Synthetic cathinones in drug-related deaths – an alarming issue or triviality?

Background

Synthetic cathinones (SC) are a group of abused stimulant drugs that are related to cathinone, the active ingredient in khat. Worldwide, SC are the second most used group of new psychoactive substances (NPS) after synthetic cannabinoids. In the early 2010’s, the SC that first emerged in Finland was MDPV. This substance entered the illicit drug market accompanied by great publicity, but it disappeared soon after having been banned in 2015. Following MDPV, there have been several other SC on the market, most of which have only been detected a few times. Alpha-PVP, however, after its first appearance in 2012, has continued to be among the most popular SC, and it is currently the most abundant NPS in Finland.

Methods

The three currently most relevant SC in Finland, alpha-PVP, alpha-PHP and alpha-PiHP, were studied in the context of post-mortem (PM) toxicology between 2018 and 2023 in terms of their incidence, user characteristics, and cause and manner of death. The data were collected from the national PM toxicology registry maintained by the Finnish Institute for Health and Welfare (THL).

Results

There were 114 PM cases positive for one or more of the three studied SC, including 66 findings of alpha-PVP, 32 of alpha-PHP, and 31 of alpha-PiHP. Two of the studied SC were detected in nine cases and all three in three cases. Alpha-PVP was found in all poly-cathinone cases. The median (range) age of the deceased was 33.5 (19–60) years and 82% were males.

Of the 102 cases where the cause of death has been determined so far, 59 deaths were attributed to drug abuse, 7 to diseases other than drug addiction, and 36 to other injuries. The other injuries typically included gunshot or stab wounds, mechanical suicides, or poisonings other than substance abuse (e.g., caused by carbon monoxide).

In 26 cases, one of the studied SC was implicated in a fatal poisoning. Among these poisoning cases, the median (range) age was 35.5 (23–57) years and 77% were males. In 28 cases, intoxication caused by SC was determined to be a contributing cause of death. In 48 cases, the detected SC was not mentioned in the cause of death. Of all cases positive for one of the studied SC, 12% were suicides but none by poisoning. Among the 26 fatal poisonings, 81% were unintentional and in the rest, the manner of death was undetermined.

Compared to the most common stimulant, amphetamine, which was detected in 44% of drug abuse cases and implicated in the cause of death in 21% of fatal drug poisonings, the numbers associated with the studied cathinones were 3% and 2%, respectively.

Conclusions

The number of SC findings only amounts to a fraction of amphetamine cases. Our data suggests that SC-related deaths usually happen to individuals with a history of prolonged drug abuse and not to those using drugs in a recreational manner. As SC can be used in place of amphetamine, they should be treated with the same concern as amphetamine, taking also into consideration their higher potency.