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Introduction: There is limited data on the awareness and use of synthetic cannabinoids SCs in high-risk population in Serbia, despite SCs becoming more and more common at illicit drug market. Aim: This pilot study aimed to examine the awareness and prevalence of use of SCs in patients with an opioid-use disorder and to identify patient characteristics and other factors associated with SCs use. Patients and methods: This cross-sectional study was conducted at the Clinic for Psychiatry, Clinical Center Vojvodina, Serbia, the largest tertiary health care institution in this region of the country. Results: Out of 64 patients median age Socio-demographic characteristics of the subjects were not associated with SCs use. There were differences in the most common sources of information reported between the SCs users and non-users. Majority of SCs users Nearly all study participants The share of respondents reporting alcohol and marihuana use was significantly higher among the SCs users Higher share of SCs users used multiple psychoactive substances The most commonly reported adverse effect of SCs among users included dry mouth Conclusion: Understanding the awareness and use of SCs among high-risk drug users, as well as associated factors can help improve substance-use disorder treatment in our setting. Educational activities targeting public are urgently needed to raise awareness on SCs, considering that social contacts are the main sources of information on SC for this vulnerable population. Users of SCs have also reported using other psychoactive substances more often, and this calls for a holistic approach addressing multiple factors to improve substance-use treatment in our setting. According to the distinguished experts in the field, NPS are also defined as narcotic drugs or psychotropic substances made available or used from the early to mids for their psychoactive properties 3. The appearance of NPS has raised considerable concern at international level. In addition, a growing number of NPS consumers have been assessed by health care professionals HCPs with very severe clinical manifestations and unpredictable NPS associated untoward effects 4 , 5. The prevalence of NPS use is very difficult to estimate, especially for the countries not included in the standard world warning and monitoring systems. Scarce data available originates from analysis of calls to national poison control centers, emergency department admissions and drug use surveys 7. Moreover, prevalence rate also varied across countries included in the study 9. Additionally, to investigate the use of selected NPS in general population, wastewater-based epidemiology has been applied in 14 European countries including Serbia during and Also, this study confirms that NPS use in Europe is much lower than the use of classical psychoactive drugs The Early Warning System in Serbia has been active since Even though the inhalation of SCs is intended to mimic the psychotropic effects of cannabis mostly euphoric effects and relaxation , SCs undesirable effects are unpredictable and more severe e. Finally, SCs use could lead to dependence, tolerance and withdrawal phenomena To the best of our knowledge, there is no available data on the awareness and use of SCs in patients admitted to drug detoxification treatment in Serbia. This survey based cross-sectional pilot study aimed to examine the awareness and use of SCs in patients with an opioid-use disorder and to identify patient characteristics and other factors associated with SCs use. This cross-sectional, observational study was conducted at the Department for substance-related and addictive disorders of the Clinic for Psychiatry Clinical Center Vojvodina. All patients hospitalized for the treatment of opioid dependence F After obtaining consent for participation, the survey was started. Based on the literature, recommended minimum sample size for pilot and feasibility studies is between 24 and 50 participants 18 — Items of the study included questions about demographics and past and current past day substance consumption tobacco, alcohol, marijuana, and other drugs. The survey also inquired about 1 source of information regarding SCs, 2 SCs product use and its frequency pattern of use , 3 undesirable subjective effects of SCs products risk and consequences of SCs use , and 4 types of SCs used and common slang names. Questionnaire used is available in the Supplementary material. Descriptive statistics, Chi-square test for categorical variables and t-test for continuous variables were used for the analysis. Out of 64 patients included in the study, one-third 21, One third of the SCs Majority of the respondents 53, The median age of respondents was Almost all Most Most of the survey subjects Regarding relationship status, one half of the participants were single There were no differences in demographic characteristics between those reporting having ever used SCs and non-users Table 1. Over one-third of the participants Higher share of non-users reported social media and internet as sources of information in comparison with SCs users Also, a third of non-users reported never having heard about SCs. Overall, approximately one third reported alcohol and marijuana use, However, the share of respondents reporting alcohol and marijuana use was significantly higher among the SCs users Ninety The most reported adverse effects associated with SCs use were dry mouth Survey subjects reported 29 different names of new psychoactive drugs available on the Serbian market, but just 3 The present study identified prevalence of SCs use and associated factors among a vulnerable population of persons being treated for opioid-use disorder in order to bring light to this understudied topic considering their increasing availability and number of SCs on the market. Persons with opioid-use disorder commonly abuse other psychoactive substances, including cannabis, which makes them vulnerable to use SCs as well. This is influenced by a combination of social, psychological and economic factors, in addition to biological features of the opioid and cannabinoid receptor systems. SCs, diverse compounds exhibiting high affinity for the cannabinoid receptors, are known to interact with opioids in many physiological and pathological functions, including addiction A neurobiological convergence of the cannabinoid and opioid systems is apparent at both receptor and behavioral levels. CB2 receptors activation indirectly stimulates opioid receptors located in primary afferent pathways, implying that cannabinoids can enhance opioid effects Pharmacological modulation of the opioid system can modify the effects of THC Cannabis use was also found to be a predictor of the duration of untreated psychosis, and of disease outcome In the present study, more than a third of respondents Several patient characteristics were examined with the respect to SCs use. Our study showed that the use of SCs was not reserved exclusively for adolescent population, as often reported, with the average age of the persons reporting SCs use being In contrast to other studies 35 , 36 , we did not find associations between socio-demographic characteristics such as income, education or social-deprivation and SCs use, but several other factors related to the use of SCs in persons with an opioid-use disorder were confirmed. These results are in line with previous findings, suggesting that SCs and other NPS use is associated with polysubstance abuse in opioid addicts. A recent study based on the urine analysis reported the prevalence of polysubstance use of Differentiating by type of NPS, new synthetic opioids were most commonly determined 8. Findings by Larabi et al. A study by Elliott et al. In Serbia, NPS were commonly consumed in combination with amphetamines, cocaine, ecstasy, alcohol and cannabis Acute side effects reported strongly support those described in the literature and included dry mouth, trouble thinking clearly, panic attack, palpitations and fear 6 , 11 , 13 , SCs users from our study were more aware of dangers associated with the SCs consumption than non-users. On the other hand, being asked to report names of SCs available in Serbia, opioid addicts in our survey reported 29 different names, of which only This pilot study has estimated prevalence of SCs use in this vulnerable population, and identified opportunities for larger scale research. With high willingness of patients to participate in study of this type, hospital setting seems a suitable one for recruitment of this population. Other that opening venue for further research, study identified several opporutnites to improve patient care, including offering a basis for preventative strategies. Firstly, the HCPs involved in the care for the patients with opioid use disorder should also be aware of the possibility of patients using SCs, as these appear to be frequent concomitants to the conventional drugs of abuse This should be included when developing treatment plans tailored to specific challenges of each individual patient to support treatment and recovery. To allow for harm reduction, patients should be informed about the dangers of such practice and the fact that these combinations can produce unwanted and unpredictable effects. It was identified that most of the SCs users in the present study were acquainted with SCs through social-contacts. According to Van Hout et al. In addition, high-risk group was older average age This calls for broader educational health communication campaigns about the risks of polydrug use and dangers of the NPS, targeting population at risk to decrease misconceptions and provide reliable information. Understanding the awareness and use of SCs among high-risk drug users, as well as associated factors, could enable more effective prevention and harm reduction within this vulnerable marginalized population. Educational activities targeting public are urgently needed to raise awareness on SCs, considering that social contacts are the main sources of information for this vulnerable population. This study had several limitations that need to be mentioned. As it was based on a survey of patients currently being treated, this might have resulted in selection bias. As with any self-reported measure, recall and reporting bias cannot be excluded, which might have resulted in under-or over-reporting of SCs use. Study included a low number of participants for a disorder with a difficult to estimate prevalence. However, even despite the limitations of this survey, findings identify several problem areas in a difficult-to-sample population. A follow-up study, including the data from health-care records in addition to self-reported measures, as well as larger sample is warranted, which would make it necessary to include other treatment centers in the country. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements. All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. United Nations Office on Drugs and Crime. Global smart update Google Scholar. European drug report Trends and developments. Luxembourg: Publications Office of the European Union New psychoactive substances: Challenges for drug surveillance, control, and public health responses. New psychoactive substances and suicidality: A systematic review of the current literature. Front Psych. Psychol Med. New psychoactive substances: evolution in the exchange of information and innovative legal responses in the European Union. Results from the European school survey project on alcohol and other drugs. Int J Ment Health Addiction. New psychoactive substances in several European populations assessed by wastewater-based epidemiology. Water Res. New psychoactive substances in Eurasia: a qualitative study of people who use drugs and harm reduction services in six countries. Harm Reduct J. European Drug Report. Clinical and analytical experience of the National Poison Control Centre with synthetic cannabinoids. Arh Hig Rada Toksikol. Cohen, K, and Weinstein, AM. Synthetic and non-synthetic cannabinoid drugs and their adverse effects — a review from public health. Front Public Health. Novel psychoactive substances of interest for psychiatry. World Psychiatry. Use of medicinal cannabis and synthetic cannabinoids in post-traumatic stress disorder PTSD : A systematic review. Medicina Kaunas. New psychoactive substances: awareness and attitudes of future health care professionals in Serbia. Browne, RH. On the use of a pilot sample for sample size determination. Stat Med. Sim, J, and Lewis, M. The size of a pilot study for a clinical trial should be calculated in relation to considerations of precision and efficiency. J Clin Epidemiol. Julious, SA. Sample size of 12 per group rule of thumb for a pilot study. Pharm Stat. Cannabinoid-opioid interactions in drug discrimination and self-administration: Effect of maternal, postnatal, adolescent and adult exposure to the drugs. Curr Drug Targets. Cichewicz, DL. Synergistic interactions between cannabinoid and opioid analgesics. Life Sci. Role of the cannabinoid system in pain control and therapeutic implications for the management of acute and chronic pain episodes. Curr Neuropharmacol. Cannabis Cannabinoid Res. Knowledge and use of novel psychoactive substances in an Italian sample with substance use disorders. Polydrug use disorders in individuals with opioid use disorder. Drug Alcohol Depend. Synthetic cannabinoids use in a sample of opioid-use disorder patients. An update from the EU early warning system. Current NPS threats , vol. Duration of untreated disorder and cannabis use: an observational study on a cohort of young Italian patients experiencing psychotic experiences and dissociative symptoms. Prevalence of novel psychoactive substance NPS use in patients admitted to drug detoxification treatment. Prevalence of new psychoactive substances NPS and conventional drugs of abuse DOA in high risk populations from Paris France and its suburbs: a cross sectional study by hair testing Health and social problems associated with recent novel psychoactive substance NPS use amongst marginalised, nightlife and online users in six European countries. Int J Ment Health Addict. Soussan, C, and Kjellgren, A. The users of novel psychoactive substances: online survey about their characteristics, attitudes and motivations. Int J Drug Policy. Lifetime prevalence of novel psychoactive substances use among adults in the USA: sociodemographic, mental health and illicit drug use correlates. Evidence from a population-based survey PLoS One. Discriminative characteristics of marginalised novel psychoactive users: a transnational study. Polydrug abuse in heroin addicts: a behavioral economic analysis. Exploration of the use of new psychoactive substances by individuals in treatment for substance misuse in the UK. Brain Sci. New psychoactive substances consumption in opioid-use disorder patients. Polysubstance use patterns and novel synthetics: a cluster analysis from three U. Recent use of synthetic cannabinoids, synthetic opioids, and other psychoactive drug groups among high-risk drug users. J Psychoactive Drugs. Keywords: synthetic cannabinoids, opioid use disorder, use, awareness, predictive factors. The use, distribution or reproduction in other forums is permitted, provided the original author s and the copyright owner s are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Top bar navigation. About us About us. Sections Sections. About journal About journal. Article types Author guidelines Editor guidelines Publishing fees Submission checklist Contact editorial office. Psychiatry , 07 March Synthetic cannabinoids awareness among patients with opioid use disorder in Serbia — A survey based cross-sectional pilot study. Method This cross-sectional, observational study was conducted at the Department for substance-related and addictive disorders of the Clinic for Psychiatry Clinical Center Vojvodina. Results Out of 64 patients included in the study, one-third 21, Table 1. Table 2. Source of information regarding SCs. Table 3. Past and current substance use. Figure 1. Reviewed by: Jolanta B.

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We understand a new drug is being offered for sale in Belgrade nightclubs, called G or Golden. What this is is an Ecstasy tablet laced with flunitrazepam, a powerful opioid of the benzodiazepine class. As the reader of our earlier article on professional poisonings will recall, flunitrazepam is the professional poisoner's preferred toxin, as it causes immobility and amnesia. It is also potentially fatal in the wrong doses. What the effects of mixing flunitrazepam with MDMA are, we can scarcely imagine; but at least one possibility must be cardiac arrest. Stay away from persons selling G. Belgrade, the capital of the Republic of Serbia, has grown substantially recently, and is now heaving with foreigners for most of the year. There are two categories of visitors. One is Russian escapees from their own country amidst the war in Ukraine; the other is international tourists coming to enjoy Belgrade's riotous and heaving nightlife that is increasingly regarded as one of the very best of anywhere in the world. Here are some pointers for a safe trip. Belgrade can be rather lawless. These problems almost never affect foreign visitors unless they are looking for trouble; but a prudent visitor should always bear in mind that there are ugly things going on that the visitor will simply not see. Accommodation prices have as much as doubled in some areas, due principally to the influx of Russian escapees. Serbian immigration law is very laxly applied to any visitor with money, and it is one of the few European countries for which Russians do not need visas and there are ample direct flights with Moscow. The new Russian movers may be here for a few years, depending on how the war in Ukraine develops. This new Russian community keeps its collective head down and does not go looking for trouble. Serbia is a society with a totally free media indeed a lot of it is plain nonsense and total freedom of speech. You can meet anyone you like and talk with them about anything you like. Nevertheless avoid conversations about the war in Ukraine, because you may be challenged over your views by people with very different perspectives from your own. Arguably Serbia is the only neutral European country left in the conflict in Ukraine, and her government is at pains to preserve that position. Avoid making light of the NATO bombing of Serbia, as Serbs virtually to a last person consider they were the victims of a historical injustice. Anti-American sentiment remains to this day over the bombings. Also avoid discussions of Kosovo unless you are an expert, as Serbs also almost universally feel very strongly about the subject and sometimes want to engage foreigners at length about it. In the context of the war in Ukraine there have been periodic pro-Russian demonstrations on Saturday afternoons in central Belgrade but they have all passed off peacefully. Just bear in mind that these events cause horrendous traffic congestion. Although there was a spurt in gang violence a few months ago, following a quiet Police crackdown on drug gang members you are no longer likely to witness any violence. Belgrade has gone back to its overwhelmingly peaceable self. We have never seen or even heard of an incident of racism against foreigners with ethnic backgrounds visiting Serbia for tourism, business or official purposes. Rumours that Serbs are racist are totally bogus. Homosexuality is legal and homosexual relationships are tolerated although homosexual displays of affection in public are rare amongst locals. Indeed all sexual displays of affection in public are rare amongst locals. Homosexual nightlife venues exist but are not advertised in the usual places. You have nothing to fear if you travel to Serbia in a homosexual couple. Although you might raise eyebrows, nobody will discriminate against you should you engage in homosexual public displays of affection. Any aggressive drunks you meet in Belgrade's nightlife are likely to be foreigners. Stay away from them. It is not socially acceptable to be publicly drunk in Belgrade, notwithstanding that the city must have the highest concentration of bars outside Manhattan. The nightlife venues scattering the city are some of them highly unorthodox e. They cater to every taste and budget. Drug use in Serbia is endemic amongst every generation and every social and professional class. If you are coming to Serbia to take drugs, please think again about the dark economy you are financing. We cannot support it. There is no distinction between hard and soft drugs either in the practical application of penology or the public understanding. At the time of writing the two easiest drugs to source are domestically manufactured powdered amphetamine sulphate and Ecstasy pills manufactured in the Netherlands. Amphetamines are extremely bad for your mental and physical health. Avoid them. If you must buy drugs, ask Serbian friends virtually any of whom will know the right people. Avoid buying drugs in nightclubs. It is dangerous and stupid. In Belgrade, after a period of searching foreigners aggressively for drugs, the Police seem to have gone back to their laissez-faire approach: a foreign passport will mostly avoid a drug search. However it is not per cent. Always carry your passport with you, and wear clothes that make you stand out as a foreigner. Police justice can be rough - for example just beating a group of people up because it is suspected they have drugs on them without actually checking. This is very unlikely to happen to a foreigner, but such things do happen. Penalties for drug possession, where due process is observed, are typically fines and fees less than EUR in total; plus a deportation order from the country that the Police will usually be considerate enough to ensure coincides with the date of your departure ticket. On the other hand, penalties for supply of drugs are swingeing: three to five years' imprisonment for a first offence. Do not supply drugs to anyone in Serbia, even as a gift or anything else equally dumb. The Police can no longer be straightforwardly bribed; do not attempt it. Indeed casual bribery has been eliminated from much of Serbian public life; many of her institutions are remarkably robust and functional. The Police can be remarkably professional and helpful to a person in dire straits. Do not hesitate to approach them for help. You will be given the best assistance and support they are able to provide. If you have been robbed in a serious way, they will act with extraordinary efficiency to hunt down your assailant there and then. The person may be presented to you for positive identification within a matter of hours. All police officers in Belgrade are trained in English, but speak slowly and clearly. There are far worse Police forces than those in Serbia; but always remain scrupulously polite no matter how upset you are. In Serbia being a police officer is a respected profession and the Police are proud of their high reputation and the effective work they do. They do not like rude people. Never get in a private vehicle with other persons you suspect to be drunk or on drugs. Call a taxi. Police stops - which are common - tend to take a view of collective responsibility and you can all end up on the same charges. If you are admitted to public hospital for a drug overdose, hospital staff may inform the Police who may come to arrest you. They will even use a private ambulance. Serbs are gregarious people. Things stay open unusually late without explanation or lawful authority. Expect large amounts of noise from adjacent hotel rooms at nights. Belgrade is not a city to get away from it all! The girls may be pretty but do not touch them. Serbia is a socially conservative society in which casual sexual encounters are uncommon and relationships, often suggested by friends and family members, are expected to end in marriage. It would be scandalous for a Serbian girl to have a casual sexual encounter with a foreigner, so do not expect it and do not suggest it unless you want that girl's large male Serbian friends which will be any large man to hand explaining to you in less than polite, and potentially in non-verbal, terms what they think of you. Treat people with respect in an unfamiliar environment. Serbia may be one of Europe's least hospitable destinations for sex tourists. Do not come here with such intentions in mind. The Police will afford you no protection if you are beaten up as a resulting of transgressing this rule. Every single incident of violence against foreigners that we have observed in Serbia has been the result of a foreign man seeking the attentions of an unknown Serbian woman; his being rebuffed politely; his persisting in an unwanted way; and his failure to comprehend that the situation around him is suddenly exponentially spinning out of control. If you do overstep the mark, apologise immediately and just step away, and the problem will be resolved. Contrary to some prejudices, Serbs are relatively slow to resort to violence. By contrast with Belgrade, the rest of Serbia can be extremely tranquil. We recommend the rest of the country wholeheartedly, even though transport connections are often poor. Although there are various borders and informal roads between the two, do not attempt to mix a visit to Serbia with a visit to Kosovo unless you are a highly experienced Balkan civil conflict specialist in which case why are you reading this? One could write an entire volume on different things that could go wrong if you try to traverse that border without knowing exactly what you are doing, and a second volume on things that have gone wrong to people who thought they did know exactly what they were doing. Be particularly careful if you intend to go to the EXIT festival, and avoid any even minor violent incident. Novi Sad's criminal gangs seem to be more violent than those in Belgrade, so take care when partying in Novi Sad. Remember that Serbia is a poor country, with a GDP per capita of approximately USD7,, so be generous wherever you find the opportunity. Generous tipping is hugely appreciated because it is rare. Serbs, in particular Serbian women, have the most curious habit of borrowing one another's clothes and not returning them for long periods of time if ever. If a Serb asks to borrow any item of clothing from you, including a pair of sunglasses, construe it as a request for a gift. Keep your jacket close by if you have removed it in a public space. The Serbs have a certain stubbornness of personality which is much to their credit. They persevere through good times and bad. And, above anything else, they like to have fun. That is surely why you will have fun here too. They are also a nation prone to crypticism, complex social habits and paranoia: their national personality an ineffable mixture of Russians, Turks, Greeks and Italians, all rolled into one complex mystery. To understand the Serbs well, and to get the most out of living with them which can be enormously rewarding , involves a lifetime of study. Fragments from a War Diary, Part 2 Volume 6. Fragments from a War Diary, Volume 2 Part 5. Fragments from a War Diary, Volume 2, Part 4. All Posts. The Paladins May 14, Recent Posts See All. Write a comment

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