Dr. David Nutt on Alcohol

Rebutting industry myths.

A couple of years ago, the European Alcohol Policy Alliance, known as EuroCare, put together a brochure addressing the common messages the liquor industry attempts to drive home through its heavy spending on advertising. The messages are not just designed to sell product, but also to influence alcohol policy at the political level. According to EuroCare, the “industry”—the alcohol and tobacco companies—“has traditionally worked closely together, sharing information and concerns about regulation. They have used similar arguments to defend their products in order to prevent or delay restrictions being placed on them.”

I wrote a blog post on EuroCare’s list of alcohol untruths called “7 Myths the Alcohol Industry Wants You to Believe." Here they are:

Message 1: Consuming alcohol is normal, common, healthy, and very responsible.

Message 2: The damage done by alcohol is caused by a small group of deviants who cannot handle alcohol.

Message 3: Normal adult non-drinkers do not, in fact, exist

Message 4: Ignore the fact that alcohol is a harmful and addictive chemical substance (ethanol) for the body.

Message 5: Alcohol problems can only be solved when all parties work together.

Message 6: Alcohol marketing is not harmful. It is simply intended to assist the consumer in selecting a certain product or brand.

Message 7: Education about responsible use is the best method to protect society from alcohol problems.

Recently, I ran across a great response to these same 7 myths by Dr. David Nutt, the British psychiatrist perhaps best known in the states as the scientist who got fired a few years ago from his post on the government’s Advisory Council on the Misuse of Drugs. Nutt’s primary sin was to suggest that, on a straightforward calculation of risks and harms, horseback riding was probably a more dangerous activity than taking the drug Ecstasy. The Home Secretary at the time insisted that you couldn’t compare a legal activity to an illegal one, or something like that, and Nutt compounded his sins by suggesting that marijuana was a safer drug than alcohol. British politicians took a serious dislike to him, the more so since most of the published medical science was on his side. After the dust settled, Nutt was one of the primary founders of the Independent Scientific Committee on Drugs (ISCD), formed to offer alternative views on drugs and addiction grounded in science.

Anyway, in his book, Drugs Without the Hot Air, Nutt has his own responses to the 7 Myths, which I excerpt here:

1. Consuming Alcohol is Normal: It’s normal, so long as you have the “normal” high-activity variant of the ALDH2 enzyme. If you don’t have that form of the enzyme, Nutt reminds his readers, as many Asians and Aleuts do not, then alcohol will affect you quite non-normally through the so-called alcohol flush reaction. Moreover, many cultures and societies unfamiliar with its effects “suffer hugely when new types of alcohol appear, particularly if they are aggressively marketed.”

2. Alcohol damage is caused by a small group of deviants: According to Dr. Nutt, statistics show that “millions of people, NOT a tiny minority, suffer harm from their own alcohol consumption, or cause harm to others…. It is the everyday drinking of people who have come to see alcohol as an essential part of life rather than the luxury it used to be, that has created a spike in cancers and stomach problems, and will see liver disease match heart disease as the leading cause of death in the UK by 2020.”

3. Normal adult non-drinkers do not exist: The alcohol industry is forever reminding politicians of how unpopular alcohol restrictions are to the voting populace. “The existence of non-drinkers obviously threatens this portrayal of society, so the industry tends to dismiss them as having something wrong with them. While some teetotalers are recovering alcoholics, many others have made a positive choice not to drink.” And there are others, I would add, often referred to as “sick” teetotalers, who have quit drinking for medical reasons unrelated to alcoholism.

4. Ignore alcohol’s harm to the body: Nutt reminds us that “there is no other drug which is so damaging to so many different organ systems in the body…. Most other drugs cause damage primarily in one or two areas—heart problems from cocaine, or urinary tract problems from ketamine. Alcohol is harmful almost everywhere.”

5. Alcohol problems can be solved when everybody works together: “In practice, what the industry means by ‘working together’ is bring in voluntary codes rather than statutory regulation—solving problems through rules that the industry CHOOSES to comply with, rather than laws which they MUST comply with.”

6. Alcohol marketing is intended to assist consumers in selecting products: Specifically, 800 million British pounds every year for advertising and promotion, according to Nutt. That’s just the kind of civic-minded bunch those alcohol sellers are. The reality, of course is that “marketing communications do have a marked effect on consumption…. All this further entrenches the false division between alcohol and illegal drugs, persuades people that consuming alcohol is safe, and makes realistic discussions of the harm alcohol causes very difficult.”

7. Education about responsible use is the best approach: “It is useful for the drinks industry,” Nutt explains, “to emphasize the value of education, because it takes the focus off regulation…. There is also extensive evidence gathered by the WHO from around the world, showing that merely providing information and education without bringing in other policy measures doesn’t change people’s drinking behavior.”

As I wrote in my original post: Who could be against the promotion of responsible alcohol use? Irresponsible zealots and deviants, that’s who. Why should all of us happy drinkers be made to suffer for the sins of a few rotten apples?

Indeed, all of the messages, overtly or covertly, send the same signal: You should drink more. It’s good for you.

Graphics Credit: http://www.holyrood.com/2011/04/at-what-price/

Do Addicts Benefit From Chronic Care Management?

Controversial JAMA study questions orthodox addiction treatment.

 What is the best way to treat addiction? The conventional wisdom has been to treat it with chronic care management (CCM), the same approach used for various medical and mental illnesses. But a study in the Journal of the American Medical Association (JAMA) purports to demonstrate that “persons with alcohol and other drug dependence who received chronic care management (CCM)” were no more likely to become abstinent that those who received nothing beyond a timely appointment with a primary care physician, and a list of addiction treatment resources.

563 patients were divided into a chronic care management group and a primary care group. The chronic care management group received extended care under a primary care physician, plus

“motivational enhancement therapy; relapse prevention counseling; and on-site medical, addiction, and psychiatric treatment, social work assistance, and referrals (to specialty addiction treatment mutual help.)” The primary care group got the aforementioned doctor’s appointment and printed list of treatment resources.

The study by researchers at Boston Medical Center found that “there was no significant difference in abstinence from opioids, stimulants, or heavy drinking between the CCM (44%) and control (42%) groups. No significant differences were found for secondary outcomes of addiction severity, health-related quality of life, or drug problems.”

But there are limitations. To wit:

1) Small sample size. 282 patients in a Boston Hospital’s chronic care management facility, and 281 participants farmed out to a primary care physician, is the total. Given the known failure rates for chronic care management as applied to smoking, diabetes, and mental illness, and variability in the counseling given the control group by individual physicians, 563 people isn’t really a sufficient cohort to be anything but suggestive. And, since many alcoholics and other drug addicts get sober by means of their own efforts, independent of formal medical intervention, percentage comparisons of such small groups are problematic in addiction studies.

2) Hard Core Cases Only. “Most study participants were dependent on both alcohol and other drugs, recruited from a detoxification unit, had substantial mental health symptoms had recently been homeless, and were not necessarily seeking addiction treatment,” according to the JAMA study. Okay, who might the findings not apply to? “Addiction treatment-seeking or less severely affected populations or to populations recruited elsewhere.”

3) Mostly self-reported data. The investigators assessed main outcomes by self-report. “Biological tests are inadequate for detecting substance use, particularly when it is not recent,” they explain. “Substance use problems and health-related quality of life are best assessed by self-report.” Outcomes were also based on self-reported 30-day abstinence.

4) Alcohol abusers did better under CCM. The research documented “a small effect on alcohol problems among those with dependence.” On alcoholics, in other words. “No subgroup effects were found except among those with alcohol dependence, in whom CCM was associated with fewer alcohol problems.” So CCM works, at least to a degree, for alcoholics, even in this study. Nonetheless, the study concludes: “CCM for substance dependence in primary care is not effective, at least not as implemented in this study and population.” (Note the caveats, and see #2 above)

5) Treatment fails for many reasons. One reason might be that the length of treatment was too short. According to the study, the intervention group “had, on average, 6 CCM visits….” Moreover, “the whole group improved over time; the change most likely was due to many participants having been enrolled at a detoxification unit….” The researchers also admit that “assessment effects in treatment trials are inconsistent and poorly understood and often absent in studies of people not seeking treatment.”

It may even be true that chronic care management, which seems so logical and successful an approach for everything from depression to smoking cessation, doesn’t work any better for drug addiction than a simple doctor’s visit and a handful of pamphlets. But this study doesn't clinch the case.

Graphics Credit: http://www.ihi.org

Saitz R. (2013). Chronic Care Management for Dependence on Alcohol and Other Drugs: The AHEAD Randomized Trial, JAMA, 310 (11) 1156. DOI: 10.1001/jama.2013.277609

Researchers Link Alcoholism and Binge Eating Behavior

Addiction and the role of genetic overlap.

More evidence has arrived, courtesy of Washington University School of Medicine in St. Louis, demonstrating a genetic link between alcoholism and binge eating disorders.

In clinical practice, it is no secret that certain binge eaters and people with bulimia also show high rates of alcoholism. Various reasons have been suggested, but one of the obvious ones is that people prone to alcoholism are also genetically susceptible to certain kinds of eating disorders. A common set of genetic factors may convey these intertwined vulnerabilities to a subset of the population.

In order to examine the matter, Dr. Melissa Munn-Chernoff and coworkers followed the time-honored route: They studied twins, both identical and fraternal, from a database of 6,000 adult twins in Australia. Twin studies have been crucial to medical understanding of comorbid disorders and addiction. In general, while alcoholism and binge/purge disorders were seen as most likely genetic in origin, it was thought that the two disorders were transmitted in families independently. Writing in the Journal of Studies on Alcohol and Drugs, the researchers conclude that “in women, some of the genetic risk factors that influenced vulnerability to alcohol dependence also influenced vulnerability to both binge eating and compensatory behaviors [purging, laxatives, diuretics].”

Previous studies cited by the researchers have pegged the individual heritabilities of alcohol dependence (50-64 percent) and bulimia (28-83%). However, the question of genetic overlap had remained relatively underexplored. Munn-Chernoff and colleagues wanted to evaluate the links between alcohol dependence and binge eating behaviors in women. Among the study group, 6 percent of women had been dependent on alcohol at some point in their lives. As for binge eating, 13% of women had experienced problems with it. 14% of women had engaged in purging or laxative abuse.

The researchers judged the genetic correlation between the two disorders to be statistically relevant: “In women, the multivariate twin model suggested that additive genetic and nonshared environmental effects influenced alcohol dependence, binge eating, and compensatory behaviors, with heritability estimates ranging from 38% to 53%.”(For the specific statistical correlations, see the full-text article. The correlation was stronger for women than for men).

In addition, the study did not find any significant shared environmental influences contributing to covariance between alcoholism and binge behaviors.

Limitations of the study include an older age cohort (mean age 44 in women), higher alcoholism rates in the Australian sample compared with the U.S., and the possibility that other comorbidities, such as depression, might influence the association.

“It appears that some genes that influence alcohol dependence also influence binge eating in men and women,” said Melissa Munn-Chernoff, in a prepared statement. “When you go to an eating disorder treatment center, they don’t often ask questions about alcoholism. And when you go for alcoholism treatment, they don’t generally ask questions about eating disorder symptoms. If centers could be aware of that and perhaps treat both problems at the same time, that would be a big help.”

Women who abuse alcohol have it tough for any number of reasons, and this study gets at one of them: “A combination of pressures to adjust to the changing body at puberty, increased access to alcohol via peer networks, and genetic predispositions for eating disorder symptoms and alcohol problems could result in comorbid alcohol dependence and bulimia symptoms."

Munn-Chernoff M.A., Duncan A.E., Grant J.D., Wade T.D., Agrawal A., Bucholz K.K., Madden P.A.F., Martin N.G. & Heath A.C.  A twin study of alcohol dependence, binge eating, and compensatory behaviors., Journal of studies on alcohol and drugs,    PMID: 23948525

Photo credit: https://www.facebook.com/WUSTLmedicine.health?group_id=0

Building Better Baby Brains: Just Say No To FAS

Fetal Alcohol Syndrome is our most preventable form of disability.

Despite a growing focus on the hazards of prescription painkillers for newborns, drinking during pregnancy remains the nation’s leading preventable cause of birth defects and developmental disorders in children. Fetal Alcohol Spectrum Disorders (FASD) encompass a wide variety of neurobehavioral and central nervous system disabilities related to alcohol use during pregnancy, including, but not limited to, developmental delays, growth retardation speech disabilities, and poor social skills. The classic physical characteristics of FASD, such as small head size, wide-set eyes and a thin upper lip, are not always present.

September 9th is International Fetal Alcohol Spectrum Disorders Awareness Day. Kenneth Warren, acting director of the National Institute on Alcohol Abuse and Alcoholism, said in a prepared statement that “Almost 40 years have passed since we recognized that drinking during pregnancy can result in a wide range of disabilities for children, of which fetal alcohol syndrome (FAS) is the most severe. Yet up to 30 percent of women report drinking alcohol during pregnancy.”

NIAAA, in a brief history of the disorder, calls fetal alcohol syndrome the “most common known cause of mental retardation.” Tragically, the knowledge of alcohol as a teratogen responsible for birth defects was not widely recognized by the medical community in American until the 1970s, when a group of crusading physicians began reporting observations of clustered birth defects among alcoholic mothers. (French doctors were on to FAS in the 1960s). In short order, the Surgeon General issued an FAS advisory, the U.S. Congress passed laws requiring pregnancy warning labels on alcoholic beverages, and doctors began warning their pregnant patients about the hazards of heavy drinking while pregnant. Nonetheless, CDC studies have shown that 0.2 to 1.5 cases of fetal alcohol syndrome (FAS) occur for every 1,000 live births.

Not surprisingly, the NIAAA finds that the risk for teratogenic injury and the severity of injury “appear to increase with greater levels of alcohol consumption.” Facial features associated with FAS are linked to early fetal exposure, so it is possible that “an embryo may escape the injury necessary to develop the characteristic FAS face but receive sufficient injury later in development to exhibit all the FAS-associated CNS and neurobehavioral deficits.”

Organ abnormalities are also characteristic of early exposure, while growth deficits are more likely the result of alcohol exposure later in pregnancy. Binge drinking—high peak dose drinking—is especially troublesome, as it has a great negative impact than low-dose steady drinking. But no period is risk-free. Genetic and environmental factors are plausibly invoked as contributors, but nobody knows what they are at present.

The disabilities caused by FASD often linger throughout adulthood, burdening families with anguish and heavy medical costs. “The message is simple, not just on Sept. 9, but every day,” says Warren. “There is no known safe level of drinking while pregnant. Women who are, who may be, or who are trying to become pregnant, should not drink alcohol.”

Graphics Credit: http://edmontonfetalalcoholnetwork.org/

A Chemical Peek at Modern Marijuana

Researchers ponder whether ditch weed is better for you than sinsemilla.

Australia has one of the highest rates of marijuana use in the world, but until recently, nobody could say for certain what, exactly, Australians were smoking. Researchers at the University of Sydney and the University of New South Wales recently analyzed hundreds of cannabis samples seized by Australian police, and put together comprehensive data on street-level marijuana potency across the country. They sampled police seizures and plants from crop eradication operations. The mean THC content of the samples was 14.88%, while absolute levels varied from less than 1% THC to almost 40%.  Writing in PLoS one, Wendy Swift and colleagues found that roughly ¾ of the samples contained at least 10% total THC. Half the samples contained levels of 15% or higher—“the level recommended by the Garretsen Commission as warranting classification of cannabis as a ‘hard’ drug in the Netherlands.”

In the U.S., recent studies have shown that THC levels in cannabis from 1993 averaged 3.4%, and then soared to THC levels in 2008 of almost 9%. THC loads more than doubled in 15 years, but that is still a far cry from news reports erroneously referring to organic THC increases of 10 times or more.

CBD, or cannabidiol, another constituent of cannabis, has garnered considerable attention in the research community as well as the medical marijuana constituency due to its anti-emetic properties. Like many other cannabinoids, CBD is non-psychoactive, and acts as a muscle relaxant as well. CBD levels in the U.S. have remained consistently low over the past 20 years, at 0.3-0.4%. In the Australian study, about 90% of cannabis samples contained less than 0.1% total CBD, based on chromatographic analysis, although some of the samples had levels as high as 6%.

The Australian samples also showed relatively high amounts of CBG, another common cannabinoid. CBG, known as cannabigerol, has been investigated for its pharmacological properties by biotech labs. It is non-psychoactive but useful for inducing sleep and lowering intra-ocular pressure in cases of glaucoma.

CBC, yet another cannabinoid, also acts as a sedative, and is reported to relieve pain, while also moderating the effects of THC. The Australian investigators believe that, as with CBD, “the trend for maximizing THC production may have led to marginalization of CBC as historically, CBC has sometimes been reported to be the second or third most abundant cannabinoid.”

Is today’s potent, very high-THC marijuana a different drug entirely, compared to the marijuana consumed up until the 21st Century? And does super-grass have an adverse effect on the mental health of users? The most obvious answer is, probably not. Recent attempts to link strong pot to the emergence of psychosis have not been definitive, or even terribly convincing. (However, the evidence for adverse cognitive effects in smokers who start young is more convincing).

It’s not terribly difficult to track how ditch weed evolved into sinsemilla. It is the historical result of several trends: 1) Selective breeding of cannabis strains with high THC/low CBD profiles, 2) near-universal preference for female plants (sinsemilla), 3) the rise of controlled-environment indoor cultivation, and 4) global availability of high-end hybrid seeds for commercial growing operations. And in the Australian sample, much of the marijuana came from areas like Byron Bay, Lismore, and Tweed Heads, where the concentration of specialist cultivators is similar to that of Humboldt County, California.

The investigators admit that “there is little research systematically addressing the public health impacts of use of different strengths and types of cannabis,” such as increases in cannabis addiction and mental health problems. The strongest evidence consistent with lab research is that “CBD may prevent or inhibit the psychotogenic and memory-impairing effects of THC. While the evidence for the ameliorating effects of CBD is not universal, it is thought that consumption of high THC/low CBD cannabis may predispose users towards adverse psychiatric effects….”

The THC rates in Australia are in line with or slightly higher than average values in several other countries. Can an increase in THC potency and corresponding reduction in other key cannabinoids be the reason for a concomitant increase in users seeking treatment for marijuana dependency? Not necessarily, say the investigators. Drug courts, coupled with greater treatment opportunities, might account for the rise. And schizophrenia? “Modelling research does not indicate increases in levels of schizophrenia commensurate with increases in cannabis use.”

One significant problem with surveys of this nature is the matter of determining marijuana’s effective potency—the amount of THC actually ingested by smokers. This may vary considerably, depending upon such factors as “natural variations in the cannabinoid content of plants, the part of the plant consumed, route of administration, and user titration of dose to compensate for differing levels of THC in different smoked material.”

Wendy Swift and her coworkers call for more research on cannabis users’ preferences, “which might shed light on whether cannabis containing a more balanced mix of THC and CBD would have value in the market, as well as potentially conferring reduced risks to mental wellbeing.”

Swift W., Wong A., Li K.M., Arnold J.C. & McGregor I.S. (2013). Analysis of Cannabis Seizures in NSW, Australia: Cannabis Potency and Cannabinoid Profile., PloS one, PMID: 23894589

Graphics Credit: http://420tribune.com

“Spiceophrenia”

Synthetic cannabimimetics and psychosis.

Not long ago, public health officials were obsessing over the possibility that “skunk” marijuana—loosely defined as marijuana exhibiting THC concentrations above 12%, and little or no cannabidiol (CBD), the second crucial ingredient in marijuana—caused psychosis. In some cases, strong pot was blamed for the onset of schizophrenia.

The evidence was never very solid for that contention, but now the same questions have arisen with respect to synthetic cannabimimetics—drugs that have THC-like effects, but no THC. They are sold as spice, incense, K2, Aroma, Krypton, Bonzai, and dozens of other product monikers, and have been called “probationer’s weed” for their ability to elude standard marijuana drug testing. Now a group of researchers drawn primarily from the University of Trieste Medical School in Italy analyzed a total of 223 relevant studies, and boiled them down to the 41 best investigations for systematic review,  to see what evidence exists for connecting spice drugs with clinical psychoses.

Average age of users was 23, and the most common compounds identified using biological specimen analysis were the now-familiar Huffman compounds, based on work at Clemson University by John W. Huffman, professor emeritus of organic chemistry: JWH-018, JWH-073, JWH-122, JWH-250. (The investigators also found CP-47,497, a cannabinoid receptor agonist developed in the 80s by Pfizer and used in scientific research.) The JWH family consists of very powerful drugs that are full agonists at CB-1 and CB-2 receptors, where, according to the study, “they are more powerful than THC itself.” What prompted the investigation was the continued arrival of users in hospitals and emergency rooms, presenting with symptoms of agitation, anxiety, panic, confusion, combativeness, paranoia, and suicidal ideation. Physical effects can includes elevated blood pressure and heart rate, nausea, hallucinations, and seizures.

One of the many problems for researchers and health officials is the lack of a widely available set of reference samples for precise identification of the welter of cannabis-like drugs now available. In addition, the synthetic cannabimimetics (SCs) are frequently mixed together, or mixed with other psychoactive compounds, making identification even more difficult. Add in the presence of masking agents, along with various herbal substances, and it becomes very difficult to find out which of the new drugs—none of which were intended for human use—are bad bets.

Availing themselves of toxicology tests, lab studies, and various surveys, the researchers, writing in Human Psychopharmacology’s Special Issue on Novel Psychoactive Substances, crunched the data related to a range of psychopathological issues reported with SCs—and the results were less than definitive. They found that many of the psychotic symptoms occurred in people who had been previously diagnosed with an existing form of mental disturbance, such as depression, ADHD, or PTSD. But they were able to determine that psychopathological syndromes were far less common with marijuana than with SCs. And those who experienced psychotic episodes on Spice-type drugs presented with “higher/more frequent levels of agitation and behavioral dyscontrol in comparison with those psychotic episodes described in marijuana misusers.”

In the end, the researchers can do no better than to conclude that “the exact risk of developing a psychosis following SC misuse cannot be calculated.” What would the researchers need to demonstrate solid causality between designer cannabis products and psychosis? More product consistency, for one thing, because “the polysubstance intake pattern typically described in SC misusers may act as a significant confounder” when it comes to developing toxicological screening tools. Perhaps most disheartening is “the large structural heterogeneity between the different SC compounds,” which limited the researchers’ ability to interpret the data.

This stuff matters, because the use of Spice-type drugs is reported to be increasing in the U.S. and Europe. Online suppliers are proliferating as well. And the drugs are particularly popular with teens and young adults. Young people are more likely to be drug-naïve or have limited exposure to strong drugs, and there is some evidence that children and adolescents are adversely affected by major exposure to drugs that interact with cannabinoid receptors in the brain. 

Graphics credit: http://scientopia.org/blogs/drugmonkey/

LSD Mutates Into NBOMe

What’s on that blotter?

It is a darkly poetic indictment of the War on Drugs that LSD, the first synthetic psychedelic, demonized for decades and the target of extremely expensive law enforcement operations, looks to be far safer than its replacements.

—Earth and Fire Erowid, in Erowid Extracts

It is called 25I-NBOMe, or 2C-I-NBOMe, or SC-B-NBOMe, or, erroneously, 2C-I. It belongs to a group of drugs called the NBOMes, which are derived from phenethylamine-based drug families made infamous by Dr. Alexander Shulgin. The NBOMe part stands for N-Benzyl-Oxy-Methyl. After it was first synthesized in 2003, Purdue University did some research on the chemical structure of NBOMes, but it was not until 2010 that the drugs began to appear in the underground market.  25I-NBOMe, the most common variety, is strongly psychedelic, with vivid visual and sensory effects. It can also cause horrid trips, especially at higher doses, and like LSD, it can cause vasoconstriction in the form of elevated blood pressure.

Earth and Fire Erowid, editors of the well-regarded Erowid drug information site, wrote a special report on the NBOMes for the July Erowid Extracts.  It is worth going over in some detail.

The NBOMes were initially freebase powders, either snorted or held in the mouth, but the authors note that there is still confusion and uncertainty about the relative effectiveness of various forms of administration. In one case noted by Erowid, three friends obtained a bottle of 25-I-NBOMe, marked as 500 micrograms per drop. “Those who took one drop enjoyed the experience,” but one of the friends, “after three drops, became incoherent and frantic, then ran from the house and drove off in his car. He crashed into a tree and woke up in the hospital two days later….”

This suggests both high potency and a rapid ramp-up of negative effects with dosage, making the NBOMes generally unreliable as street drugs. As the article in Erowid Extracts notes, “The unusually high potency makes overdoses more likely. Unfortunately, the risks of 25I (and perhaps other NBOMes) at high doses seem to include delirious, dangerous behavior (with some accidents resulting in death), as well as the possibility of death from direct pharmacological effects. Medically dangerous doses may be as low as 3-5 mg.”

Even worse, 25I and 25C, when sold as powders, makes dosing even more precarious. Drugs this strong in powder form should only be handled by someone wearing Walter White-style hand and eye protection. “Many people have prior experience with insufflating small lines or bumps of a psychedelic or stimulant,” says Erowid. “It’s a fairly new phenomenon that a similarly-sized line of a drug could lead to death.”

On another note, the incredible potency of the NBOMes makes them imminently smuggleable. A single 750-mcg dose equals about 6 grains of table salt. You could hide about 100,000 doses of 25I in a soda pop can.

For historical perspective, the authors point to the DEA’s bust-up of global supply chains for LSD in the early 2000s. Figures from the Monitoring the Future survey show that use of LSD by 18 year-olds has gone from about 8% in 1999 to less than 2% by 2009. What to do with all that perforated blotter paper? One time-honored response from dealers is to dump a different chemical on the paper and sell it as LSD. Erowid reminds us that LSD sold as the more expensive and difficult-to-synthesize mescaline in the hippie heydays was an early example of this practice.  As one Erowid contributor put it, “Which do you think would sell better, blotter sold as ‘25I-NBOMe’ or blotter sold as the now nearly mythical ‘acid’?”

Erowid found that at the online drug  site Silk Road, NBOMes were being offered at prices 5 to 10 times cheaper than LSD. Silk Road sells 25B-NBOMe powder for between $90 and $200 a gram. Hit size is often 1 mg or more, which is definitely a large dose. Vendors at Silk Road also sell perforated blotter paper with classic acid blotter designs from the past, like Albert Hofmann and the Beatle’s Yellow Submarine.

All of this adds up to erroneous reports of death by LSD, amid actual overdoses caused by an incredibly powerful and relatively untested new drug with a murky track record. Acid is not a lethal drug, and no deaths by overdose have ever been clearly and directly attributed to LSD.

The state of Virginia banned the NBOMes last year, and so far this year, several other states and nations have joined in. But Erowid points out that the U.N.’s World Drug Report 2013 concluded that “no sooner is one substance scheduled, than another one replaces it, thus making it difficult to study the long-term impact of a substance on usage and its health effects.” All of which, says Erowid, begs the question of what drugs will pop up to replace 25I-NBOMe once it is banned? Erowid has high hopes for a landmark New Zealand bill calling for a vendor framework in which the drugs are sold legally only if registration, safety testing, and recordkeeping meet certain standards. The bill is expected to become law in New Zealand later this year.

As Erowid notes, other countries will be watching New Zealand closely. A report by the Health Officers Council of British Columbia points out that “Prohibiting a substance does send a message of social disapproval of use… but the value of using prohibition to send a message to dissuade use must be weighed against the harmful consequences of implementing prohibition….”

Photo Credit:  http://ewsd.wiv-isp.be