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The low profile of legal highs

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Within the law, but off the clinical radar. Little Within the law, but off the clinical radar. Little is known of the changing compostion and long-term effects of legal highs

Ask what’s keeping most drug workers awake at night at the moment and the answer might surprise you. It’s not powders smuggled in from Afghanistan or Colombia, and sold by thugs on rundown estates.

Legal highs, a technically correct yet practically misleading term, can be bought in corner shops. Look for them on the internet, and you won’t have to trawl through the darknet. A simple Google search will leave users three clicks away from accessing untested, potentially lethal drugs.

And their hit is potent enough to satisfy the most hardened system. ‘We have seen a lot of heroin users turn to legal highs such as spice,’ says Kirstie Wood, a drugs and alcohol support worker at the Wellspring, which supports vulnerable people in Stockport. ‘Legal highs are cheaper, more readily available, and have a similar effect to illegal drugs.’

Perhaps even more worrying is their appeal to teenagers, as the bubblegum packaging gives them an alcopops feel. Research from the Angelus1 foundation, a charity that raises awareness about legal highs, found that 13.6% of 14 to 18 year old school students and 19% of university freshers had tried one or more of the substances. ‘We have seen a number of young people with problems with legal highs, and that number is increasing,’ says Ms Wood.

‘Legal highs’, or new psychoactive substances (NPS) are cocktails of chemicals which produce similar effects to illegal drugs. Often marketed as bath salts, plant food or incense (and marked ‘not for human consumption’), their shifting formulas make them difficult to proscribe under the Misuse of Drugs Act 19712, but these drugs can seriously damage, and even kill users. Yet awareness of their risks and effects is much lower, due to the perception of legitimacy attached to the classification of legality.

Playing whack-a-mole
The situation is further complicated by the new products coming on to the market at the rate of one-a-week, leaving the authorities playing whack-a-mole trying to control the drugs, and treat their users. ‘These substances are also dangerous because it can be hard to identify their active constituents and there is lack of experience of their adverse effects, making it difficult for treating clinicians to manage people experiencing toxic effects effectively,’ says Professor Simon Thomas, of the National Poisons Information Service (NPIS), a harmful substances advisory body run by Public Health England (PHE).

‘People should be aware that as many of these products are relatively new there is much less information available about their safety,’ he adds.

The NPIS says3 that branded and unbranded legal highs were the first and second most common topic for its telephone enquiry service last year, up by 21.4% with requests for information about misuse of drugs such as cocaine, MDMA and cannabis down by 16.3%, 21.3% and 13.9%, respectively.

The most notorious of the legal highs that nurses and other healthcare professionals are likely to encounter is spice. This synthetic form of cannabis replicates the feeling of being ‘stoned’ with a family of chemicals named for their discoverer, John W. Huffman4, but is also known to cause psychotic episodes, seizures, vomiting and severe paranoia. The substance is also highly addictive, with reports of users becoming physically dependent within a month.

‘Drugs like this can be as bad, if not worse, than heroin. Starting in 2010, there was a heroin drought, and many users turned to legal highs like spice,’ says David Solomon, senior lecturer in advanced nursing practice, and a nurse prescriber with experience of supporting patients with legal high addictions.

‘With heroin we all know the guidance, but with legal highs like spice, there is almost no evidence surrounding the effects. We know they cause anxiety, panic attacks, depression, and paranoia. These substances are very dangerous and people just do not know the full picture.’

What are the risks?
According to data from the Office of National Statistics,5 67 people died in the last year from complications resulting from use of NPS. However, Mr Solomon thinks that the recorded death toll is too low, and hides a much greater problem. ‘Many of these substances have been manipulated so that the metabolites do not show up in urine screening,’ he says. ‘This means that when people die, their system is not recognised as containing drugs, and the link to legal highs goes unrecorded.’

A report by the Royal Society of Psychiatrists found that users of legal highs experienced mental health problems and the development of longer-term psychological dependency on the substances, as well as physical reactions such as heart irregularities, and damage to internal organs.

One study6 examined the prevalence of the use of legal highs among mental health patients. It identified a prevalence rate of legal high use at 13%, with over half of users reporting an effect on their mental state. This risk significantly increased for those with a history of a psychotic disorder. Two-thirds of users with a diagnosis of schizophrenia or schizoaffective disorder reported an exacerbation of psychosis when they took legal highs.

‘Legal highs affect both the physical and mental health of users. Many have similar effects on mental health as other illegal drugs,’ Ms Wood adds. ‘We have been given some training but no one is actually sure of how bad the damage can be. At the moment, we treat users in the same way we would someone who smoked cannabis. However, users also experience withdrawal symptoms such as sweating and grinding their teeth, unlike normal cannabis.’

What can be done?
Due to the difficulty in discovering legal high use through means such as urine testing, nurses should be alerted to potential risk when a patient presents in a clinical setting with signs mirroring withdrawal symptoms, says Mr Solomon. ‘When you see a patient who seems agitated, pale, with clammy skin, but no signs of drug use, it is important for nurses to take a thorough psychosocial history of the patient’s recent activity,’ he says. ‘Nurses should ask the patient where they have been living, who they have been associating with, and if they have begun taking legal highs. It really is about asking the right questions so the patient can be referred to the right service.’

The report from the Royal Society of Psychiatrists7 suggests that the UK’s drug treatment services are using a 20th century strategy to handle a 21st century problem. It states that many specialist service staff are more familiar with opiate and crack cocaine users than the emerging population of those using legal highs. This means that before staff can provide support to these groups, they will need guidance and training to deliver interventions in legal high users.

However, due to the rapidly evolving nature of these substances, there is little in the way of a comprehensive evidence base on how this can be achieved.

‘It is clear that the NPS and club drug market is rapidly evolving with increasing evidence of harm to users,’ says Dr Owen Bowden-Jones, a consultant addiction psychiatrist at the Club Drug Clinic, Central and North West London NHS Foundation Trust. ‘The challenge to the UK’s existing drug services is now to keep pace with this growing problem, while continuing to meet the demands of more established substance misuse problems associated with alcohol, heroin and crack cocaine.’

Others cited a need for better education surrounding the risks of legal highs, which may not be apparent to many people. Jeremy Sare, of the Angelus Foundation says: ‘The fact that these substances are legal causes confusion around their risk. Most people have grown up all their lives with every product they buy having a mark of safety on them. There is often assumed to be a degree of assessment in the production of legal highs.

‘A small amount of a substance, such as GBL [a substance with similar effects to ecstasy, now a class C drug], when mixed with alcohol can be fatal. A little knowledge can improve younger people’s safety.’

The most substantial body of evidence on the risks of legal highs, as well as clinical guidance for healthcare professionals on legal highs is the NEPTUNE network. This covers both ‘club drugs’ such as ecstasy and MDMA, as well as legal highs. It contains information for the treatment of both acute and chronic problems with these substances.

Parliament is currently considering the Psychoactive Substances Bill, which would criminalise many legal highs, reflecting the emerging evidence that the substances can be as, if not more, dangerous than typical drugs.

The bill will make it an offence to produce, supply, offer to supply, possess with intent to supply, import or export psychoactive substances; that is, any substance intended for human consumption that is capable of producing a psychoactive effect. The maximum sentence will be seven years’ imprisonment. This will exclude legitimate substances, such as food, alcohol, tobacco, nicotine, caffeine and medical products. In the mean time substances with no clinical history are flooding onto the UK’s streets, under the guise of legality and safety, and often harming the young and vulnerable as a result. Health professionals need to be aware that the war on drugs has taken an asymetric turn.


1. Angelus Foundation. We need drugs education as much as we need a ‘legal highs’ ban.

2. Parliament. Misuse of Drugs Act 1971.

3. PHE. National poisons information service

report 2014/15.

4. Wikipedia. John W. Huffman.

5. Office of National Statistics. Deaths relating to use of ‘legal highs. 2014

6. Lally J, Hallaghan B et al. Prevalence study of head shop drug usage in mental health. B J Psych. 2013. doi: 10.1192/pb.bp.111.038315

7. Royal College of Psychiatrists. One new drug a week – Why novel psychoactive substances and club drugs need a different response from UK treatment providers

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