Knowledge and ( Ab ) Use in Connection with Novel Psychoactive Substances : A Cross-Sectional Analysis of Iraqi Medical Students

Background: The extent of (ab)use of the Novel Psychoactive substances has been thoroughly mapped in the developed world, particularly in the US, Canada, UK, Western Europe, Australia, and New Zealand. However, there are still untapped geographic locations particularly in the developing world including the Middle East. Materials and Methods: This study is observational in nature and cross-sectional in design; it is based on a survey that will aim is to estimate the level of knowledge and the extent of (ab)use of psychoactive substances, traditional and novel, in a population of undergraduate medical students from Iraq. There will be an implementation of inferential statistical analyses for the purpose of hypothesis testing. Ethical approvals were granted from the College of Medicine at the University of Baghdad and the University of Hertfordshire. Results: There was some degree of knowledge in connection with psychoactive substances among a population of medical students. However, the extent of (ab)use is still minimal when compared to that of the developed countries. In general, the knowledge and the extent of NPS (ab)use did not vary substantially as the students progressed through the medical college. Conclusion: The use of observational analytic tools for assessing the diffusion of the phenomenon of psychoactive and novel psychoactive substances is indispensable. The extent of knowledge and (ab)use of NPS in the Middle East may still be considered minute or insignificant. Further analyses are required in the Middle East; different populations are to be targeted including; students, academics, researchers, medical and paramedical staff, psychiatric patients, prisoners, military and para-military organisations, and even terrorists.


Background
Novel psychoactive substances (NPS), also known as research chemicals and designer drugs, represents a unique phenomenon that has witnessed an explosive growth globally; its threats to the economy and public health are innumerable (Boyer et al., 2007;Burns, 2013).The prevalence of the NPS phenomenon within the region of the Middle East is still ambiguous (Al-Imam et al., 2016;Al-Imam et al., 2017;Bigdeli et al., 2013).
A critical question remains unanswered; how to estimate the magnitude of the NPS in this region?Can the extent of NPS (ab)use be determined by modalities other than observational studies of the web?The answer is yes; it can be inferred by modes other than web analytics, for example; cross-sectional studies and survey in a real (non-virtual) population of users, and retrospectively from; seized batches of illicit substances, databases from criminal records, hospital emergency units, border patrol agencies, police departments, and counter-terrorism units.Some of these modalities of research have been already extensively implemented by regulating bodies including; the World Anti-Doping Agency (WADA), the United Nation Office on Drugs and Crime (UNODC), the INTERPOL, and the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (Burns, 2014 ;Ferri et al., 2015;Mackey & Liang, 2013).
The majority of studies that were implemented to assess the extent and prevalence of (ab)use were carried out in the developed countries; few attempts were prosecuted in the developing world, and even a fewer attempts were committed for the Middle East and Arabic countries.For instance, the work accomplished by Al-Hemiary and colleagues (Bigdeli et al., 2013;Al-Diwan et al., 2015;Al-Hemiary et al., 2014;Al-Hemiary et al., 2015;Al-Hemiary et al., 2016).However, the advent of intranet networks and virtual social communication media enabled studies to be carried out promptly and with an unrivalled efficiency (Hadgar, 2016;Joh et al., 2017;Moorhead et al., 2013).
In this observational analysis, a cross-sectional survey will be targeting a population of undergraduate medical students from Baghdad-Iraq.As a whole, this study will explore the magnitude of knowledge in relation to the NPS phenomenon, and the extent of use and misuse in the studied population.The study will aim to derive an inference via hypothesis testing models of data science; this study is the 1 st of its kind to be carried out in Iraq.The overall level-of-evidence of these integrative analyses is estimated to be of level-2b in accordance with the classification system imposed by the Oxford Centre for Evidence-Based Medicine (University of Oxford, 2009).

Materials and Methods
This study has been ethically approved by the Institute Review Board (IRB) of the College of Medicine-University of Baghdad under the authority of the IRB meeting no.7 on the 20 th of December 2016; the study was also approved by the University of Hertfordshire (Protocol no.LMS/PGR/UH/02723).The nature of the study is observational and cross-sectional; it is based on a survey targeting a population of undergraduate medical students at the College of Medicine, University of Baghdad.It is estimated that the study will reach-out to 1/4 th of the total students' population at the College of Medicine.The aim of the survey is to infer an estimate in connection with; the level of knowledge of medical student about psychoactive substances including novel ones (NPS) (1), the extent of (ab)use of these substances, if any exist (2), and the correlation with other parameters including demographics, social status, medical illnesses, and past psychiatric history (3).A population of approximately 1800 students was targeted; the survey was made available to students starting from the 17 th of March 2017 to the 28 th of March 2017.The survey was transferred into an electronic form (e-form) which was composed of three main sections dedicated for; demographic parameters of participants (1), knowledge and the extent of (ab)use of NPS (2), and the smoking, alcohol drinking habits, and other social habits (3).
The time required to complete the survey was estimated to be in the range of 4-7 minutes.The survey questionnaires addressed specific variables; age, gender, handedness, ethnicity, religious affiliation, number of siblings, place of residence, marital and social status, past medical and psychiatric history, the knowledge in connection with psychoactive substances, the knowledge about specific substances including NPS, the extent of use, the experienced adverse effects, drinking and smoking habits, and other related social practices.All responses were anonymous; personal data including name and physical address were neither required nor asked for via the e-survey.
The e-form of the survey was pilot-tested (Figure 1) by a group of 20 students; the average duration of time required to complete the questionnaire was 5.3 (+/-1.2) minutes.The total number of participants was 458, including participants from year-1 students (n=157), year-2 to year-6 (n=301).This 1:2 ratio will enable an intergroup group analyses to be carried out in between students from years-1 versus students from year-2 to year-6; the aim is to test the hypothesis whether the level of knowledge and the extent of (ab)use will significantly vary as the students progress in the medical college.The survey itself (e-survey) was created using Google Forms online tool; it was distributed to students electronically via the University's encrypted intranet system; the intranet is known as the Iraqi Network Learning Environment (INLE) (Iraqi Ministry of High Education and Scientific Research, 2017).The students have been prompted about the nature and the topic of the survey prior to its distribution.Once it was distributed, each student had only one attempt to fill and submit the e-form.Afterwards, responses were not accepted, and the e-form was electronically closed.Responses were later downloaded as comma-separated values (.csv) file format, which was converted into a database on Microsoft Excel 2017, upon which graphical presentations and statistical analyses were carried out.
Inter-group analyses were done between year-1 medical students versus other medical students from year-2, 3, 4, 5, and 6.The implemented statistical analyses were both descriptive and inferential; inferential statistics included both parametric and nonparametric tests.Alpha (α) value of 0.05 was set as the cutoff margin for statistical significance, and at a confidence interval of 95% (95% CI).Data in relation to this survey were stored on a secure 256-bit encrypted personal computer (PC) with an active firewall deploying anti-virus and anti-malware technologies; the PC was also password-protected, and only one user (the leading researcher) had access to it.

Discussion
In the past two decades, designer drugs represented a significant evolving threat to the public health and economy; the phenomenon has been escalating at a logarithmic pace, paralleled only by the explosive collateral evolution within the discipline of information and communication technologies (Al-Imam, 2017;Al-Imam et al., 2017;Brew, 2016;Dargan & Wood, 2013;Lin et al., 2014).The technologic advancement in the developed western world made it feasible for the NPS, its e-commerce, and the collateral e-phenomena on both divisions of the web to flourish to unprecedented levels beyond the control of legal authorities and regulating bodies.Accordingly, the NPS phenomena are more spread in the developing world (Al-Imam et al., 2016;Al-Imam et al., 2017;Bigdeli et al., 2013).In 2014, Best and colleagues studied the online platforms including the social media in connection with the adolescent well-being; their systematic review of the literature was based on assessing 43 original studies that were committed for the purpose of evaluating the harmful and beneficial effects of these online platforms.There was a contradictory evidence while revealing although it was concluded that online platforms and technologies could have a detrimental effect on health well-being and yet can also be exploited for health and social care purposes (Best et al., 2014).
Few research attempts were dedicated to the NPS phenomenon in the developing world as in the case of the Middle East, Latin and Central America, Africa, and Asia (Dargan and Wood, 2013).This observational cross-sectional analysis represents one of the few attempts to analyse selected populations from the Middle East in connection with the extent of spread and (ab)use of psychoactive substances.However, there have been prior attempts dating back to to the end of the last decade (Al-Hemiary et al., 2010;Dargn & Wood, 2013).
Al-Hemiary and colleagues have led one of the earliest attempts in Iraq.By 2012, those authors have concluded that the most commonly used substances were alcohol, cannabis, and prescription-related chemicals; Novel drugs (NPS) started to appear on the drug scene as in the case of amphetamine-type substances (ATS) including captagon and crystal (methamphetamine); other traditional psychoactive substances were also found in abundance including tramadol, Afghan opium, teriac (an opioid), and heroin (Al-Hemiary et al., 2010;Al-Hemiary et al., 2014;Al-Hemiary et al., 2016).Subsequent research attempts by Al-Imam and colleagues in 2016 has confirmed that captagon was infiltrating the destabilized countries of the Middle East; captagon was available in e-commerce within the UAE, Syria, Iraq, and Turkey; the substance was diffuse in a dozen of e-markets on the darknet, including AlphaBay, Agora, Valhalla, and Hansa (Al-Imam et al., 2017).Further, Al-Diwan and coworkers inferred that high household density (crowding density) and low educational status were correlated with alcohol and substance abuse; the peak age for using psychoactive substances was found to be 24-35 years (Al-Diwan et al., 2015).In 2013 and 2014, Bigdeli and colleagues discovered the existence of fourteen new substances; data were extrapolated from 104 websites.The majority of these substances were either herbal, synthetic, pharmaceutical, or combinatory chemicals that are promoted via the e-commerce (Bigdeli et al. 2014).
Very recently (2017), Joh and co-workers have conducted cross-sectional analyses among Korean University students with an aim to assess the health promotion in young adults following a three-days university-wide health promotion program; the program was aiming at enhancing health awareness via promoting a healthy diet, healthy behaviour, and an active lifestyle (Joh et al., 2017).An earlier attempt back in 2012, Dargan & Wood have studied the recreational drug use, including those of traditional and novel psychoactive substances in the Asia Pacific region via critical analysis of the UNODC programmes of relevance to the topic; they have concluded that there are still gaps to be filled (Dargan & Wood, 2012).

Conclusion
Data on the knowledge of NPS seems to be either primitive or completely lacking.Similarly, the extent of (ab)use of NPS in the studied population of Iraqi medical students was also found to be minimal, unlike those of the western societies in developed countries.However, there seems to be some degree of knowledge on NPS derived from prototypical medicines and traditional psychoactive substances.The level of knowledge on NPS did not substantially differ upon the transitions of students from year-1 to subsequent years of medical training; the level-of-knowledge was also not significantly different.However, the knowledge in relation to specific NPS substances increased substantially.Similarly, the chronicity of use was significantly different in between year-1 students and year-2 to year-6 students.The encountered adverse effects were very similar; the most frequently reported reactions included loss of consciousness, musculoskeletal-related, and hallucinations.To be concluded, the extent of (ab)use in this particular population from the Middle East was minute when compared to that of the developed world.Future studies to be deployed in the Middle East should target a varied array of populations including; students, medical professionals, researchers, medical and psychiatric patients, convicts and criminals, military personnel, and even terrorists.

Figure 1 .
Figure 1.Boxplot Presentation: Time Required to Complete the Survey

Figure 4 .
Figure 4. Most Commonly Encountered Adverse Reactions for NPS (ab)use in Year-1 Students

Figure 5 .
Figure 5. Age of Participants from Year-2 to Year-6: Boxplot Presentation

Figure 8 .
Figure 8.Most Commonly Encountered Adverse Effects in Year-2 to Year-6 Students.