1997; Parrott, Sisk, & Turner, 2000; Banks & Dinges, 2007; Jones, Callen, Blagrove, & Parrott, 2008; Schierenbeck, Riemann, Berger, & Hornyak, 2008; Fisk & Montgomery, 2009). One case study has illustrated mephedrone dependence and psychosis through use, however, recovery was made after inpatient treatment and administration of the anti-psychotic olanzapine (Bajaj, Mullen, & Wylie, 2010). Although recent research suggests that mephedrone is similar in effect to MDMA, amphetamine and cocaine, it is a separate drug, which needs greater investigation. In questioning the effects and risks of mephedrone, it is also necessary to consider its concurrent use with other substances. The users of mephedrone have been reported to use other substances including alcohol, cannabis, amphetamine, cocaine and ecstasy, with alcohol and cannabis being the main drugs of concurrent use (Measham et al., 2010; Gibbons & Zloh, 2010; Winstock et al., 2010). This may be because alcohol and cannabis are two of the most commonly abused substances in the UK. There is much research to support the detrimental effects of these cannabis and alcohol when used alone or together, and with other drugs (Ashton, 1999). However, there is little known about the use of mephedrone in the equation (Gibbons & Zloh, 2010). Cannabis symptoms can include paranoia, nausea, lethargy, depression, anxiety and a regular cough from smoking. These effects can be heightened by the simultaneous use of alcohol and other drugs (Ashton, 1999). Alcohol is widely available in most countries of the world, and its social acceptance and availability means it is often used in conjunction with other drugs (Harris & Alan, 1989). Alcohol 7 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health lowers inhibitions and alters normal judgement, which may lead a non-drug user to try a drug when in sobriety they may not. Studies illustrate that alcohol is often consumed with mephedrone in a party or clubbing environment, and cannabis is used to alleviate the „come-down‟ period (Measham et al., 2010). When alcohol is consumed with other drugs, it can dramatise the effects and sometimes pose a serious danger. In regards to amphetamines and ecstasy/MDMA, alcohol can dangerously affect hydration levels and exaggerate vulnerability to shock and disorientation (Thomas, 1996). In regards to cannabis, the concurrent use of alcohol or amphetamines can worsen anxiety and paranoia (Thomas, 1996). As mephedrone is likened to ecstasy/MDMA, cocaine and amphetamine, concurrent use with cannabis and alcohol may present similar negative effects, such as dehydration and paranoia. In a more severe case of poly-drug use, there has been a case of intravenous mephedrone use in conjunction with heroin, in a method known as „snowballing‟. Snowballing is usually the use of heroin and crack cocaine in the same syringe and is extremely addictive and dangerous. This case of mephedrone „snowballing‟ illustrated to be fatal due to toxicity (Gibbons & Zloh, 2010; Dickson, Vorce, Levine & Past, 2010). As the negative effects of mephedrone appear to be worse than ecstasy/MDMA, amphetamine and cocaine, is necessary to consider the reason for its sudden popularity and widespread use. It appears that legality, availability and price are paramount factors, and some users have argued that their reason for use is the decline of good quality illegal recreational drugs, such as cocaine and ecstasy/MDMA (Measham et al., 2010; Winstock et al., 2010). This may reflect the recent success of stricter border control and large cocaine and ecstasy/MDMA drug seizures in the UK (Brunt, Poortman, Niesink, & van den Brink, 2010; Measham et al., 2010). The legality, availability, uncut quality and low price of mephedrone appear be some of 8 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health the main reasons for use and popularity (Dyer, 2010; Measham et al., 2010; Wood et al., 2010; Winstock et al, 2010). The legal and illicit classifications of drugs appear to present some confusion towards health related decisions. Many individuals viewed mephedrone and accept legal highs, such as benzylpiperazine, or „BZP party pills‟, as safe due to their legal status (Measham et al., 2010). This bears question to whether the average individual bases the danger of illicit drugs on the classification system, i.e. C is safer than B, and A is more dangerous than B, etc. However, this is not always the case in regards to physical or psychological harm, such as the previously legal mephedrone, and making judgements based on this schema could illustrate to be unsuccessful (Measham et al., 2010). Some have argued that the UK classification system does not properly reflect the dangers of drugs in order, especially in consideration to cannabis, ecstasy and LSD. This may illustrate that in order to provide good quality public health information, more emphasis must be placed on the effects of usage over drug classification systems, and that legal drugs can pose risks to health, just as illegal drugs. The aim of prohibition and criminalisation is to protect national health and well being, and as the use of recreational substances can be very dangerous and poses a significant risk to the public, it causes authorities to immediately prevent such behaviours through means of law. However, this does not necessarily prevent such behaviours, as many individuals use illicit drugs despite fear of criminalisation. It appears that the approach of prohibition and criminalisation provides more harm to the individual drug-user than its intention of protection. This is for a variety of reasons, but one of the main arguments is that illegal drugs are not health and safety monitored by authorities, in the same way as alcohol. The individuals who market 9 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health illegal drugs are not usually more concerned about cash flow than drug users safety, and these substances are often contaminated and diluted, there is also danger in associating with street dealers. This is accompanied legal penalisation of the individual. These are some of the reasons for the sudden popularity of mephedrone, and whilst mephedrone and the cathinone family are now banned in the UK, the designer chemists threatened to continue fabricating compounds which do not yet have any legislation. These threats have been fulfilled in the appearance of NRG-1 and other substances (Brandt, Sumnall, Measham, & Cole, 2010). However, some studies have illustrated that these „legal‟ drugs contain mephedrone and mephedrone like substances, of which are now illegal, and it is warned that the individuals should be vigilant in their purchase. Some have argued that this scenario could eventually lead to the fabrication of unlegislated chemicals which are potentially more dangerous to the user than substances such as mephedrone (Winstock et al., 2010). This bears question whether prohibition is the best main method of action in addressing this type of substance misuse. It is necessary to examine the cause or the reasons for the widespread issue of substance use, in order to prevent risk behaviour (Gibbons & Zloh, 2010). With the release and subsequent popularity of mephedrone, it is evidential that there is a high desire for consciousness-altering substances within the UK, particularly with weekend club/party-goers (Winstock et al., 2010). Studies have illustrated that availability and cost are major influences in the use of mephedrone (Measham et al., 2010; Gibbons & Zloh, 2010; Winstock et al., 2010; Wood et al., 2010) However, there are many theories for drug use. The full causation of substance use is still unclear. This may be due to the vast range of substances which are abused, the way they are used and also, individual 10 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health differences of person. Many public health organisations view „drug abuse‟ as an array of addictions, all pertaining to the same underlying diagnosis of addiction, however, Johnson and Gerstein (1998) explain this as being the reason why substance abuse poses such mystery. It is necessary to examine each drug on its own in order to gain a greater perspective of the reasoning behind substance abuse. Generalising a vast spectrum of substances that work differently and produce a wide range of effects, as a different stroke of the same disorder is very limiting to understanding the real reasons of abuse (Johnson & Gerstein, 1998). In effort to clarify substance use causation, it is necessary to examine each drug of abuse in its own right and to evaluate crucial predictors, so that those at risk can be informed and aware of their choices, and practitioners can formulate best methods of approach. Some suggest that substance misuse is genetic, and that internal chemistry and biology can predispose some individuals to abuse substances such as alcohol (Searles, 1988). Others propose that some substance use, such as alcohol and nicotine, is performed to alleviate feelings of anxiety and depression, and those more sensitive to negative feeling may be inclined to use more often (Stewart, Karp, Pihl, & Peterson, 1997). However, social and pleasure factors are also implicated in the mediation of substance use behaviour, these include staying awake to socialise and enjoying the feeling of intoxication (Boys, Marsden & Strang, 2000). It appears that most substance use can be explained by genetics, environment and psychosocial factors; however, individual differences between people and substances can affect the weight of each factor. Substance use often runs alongside psychiatric disorders. This has caused professionals to consider whether the psychiatric disorder initiates the drug use, or whether the drug use initiates the disorder. However, it is thought that individuals with psychiatric conditions will sometimes „self-medicate‟ to deal with 11 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health their issues, but in turn this can worsen original problem (Merikangas, Mehta, Molnar, Walters, Swendsen, Aguilar-Gaziola, Bijl, Borges, Caraveo-Anduaga, Dewit, Kolody, Vega, Wittchen, & Kessler, 1998). Although users provide different reasons for using different drugs, coping methods are often indicated. Amongst the literature, societal stressors and socioeconomic status are mentioned as contributing factors for use. Societal or social stressors can be difficulties in obtaining desired social status, lack of community support, and general day to day stressors such as inability to pay bills or encountering others who are inconsiderate or insulting (Boardman, Finch, Ellison, Williams, & Jackson, 2001). This presents a controversial matter, as society places stress on the individual, who subsequently abuses legal or illegal drugs, and society then punishes the illicit drug user, in order to protect health and wellbeing. Although at first prohibition appears to be the correct response in dealing with dangerous drugs, it does not properly resolve the initial issue. The most important factor in the prevention of using dangerous drugs is to properly educate the individual. If society continues to advance and grow, and stressors become greater, it is possible that in the future, individuals may be more reliant on drugs to enable them deal with daily life. It is necessary to educate about drugs as coping methods, and healthier alternatives, such as exercise and healthy diet which promote stress relief and well-being in the longer term. It is clear that more effort must be exerted in finding out the reason behind the adopted modern day drug use behaviour in order to prevent, educate and campaign against unhealthy and risky decisions (Gibbons & Zloh, 2010). However, this is a difficult topic to examine as drug use is a very subjective matter, and reasons can be very diverse in nature. 12 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health Some authors have described the theory of reasoned action (TRA) and the theory of planned behaviour (TRB) as an explanation for illicit drug use (Fishbein & Marsden, 1987; Ajzen, 1991). The TRA and TRB work on an equation basis, and evaluations of perceptions of self-conducted behaviour illustrate good predictors of use. The TRA broadly explains likelihood of engaging or avoiding certain behaviours, as a set of cognitive evaluative hypotheses. Firstly, there is an evaluation of a given behaviour and personal intention, with a positive, neutral or negative evaluation of the behaviour, and an evaluation of the behaviour in respect to social norms. These factors are compared and „added-up‟ to determine behaviour. However, these beliefs are not always the same for different individuals and circumstances, and one person‟s belief structure for using drugs may be completely different to another, but still arrive at a similar evaluation. It is noted that salient and normative beliefs differ across individuals and populations, and these beliefs must be examined to understand the motivation underlying certain behaviour (Fishbein & Marsden, 1987). This study aims to examine the impact of mephedrone use on mental health and wellbeing, by inspecting its potential for causing depressive symptoms. It also aims to explore the relationship between mephedrone and other drugs. It will mainly examine this with cannabis and alcohol use as they are the most commonly reported accompanying drugs of use. It also aims to gather a greater understanding of mephedrone use and reasons for substance use. The hypothesis is that mephedrone has a greater potential for causing depressive symptoms than alcohol and cannabis, respectively, and that mephedrone users will present greater depressive symptoms if used in conjunction with cannabis and alcohol. 13 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health Method Participants There were 94 participants, 48.9% were male (Mean age = 26.07, SD = 7.368) and 51.1% were female (Mean age = 24.87, SD = 5.873). They were sourced via online forums and social networking websites using the „snowball‟ method, and represented an international demographic including Wales (42.6%) rest of UK (22.3%), rest of Europe (5.3%), USA (24.5%), and elsewhere in the world (5.3%). They were students (44.1%), in employment (30.1%) and self-employed (10.8%). An incentive was provided through a prize draw for gift vouchers. The study recruited 115 participants in total; however, 26 were excluded from the analysis through incomplete CES-D questionnaires or reported use of heroin. Users of heroin were excluded because of the nature of the drug and how it causes users detached or numbed to negative feeling and emotional pain (Aharonovich, Nguyen, & Nunes, 2001). Those abstaining or recovering from the drug were also disregarded, because of the depression, guilt, and shame, which is observed amongst recovering heroin addicts related to their drug abuse (Meehan, O'Connor Berry, Weiss, Morrison, & Acampora, 1996). Respondent entries with missing cases on the CES-D questionnaire were not included in the main analysis in order to avoid false low depression scores. Materials The student self-designed and programmed a three-part JavaScript and PHP online questionnaire application linked to a security protected MySQL database storage system. The questionnaire was programmed to disable the „enter‟ and „backspace‟ 14 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health keys of the keyboard, to prevent accidental submissions and loss of data. The participants were required to click on the submit button to submit data, and would have to intentionally close the webpage to abort the study. Multiple responses were controlled for through attaching the date and time of submissions in the event that the submit button was clicked more than once, if submission dates and times were very similar, all but the first of each case were disregarded. The questionnaire was programmed to allow participants to leave null answers, some online questionnaires do not allow this and enforce that an answer must be given for each question. This method was not adopted as some authors have reported that ecstasy/MDMA users will often miss elements of a task, such as a questionnaire, due to problems with impulsivity or serotonergic dysregulation, and working and prospective memory (Rodgers, Buchanan, Scholey, Heffernan, Ling, & Parrott, 2001). Participants were allowed to leave blank responses to all the questions, including those that applied to all groups. Table 1. An example of questionnaire one before selecting substances Q1. What is your occupation? Student Employed Self-emplyed Unemployed Unemployed due to sickness Other (Please give details) Q2. Please give details about some of your hobbies and interests 15 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health Q3. Are you prescribed medication? No Yes (Please give details) Q4. Would you consider yourself healthy? Yes No (Please give details) 5. Please state whether you use, or have used any of the substances below (check all that apply). Note, for each selected substance please explain the benefits and risks that you are aware of, how much you consume/d e.g. amount per day/week and the last time you consumed. Please try to be as specific as possible. Caffiene Yes Nicotine Yes Alcohol Yes No No No Cannabis Yes No Amphetamine Yes Cocaine No 16 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health Yes No Ecstasy/MDMA Yes No Meow-Meow/Mephedrone Yes Other Yes No (Please state) No Please check all answers before clicking submit Submit Reset The first part questionnaire investigated occupation, hobbies, interests, health, medication, and drug use. The drugs caffeine, nicotine, alcohol, cannabis, amphetamine, cocaine, ecstasy/MDMA, mephedrone were listed, and there was one „other‟ box to allow respondents to specify drugs not included in the study, see above (table 1). The questionnaire was designed so that participants had to respond yes or no to each of the substances, which was partly to control for issues in working memory, as described above. Upon selecting yes for any of the substances, the questionnaire was programmed to present the participants with additional questions investigating the cost/benefit ratio, consumption in lifetime, last use, feelings of happiness and subsequent feelings of depression for each substance, see below (table 2). This part of the questionnaire aimed to explore the participants‟ drug use, whilst controlling for extraneous variables that may contribute to depression, such as sickness or unemployment, and lack of hobbies and interests. 17 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health Table 2. Examples of presented additional questions upon selecting a substance Alcohol Yes No Does Alcohol Does Alcohol make make you feel you feel happy? depressed afterwards? No Slightly Moderately Strongly Very Strongly No Slightly Moderately Strongly Very Strongly Benefits Risks Consumption Last time of use None Few Some Many Plenty None Few Some Many Plenty Less than 1 unit a week 1-10 units a week 10-20 units a week 21-40 units a week 40+ units a week Cannabis Yes No Does Cannabis make you feel happy? No Slightly Moderately Strongly Very Strongly Does Cannabis make you feel depressed afterwards? No Slightly Moderately Strongly Very Strongly Benefits Risks Consumption Last time of use None Few Some Many Plenty None Few Some Many Plenty Less than once a month 1-3 times a month Once a week 2-4 times a week Daily Mephedrone/Meow-Meow Yes No Does Mephedrone make you feel depressed afterwards? Benefits Risks Consumption Last time of use Does Mephedrone make you feel happy? 18 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health None Few Some Many Plenty None Few Some Many Plenty 1-2 times in life time 3-10 times in life time 10-30 times in life time 31-50 times in life time 51+ times in life time No Slightly Moderately Strongly Very Strongly No Slightly Moderately Strongly Very Strongly To investigate the participants‟ well-being and emotional state, the second part of the questionnaire used the Center of Epidemiologic Studies Depression Scale (CES-D). The CES-D is a formulated scale to measure the severity of depressive symptoms and was created by using elements from other valid depression scales. It examines the level of depressive symptoms, including feelings of helplessness and hopelessness, loss of appetite and motivation, sleeping problems, and feelings of worthlessness and guilt (Radloff, 1977). The CES-D lists 20 statements relating to depressive symptoms and wellbeing, such as „I felt depressed‟, „Everything I did felt like an effort‟ and „I felt hopeful about the future‟, in regard to the past week, see below (table 3). Table 3. A section example of the CES-D questions and responses 6. I felt depressed. Rarely or none of the time (<1 day) Some or a little of the time (1-2 days) Occasionally or a moderate amount of the time (3-4 days) Most or all of the time (5-7 days) 19 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health 7. I felt everything I did was an effort. Rarely or none of the time (<1 day) Some or a little of the time (1-2 days) Occasionally or a moderate amount of the time (3-4 days) Most or all of the time (5-7 days) 8. I felt hopeful about the future. Rarely or none of the time (<1 day) Some or a little of the time (1-2 days) Occasionally or a moderate amount of the time (3-4 days) Most or all of the time (5-7 days) .These responses are accompanied by a valued ranging from „0‟ to „3‟, „0‟ being the least depressive response and „3‟ being the most depressive response (Radloff, 1977). The value from „0‟ to „3‟ attached to the response would change depending on whether the statement was related to negative or positive affect. This helps to control for response bias, in calculating an overall score. The scores of the CES-D can range from 0 to 60 and reflect the frequency of experienced depressive symptoms. It is considered that although there is no definite cut-off point, a CES-D score of 16 or higher is thought to be guideline of concern for mild to moderate depression (Radloff, 1977), and individual scores can gauge severity of client depressive symptoms. The third part of the questionnaire investigated opinions about substance use and mood, reasons for substance use, and opinions about mephedrone use. 20 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health The final part of the questionnaire held three questions asking the participants for their opinions on substance use. The first question required participants to explain their beliefs on substance use and mood. The second question asked participants to explain their reasons for using each substance reported in the first questionnaire. The third question asked participants for their opinions about substance use and mood, reasons for using drugs and opinions of the use of mephedrone. Procedure Each participant completed the questionnaire on their own personal computer or laptop in their choice of location. The participants were instructed on the screen to complete the questionnaire drug-free, in a quiet area free from distraction. Details were provided on screen describing the outline of the study, participant requirements and the confidential and ethical conduct of the study. Participants were also provided with contact details for the event of technical errors, confusion over instructions, or if they felt that they had additional relevant information relevant to the study topic. The participants were required to give consent to the study by entering their name and email and clicking on a proceed button. Once the participants completed all three questionnaires, they were presented with helpline numbers for drug use and counselling in the event that any personal issues were raised by the questions. 21 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health Results The participants reported a wide range of drug use including alcohol, nicotine, cannabis, ecstasy/MDMA, amphetamine, cocaine, mephedrone, dimethyltryptamine (DMT), lysergic acid diethylamide (LSD), ketamine, psilocybin, painkillers, tranquilisers, methylone, methylenedioxypyrovalerone (MDPV) and other drugs (fig. 1). Other Psilocybin MDPV Ketamine Methylone Tranquilisers Painkillers LSD DMT Mephedrone Amphetamine Cocaine ecstasy/MDMA Cannabis Nicotine Alcohol 0 10 20 30 40 50 60 70 80 90 100 Fig. 1. Overall participants reported drug use However, the participants were divided into the drug groups of alcohol, cannabis and mephedrone, as these were of main interest. The alcohol group also used nicotine, ecstasy/MDMA, amphetamine, cocaine, LSD, tranquilisers, painkillers, and „other‟ drugs (fig. 2). 22 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health Other Painkillers Tranquilisers LSD Cocaine Amphetamine ecstasy/MDMA Nicotine 0 2 4 6 8 10 12 Fig. 2 Alcohol group reported use of other drugs The cannabis group also used alcohol, nicotine, amphetamine, cocaine, ecstasy/MDMA, Dimethyltryptamine (DMT), lysergic acid diethylamide (LSD), methylone, painkillers, tranquilisers and „other‟ drugs (fig. 3). Other Tranquilisers Painkillers Methylone LSD Dimethyltryptamine (DMT) ecstasy/MDMA Cocaine Amphetamine Nicotine Alcohol 0 5 10 15 20 25 30 35 Fig. 3 Cannabis group reported use of other drugs The mephedrone users also used nicotine, alcohol, cannabis, amphetamine, cocaine, ecstasy/MDMA, DMT, ketamine, tranquilisers, painkillers, LSD Methylenedioxypyrovalerone (MDPV), and „other‟ drugs (fig. 4). 23 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health Other MDPV LSD Painkillers Tranquilisers Ketamine DMT Amphetamine Cocaine ecstasy/MDMA Cannabis Nicotine Alcohol 0 5 10 15 20 25 30 35 40 45 Fig. 4 Mephedrone group reported use of other drugs The means (M) and standard deviations (SD) of the drug group depression scores were calculated as follows, alcohol (M = 20.294 SD = 10.734), cannabis (M = 15.600 SD = 13.226) and mephedrone (M = 23.282 SD = 13.877). The participant data was entered into a one-way between subjects ANOVA, to compare the effect of drug use (alcohol, cannabis and mephedrone) on depression scores. This did not show a significant difference between drug use and depression scores, [F (3, 90) = 2.594, p = .057]. A Tukey HSD post hoc comparison was used for further investigation. The Tukey HSD illustrated that the cannabis users (M = 4.778, 95% CI [10.227, 19.384]) had lower depression scores than the mephedrone group (M = 23.024, 95% CI [18.730, 27.318]), p = .038. Comparisons between alcohol (M = 20.294, 95% CI [14.775, 25.813]) and cannabis (M = 4.778, 95% CI [10.227, 19.384]) p = .487, and alcohol and mephedrone (M = 15.333, 95% CI [-25.510, 51.177]) p = .884, did not show significant differences in depression scores at p = <.05. Overall, a high number of participants had a CES-D score of 16 or higher (52.1%), which is thought to be a concern guideline for mild/moderate depression. 24 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health The depression indication data was entered into a one-way ANOVA, to observe the differences between mephedrone, cannabis, and alcohol. There was a significant difference observed between cannabis, and mephedrone and alcohol, and depression indication [F (3, 90) = 5.255, p = .002]. The Tukey HSD post hoc analysis illustrated that the cannabis group (M = 1.273, 95% CI [1.112, 1.433]) had significantly less participants with a CES-D score of 16 or higher than the mephedrone (M = 1.659, 95% CI [1.507, 1.810]) p = .004 and alcohol (M = 1.706, 95% CI [1.464, 1.947]) p = .014, but significant differences were not observed between the mephedrone and alcohol groups, p = .985. This study observed no significant effects for depression scores and gender, [F (1, 92) = .006, p = .940], location, [F (4, 89) = .954, p = .437], occupational status, [F (4, 88) = 1.386, p = .245], or active/physical hobbies [F (1, 92) = .049, p = .825]. The mephedrone group were questioned on their percieved benefits and risks, increase in feelings of happiness and subsequent feelings of depression, for which there were two responses, „high‟ and „low‟, this was examined against consumption (times in lifetime) in a one way ANOVA. There were no significant differences observed between the mephedrone group subgroups of consumption (times in lifetime) and percieved risks [F (4, 36) = 1.701, p = .171]. There were also no significant differences observed between consumption and subsequent depression F (4, 30) = .716, p = .588]. Perceived benefits of mephedrone were compared between consumption subgroups. There was a significant difference observed between mephedrone consumption and percieved benefits, [F (4, 36) = 4.306, p = .006]. The Tukey HSD demonstrated that significantly more participants in the 51 times or more (in lifetime) consumption subgroup (M = 1.90, 95% CI [1.624, 2.167]) percieved mephedrone as offering a „high‟ amount of benefits than the 1-2 times (M = 1.250, 25 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health 95% CI [.941, 1.559]) p = .024, and 3-10 times subgroups (M = 1.300, 95% CI [1.024, 1.576]) p = .028, but no significant differences were observed for the other two groups p = < .05. Perceived increase in feeling of happiness through mephedrone intoxication was compared between consumption subgroups. There was a significant difference observed between mephedrone consumption and percieved increase in feelings of happiness, [F (4, 36) = 4.751, p = .004]. The Tukey HSD demonstrated that significantly more participants in the 51 times or more (in lifetime) consumption subgroup (M = 2.000, 95% CI [1.791, 2.209]), percieved mephedrone as offering a „high‟ increase in feelings of happiness than the 3-10 times subgroup (M = 1.500, 95% CI [1.281, 1.719]) p = .016. There were significantly more participants reporting a high increase of feeling of happiness in the in the 31-50 times subgroup (M = 2.000, 95% CI [1.738, 2.262]) than in the 3-10 times subgroup (M = 1.500, 95% CI [1.281, 1.719]) p = .040, but there were no observable significant differences for the other groups p = <.05. The reasons for drug use were examined for alcohol, cannabis and mephedrone. The most reported reasons for using alcohol were social (52.6%), pleasure (19.7%) and coping (9.2%). The most reported reasons for using cannabis was social (29.2%), coping (25.0%) and pleasure (22.9%). The most reported reasons for use of mephedrone was social (35.0%), pleasure (20.0%) and coping (15%). One participant reported using mephedrone because of dependence. Another participant stated that they only used mephedrone because of lack of alternative drugs. However, this was also mentioned among respondents who stated reasons of social and pleasure (16.8%). It was mentioned that price and availability of mephedrone in contrast to other illicit drugs are predominant factors in its recreational use. Some participants 26 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health reported that the legislation has not really affected the availability and price, and others reported that new „research chemicals‟ or „legal highs‟ have been created to replace mephedrone. The participants were questioned about their opinions surrounding mephedrone, some of the participants subjective responses can be observed below. The level of knowledge about mephedrone between mephedrone users was varied, with some suggesting that it may have medicinal uses and others claiming that it is a very dangerous drug, which causes harm. Subjective Findings Participant no. 93 response to mephedrone question: „In my opinion Mephedrone is a dangerous substance. I only started taking it because MDMA started to be in short supply. Now I find myself with a level of dependence on the substance. I think that the level of dopamine-based addiction was overlooked when the Government classified it. I think they underestimate just how many young people are just as addicted to it as people are to Cocaine. Making Mephedrone Class B has in no way stopped the market and peoples addictions to the substance are only going to increase.‟ Participant no. 22: „I hate [mephedrone], it‟s really getting to people and screwing there heads up. I seen some mad things from people it but the only reason why everyone is taking it now is because there‟s no good cocaine or ecstasy pills around.‟ 27 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health Participant no. 30: „Mephedrone is a Semi-addictive euphoric stimulant. The ban of it has not stemmed the use by much amongst certain circles [it] however has turned people that were once normal people into criminals, thus alienating them from society. The drug hasn't changed, its availability has not either, nor has price vastly, all that has since the ban is that people who once were not criminals, now are considered so in the eyes of the law.‟ Participant no. 55: „[Mephedrone] was amazing but I think very addictive the smell can make you want more you need to take more and more each time messed up my eyesight big time.‟ Participant no. 33: „I find mephedrone a good alternative to MDMA or amphetamine. It is available and has been reliable, MDMA prohibition has causes many substances that I do not want to experience to be sold as MDMA. Mephedrone has had little side affects in me or my friends. I would like to see more research done on mephedrone.‟ Participant no. 38: „I got into it right before the UK ban and always regretted not coming earlier. [I] loved the stuff but extremely moreish and addictive. Oral administration is probably best to avoid cravings.‟ 28 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health Participant no. 45: „[Mephedrone] should not have been banned it should be researched there are some side effects but after taking a dose of say 200 on average twice a week for nearly two years, the benefits far out weigh the cons. We would both gladly love to assist in this further if required, it really was a life saver to us.‟ Participant no. 24: „[Mephedrone is a] good thing, but it very tricky and can led to dependence, suggested only for very experienced users, with strong will.‟ Participant no. 48: „I believe [Mephedrone] is no safer or more dangerous than any other wellknown drug in its class (MDMA, cocaine, etc.) Like all drugs, it has the potential to be used responsibly or irresponsibly and could have medical uses that deserve further investigation. uncontrollable.‟ It seems to promote impulsive use, though this is by no means Participant no. 62: „[Mephedrone is] horrible stuff, hate it makes me paranoid and my heart is pumping ten times faster than on any other drug. Thrown the rest of mine out, never want to do it again „ 29 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health Participant no. 81: „I used to do it for fun. Then it just became something to do with my friends. Lately it seems like its the only thing we do. „ Participant no. 16: „Mephedrone is a very dangerous drug and shows that the legal highs business must be controlled. The first years, people used it very uncautiously when they discovered it seemed to lack many side-effects compared to other euphoric empatogenic drugs. When the purple joints/knee etc. side-effects started showing up, probably due to toxic long-time resident metabolites, the addictiveness prevented many from laying it off, and it being legal for such a long time didn't help. It would be of great interest if some research into the pharmacological properties of the drug was published.‟ These qualitative findings are mixed in positive and negative opinions toward mephedrone. Whilst some participants have reported very negative effects, others report little or no side effects, and one participant stated that the benefits outweigh the costs by far. The qualitative data indicates that the effects of mephedrone can include addictive potential with strong feelings of craving more, euphoria, elevated heart rate, and paranoia. However, one participant explained that the feelings of craving more can be reduced by ingesting mephedrone orally (38). Although one participant reported negative experience in contrast to other drugs (62), a number of participants explained that it is alternative to amphetamine, ecstasy/MDMA, and cocaine (22) (33) (93), which has been preferable due to lack of availability and quality of these drugs. 30 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health However, one participant reported some visual impairment through use of mephedrone (55). Some participants explained that the prohibition of mephedrone has not drastically affected its availability or price (30) (93). One participant reported having some level of dependence on mephedrone (93), however a number reported its addictive effects (16) (24) (38) (55) (30). This study has found that mephedrone has significantly more potential for causing feelings of depression than the concurrent use of cannabis and alcohol, but not alcohol alone. There was a significant difference between percieved benefits and feelings of happiness on consumption. A high number of mephedrone users reported use of other drugs, including rarer drugs such as DMT. Participants‟ responses indicate that mephedrone has addictive potential, poses physical and psychological harm, the prohibiting of mephedrone has not drastically affect use or availability and it is taken due to lack of familiar alternatives such as ecstasy/MDMA or cocaine. 31 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health Discussion This study designed and programmed a three-part JavaScript and PHP online questionnaire application, which linked to a security protected MySQL database storage system. This required a fair understanding of each programming language, the development of dynamic web applications, and website maintenance. To prevent accidental submissions or loss of data, the questionnaire was intentionally programmed to disable the „enter‟ and „backspace‟ keys of the keyboard. In order to submit the questionnaire data the participants had to purposely click on a „submit‟ button, and needed to close the webpage to abort the study. It was also programmed to allow null responses as it is illustrated that ecstasy/MDMA users often miss elements of a task, such as a questionnaire, due to problems with impulsivity, serotonergic dysregulation, and working and prospective memory (Rodgers et al., 2001). The database was programmed to include the date and time of questionnaire submission, so that multiple responses could be observed with more ease. It appears that programming an online questionnaire and online database system is a good way to recruit large samples of participants in a constrained time frame. It may recruit participants normally inaccessible through ease of access, where telephone and face-to-face contact, or travelling to a venue would normally be inconvenient, or avoided for legal reasons surrounding recreational drug use. The online aspect also allowed the participants to complete the study at a time that most suited them, which included after normal working hours. This allowed the gathering of participants that may have normally been inaccessible or unavailable, and allowed for a wider diversity that conventional methods may not have achieved. 32 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health The functionality of the online questionnaire could be developed in a variety of ways. In investigating the potential of mephedrone and related substances on mental health, it may be of use to implement more questions relating to use, such as frequency and duration of use, and average quantity used per session. Some of the respondents explained that some of the questions of the third part of the questionnaire were too broad, and did not allow enough space to give more information. The questionnaire could be programmed so that if the respondents wanted to give more information, they could do so by clicking a button where an unlimited additional textbox would appear. This would help to gather a clearer path for future large-scale quantitative research. One limitation in using online questionnaires is that there is not an experimenter present to clarify participants‟ uncertainty about the questions, or to ensure that bogus responses are not being given. However, the questionnaire could also be programmed to provide a clickable information icon, which gives further information about the intention of the question in the event of participant uncertainty. Bogus responses could be filtered by purposely examining responses for unlikely scenarios, for example, postgraduate level of education at a premature age, current location could also be used to expose this type of entry by providing responses that are located in internet black spots, such as China and North Korea. However, the likelihood of bogus responses may be lower in longer questionnaires, as adopted in this study, due to loss of interest and boredom. Though this may be the case, researchers utilising online methods should be cautious of this possibility. Depression scores were significantly lower for the cannabis group in comparison to the mephedrone group (Tukey post hoc analysis: P < 0.05). However, it was difficult to assess the depressive potential for each substance separately as the majority of the mephedrone users also used cannabis and alcohol, and the cannabis 33 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health users used alcohol. Mephedrone users reported significantly higher depression scores than the users of cannabis and alcohol, but not users of alcohol alone. The cannabis group had a significantly lower amount of participants with a score of 16 or higher, which is a guideline concern for mild to moderate depression, than the mephedrone and alcohol groups. However, it was difficult to assess the depressive potential for each substance separately, as the majority of the mephedrone users, also used cannabis and alcohol, and the cannabis users also used alcohol. There is little antecedent evidence surrounding the depressive potential of mephedrone, but some studies report stronger symptoms of depression with longer-term or prolonged use, due to dopaminergic and serotonergic neurochemical depletion (PWRG, 2009; Schifano et al., 2011). However, it is difficult to gauge the quantity and duration of mephedrone use needed to cause depressive symptoms and neurochemical depletion (Schifano et al., 2011). Depression can be considered as a fluctuation in normal mood which can affect people in a spectrum of severity, it can be experienced in mild form in day to day life, but for others, it can become so debilitating that it interferes with normal everyday functioning (Paykel, & Priest, 1992; Ressler & Nemeroff, 2000). Normal depression would be considered to be the lowering of mood, but this tends to pass within a short time (Paykel, & Priest, 1992). However with greater severity, the lowering of mood can last for periods of days, weeks or longer, and is usually accompanied by crying spells and a loss of interest or pleasure in things that were previously enjoyed. It is also common for sleeping and eating patterns to be disturbed (Paykel, & Priest, 1992; Ressler & Nemeroff, 2000). Depression is typically characterised by negative thinking patterns, and sometimes it is unclear if the depression causes the negative thinking, or if the negative thinking causes the 34 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health depression (Teasedale, 1983; Paykel, & Priest, 1992). However, it would appear that depression and thinking style have a dual impacting relationship (Teasedale, 1983; Paykel, & Priest, 1992). It is understood that serotonin and noradrenaline have influential roles in depression and anxiety (Ressler & Nemeroff, 2000), and medications such as Selective Serotonin Re-uptake Inhibitors (SSRI‟s) and SerotoninNoradrenaline Re-uptake Inhibitors are prescribed to regulate neurochemical dysfunction. The significantly lower difference between cannabis and mephedrone scores may be illustrative of the „party‟ lifestyle and neurochemical effects of stimulant drugs. Stimulant drugs can affect quality of sleep to a greater extent than cannabis, and quality of sleep is often a factor to consider when experiencing feelings of depression, anxiety or irritability. There is an abundance of research supporting that poor quality of sleep can not only affect cognition, but also mood, wellbeing and purpose and meaning in life (Pilcher, Ginter, & Sadowsky, 1997; Banks & Dinges, 2007; Steptoe, O'Donnell, Marmot, & Wardle, 2008). Dinges et al., (1997) found that experiencing poor quality of sleep for as little as a week can cause symptoms of irritability, mental confusion, anxiety and depression. Regular „party-drug‟ users may find missing sleep a normality, and continue this behaviour in periods of non-drug use (Fisk. & Montgomery, 2009). Mephedrone is somewhat similar to ecstasy/MDMA, and offers similar effects to this, amphetamine, and cocaine, because it works on similar neurochemical systems. Ecstasy/MDMA can also affect sleep quality in periods of non-use (McCann, Peterson, & Ricaurte, 2007). One study examined the differences in level of sleep quality between ecstasy/MDMA poly-drug users and users of only cannabis (Fisk. & Montgomery, 2009). Fisk and Montgomery (2009) found that ecstasy/MDMA 35 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health polydrug users reported poorer quality of sleep, with an evening type pattern of routine in contrast to cannabis and non-drug users. It was found that ecstasy/MDMA polydrug users were more likely to avoid sleeping at certain times. This particular study suggested that dysfunction in serotonergic activity related to ecstasy/MDMA use may cause a shift in circadian rhythms, resulting in a disturbed sleeping pattern (Fisk. & Montgomery, 2009). Serotonin dysregulation can cause poor quality of sleep and low mood, and as quality of sleep can also affect mood, the lifestyle choices in relation to sleeping patterns of ecstasy/MDMA users may contribute to the low mood. It is reported that the complaints of low mood and cognitive deficits in regards to ecstasy/MDMA users may be explained by neurochemical depletion (Parrott & Lasky, 1998). It is understood that ecstasy/MDMA stimulates the release of monoamine neurotransmitters, including serotonin (5-hydroxytryptamine, 5-HT), dopamine and noradrenaline, (Kalant, 2001; Zemishlany, Aizenberg, & Weizman, 001), a similar activity is understood for mephedrone (PWRG, 2009; Winstock et al., 2010; Schifano et al., 2011). It reported that long-term or regular users of mephedrone can experience similar subsequent neurochemical depletion to that of ecstasy/MDMA users, and stronger symptoms of depression (PWRG, 2009; Schifano et al., 2011). Many studies indicate that use of ecstasy/MDMA can affect quality of sleep (Parrott et al., 2000; Jones et al., 2008; Schierenbeck et al., 2008; Carhart-Harris, Nutt, Munafò, & Wilson, 2009; Fisk. & Montgomery, 2009), with some reporting disturbances in sleep for up to a week after use (Jones et al., 2008), and heavy use leading to continuous sleep problems and disturbance (Parrott et al., 2000; Schierenbeck et al., 2008). This may reflect serotonin dysregulation, as serotonin is implicated in regulating sleep and wakefulness (Jouvet, 1999; Dugovic, 2001). 36 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health In contrast, cannabis is reported to induce feelings of sleepiness and desire to rest. Sleeping problems in regards to cannabis use mainly lie with cessation after heavy use, as reports describe feelings of anxiety and sleeping issues such as insomnia during withdrawal period (Bolla, Lesage, Gamaldo, Neubauer, Funderburk, Cadet, David, Verdejo-Garcia, & Benbrook, 2008; Schierenbeck et al., 2008). Some authors have reported that cannabis use decreases feelings of depression (Denson & Earleywine, 2006), however there are mixed perspectives on this topic. Some argue that these mixed findings of depression may be due to methodology, as it is reported that cannabis was found to have an association with depression when the participants were seeking treatment for cannabis, rather than participants who were recreational users looking to participate in research. Thus, it is argued that the treatment seeking is more predictive of depression than cannabis use (Mariani, Haney, Hart, Vosburg, & Levin, 2009). Some studies, using mice and rats, have illustrated that cannabinoids and THC may have antidepressant and anxiolytic effects which may be related to mood elevation (Jiang, Zhang, Xiao, Van Cleemput, Ji, Bai, & Zhang, 2005; El-Alfy, Ivey, Robinson, Ahmed, Radwan, Slade, Khan, ElSohly, & Ross, 2010). As the alcohol users had significantly lower depression scores in the cannabis group, in contrast to the mephedrone group and the sole alcohol users, these findings may support that the findings that cannabis may act as an anti-depressant or anxiolytic in lower doses (Jiang et al., 2005; Denson and Earleywine, 2006; El-Alfy, 2010). Although all of these drugs alter sleep and mood, the more drastic effects observed in this study in regards to cannabis and mephedrone may illustrate the differences in neurochemical activity and depletion, quality of sleep and related lifestyle choices. 37 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health The mephedrone group were further examined to inspect the associations between consumption, percieved benefits and risks, mephedrone induced increase in feelings of happiness, and subsequent feelings of depression. The responses were divided into groups of low and high, and compared against the consumption subgroups. It there was an association between mephedrone consumption and perceived benefits and increase in feelings of happiness. This was not found for perceived risks or subsequent feelings of depression. The majority of participants stated that mephedrone causes a very strong increase in feelings of happiness with only moderate subsequent feelings of depression. This may illustrate that the percieved benefits outweigh the perceived risks, however, this may also reflect the media coverage reporting many deaths from mephedrone, which were not all were definitely confirmed (Wood, Greene, & Dargan, 2010). The data reflected that percieved risks were not associated with mephedrone use and this may illustrate that drug users believe that drugs pose risks, but still continue to engage in the behaviour. This may reflect a perceived locus of control, and a belief that whilst drug use poses risk, it is possible to minimise the dangers. Although many individuals reported that mephedrone poses many risks, this did not appear affect their consumption. The association between perceived benefits and consumption of mephedrone, and happiness and consumption of mephedrone, illustrates that individuals who view it as offering positive effects are likely to use it more often. In an ideal world, if a „legal-high‟ could be created, which did not damage mental or physical health, and brought feelings of happiness and energy, then the use of drugs such as mephedrone would cease, as the benefits would be greater. However, the creation of such a „legal-high‟ would seem unlikely, as pharmacologic rationale for the use of drugs is that any increase in feeling, is at a cost of a subsequent 38 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health decrease, and the greater the high, the greater the low, due to fluctuations in neurochemical activity. Perhaps in educating about drugs, it may worthy to illustrate that whilst certain drugs may offer benefits such as happiness and energy for a short duration, regular physical exercise and healthy lifestyle choices can offer similar benefits, but in long-term everyday life. It may also be worthy in drug campaigning to highlight that whilst drug use may cause an immediate increase in happiness, there is a subsequent decrease as a matter of balance. This may help unknowing individuals to make informed choices about consumption. The lack of research on mephedrone and related may have added to their popular use. As the compounds are little researched, it weakens the power of health promotion and drug campaigns. The participants reported a wide range of drug use, including alcohol, nicotine, cannabis, amphetamine, ecstasy/MDMA, cocaine, mephedrone, lysergic acid diethylamide (LSD), dimethyltryptamine (DMT), ketamine, psilocybin, painkillers, tranquilisers, methylone, methylenedioxypyrovalerone (MDPV) and other drugs. „Methylone‟ (3,4-methylenedioxy-N-methylcathinone) is a new synthesized relation of mephedrone and is part of the cathinone family. The use of the substance has been explored by other studies, and it is indicated that the effects are very similar to ecstasy/MDMA, like mephedrone (Brunt et al., 2010; Winstock et al., 2010). Some participants also reported use of MDPV (3, 4-methylenedioxypyrovalerone), which is another synthetic cathinone mentioned in other reports (Brunt et al., 2010; Gibbons & Zloh, 2010). Some of the mephedrone users reported use of DMT. This may support the suggestions that mephedrone is a drug used by experienced poly-drug users (Measham et al., 2010). DMT is a strong hallucinogen traditionally used by shamans in a brewed form known as Ayahuasca. The shamanic members would consume 39 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health Ayahuasca to “travel” to a “spirit realm” in order to gather information, related to unknown nearby sources of food, and secrets about themselves and spiritual development (Cott & Rock, 20098; Cakic, Potkonyak, & Marshall, 2010). Although not widespread, DMT is reported to be used recreationally in other studies (Cott & Rock, 2008; Cakic et al., 2010). DMT is a curious hallucinogen because the users of this drug all report very similar experiences to those described by shamanic communities (Cott & Rock, 2008). Users report “travelling” to another world or plane of existence, where they are met by spiritual entities who reveal information about the universe, existence, and themselves (Cott & Rock, 2008). The beings encountered in this DMT “hyperspace” are independent of the users own mind and feelings, and will impart information previously unknown to the user. Some individuals describe the use of DMT as a „higher intelligence‟ that could be turn to for answers (Cott & Rock, 2008). Unlike other hallucinogenic and psychedelic drugs such as LSD, users of DMT feel a sense of realness and veridicality to their experience, even after the event, and describe feeling sober and fully aware in the DMT “realm” of consciousness (Cott & Rock, 2008). This study gathered qualitative data about the participants‟ opinions and experience of mephedrone use, and observed very mixed finding. The participants response varied from strongly positive and strongly negative. It was commonly elucidated between response that mephedrone is used as an alternative illicit drugs such as ecstasy/MDMA, amphetamine and cocaine, for reasons of purity and availability, for similar effects of euphoria and pleasurable experience. This is widely reported amongst the current literature (Brunt et al., 2010; Measham et al., 2010; Winstock et al., 2010a). This has been explained as the successful UK cocaine and ecstasy/MDMA seizures in the past two years, which has resulted in lower availability 40 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health and purity of these drugs, and a preference for readily available and better quality recreational substances like mephedrone has emerged (Brunt et al., 2010; Dyer, 2010; Measham et al., 2010; Wood et al., 2010; Winstock et al, 2010). In respect to the negative effects of mephedrone, one participant explained that it caused an increase in heart rate, like no other drugs of personal experience, and another participant reported an interruption in visual function. It is possible that these claims are related, in that the participant who experienced some visual impairment may have done so because of increases in heart rate and body temperature, and subsequent vasodilatation. Previous studies have indicated that rising heart rate, vasodilatation and blurry vision are some of the negative side effects of mephedrone use (Winstock et al., 2010a; Wood et al., 2010). A high number of participants reported the addictive potential of mephedrone, with descriptions of intense craving, and one participant out rightly stated that they are experiencing some level of dependence on mephedrone. One participant reported „some level of dependence‟ on mephedrone. It is suggested that with chronic use, dependence on mephedrone can develop (Winstock, 2010a), and this has been reported in a case study by Bajaj et al. (2010), and a study by Dargan et al. (2010). The findings support the thought that mephedrone has an addictive potential, with many users reporting its strong effect of craving more (Gibbons & Zloh, 2010; Marsden et al., 2010; Winstock et al., 2010; Wood et al., 2010; Schifano et al., 2011). One participant explained that the craving feelings can be reduced by opting to ingest mephedrone orally, instead of nasally. This subjective difference in administration route has been previously described by Winstock, et al. (2010a), and is perhaps something which should be educated amongst uninformed mephedrone users. 41 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health The qualitative data reflects that the experience of mephedrone use is varied between users, and it is necessary to consider why this is. It could be that these participants who reported negative effects had used mephedrone more often and in higher quantity. However, one participant reported weekly use for almost two years and explains it offers more benefits than detriments, and the participant who reported paranoia and a high increase in heart rate appeared to be a first time user, in stating no intention to take it again. This may reflect the effects of tolerance, but as many individuals have reported physical and psychological complaints, it is curious why this participant did not report this. The qualitative data indicates that the prohibition of mephedrone has not dramatically affected its availability and price, and users feel quite strongly about the Governments haste in decision, as they are now being penalised for something they were previously not, without full research of its dangers. This adds to the concern that this substance is now being dealt by illicit dealers and may be at risk of contamination with more dangerous chemicals (Winstock et al., 2010). Some participants explained that the ban of mephedrone has lead to the creation of new designer drugs. This is concerning because although there is a shallow amount of research on the effects of mephedrone, a general understanding has been gathered about its risks over past two years (Brunt et al., 2010; Dyer, 2010; Measham et al., 2010; Winstock et al., 2010a; Wood et al., 2011). If the prohibition of mephedrone has lead to the fabrication of new chemicals, it has also caused the need to begin much needed research, once again. Some authors have described this scenario as a „game of cat and mouse‟ and it is proposed that whilst these new substances become prohibited, new chemicals are being formulated which may pose a 42 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health more serious danger (Measham et al., 2010). This recurrent cycle of new „legal-high‟ synthesis and health research poses difficulty in respect to time span. In examination of the limitations of this study, it is important to recognise that the alcohol group was smaller than the cannabis group, and the cannabis group was smaller than the mephedrone. This was a result of opportunnity sampling and the snowballing method, but it may also illustrate that drug users are more interested in substance use research than non-users. It was difficult to assess the differences between these substances as the majority of cannabis users also used alcohol, and the majority of mephedrone users also used cannabis and alcohol. This made assessment of whether the conjunctive use of alcohol, cannabis and mephedrone, increases depressive symptoms, in comparison to the singular use of mephedrone. Whilst this is so, it illustrates that individuals often use more than one drug of choice, and it may be necessary to consider that concurrent drug use may pose twice the damaging effect. There were limits in investigating participants use of drugs not already included in the questionnaire fully, as there was only one „other‟ box provided for response. The limitations in stating other drugs not included in the questionnaire may have affected participants‟ ability to report the use of other mephedrone related compounds. Although previous authors have reported use of NRG-1 or naphyrone (naphthylpyrovalerone, O-2482), as a legal replacement of mephedrone (Brandt et al., 2010), there were no reports of its use in the current study. However, some users reported methylone and MDPV. This study did not control for the newer mephedrone related substances that have been synthesised. It is possible that if the questionnaire allowed for the respondents to specify more than one other drug not already included on the questionnaire, more reports of mephedrone replacements may have been apparent. 43 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health Whilst this study controlled for mephedrone consumption (times in lifetime), benefits and risks, increased feelings of happiness and subsequent feelings of depression, it did not fully examine frequency and duration of use, and estimated quantity of use in a session. Other studies have illustrated that with long-term or prolonged use of mephedrone, users may experience stronger symptoms of depression as a result of dopaminergic and serotonergic neurochemical depletion (PWRG, 2009; Schifano et al., 2011). The participants were not questioned about negative life events, past, recent or present. This may have had an impact of results and future studies may control for this by providing a question which asks about negative life events, with a small space for providing details. This could also be used to examine whether certain life experiences have an impact on drug misuse. This study did not investigate whether the participants had previously received a depression diagnosis. It has been previously put forth that a CES-D score of 16 or higher is a guideline of concern for depression (Radloff, 1977), and a large number of participants were found to have a score of 16 or higher. It may be worthy for future studies to examine whether participants have been professionally diagnosed with depression, in examining the depressive potential of cathinone and other substance use. This could also be used to examine whether individuals who suffer with depression are more likely to use drugs in a „self-medicating‟ or escaping manner. The participants were not extensively questioned about their social affiliation or socioeconomic status, other than occupational status. This may have been investigated this further by collecting religious affiliation, educational attainment, career position, or annual income. Some studies have illustrated that religious involvement helps to guard against depressive symptoms and social involvement and 44 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health meaning in life are powerful factors (Miller, 1998; Steger, & Frazier, 2005). This may also be represented in career position, those at the beginning of their career may feel a little less worthy than those above them, and those at the top may feel the pressures of responsibility. Annual income may also reflect an influence on drug use, as some have illustrated that socioeconomic status can have an influence on drug use (Boardman et al., 2001). This study did not control for level of education, other than the occupational response „student‟, and educational pursuit or attainment may have had an influence on drug use and depression scores. Previous studies have illustrated that socioeconomic status and societal stressors can influence drug use and depression (Boardman et al., 2001), thus, all of the above mentioned factors may have had an impact on use or depression scores. This study attempted to ensure external validity by recruiting an opportunnity sample and using the snowball method, from a multitude of lifestyles and locations online, from a variety of websites and social circles. It attempted to secure internal validity by controlling for a range of variables including lifestyle, such as hobbies and occupational status, and other drug uses. In repeating this study, it would aim to control for frequency, quantity and duration of mephedrone use, newer cathinones, negative life events and diagnosis of depression. It would also be useful to control for religious affiliation, career position, annual income, and level of education. This study proposes that future research inspecting the impact of mephedrone, cannabis and alcohol use on depression, should also include other known cathinone family derivatives. Future studies may consider examining the cathinone family in greater depth against ecstasy/MDMA, as such a high majority of mephedrone users also used ecstasy/MDMA. It may also be necessary to examine the current average quality and purity of ecstasy/MDMA street drugs, as they may become contaminated 45 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health with mephedrone and other cathinones due to similarity, convenience and costcutting. Future studies in examination of the depressive potential of mephedrone would benefit greatly from inclusion of all the newer known mephedrone and cathinone related drugs which are available to users, such as methylone, MDPV and NRG-1. This would also help to gather a greater understanding of which cathinones are used most frequently amongst social circles, the trends of new synthesized legal highs, and how these types of drug impact psychological well-being. The findings of this study with regard to the addictive potential of mephedrone are in congruence with previous research, and one participant who disclosed some level of dependence on mephedrone explained that it is possible that cases of mephedrone may become more apparent as use continues. Whilst the addictive potential of mephedrone was not of central focus in this study, findings from the present and other studies indicate that investigation into mephedrone dependency is needed. It is possible that mephedrone may pose similar addictive risks to cocaine. Given that the majority of individuals now use the internet, it would be worthy for future studies investigating mephedrone and related cathinones on mental health and wellbeing, and also other illicit drugs, to implement the approach of online research. Utilising online questionnaires as in the present study may allow researchers an advantage in keeping up with the formulation of these new designer drugs, in order to provide valid health related information. It also allows access to parts of the population which may normally be inaccessible. Mephedrone was prohibited and classified without extensive research, and this was not enough to encourage the public to make sensible health-related choices. In order for the general public to trust health and drug campaigns, information must be validly researched and presented effectively, so that the individual can understand and 46 Mephedrone, Cannabis and Alcohol: the New Risks to Mental Health evaluate the evidence for themselves in choosing to engage in drug related behaviour. In aim of reducing mephedrone risk related behaviour, it may be necessary to campaign with detriments of its use, such as the reports of blue joints and digits, which greatly outweigh percieved benefits and increased feelings of happiness. Future research in regards to mephedrone and other illicit drug use and depression should aim to control for all other known similar cathinone compounds, as it appears that these are replacing and are being used alongside mephedrone. However, it is uncertain how much of these drugs are now also in other recreational drugs such as ecstasy/MDMA. Future studies should also aim to control for frequency, duration and estimate of quantity used in a session, to examine long-term or prolonged use of mephedrone and depressive symptoms in more depth. The appearance of mephedrone and related substances on the drug market has certainly posed a challenge to current research on recreational drugs. Its synthesis, and the synthesis of related or similar compounds may continue, and in order for individuals to make informed health related decisions, it is necessary for researchers to keep up with the formulation and distribution of new these „legal highs‟. The working hypothesis is that mephedrone has potential for causing depressive symptoms more so than the concurrent use of cannabis and alcohol, which may reflective of the neurochemical depletion observed in ecstasy/MDMA users. 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