Center of Excellence for Reducing the Supply of Illicit Drugs - CdE

New Psychoactive Substances and Early Warning Systems

Published in October 2022

Contextualization of the theme

New psychoactive substances, better known by the acronym NPS (New Psychoactive Substances), comprise an extensive and complex group of substances often known as designer drugs, synthetic drugs, legal highs or “legal drugs” (LUETHI and LIECHTI, 2020) (PEACOCK, 2019). et al., 3,4). Most of these drugs are represented by substances analogous or mimetic to classic drugs, such as methamphetamine, 9-methylenedioxymethamphetamine (MDMA – ecstasy) and ∆2016-tetrahydrocannabinol (THC – marijuana) (SOUSSAN and KJELLGREN, 2010). Due to their characteristics, such as the number of existing compounds, chemical nature and composition, NPS represent a huge challenge for health systems and drug control policy, being considered a growing worldwide epidemic (GRIFFITHS et al., 2020) (LUETHI). and LIECHTI, XNUMX).

The EMCDDA (European Monitoring Center for Drugs and Drug Addiction) classifies NPS as substances of abuse in pure form or in the product of a mixture, and they are not under the control of international legislation, such as Single Convention on Narcotic Drugs (1961) and the Convention on Psychotropic Substances (1971) (EUROPEAN MONITORING CENTER FOR DRUGS AND DRUG ADDICTION, 2019). The emergence and consequent consumption of NPS has been a growing worldwide trend, constituting a huge challenge for governments. As it is a relatively recent and very dynamic phenomenon, information on the effects and harm to users is limited. Also noteworthy is the diffusion and ease of access to computer networks, where the acquisition of NPS is very agile and involves few risks (HAGAN and SMITH, 2017) (WELTER-LUEDEKE and MAURER, 2016).

NPS constitute a heterogeneous group of substances and their main representatives are: synthetic cannabinoids, synthetic cathinones, tryptamines, piperazines and phenethylamines. In 2015, the UNODC (United Nations Office on Drugs and Crime) report presented a total of 541 NPS identified and reported, with synthetic cannabinoids in first place, corresponding to 39% of the products reported. , followed by phenethylamylnes (18%) and synthetic cathinones (15%). More recently, looking at data through December 2020, governments, laboratories and UNODC Early Warning Advisory (EWA) or Early Warning System (SAR) partner organizations reported 1047 substances classified as NPS. Unlike the report presented in 2015, most of the substances reported were classified as stimulants (36%), followed by synthetic cannabinoids (29%), as shown in Figure 1 (UNITED NATIONS OFFICE ON DRUGS AND CRIME, 2021).

New synthetic psychoactive substances, classified by their effects on the human body (until December 2020)

  • Stimulants
  • Synthetic cannabinoid receptor agonists
  • classic hallucinogens
  • opioids
  • Others
  • Sedatives and hypnotics
  • Dissociative

Source: Adapted from UNODC Early warning advisory on new psychoactive substances, 2021. Accessed on: 15 Apr. 2021.

It is important to mention that the emergence of new substances in illicit markets that were not yet controlled by national (one or more countries) and international legislation, with subsequent legal adaptation, is not unprecedented. What is new is the dynamics of NPS that the world has witnessed in recent years, resulting from the exploitation of the growth in the production capacity of these substances in northern European countries, China and India, as well as the globalization of commercial transactions and sales through from the internet (BRANDT et al., 2014).

At the end of 2020, the EMCDDA monitored around 830 new psychoactive substances, of which 46 were reported for the first time in Europe in 2020. This represents a considerable decrease when compared to the 100 NPS introduced on the European market per year between 2014 and 2015. 2021 — which can be considered a positive result of the strategies adopted to control NPS (EUROPEAN MONITORING CENTER FOR DRUGS AND DRUG ADDICTION, XNUMX).

The use of NPS is often associated with health problems, with reports of hospitalized users suffering from serious intoxications. Safety data on toxicity and carcinogenic potential of many NPS are either unavailable or very limited, and information on adverse effects or long-term risks is still unknown. The advent of the increasing use of NPS can bring, in addition to the acute clinical effects, such as intoxications, also the emergence of diseases transmitted by intravenous routes, since the administration of several NPS occurs in this way (RÁCZ et al., 2016).

The purity and composition of products containing NPS are often unknown, which puts users at high risk, as evidenced by emergency hospital admissions and associated deaths. By 2020, more than 60 countries have implemented legal responses with the aim of controlling NPS, many have updated current legislation, while others have used innovative legal instruments. Several countries, where large numbers of NPS emerged quickly, have adopted controls on entire groups of these substances, using a generic approach, which prevents small molecular changes from circumventing the bans. Other countries have introduced similar legislation that invokes the principle of “chemical similarity” to an already controlled substance, not needing to specify the name of the molecule in the legislation (UNITED NATIONS OFFICE ON DRUGS AND CRIME, 2016b).

In short, there is an unquestionable need to increase knowledge about production and the potential risks associated with NPS to enable the identification of intervention areas and focal points for the development of preventive strategies. The implementation of SARs enables a faster and more assertive response to new threats involving NPS. A SAR is defined as an inter-institutional and multidisciplinary network composed of several stakeholders that generate and exchange information with the objective of: a) early detection of events that can generate threats to public health resulting from the appearance of NPS; b) verification of risks related to the presence of these substances; and c) the need for early warnings to result in effective and rapid responses against potential risks identified by NPS.

SARs involve not only law enforcement and health institutions, but also—of fundamental importance—universities and non-governmental research entities that develop a database for the exchange of information on analytical methods in identifying and disseminating NPS information. In this sense, the creation of a national rapid alert system is shown to be a relevant strategy for countries to advance in preventing the growing number of new substances and their potential harm to health.

Rapid Alert Systems

The SARs identified for the development of this chapter generally follow a common construction methodology, which was developed in steps described below:

  • Regulation: provide technical support for the formulation of resolutions, as well as ordinances and other resulting acts involved in the creation of the SAR;
  • Fostering an Interinstitutional Network: articulation between the different key actors in the creation and maintenance process
    of the SAR;
  • Dissemination: production, validation and analysis of data, as well as the dissemination of information through periodic reports.

The main strategies and best practices of SARs available at the international level were selected, via literature search and/or direct contact with institutions that have implemented similar systems around the world.

Methodology and description of experiences

Overseas hubs

Within the framework of the United Nations (UN) drug conventions, the Global Synthetics Monitoring Program (SMART) was created in 2008 with the aim of helping Member States in NPS identification and reporting. The SMART program functions as a global repository of information on NPS, contributing to a better understanding of synthetic drugs, trends and patterns of distribution and use, and the harm associated with these substances, as well as providing a platform for the provision of technical assistance. Member States to improve countries' capacities to generate data and analysis on synthetic drugs (UNITED NATIONS OFFICE ON DRUGS AND CRIME, 2020). The SMART program operates from the Vienna office and has teams in Asia (Thailand) and America (Panama).

In addition to SMART, UNODC launched, in 2013, a global SAR (–EWA) as a response to the global emergency of NPS. EWA aims to monitor, analyze and report trends in NPS to help implement evidence-based public policy responses. In addition, it also acts as a repository for information and data on these substances, through its platform called Tox-Portal. This system was developed in collaboration with the International Association of Forensic Toxicologists (TIAFT), which collects toxicological and health data related to NPS use. EWA is administered by the SMART program and aims to enhance Member States' ability to generate, manage, analyze and report information on synthetic drugs.

SAR information on drug seizures, as well as identifications of drugs in biological fluid, allow for a more comprehensive overview of NPS, making health threats more accessible. To assist in this work, UNODC provides assistance in the areas of quality assurance to forensic laboratories, provision of manuals and guidelines, kits and portable drug and precursor detection devices, as well as training in the UNODC laboratory in Vienna and in the field (UNITED NATIONS OFFICE ON DRUGS AND CRIME, 2020).

América do Norte

The US has the National Drug Early Warning System (NDEWS) (NATIONAL DRUG EARLY WARNING SYSTEM, 2021) with support from the National Institute on Drug Abuse (NIDA) since 2014, which functions as a SAR. The NDEWS is supported by an early monitoring network (Early Warning Network – EWN) made up of 18 sentinel sites that quickly provide NPS surveillance information to all partner agencies in the system. Figure 2 lists the institutions participating in the EWN.

Methodology and description of experiences

Overseas hubs

Within the framework of the United Nations (UN) drug conventions, the Global Synthetics Monitoring Program (SMART) was created in 2008 with the aim of helping Member States in NPS identification and reporting. The SMART program functions as a global repository of information on NPS, contributing to a better understanding of synthetic drugs, trends and patterns of distribution and use, and the harm associated with these substances, as well as providing a platform for the provision of technical assistance. Member States to improve countries' capacities to generate data and analysis on synthetic drugs (UNITED NATIONS OFFICE ON DRUGS AND CRIME, 2020). The SMART program operates from the Vienna office and has teams in Asia (Thailand) and America (Panama).

In addition to SMART, UNODC launched, in 2013, a global SAR (–EWA) as a response to the global emergency of NPS. EWA aims to monitor, analyze and report trends in NPS to help implement evidence-based public policy responses. In addition, it also acts as a repository for information and data on these substances, through its platform called Tox-Portal. This system was developed in collaboration with the International Association of Forensic Toxicologists (TIAFT), which collects toxicological and health data related to NPS use. EWA is administered by the SMART program and aims to enhance Member States' ability to generate, manage, analyze and report information on synthetic drugs.

SAR information on drug seizures, as well as identifications of drugs in biological fluid, allow for a more comprehensive overview of NPS, making health threats more accessible. To assist in this work, UNODC provides assistance in the areas of quality assurance to forensic laboratories, provision of manuals and guidelines, kits and portable drug and precursor detection devices, as well as training in the UNODC laboratory in Vienna and in the field (UNITED NATIONS OFFICE ON DRUGS AND CRIME, 2020).

América do Norte

The US has the National Drug Early Warning System (NDEWS) (NATIONAL DRUG EARLY WARNING SYSTEM, 2021) with support from the National Institute on Drug Abuse (NIDA) since 2014, which functions as a SAR. The NDEWS is supported by an early monitoring network (Early Warning Network – EWN) made up of 18 sentinel sites that quickly provide NPS surveillance information to all partner agencies in the system. Figure 2 lists the institutions participating in the EWN.

Geographic location of the sentinel sites that make up the United States of America early warning network and the respective institutions

Source: Adapted from NDEWS. Accessed on: 10 Dec. 2021.
*Minneapolis sentinel institution is yet to be defined.

The information generated by EWN is primarily analyzed by researchers at the University of Maryland Substance Abuse Research Center. After analysis, the data goes to the Coordination Center, composed of scientists from the universities of Florida, New York and the Atlantic University of Florida, with cooperation from NIDA. Through the second analysis, the NDEWS incorporates real-time monitoring for early detection of signs of potential drug epidemics, using modern surveillance methods to rapidly compile and disseminate data. A Scientific Advisory Group, consisting of 12 US scientists and 5 experts from the DEA (US Drug Enforcement Administration), the Centers for Disease Control and Prevention (CDC) and the National Office of Policy and Control on Drugs (ONDCP – Office of National Drug Control Policy) guide the management of the NDEWS (NATIONAL DRUG EARLY WARNING SYSTEM, 2021).

In an innovative way, the SAR in the US continues to expand, combining improvements in analysis strategies in the identification of NPS by traditional resources (eg forensic laboratories, emergency rooms), and also with methods of surveillance of these substances through machine techniques. online and social media drug market research and learning (COTTLER et al., 2020). Emerging drugs and changes in usage patterns are monitored by each sentinel site using data on overdose deaths, treatment admissions, hospital admissions, poison centre searches and seizures (NATIONAL DRUG EARLY WARNING SYSTEM, 2020). Analyzing this constantly evolving scenario, it can be seen that, although traditional follow-ups for monitoring psychoactive substances are useful as national estimates to observe drug use and associated consequences, a national system is essential to detect risk trends, as they appear (COTTLER et al., 2020).

Once specific drugs are identified, researchers study pharmacological and toxicological aspects. Several NIDA and DEA sponsored laboratories are already established to carry out laboratory investigations. The most effective strategies to alert and educate the population about the dangers of NPS are the provision of reliable scientific data on NPS and informational websites, such as those sponsored by NIDA and NDEWS (BAUMANN and VOLKOW, 2016).

Canada, on the other hand, has an early warning system in the form of a monitoring network, called the Canadian Community Epidemiology Network on Drug Use (CCENDU), created in 1995. a national network of community partners that reports on emerging drug use trends and associated risks. CCENDU is assisted by the Canadian Center on Substance Use and Addiction (CCSA) in coordinating partner institutions and issuing alerts and information to the community about local drug-related problems. . Each partner located in the different provinces joins the network on a voluntary basis.

Local institutions collect quantitative and qualitative information about the use and harm related to psychoactive substances and pass this information on to CCENDU, which analyzes the risks at the national level. Each Canadian province has an institution responsible for compiling and submitting information to CENDU, mainly in the areas of health and assistance. If necessary, an alert is issued to police forces, health systems, care institutions and the drug user community itself (CANADIAN CENTER ON SUBSTANCE USE AND ADDICTION, 2021).

Unlike SARs that have a formal structure of action, with actors defined by legislation, the Canadian system has a reduced capacity for monitoring, at the regional level, and depends on the strength and performance of institutions in each province. In addition, as it does not have a formal structure, the link with the processes is weakened, depending on voluntary actions. On the other hand, networking can help to deepen partnerships between regional and national institutions that, according to adherence and effective functioning, will help to increase the ability to identify new substances and trends in the use of NPS.

Latin America

In recent years, there has been a significant increase in the number of NPS alerts in the Latin American region. Between 2019 and 2020, 68 substances were detected and reported to UNODC by 11 Latin American countries, with Brazil being the main one to report NPS (36 substances), followed by Chile, Colombia, Argentina and Uruguay (24, 16, 12 and 6 substances, respectively). Stimulants and synthetic cannabinoids were the groups with the highest presence in Latin America and the Caribbean in the last two years, as shown in the following figure.

New psychoactive substances reported to UNODC in Latin America and the Caribbean, classified by their effects on the human body, 2019-2020

  • Stimulants
  • synthetic cannabinoids
  • classic hallucinogens
  • Dissociative
  • hypnotic sedatives
  • synthetic opioids

*2020 data is not complete and may change.
Source: Adapted from Global SMART Newsletter for Latin America and the Caribbean.
Access on: 10 Dec. 2021.

Since 2011, the Inter-American Drug Abuse Control Commission (CICAD), through the Inter-American Observatory on Drugs (OID) and the Hemispheric Strategy on Drugs, has warned that member countries of the Organization of American States (OAS) should begin to give due attention to the monitoring of synthetic drugs. As a way of responding to the growing threat of NPS, CICAD/OID established, in 2019, the Rapid Alert System for the Americas (SATA – in its Spanish acronym). With the aim of compiling information at the regional level, SATA compiles data from SARs already implemented in the region, in addition to alerts issued by countries where the systems are not yet fully implemented. The information gathered to date shows that NPS have become prevalent in Latin America and the Caribbean, requiring monitoring and surveillance in the same way as more conventional drugs such as marijuana and cocaine (INTER-AMERICAN COMMISSION FOR THE CONTROL OF DRUG ABUSE, 2020).

In Latin America, and in other Spanish-speaking countries, you can find the term SAT (Sistemas de Alerta Temprana) to describe a SAR. The first systems created are listed below and described in sequence:

  • Colombia: 2014;
  • Uruguay: 2014;
  • Argentina: 2016;
  • Chile: 2016.
Colombia

In 2014, through Resolution No. 001 of 2016 of the National Narcotics Council (COLOMBIA, 2016a), the Colombian SAR was created to combat the emergence of emerging drugs, based on the networking of national institutions. The system is coordinated by the Colombian Observatory on Drugs of the Ministry of Justice and Law. Important results were obtained, such as the cooperation between the participants of the system and the subsequent development of operational protocols, in addition to the detection and characterization of NPS. As a result, there was a strengthening of national institutions responsible for studying the evolution of NPS in the judicial, administrative, forensic and operational spheres (COLOMBIA, 2016b).

The SAR is classified by the Government of Colombia as fundamental for public health, being responsible not only for the detection of drug consumption, but also for the characteristics of consumers, the forms of use and the contexts in which the substances are inserted. In this way, human, technical and medical resources are optimized. The SAR works with a set of information that interacts with each other to support the actions necessary for a more efficient control of drug consumption and its consequences on public health.

The system also maintains partnerships with Spain. The advice and partnership with the Igenus Foundation, from that European country, and with the Inter-American Commission for the Control of Drug Abuse of the Organization of American States (CICAD/OAS) resulted in the development of the Epidemiological System of Rapid Alert to the Consumption of Emerging Drugs in city ​​of Medellín (RADAR) (CASTAÑO PÉREZ et al., 2013).

In 2016, institutions that are part of the SAR in Colombia reported the emergence of mixtures of up to five psychoactive substances in the same analyzed material. Such psychoactive substances have different effects on the central nervous system — including stimulant and hallucinogenic effects. Added to this is the concern about the simultaneous use of more than one type of psychoactive substances on a single occasion, as the risks can be unpredictable. The worldwide concern with the consumption of NPS lies precisely in the unknown adverse effects and risks they pose to public health, due to the scarcity of toxicological information and assessment of the risk of consumption (COLOMBIA, 2017b).

With the aim of prioritizing control over the NPS, the Colombian police services carry out the following actions:

  • Standardize and document procedures to combat NPS;
  • Develop modules for police training programs aimed at controlling NPS;
  • Acquire state-of-the-art equipment to support the police service (eg RAMAN Technology – portable equipment for identification of substances in the field);
  • Form special groups and joint work with private and public institutions to face the growing phenomenon of production, transport and consumption of NPS (COLOMBIA, 2017a).

Other important strategies were implemented in the country for the consolidation of the SAR. Of note is the organization of a seminar with the participation of experts from different countries, with the aim of increasing knowledge about the different methodologies used for drug detection and establishing a network of communication and cooperation between them. Certified reference material was also donated to all official forensic laboratories in Colombia, allowing the detection of NPS and its precursors. In the clinical area, the national toxicological emergency management guide was updated, including a chapter on new psychoactive substances. In addition to seeking to learn about the experience of other countries, Colombia has also improved the communication of alerts thanks to cooperation with civil society, including the development of harm reduction strategies by non-governmental organizations (NGOs). The NGO Acción Técnica Social, for example, has generated forms of communication that inform the findings of the SAR aimed especially at at-risk youth (UNITED NATIONS OFFICE ON DRUGS AND CRIME, 2017).

Uruguay

Uruguay's Rapid Alert System, called SATdrogas, was established in November 2014 and is made up of a network of institutions. In this system, more than 15 institutions nationwide, civil society organizations and the private sector (treatment centres for drug addicts) are represented. International institutions such as UNODC, CICAD/OAS, COPOLAD (Cooperation between Latin America, the Caribbean and the European Union on Drug Policy) and SARs from other Latin American countries are also part of it. SATdrogas operates under the coordination of the Junta Nacional de Drogas (the highest body of the National Drug Policy of Uruguay). The direct management of SATdrogas is carried out by the Uruguayan Observatory of Drugs (OUD), whose main scope is the compilation, systematization and analysis of information on drugs in the country, being responsible for the generation of scientific evidence on the subject and the elaboration of periodic reports that serve as foundations in the elaboration of the National Drug Policy (OBSERVATORIO URUGUAYO DE DROGAS, 2019).

The operationalization of SATdrogas takes place through an online platform in which the exchange of information between the institutions of the network takes place. This same tool can also be accessed by the population, who can make complaints about events related to the objectives of SATdrogas, such as: marketing of new drugs, new forms of consumption and any events that put users' health at risk.

Since the beginning of its operation, SATdrogas has already received 86 complaints from partner institutions, 20 complaints of intoxication cases, and identified more than 20 substances and 25 drug units seized (pills, stamps, among others). It has already produced three public alerts for the Uruguayan population and 5 international alerts, in addition to 6 newsletters.
Public alerts are one of the main tasks of SATdrogas, as they make it possible to raise awareness and inform various actors about the risks associated with the consumption of NPS and about the emerging drug phenomenon. An alert is associated with an unusual risk situation or a prominent threat within the scope of public health, whose objective is to give differentiated attention, highlighting the importance and significance of the event that requires special surveillance, control or precaution.

Argentina

In December 2016, Argentina created a national rapid alert system (Sistema de Alerta Temprana – SAT) through the Argentine Drug Observatory (Observatorio Argentino de Drogas – OAD) — a division of the Nation’s Comprehensive Drug Policy Secretariat Argentina (Secretaría de Policies Integrales sobre Drogas de la Nación Argentina – SEDRONAR) and based on Decree 33/2017, which modified Decree No. 357/2002 (UNITED NATIONS OFFICE ON DRUGS AND CRIME, 2016a) (ARGENTINA, 2017, 2016b) .

The Argentine SAR consists of a set of technical and communication procedures between various government agencies and society organizations, with the objective of obtaining information for the detection of the use of NPS, preventing and reducing the impact on the health of users, as well as on the health of the users. public, and create early responses to the challenges that arise on the national scene with the NPS. The role of this SAR consists of the constant monitoring of the emergence of new psychoactive substances and changes in the form of consumption or commercialization of NPS. It also acts in the chemical identification of detected substances, elucidating the structural composition, possible adulterants, toxicity and the ability to cause dependence in users. Within the scope of national public health, it assesses individual and population risks in the consumption of psychoactive substances (ARGENTINA, 2016a).

The Argentine SAR observation process consists of three stages: pre-alert, alert and confirmed case. The first phase is constituted by a probable detection of NPS and/or new patterns of consumption or commercialization. The information is directed to the national information technology systems, under the responsibility of the SAR, which follows the procedures for validation and confirmation of information. Subsequently, the alert is defined as a possible risk situation in the area of ​​public health, resulting from the detection of an NPS and/or new patterns of consumption and trade thereof. In the event of a suspected case, generated from the clinical history and/or report of the user himself or his friends, companions or witnesses of the consumption of a drug with the potential to belong to the NPS, the investigation is directed to laboratory analyses, using matrices biological substances such as blood and urine. Once the substance is identified in the biological sample or in non-biological materials, such as syringes or other instruments related to drug consumption, there is a confirmed case (ARGENTINA, 2016).

Another strategy adopted by Argentina was to change the frequency of updating the national drug list. Between 1991 and 2015, the document was updated twice and, starting in 2016, it is revised annually. The chemical analyzes originating from this system were published on the UNODC website and are available worldwide for access (VERRIER, 2020) (UNITED NATIONS OFFICE ON DRUGS AND CRIME, 2019). Argentina, along with Brazil, is one of the few countries in South America that have adopted generic definitions of NPS in their national legislation. UNODC's EWA contributed to the development of this inclusion in the legislation, providing up-to-date information on NPS trends and scientific data on individual chemical substances, allowing greater agility of national legislation in the face of the challenges of the dynamic and agile market of NPS (UNITED NATIONS OFFICE ON DRUGS AND CRIME, 2019).

Chile

In 2016, Chile created its SAR, composed of 23 institutions, seeking to quickly identify events related to NPS that could be a major threat to public health. The national multidisciplinary network is managed by the National Service for the Prevention and Rehabilitation of Drug and Alcohol Consumption (Servicio Nacional para la Prevención y Rehabilitación del Consumo de Drogas y Alcohol – SENDA), responsible for creating and exchanging information for the early identification of NPS. Systematic monitoring of the availability and consumption of substances makes it possible to quickly and efficiently assess risks and impacts in the country, disseminating information to the general population, to those at risk due to consumption or exposure to substances, and to professionals who deal with the theme. In this way, it is possible to gather evidence for the formulation of public policies aimed at reducing demand and greater control over the drug trade (CHILE, 2020).

However, Chile already had strategies for acting against NPS before 2016. On March 31, 2015, the National Council for New Psychoactive Substances (National Table of NSP - MNNSP) was created to implement a mechanism for continuous inter-institutional analysis of new substances, issuing annual reports recommending the inclusion of newly identified substances in the lists of banned compounds in the country. The MNNSP documents made available each year provide updates on its activities, scientific and legal analysis on NPS identified by the UNODC SAR, by another international system or by Chilean authorities. Using the information from the analyzes contained in the reports, the MNNSP sends a recommendation to the Ministry of the Interior and Public Security on which molecules deserve to be added to the articles of Decree 867/2007 — which control prohibited substances in the country (CHILE, 2015).

The Chilean model develops inter-institutional analyzes on NPS that arise worldwide and that can reach Chile, that is, it has a preventive action, not acting only when an NPS appears in the country. In the evaluations, the toxicities, effects and adverse consequences of the drug in question are considered. As an example of the effectiveness of this proactive stance, which anticipates the inclusion of substances not yet present in the country in the national legislation on drugs, we can mention the synthetic cannabinoid XLR-11, which was already included in the list of prohibited substances in 2016, being that the first seizure of this NPS in Chile took place in 2017. In addition, the synthetic cathinones ethylone and pentedrone were also added to the regulations of the United Nations Convention on Psychotropic Substances during the month of March 2017, and in Chile they were already regulated since 2016. Prior control, in addition to the great importance given to public health, provides regulatory strengthening, expands consumer or user knowledge and awareness, in addition to discouraging or hindering the use of the country as a point of interconnection with other transnational consumer markets. The MNNSP, in its conception, opted for the most difficult and strictest strategy, however, it judges it as the most adequate to its reality. In this concept, each NPS deserves to be individually analyzed and categorized with the correct proportionality obtained by the thorough analysis (CHILE, 2016, 2017).

Brazil

Nationally present since 1999, the National Health Surveillance Agency (ANVISA), an agency that inspects sectors related to products and services that may affect the health of the Brazilian population, has carried out more than 35 updates to Ordinance 344/1998 (responsible for the commerce and use of special control drugs), from the list of controlled substances, published in 2012. National drug legislation, similar to Argentina's, adopts generic definitions of NPS (UNITED NATIONS OFFICE ON DRUGS AND CRIME, 2015). Many countries are trying to keep their lists of proscribed drugs up to date, but the emergence of NPS has been faster than the inclusion processes. As a consequence, a large amount of unregulated synthesized NPS is marketed worldwide, including through the internet (UNIVERSIDADE FEDERAL DE SÃO PAULO, 2018).

Aware of the particular characteristics of NPS, and with the objective of speeding up the updates of Annex I of Ordinance SVS/MS nº 344/98, the Brazilian authorities created the Working Group for Classification of Controlled Substances (GT), through Ordinance ANVISA nº 898, of August 6, 2015. Among the objectives, we highlight the improvement of regulatory documents for the classification and control of narcotic, psychotropic, precursor, proscribed and plant substances. The Group is permanent and was created within the scope of ANVISA, with the participation of the Ministry of Justice and Public Security – represented by the Federal Police (PF), the National Secretariat for Drug Policies and Asset Management (SENAD) and the National Secretariat for Public Security (SENASP). Thus, it becomes a multidisciplinary and multiprofessional team, with specialists in the areas of public health, forensics, legal and drug policy, significantly expanding the actions necessary to combat problems arising from drugs in the national territory (AGÊNCIA NACIONAL DE VIGILÂNCIA SANITÁRIA, 2017a, 2017c).

There are two GT reports available electronically. The first presents the results for the years 2015 to 2016 (AGÊNCIA NACIONAL DE VIGILÂNCIA SANITARIA, 2017b) and the second, from 2017 to 2018 (AGÊNCIA NACIONAL DE VIGILÂNCIA SANITARIA, 2019). The first report shows that after the creation of the group, there was a reduction in the period required for analyzing and classifying substances. There was also an increase in the frequency of updates to Ordinance 344/98, resulting in 9 updates since the creation of the WG and the inclusion of 31 substances in the list, 27 of which are represented by NPS (AGÊNCIA NACIONAL DE VIGILÂNCIA SANITARIA, 2017b). Between 2017 and 2018, 10 updates were presented in Annex I of the aforementioned ordinance on the control of psychotropic substances, with the insertion of 37 substances, 30 of which were NPS, 2 precursors of narcotics and/or psychotropic drugs and 5 components of drugs registered with ANVISA (AGÊNCIA NATIONAL HEALTH SURVEILLANCE, 2019). In both reports, there are quotes about the WG's work to obtain knowledge about trends in substance use and abuse in the global context, through constant monitoring and consultation with the UNODC and EMCDDA SARs. The Federal Police also carried out surveys and produced a report on synthetic drugs in the national territory. In 2018, 43 NPS were identified, of which 16 were identified for the first time, corresponding to an increase of 60% compared to the previous year (BRASIL, 2018).

NPS are already frequently identified in the national territory (SANTOS et al., 2016) (ARANTES et al., 2017) and there are scientific publications in which it is possible to verify the increase in the amount of substances in materials that formerly had a single class of molecules psychoactive. In the State of Santa Catarina, for example, on stamps seized between 2011 and 2017, analyzes were carried out to identify the types of substances found in the material. It was found that, in 2011, only LSD (lysergic acid diethylamide) was found, while, in 2017, the seals were composed of 25 different substances, the main one being 25I-NOBH, an NPS derived from phenylethylamines (DE SOUZA BOFF et al., 2020). The result makes evident how dynamic and extensive the NPS listing is and the need for an up-to-date national system on information on these and other drugs.

The importance of a consolidated SAR in Brazil is clear when analyzing the increasingly frequent evidence of NPS detections in the national territory. In July 2016, an unknown substance was submitted to the Forensic Chemistry Laboratory of the Federal Police of Brazil (SEPLAB/PF). A report was prepared with all the technical data and interpretation of the results and, subsequently, shared with ANVISA, which placed 25I-NBOH under the control of national legislation in October 2016 (INTER-AMERICAN COMMISSION FOR THE CONTROL OF DRUG ABUSE, 2020) (ARANTES et al., 2017).

Even before the implementation of the SAR, there were already national actions to expand the knowledge of forensic professionals working in the identification of NPS. The Minerva Project, from the Ministry of Justice and Public Security, for example, combines the knowledge of the Federal Police with the experiences of state expertise, resulting in increased understanding and exchange of information about NPS (BRASIL, 2019).

In line with initiatives such as the Minerva Project, Decree No. effects, damages and target populations, in order to outline prevention, treatment and supply repression actions” and also “to structure, within the scope of the National System of Drug Policies (SISNAD), a rapid alert system for new drugs, and to encourage universities and other research institutions, public or private, to research new drugs, in relation to their composition, action potential, toxic potential, health problems and chemical dependence, among others”.
In the academic area, there are projects whose focus is to expand knowledge about NPS.

Recently, the Coordination for the Improvement of Higher Education Personnel (CAPES) and the Ministry of Justice and Public Security approved the study “INSPEQT Project: Investigation of New Psychoactive Substances in Forensic Chemistry and Toxicology”, in which the integration of state expertise will take place. , Federal Police and universities to implement improvements and advances in forensic research areas (BRASIL, 2021a). Within the scope of this project, the detection of SPN in prison environments has already been reported: synthetic cannabinoids infused in papers seized in prisons in the State of São Paulo between 2016 and 2020 were identified, with seven different synthetic cannabinoids being identified, in combination or not. . These data corroborate a trend towards an increase in NPS in penitentiaries around the world, due to the greater ease of smuggling (RODRIGUES et al., 2021).

On August 30, 2021, Resolution No. 6 was published, creating, on an experimental basis, the SISNAD Rapid Alert Subsystem. The SAR is a subsystem of SISNAD and is intersystemically articulated with the Unified Public Security System (SUSP) and the Unified Health System (SUS). The SAR is coordinated by SENAD and provides for the participation of various national and state agencies in the areas of public safety and health, as well as universities and specialized toxicology units. It is also composed of a Technical Committee, with the purpose of defining criteria for inserting information into the Subsystem's database — which will be composed of specialists in the forensic and health areas belonging to the institutions providing data to the SAR. The implementation of the SAR will take place gradually and is expected to be completed in all 27 federative units within five years (BRASIL, 2021b).

The national SAR will be a strategic reference source for the country, obtaining information proactively, anticipating an event, before finding the existence of NPS in Brazilian territory, and collecting national data in emergency rooms, poisoning centres and state or federal police, as well as universities. By sharing information, it will be possible to assess risks and develop possible legal control at national or international level.

In addition, it will support public health and safety policies, through rapid responses to adverse changes caused by NPS, minimizing the risks associated with the consumption of these substances. The SAR also intends to carry out systematic monitoring of the availability and use of these substances (including new patterns of use, such as the injectable form, currently little used, but with considerable risk of expansion), in addition to observing adverse events resulting from the consumption of NPS, including possible adulterants.

Europe

In Europe, the regional SAR has existed since 1997 and is composed of 2 agencies (EMCDDA and Europol) and 29 national SARs. In the flow of information, there are three strategies in the legislation that allow the European Union (EU) to take agile actions to detect, assess and respond to public and social health threats caused by NPS: rapid alert system, risk assessment and control measures. about NPS. The EMCDDA is responsible for the first two, working together with the EU on the SAR on new psychoactive substances, and Europol develops criminal risk assessments related to NPS. The EMCDDA and Europol are subordinate to the European Commission, which is responsible for proposing measures to control substance use. The main objective of the SAR is to ensure accurate and as specific information as possible about NPS, directing it to the appropriate and capable people – thus allowing for quick decision-making and effective actions to prevent or reduce the risk of harm. Responses must be created according to the substance under analysis, type and threat level, and actions can be taken at different levels such as practices, policies and research. The detection information of an NPS at the national level is quickly passed on to the SAR. This information network is called REITOX (French acronym: Réseau Européen d'Information sur les Drogues et les Toxicomanies) and its creation occurred concomitantly with the creation of the EMCDDA.

One of the main applicability of the SAR is the exchange of information on NPS, as well as the use of monitoring to identify, evaluate and provide elucidation of issues related to public health and social threats. In this context, there are risks not necessarily resulting from the NPS themselves, but arising from risks associated with their consumption. There are several examples: harmful adulterants to living organisms, diluents, impurities from the synthesis and manufacture of NPS, in addition to biological contamination and transmission of infectious diseases. The SAR plays a prominent role in exchanging information on new trends in the use of psychoactive substances and/or combinations of these, in which there are potential risks to public health, in addition to offering knowledge on possible actions to protect the life of the population (EUROPEAN MONITORING CENTER FOR DRUGS AND DRUG ADDICTION, 2019).

The information allows the country network to detect and assess any potential threats, as well as enabling the identification and implementation of necessary measures in response. In the analytical area, forensic and toxicological science laboratories include the substance that was formally notified in the scope of laboratory screenings, thus providing identification and monitoring. Communications to relevant agencies (health and safety, for example), and NPS consumers, can also be included in the actions. There are situations in which actions include risk assessments, resulting in restrictive measures aimed at reducing the supply and availability of a substance. Specifications about a new substance, when it is uniquely identified in the drug market, can be scarce. Therefore, the actions to be developed may include studies to reduce doubts about the identified drug. Research with available scientific articles also has the potential to include information on pharmacology and toxicological effects, thus helping to understand the epidemiology of NPS under analysis (EUROPEAN MONITORING CENTER FOR DRUGS AND DRUG ADDICTION, 2019).

Effective development of the SAR requires a well-defined strategic objective and multi-sectoral support from different agencies and multidisciplinary expertise. Tackling NPS requires efficient infrastructure, policies and procedures, as well as trained and experienced professionals at all levels of the European Community Member States (cities, states and countries). Communications must be efficient, particularly between forensic science and toxicology laboratories, poison centres, government departments responsible for implementing national drug policies, drug regulatory agencies and Europol national units.

It is important to remember the relevant dimension and heterogeneity of the European Union. The production and market of drugs, the use of psychoactive substances, social problems and drug legislation can vary significantly. Member States need to consider such dissimilarities within their territories, assessing the possibility of failures in local systems and, where necessary, developing local actions to strengthen national SARs. The same reasoning can be extended to the reality of a single country, which, internally, can have wide regional differences (EUROPEAN MONITORING CENTER FOR DRUGS AND DRUG ADDICTION, 2019). The success of the EU regional SAR is explained by the structure in which it is configured, working from the compilation of data from national SARs. In this way, as soon as the notification of a new NPS is issued in a country, the other member countries of the network are alerted as quickly as possible, which makes it possible to detect and assess potential risks in an early way (EUROPEAN MONITORING CENTER FOR DRUGS AND DRUG ADDICTION, 2019). The Decision of the Council of the European Union 2005/387/JHA describes, in its article 4, the obligation of all Member States to provide information on the manufacture, trafficking and use of NPS, guaranteeing the instruments to subsidize the unified system of the bloc ( US, 2005).

As an example of a national SAR in the European Union, the German system consists of an informal network of national relevance. Information flows through the EMCDDA to the German focal point and, finally, to the national institutions, and the reverse path is also valid. The German SAR was implemented in 1997 through the European Council's Joint Action on New Synthetic Drugs, and acts as an advisory body to the Ministry of Health, having no formal mandate for the decision-making process in public policies. Thus, its action is restricted to the areas of collection and exchange of information at the national and international level. Each federal state has a different institution participating in the SAR, which can be police, health and assistance institutions, which generates a complex network with obstacles for the formation of alerts and data compilation. The German SAR also has a close relationship with the Federal Police Office, to receive information related to chemical analyzes of new and unknown substances, as well as to establish a regional network, in each state, with experts in epidemiology, prevention, treatment and reduction of damage.

Summary table of information on Rapid Alert Systems

Results

NPS belong to a differentiated class of psychoactive substances that are of worldwide concern due to their characteristics. There are no absolute global rules to reduce the supply and use of NPS, as there are significant differences between countries and, in the same national location, there may not be uniformities between regions.

Overall, the main objective of an SAR is to maintain a surveillance system that includes multidisciplinary information from diverse sources such as epidemiology, public health, safety and NPS data, in order to support the development of rapid interventions. This information generated within the scope of the SAR can support actions for health professionals, legal, customs, police and the general public. SARs play an essential role in this scenario, as they are able to generate and manage information in an adequate and agile way, in addition to contributing to communication between all agencies and professionals involved in dealing with NPS.

Operationally, SARs make up an institutional network with actors that are directly or indirectly linked to drug control, preferably coordinated by a national drug council or institution such as, in the case of Brazil, SENAD. The institutional network is maintained through collaboration and interaction between the institutions involved, which contribute with knowledge related to their respective area of ​​activity. The formation of these networks makes it possible to exchange information that supports the establishment of joint projects and activities with the objective of controlling, inspecting, identifying, detecting and regulating NPS. In addition, toxicological profiles of these substances can be delineated in order to facilitate possible detections and public health actions.

For the effective functioning of a SAR, the legislation in force in each country must respect its structures and particularities. NPS can be regulated by different legislative structures: generically, analogously or specifically, taking into account the chemical structure of the substance in question. Specific checklists are aimed at monitoring a single substance. However, in view of the rapid development and evolution of new molecules, the list of controlled substances may lag in a short period. In addition, the inclusion of new substances in checklists can be a time-consuming process, depending on information regarding health and toxicological risks (UNITED NATIONS OFFICE ON DRUGS AND CRIME , 2013).

In federative countries, such as Brazil, the complex structure of different public security and health agencies can make the standardization of analyzes a lengthy and bureaucratic process. Thus, in countries with this structure, the adoption of a generic model of NPS control becomes more attractive. These generic legislations focus on monitoring groups of substances rather than those listed individually. Like the United Kingdom, Hungary, Italy and Ireland, Brazil has also adopted generic legislation to control these substances (UNODC, 2013).

The identification of new substances, adulterants or precursors, can activate mechanisms for control and regulation using different legislative and regulatory tools that vary from country to country with the objective of reducing both the production and trafficking of these substances.
Additionally, there are differences especially between countries that are configured in a federative manner and those formed by a centralized structure in terms of obtaining and unifying data, since countries with a single structure at the national level have ease in compiling data, as the institutions involved. For example, the same police institution operates comprehensively throughout the national territory; in this way, internal procedures and communication processes between different institutions are reduced. Thus, data integration occurs faster and without institutional obstacles.

On the other hand, in the federative context, each federative unit exists autonomously, having specific characteristics, as well as its own police, health system and judicial institutions. Thus, the diversity of actors involved makes the unification of data into a single system a much greater challenge when compared to unitary countries, which have few institutions. As a result, in federative countries, the trend is towards the creation of SARs more similar to the concept of “networks”, with relationships established by membership and differences between the institutional links of the participants. In this sense, it is possible to mention the experience of the USA, which established several sentinel sites with agile communication flows, enabling real-time surveillance; and also the European continent, with the establishment of focal points for the System in the participating countries, striving for rapid inter-institutional interconnectivity.

In addition, SARs supported by a concept of “networks” tend to involve greater participation of civil society bodies, such as universities and research centres, which can contribute to the capillarity of the implemented actions, as well as the strengthening of analytical capacities and the use of new technologies for the continuous improvement of the surveillance system.

Identified innovations

Analysis of seized raw materials

The challenges posed by the growing threats posed by NPS require, in addition to quick responses and strategies, a broad and multidisciplinary approach. The exchange of information is crucial for understanding the aspects and risks of NPS, in addition to enabling a more concrete and targeted approach to the problem. In view of this, consortia and partnerships have already been formed around the world in order to strengthen the fight against the growth of synthetic drugs and NPS.

The URITo.N Consortium (Unit of Research and Innovation in Forensic Toxicology and Neuroscience of Addiction) was created by the Toxicology Division of the University of Florence, Italy, and has a multidisciplinary team composed of forensic toxicologists, chemists and physicians responsible for researching all aspects of drugs of abuse, especially NPS. The group uses the technologies of liquid and gas chromatography coupled with mass spectrometry, with nuclear magnetic resonance. Such technologies allowed the research group to identify the NPS 1-(benzofuran-5-yl)-N-methylpropane-2-amine (MAPB), 2-amino-1-(4-bromo-2,5-dimethoxyphenyl) ethane- 1-one (bk-2-CB) and 3-(2-aminopropyl)indole (α-methyltryptamine) in seized materials. URITo.n, as a highly specialized research unit, was able to identify substances by combining different analytical techniques, even without the use of analytical standards, which represents a huge gain in the “time” factor — essential for making information available to national, regional and international health, legislative and monitoring services (BERTOL et al., 2017).

Poison and emergency centres

In Sweden, a national project called STRIDA (the name is an acronym of the name of the Swedish project and also means “to fight”), started in 2010 with the objective of monitoring the occurrences and health risks caused by NPS in the territory. Swedish. Data are collected on assessments of analytically confirmed serious adverse events among patients who required emergency hospital care. The project was developed with the interaction of the Karolinska Institute, the Karolinska University Laboratory and the Swedish Poisons Information Center (PIC) in Stockholm. PIC is a national telephone consultation service, available uninterruptedly (similar to the Brazilian Toxicological Assistance Center - CEATOX) for acute intoxications, directed and operated by pharmacists and physicians, being available to health professionals and the general public. All emergency departments (emergency
departments – ED) and intensive care units (ICU) in the country were communicated by correspondence about the study. The ED/ICU also received a form to request laboratory services from the project, which allowed for a complete toxicology analysis to be performed. The biological samples collected were urine, plasma or blood serum. After sampling, the body fluids were sent to the Karolinska University laboratory and, after the analysis, the samples were frozen for future studies (HELANDER et al., 2020).

The results of the STRIDA project were positive, as they provided an overview of the Swedish drug scene — classic or recent. The work contributed significantly to the SAR, through the sharing of information obtained on incidence, distribution, identification of adverse effects and treatments of acute poisoning, confirmed in analytical laboratories. The project also highlighted the important collaboration between the PIC and the laboratory in the identification of suspected cases of NPS consumption, in addition to showing the relevance of using adequate analytical equipment for research and elucidation. Also noteworthy were the collaborations between the police and customs, in addition to the promotion of chat forums on drugs. The sharing of information, mainly related to NPS, through lectures and publications, also deserves to be highlighted (HELANDER et al., 2020) (BÄCKBERG et al., 2018) (JOHANSSON et al., 2014).

Wastewater analysis

Wastewater analysis (WWA) can be classified as suitable proposals to provide temporal and spatial trends in NPS use, as they provide information on the types and amounts of drugs being used at any given time. Wastewater-based epidemiology (WBE) is a prominent tool in facing the challenges of NPS monitoring. Urban wastewater presents some characteristics of the analyzed population. After the use of a xenobiotic, it can be eliminated in feces or urine, either in its original form, without alterations, and/or its biotransformation product, in the urban sewage system. Its application in the field of toxicology is not recent, having been used for more than 10 years (ZUCCATO et al., 2005) (VAN NUIJS et al., 2011), and is currently applied in the forensic toxicological statistical field to evaluate the use of NPS. (GONZÁLEZ-MARIÑO et al., 2016).

The advantages of the WBE make it an indicator of drug consumption that is complementary to the classic tools for monitoring the use of psychoactive substances, with the differential of providing objective and updated data on the population under analysis in a narrow period of time (EUROPEAN MONITORING CENTER FOR DRUGS AND DRUG ADDICTION, 2016a).

Analysis of post-mortem biological samples and mortality reporting systems

Suspicious or violent deaths are routinely investigated by the Medico-Legal Institutes (IMLs) in Brazil. Blood alcohol dosage tests and/or verification of the use of other drugs in necropsied victims in these institutes can be requested by both police authorities and coroners. Thus, alcohol and/or other drug use verification tests are not performed on all victims of deaths from external causes, as the coroner may find it unnecessary to perform an internal examination to establish the cause of death or for other reasons. reasons, such as lack of resources and adequate infrastructure.

The lack of national data on the relationship between the use of psychoactive substances and violent deaths (eg traffic accidents, homicides and suicides) makes it difficult to implement adequate public policies. In order to reduce this problem, SENAD signed, in December 2020, an agreement with the University of São Paulo to carry out a study to verify the relationship between violent deaths and the use of alcohol and drugs in the five regions of Brazil. The objective of the study will be the implementation of a data collection model in order to obtain a population-based estimate of the context of different injuries that resulted in deaths, as well as the use of a variety of drugs identified by rigorous methods of toxicological analysis. . The study will be carried out in the five major regions of Brazil, in five capitals and four other cities with high mortality rates: Curitiba and São José dos Pinhais/PR; Vitória and Cariacica/ES; Goiania/GO; Recife and Paulista/PE; and Belém and Ananindeua/PA.

Post-mortem blood samples will be collected and analyzed in the Toxicology laboratory of the Center for Forensic Sciences of the University of São Paulo, using a methodology already developed in the city of São Paulo (ANDREUCCETTI et al., 2018; ANDREUCCETTI et al. , 2017).

In the US, the Fatality Analysis Reporting System (FARS) compiles traffic fatality data for all 50 US states, the District of Columbia, and Puerto Rico. This system was created in 1975, coordinated by the National Center for Statistics and Analysis (NCSA), which in turn is linked to the National Highway Traffic Administration (NHTSA). Safety Administration) of the US Department of Transportation (NHTSA, 2021a). NHTSA has an agreement with an agency in each state to provide information on road traffic fatalities so that it is compiled and reported at the national level on an annual basis (NHTSA, 2021b). Data are obtained from different state institutions and can be compiled through police reports, death certificates, autopsy reports, medical reports, among others. FARS is routinely used by researchers in studies involving the analysis of road accident risk and culpability associated with the use of alcohol and other drugs (CHEN, 2018).

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