News stories about 'legal highs' are an increasingly common sight in the UK, and more of these substances are coming into circulation all the time. Figures for 2013-2014 show that in England, 'legal highs' were the primary drug for only a small proportion of adults in contact with drug treatment (0.07%). Data for those under the age of 18 shows that 0.63% had legal highs as their primary drug. (1) This, however, does not reflect the higher level of use for those not accessing treatment, as, for example, a Europe-wide poll found 8% of 15-24 year olds in EU member states reported using NPS (10% for the UK). (2)

Although this group of drugs, more properly known as Novel Psychoactive Substances (NPS), form a minority of those being misused, they are causing considerable and growing concern. In response to this, the Psychoactive Substances Bill was introduced to Parliament in May 2015, aiming to prohibit and disrupt the production, distribution, sale and supply of NPS in the UK. The bill is currently awaiting its second reading in the House of Commons. But what exactly are these drugs, and what risks do they carry with them?

The emergence of NPS

The different terms for these substances (legal highs, herbal highs, party pills, novel psychoactive compounds, designer drugs etc) can all be unhelpful in different ways but the Home Office's expert review panel, whilst recognising some of the difficulties, used the term 'New Psychoactive Substances', which they defined as 'Psychoactive drugs, newly available in the UK, which are not prohibited by the United Nations Drug Conventions but which pose a public health threat comparable to that posed by substances listed in these conventions'. (3)

Although termed 'new' or 'novel', many of these drugs have been produced in the past, but have only recently started to be misused. This had occurred previously, for example although ecstasy (MDMA) arrived on the drug scene in the UK in the mideighties, MDMA had been discovered as far back as 1912. (4) The difference now is the large numbers of new drugs available and a rapidly changing picture.

The emergence of NPS has introduced a range of new and exotic sounding drugs that people report using, such as Black Mamba, Bliss, Clockwork Orange, Mary Jane and Spice. Indeed the number of NPS identified in Europe each year has increased during the current decade - 41 (2010), 49 (2011) 74 (2012), and 81 (2013) (5) - although it is felt that most of the substances identified by early warning systems are not widely used.

Key drugs to know about

Within NPS there are three main groups of drugs, Cathinones, Synthetic Cannabinoids and Piperazines:

• Cathinones: A naturally occurring stimulant found in the plant Khat. It has been synthetically produced as a number of substances, most notably mephedrone (also known as 'Meow Meow', MCAT) and MDPV (Bath Salts). It may be viewed as a 'cousin' of the amphetamine drugs (speed and ecstasy), whilst there are similarities with the effects of PCP, Phencyclidine (Monkey Dust). They cause feelings of euphoria and empathy as well as increasing alertness and talkativeness. (9) They are sold as bath salts, plant food and insecticides, and labelled as not fit for human consumption to avoid some of the regulations on human products.
• Synthetic Cannabinoids: Cannabis is derived from the Indian hemp, Cannabis Sativa, with the most important ingredient being delta-9-tetrahydrocannabinol (THC). Various different preparations are used with the most common being marijuana (crushed leaves and flower heads), hashish (cannabis resin) and hash oil (concentrated resin extract). All are normally smoked, and vary in their THC content; marijuana (5% THC), hashish (20% THC) and hash oil (60% or more THC). (10) Adverse effects appear to be more likely as the THC content rises, and they are taken for their euphoric and relaxant properties, but may also affect perception and coordination. Synthetic Cannabinoids are chemicals that act like cannabis, with many different products including Black Mamba, K2, Spice and Annihilation. (11) They are sprayed onto herbal base material, and may be sold as 'herbal' preparations. They tend to have more potent effects than natural Cannabinoids, with shorter duration of action, quicker time to peak effect and more side effects. (12)
• Piperazines: A broad group of drugs which mimic the effects of ecstasy. May be known as Legal X, Nemesis, Smileys, the most common products are BZP, TFMPP, DBZP and mCPP. (13) Again, they will be taken for their arousing and euphoric effects.
Other drugs to consider in this discussion would be:
• Salvia:strong> 'Herbal ecstasy' derived from a Mexican plant with psychoactive chemicals in its leavesthat produce hallucinations when chewed or when dried and smoked
• Ketamine: A general anaesthetic used on humans and animals
• Nitrous oxide: 'Laughing gas', with a number of recent incidents of alleged use by celebrities, (Both Ketamine and Nitrous Oxide may not strictly meet the NPS definition but have seen significant changes in their patterns of recreational use and thus present similar challenges)
• GHB/GBL: Developed as an industrial solvent, often sold as 'liquid ecstasy' but with no relation to ecstasy, it is taken for its euphoric and relaxant effects, with heightened sex drive (a 'date rape' drug) and increased sociability. Short acting effects mean frequent doses may be taken. (14)
Levels of use Use of NPS, particularly amongst younger people, has generated increasing concern over the last decade. It is difficult to get a clear picture as to levels of use, given the introduction of new substances, uncertainty from people about what they are taking and changing patterns of consumption. Mephedrone use has fallen from a peak of 1.3% of 16-59 year old in 2010-11 to 0.6% in 2013-14; levels of use tend to be around three times higher in 16-24 year olds. The use of Salvia was first recorded in 2012-13 at 0.3%, but by the following year had risen to 0.5%. (15)However it is important to recognise that there can be much higher levels of use in specific subgroups. A report on drug use in prisons states the use of NPS 'has skyrocketed...over recent years', and describes it as an epidemic. For example, seizures in prisons in England and Wales for the synthetic Cannabinoid 'Spice' having risen from 15 in 2010 to around 737 in 2014. (16) 12.5% of regular night club users reported using Mephedrone in the last year. (17) The UK government's expert panel felt this can be attributed to 'low price, easy availability and enhancement of sexual activities'. (18) Theological reflections Paul told the Corinthians that while some actions may be lawful, not all are positive or helpful. 6 So it is with Novel Psychoactive Substances (NPS). Human beings are made in the image of God and Christians believe our bodies are his temple. 7 Anything that despoils our bodies therefore dishonours our maker. As John Wyatt has written, how we treat god-like human beings will create opportunities to express wonder, respect, empathy and to offer protection. 8 The diagnosis, treatment and aftercare of those who are addicted (or in danger) and people who are in close relation to them, requires a holistic understanding both of addiction and its treatment. The Editors What's the problem? A legitimate question is what harm are NPS causing? As with most drugs, we can look at the harm caused to the user of the drugs (eg physical, psychological or social harm) or to other people (eg victims of drug-related crime). Harm may also be due to intoxication or being in withdrawal. Lack of awareness about NPS may see its effects going unrecognised but data available does indicate some areas of concern. It also should be noted that due to the 'new' nature of these drugs we do not know the consequences of long-term use.Links to deaths: In England and Wales in 2013, 1,957 deaths were attributed to drug misuse. Deaths related to NPS are not a large contribution to this but rose from nine in 2007 to 60 in 2013. This is largely due to deaths linked to the cathinones drugs rising during the same time period from zero to 26. In 2013, 18 deaths were also attributed to both GHB-GBL and mephedrone. (19)Links to A&E attendances/emergency presentations: A study in Bristol found that 6.9% of all A&E patient attendances were either directly or indirectly linked to illegal drug use. (20) Precise figures on how many such presentations involve NPS are not readily available. But some inferences can be drawn from requests for help from poison centres which provide information and advice to health professionals. 'Legal highs' (not otherwise specified) and mephedrone both featured in the top ten drugs for telephone enquiries. The centres also saw the rates of enquiry for a particular drug fall after it was classified as illegal, but this may be accompanied by increased enquiries about similar drugs which have not (yet) been banned. (21)Specific health risks are outlined in a Royal College of Psychiatrists report: (22)
• GHB: Dependence and severe withdrawals, confusion and loss of consciousness, delirium, paranoia, aggression, hallucinations, decreased sexual inhibitions.
• Ketamine: Bladder and kidney damage, memory impairment, anxiety, panic attacks, depression, paranoia, delusions.
• Mephedrone: Heart problems, agitation, psychosis, increased sex drive.
• Synthetic Cannabinoids: More potent than natural cannabis, associated with tachycardia, vomiting and psychotic symptoms.

They are often taken in association with other drugs, particularly alcohol, which increases the health risks. Episodes of intoxication will often require supportive care based on the symptoms described above. This may include acute medical care.

Links to crime: Drug-related crime seems most closely linked to heroin and crack cocaine use, and at present there is insufficient evidence to link NPS use to acquisitive crime, but with the development of opioid NPS this could become more of an issue. (23)

Must be safe if they're legal?

The root of the challenge of NPS is their legal status. When the sale of these substances is not controlled by laws, they can be sold online or from 'headshops' (shops specialising in the sale of NPS; 250 are estimated to exist in the UK). (24) When any of these drugs are made illegal, people may switch to buying them from drug dealers, as with other illicit substances.

The Misuse of Drugs Act 1971 aimed to prevent the non-medical use of certain drugs, putting them into classes A, B and C, with varying sanctions for the different classes. Where drugs are not specifically included in these lists they may be viewed as not illegal, and hence legal, and often then viewed in some way as being safe, despite the Advisory Council on the Misuse of Drugs (ACMD) in 2011 stating that 'Just because a substance is termed "legal" this does not make it safe, nor may it be legal'. (25) This seems to be in line with Paul's advice in 1 Corinthians 10:23, where he indicates that some actions, although not breaking the law, may hinder Christian living.

This has led to other legislation seeking to close loopholes but the producers of the drugs change the synthetic compounds and people using the drugs adjust what they are taking. An example of this was seen with GHB which was classified as a class C drug in 2003, after which some users switched to taking GBL (which has a faster onset of action than GHB). GBL itself became a class C drug six years later. With new drugs being produced each year, the UN reports: 'the international drug control system is floundering, for the first time, under the speed and creativity of the phenomenon known as new psychoactive substances'. (26)

As stated above, the UK government is now seeking to introduce legislation specifically to address this area, the Psychoactive Substances Bill.

Responding to the challenge

NPS appear to present a number of challenges, some of which can be addressed by politicians, some by health and other professionals, and some by individuals, including church-goers. It is clear these drugs, despite the 'legal' part of their name, can have serious consequences and should be viewed in a similar way to other drugs. For the Christian they may hinder their ability to live as God intended.

For health professionals, the Royal College of Psychiatrists report, referred to earlier, proposes six areas of action. (27)

Widen the front door: Addressing the previously narrow focus of drug services.

Support the front line: Help staff to become more knowledgeable about the issues and management of NPS. As health professionals become informed, they should be able to recognise the drug use and offer appropriate help. As with other drugs, single sessions of motivational interviewing can be helpful, but if there is a poor response or accompanying mental health problems are found then referral to specialist services should follow. (28)

Connect the front line: Enhance links between drug specialist services and the non-specialist services where people are presenting; eg Aamp;E, acute physical and mental health services, primary care and sexual health clinics.

Watch all horizons for harm: Ensure people are up to date with changing patterns of us.e

Promote research into NPS and club drugs.

Empower users through education: for drug users and the general public.

Some of these - such as 'widening the front door' and being contemporary - seem good principles for churches to adopt, (both generally and specifically in relation to NPS), as we seek to follow the Lord's mandate: 'To proclaim good news to the poor. He has sent me to bind up the brokenhearted, to proclaim freedom for the captives and release from darkness for the prisoners'. (29) We need to be aware of the emergence of these substances so that as we come across people who use them, whether in our clinics or our churches, they feel understood and open to help.