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CORK Bibliography: Khat

53 citations. January 1997-present

Prepared: March 2009

Ai-Dubai W; Al-Habori M; Al-Geiry A. Human khat (Catha edulis) chewers have elevated plasma leptin and nonesterified fatty acids. Nutrition Research 26(12): 632-636, 2006. (46 refs.)

In this study, the effect of regular khat (Catha edulis Forsk) chewing (200 and 400 g) in humans on plasma leptin, nonesterified fatty acid, triacyglycerol, and total cholesterol levels was investigated. The results presented show that khat chewing increases plasma leptin concentration particularly in individuals who chew 400 g of khat leaves. The significance of increased plasma leptin is in explaining the underlying mechanism of the observed effects associated with khat chewing such as loss of appetite, decreased body weight, and hyperthermia. The decreased body weight was evident from the significantly lower body mass index of the khat leaves chewers group as compared to the non-khat leaves chewers group (control). Moreover, like leptin, the plasma levels of nonesterified fatty acids were significantly higher in those chewing 400 g of khat leaves. On the other hand, the plasma levels of triacylglycerol were significantly lower in the 2 khat-chewers groups (200 and 400 g of khat leaves), whereas plasma cholesterol levels were not affected by the 2 levels of khat leaves used in this study. The significance of these results may suggest that khat leaves may contain a component(s) that has the ability to reduce body weight via decreasing appetite.

Alem A; Kebede D; Kullgren G. The prevalence and socio-demographic correlates of khat chewing in Butajira, Ethiopia. Acta Psychiatrica Scandinavica 100(Supplement 7): 84-91, 1999. (33 refs.)

A house-to-house survey was carried out in a rural Ethiopian community to determine the prevalence and socio-demographic correlates of khat use. A total of 10 468 adults were interviewed. Of these, 58% were female, and 74% were Muslim. More than half of the study population (55.7%) reported lifetime khat chewing experience and the prevalence of current use was 50%. Among current chewers, 17.4% reported taking khat on a daily basis; 16.1% of these were male and 3.4% were female. Various reasons were given for chewing khat; 80% of the chewers used it to gain a good level of concentration for prayer. Muslim religion, smoking and high educational level showed strong association with daily khat chewing.

Al-Hadrani AM. Khat induced hemorrhoidal disease in Yemen. Saudi Medical Journal 21(5): 475-477, 2000. (19 refs.)

Objectives: The aim of this study was to evaluate the potential association between the habit of khat chewing and the development of hemorrhoidal disease. Method: Four hundred and seventy four individuals (373 men and 101 women) with ages ranging from 17 to 80 years were divided into 2 groups. Group 1 (n=247) chronic khat chewers. Group 2 (n=200) non- khat chewers. Data was collected regarding chewing habits, colorectal symptoms, abdominal, proctoscopic, and operative findings. Results: The key difference between the 2 groups was the incidence of hemorrhoids and hemorrhoidectomy. In the chronic khat chewers group: 169 (62%) had hemorrhoids. Of these 124 (45.4%) underwent hemorrhoidectomy. In the control group there is 8 (4%) had hemorrhoids and one patient underwent hemorrhoidectomy (0.5%). P- value (0.05). Conclusion: The study demonstrated a significant association between the habit of khat chewing and the development of hemorrhoidal disease.

Al-Hebshi NN; Skaug N. Effect of khat chewing on 14 selected periodontal bacteria in sub- and supragingival plaque of a young male population. Oral Microbiology and Immunology 20(3): 141-146, 2005. (33 refs.)

Background/aims: The habit of chewing khat (Catha edulis) for its amphetamine-like effects is highly prevalent in Yemen and east Africa, and has expanded to Western countries. The purpose of this study was to estimate and compare the prevalence and levels of 14 periodontal bacteria in gingival plaque of khat chewers and khat nonchewers, as well as of khat chewing sides and khat nonchewing sides. Methods: A total of 408 sub- and supragingival plaque samples were collected from 51 young males (29 khat chewers and 22 khat nonchewers; age range 19-28 years) and analyzed using whole genomic DNA probes and checkerboard DNA-DNA hybridization. Clinical parameters were recorded for all teeth at six sites per tooth. Results: Streptococcus intermedius and Veillonella parvula were significantly more prevalent in the subgingival plaque of chewers, which also showed significantly higher levels of V. parvula and Eikenella corrodens. Similar results were found for the subgingival plaque of the chewing sides compared to the nonchewing sides. However, there was a significantly higher prevalence and higher levels of Tannerella forsythia in the subgingival plaque of the nonchewing sides. No significant differences were observed for the supragingival plaque between the two study groups. There was a significantly lower prevalence of Capnocytophaga gingivalis and Fusobacterium nucleatum in the khat chewing sides, and higher levels of V. parvula and Actinomyces israelii. Conclusion: The data suggest that khat chewing induces a microbial profile that is not incompatible with gingival health.

Al-Hebshi NN; Skaug N. Khat (Catha edulis): An updated review. (review). Addiction Biology 10(4): 299-307, 2005. (112 refs.)

The habit of chewing fresh leaves and twigs of khat (Catha edulis) for their stimulating amphetamine-like effects is highly prevalent in East Africa and southwest on the Arabic peninsula. There is an extensive literature on khat providing information about its history, botany, production, geographical distribution, chemistry and pharmacology, and exploring the social, economic, medical., psychological and oral aspects related to its use. Some of this literature dates as early as the 11th century; however, most of it appeared after the first scientific description of khat by Peter Forskal in 1775. This review provides a panorama of khat and the various aspects of its use. A non-technical description of the plant chemistry and pharmacology is included. The medical, psychological and oral aspects are emphasized, and the current knowledge about the microbiological effects of khat is also presented.

Al-Motarreb A; Baker K; Broadley KJ. Khat: Pharmacological and medical aspects and its social use in Yemen. (review). Phytotherapy 16(5): 403-413, 2002. (61 refs.)

Fresh leaves of the khat tree (Catha edulis Forsk.) are chewed for their euphoric properties in East Africa and parts of the Middle East, such as The Yemen. This review describes the history, cultivation and constituents of khat, and the social aspects of khat chewing in Yemen. The major pharmacologically active constituent of the fresh leaves is (-)-S-cathinone. The pharmacology of (-)-S- Cathinone in the central nervous system and the peripheral effects are described. (-)-S-Cathinone is regarded as an amphetamine-like sympathomimetic amine and this mechanism of action is discussed in relation to the central stimulant actions and the cardiovascular effects of increasing blood pressure and heart rate. The risk factors associated with khat chewing are described, with emphasis on the reported increased incidence of acute myocardial infarction.

Anderson D; Beckerleg S; Hailu D; Klein A. The Khat Controversy: Stimulating the Debate on Drugs. Oxford: Berg Publishers, 2007

Khat is a natural stimulant that, in the Middle East, is as common as coffee is in the West. It is popular in a number of African and Arab populations. This book examines the use of khat, its increasing availability and introduction to areas beyond those where it has been used historically. Included in this discussion is the role of globalization, ethnicity and culture. With its popularity escalating in large metropolitan areas from London to Rome, Toronto and Copenhagen, khat is fast being viewed as a problem in the West. Warning voices have been raised about its addictive properties and potential for being the next drug fad. This book is drawn from research efforts conducted by the authors to discern the trade in khat, the nature of related policy, and related policy issues. Following an introductory chapter which outlines the nature of khat use, discussion turns in Part I to khat Ethiopia and the Somaliland, the role of khat production, the role in export and foreign change. Part II turns to East Africa, with attention to Kenya, Meru and Uganda, their the khat trade, the impact of colonial controls, and campaigns against the drug. Part III reviews the global emergence of khat, the international trade, related social issues, and incorporates two case studies, the experience of control efforts in Canada and Sweden. The concluding chapter addresses the policy debates and the case for and against prohibition.

Armstrong EG. Research note: Crime, chemicals, and culture: On the complexity of khat. Journal of Drug Issues 38(2): 631-648, 2008. (68 refs.)

In 2006, khat was the object of a federal government operation, which dismantled a Somali trafficking organization and seized five tons of the plant valued at $2 million. Khat is an evergreen tree that grows in Africa. Its leaves are chewed as a stimulant by six million people every day. This paper describes the complexity of khat, beginning with an overview of its international usage and its contradictory portrayals. Primary concern, however is focused on khat's complexity in terms of its criminal, chemical, and cultural dimensions. According to the FBI, khat is a controlled substance. But others disagree. A khat plant might contain cathinone, a Schedule I drug. But shortly after harvesting, cathinone decomposes. Throughout history, colonizers have used laws against khat to control indigenous Muslim populations. In the U. S., utilization of khat is central to the lives of many members of immigrant communities. Targeting khat can be viewed as targeting members of these communities.

Beckerleg S. Khat in East Africa: Taking women into or out of sex work? Substance Use & Misuse 43(8/9): 1170-1185, 2008. (31 refs.)

Women's drug use is often associated with sex work as a means of raising money for consumption. Similarly, in Kenya and Uganda, journalists, the general public and aid agencies associate female consumption of the stimulant drug, khat (Catha edulis), as pulling women into prostitution. In contrast to Yemen and Ethiopia, these views are expressed by people living in areas where there are no rituals or traditions of female khat consumption. This paper presents data from a study carried out in Kenya and Uganda in 2004 and 2005 that documents that the majority of women engaging in khat chewing are not sex workers. Frequently, however, women who retail khat are often assumed by men to be sexually immoral. The role of women in the retail and wholesale khat trade is examined. The stigma attached to selling khat is linked to the overall situation of independent women in East Africa and the place of commercial sex in urban life.

Beckerleg S. Special issue on Khat: Use, users and unresolved issues - Khat special edition introduction. Substance Use & Misuse 43(6): 749-761, 2008. (28 refs.)

Although khat (Catha edulis) is not widely known outside its countries of production in East Africa and Yemen, it evokes strong views among consumers, development workers, and government officials who often behave as self-styled experts on the drug. Yet, the evidence of harm to health is scant. As khat consumption has spread to five continents it is perceived as being "exotic" and "alien" and to be a major cause of poverty and underdevelopment. However, it is argued here that khat is being used as a scapegoat for a wide range of social and economic ills across the world.

Belew M; Kebede D; Kassaye M; Enquoselassie F. The magnitude of khat use and its association with health, nutrition and socio-economic status. Ethiopian Medical Journal 38(1): 11-26, 2000. (21 refs.)

Although the literature on khat (Catha edulis Forsk) is fairly extensive, and several authors have stated the potential-adverse effects of habitual use of khat on mental, physical and social well- being, very few population based studies exist to substantiate those statements in Ethiopia. A house-to-house survey of a representative sample of 1200 adults from a rural Ethiopian community was conducted from January to September of 1997 to determine the prevalence of khat use and its association with health, nutritional status, mental distress, substance use, family and social functioning and economic well-being. The current prevalence of khat chewing was found to be 31.7%. Muslims more than Christians, males more than females, these between the ages 15 and 34 years more than other age groups were habitual users. The following factors were found to be significantly associated with khat use: physical illness, (OR=1. 52, 95% CI=1.14- 2.02); injuries (OR=2.31,95%CI=1.42-3.79), undernutrition (OR =1.76,95% CI = 1.24-2.48), mental distress (OR=8.30,95% CI=5.20-13.31). Family functioning among current khat users was significantly higher than non users (OR-56,95%-CI=1.04-2.28). Social functioning and economic well-being were not significantly associated with khat use. It is concluded that a fairly large proportion of the population consumes khat and that this is related to physical and mental ill- health, although family and social functioning, and economic well- being seem to be unrelated to khat use.

Belhadj-Tahar H; Sadeg N. Methcathinone: A new postindustrial drug. Forensic Science International 153(1): 99-101, 2005. (15 refs.)

Methcathinone, a methyl derivative of cathinone, is an illicit drug also known as ephedrone. It is a stimulant found in the "khat" plant, Catha edulis, which can easily be synthesized from pseudoephedrine. Its intoxication is difficult to diagnose and cure properly for two reasons: (i) target consumers are usually "well-educated people" aware of the risks and precautionary measures and (ii) intoxication by cathinone derivatives of synthetic or natural (derived from the khat) origin induce misleading symptoms. As a result, documented reports of methcathinone intoxication that are based on reliable analyses are rare. This paper describes a case of reiterated coma due to an overdose of methcathinone dissolved in alcohol that was taken with bromazepam. A 29-year-old woman was admitted to an emergency department for a coma of toxic origin. Medical files showed that it was her second such episode to occur that month. Moreover, the family indicated signs of depression, incoherent behaviour and intake of "amphetamine-like" drugs. Clinical examination revealed a Glasgow coma score of 9, symmetrical reactive pupils with mydriasis and no convulsions. The patient presented with rapid respirations and her blood pressure was 93/53 mmHg. The ionogram and the blood gas analyses were normal, while the blood alcohol level was 0.167 g/dL. Urinalysis revealed the presence of benzodiazepines and a high concentration of amphetamines (methcathinone: 17.24 mg/L, ephedrine: 11.60 mg/L and methylephedrine: 11.10 mg/L). In addition, serum analysis revealed bromazepam (8.89 mg/L), methcathinone (0.50 mg/L) and methylephedrine (0.19 mg/L). This case showed that the consumption of bromazepant and alcohol altered the typical clinical symptoms of cathinone derivative intoxication, namely hypertension and convulsions. Methylephedrine, an impurity resulting from the alkylation of a primary amine, can be considered a chemical tag indicating fraudulent synthetic origin of the drug. This case describes a documented example of new addictive behaviour of "well-educated" people involving the intake of methcathinone, a postindustrial psychostimulant intentionally combined with an anticonvulsant benzodiazepine. However, this specific case suggests that in spite of a very high bromazepam concentration in presence of the potentiator alcohol, the vital respiratory function would be probably maintained, thanks to the association with methcathinone.

Bentur Y; Bloom-Krasik A; Raikhlin-Eisenkraft B. Illicit cathinone ("Hagigat") poisoning. Clinical Toxicology 46(3): 206-210, 2008. (37 refs.)

Introduction. Khat leaves (mainly cathinone and cathine) have been chewed for centuries as stimulants. Hagigat (capsules of 200mg cathinone) have been marketed in Israel as a natural stimulant and aphrodisiac. The consequences of illicit exposure to cathinone are reported. Methods. Prospective observational study of calls to the Poison Center regarding exposure to Hagigat during the course of 10 months. Demographic and clinical data were abstracted from patients' records and telephone follow up was performed. Results. Data of 34 consecutive patients aged 16-54 years were analyzed. The amount consumed was 1/2 - 6 capsules (ingestion - 32, sniffing - 2). Main clinical manifestations were headache, vomiting, hypertension, nausea, tachycardia, dyspnea, chest pain, and myalgia. Main complications were myocardial ischemia (3), pulmonary edema (2), and intracerebral hemorrhage (1), all in young subjects. Treatment was supportive; one patient underwent neurosurgery. Conclusion. Exposure to illicitly synthesized cathinone is associated with serious cardiovascular and neurological toxicity, even in young subjects.

Bhana A; Parry CDH. The South African Community Epidemiology Network on Drug Use (SACENDU): Findings, implications and future directions. IN: Community Epidemiology Work Group, eds. Epidemiologic Trends in Drug Abuse. Volume II: Proceedings of the Community Epidemiology Work Group. June 2000. Bethesda MD: National Institute on Drug Abuse, 2000. pp. 373-385. (2 refs.)

This chapter summarizes information from the most recent administration of this project. As in the six previous surveys, alcohol was the most frequently reported substance of abuse in each of five sites. Trauma unit indicators highlight the heavy burden associated with alcohol abuse. Cannabis and methaqualone (Mandrax) either alone or in combination are the most frequently reported illicit drugs use. There has been a rise in requests for treatment for cannabis abuse. Cocaine/crack have shown an upward trend, and crack seizures have increased in three sites. In three sites, 9 percent of persons arrested on housebreaking and murder charges tested positive for cocaine. Heroin indicators remained fairly stable; however, there are concerns about the increased quality of heroin. Ecstasy use continues to be reported among young persons in the club scene, alone or in combination other amphetamines, LSD, and methamphetamine. Other substances that have entered the market include gamma hydoxybutyrate (GHB), and Khat (a plant with stimulant properties grown mostly in East Africa.

Public Domain

Bono JP. Criminalistics. IN: Karch SB, ed. Drug Abuse Handbook. Boca Raton FL: CRC Press, 1998. pp. 1-76. (90 refs.)

This chapter provides an overview of factors related to drug testing and forensic considerations related to controlled substances. It begins with a definition of the scheduling of drugs, and the analogue enforcement act of 1986. There is discussion of the major controlled substances, both illicit drugs -- heroin, cocaine, marijuana, peyote, psilocybin mushrooms, LSD, Peyote, fentanyl, methcathinone, Khat, anabolic steroids and pharmaceutical preparations -- stimulants, narcotic analgesics, and CNS stimulants. For each of these, there is a review of production and manufacture process, and laboratory analysis. and comparative analysis. There is also a discussion of the clandestine laboratories.

Carrier N. Is miraa a drug?: Categorizing Kenyan khat. Substance Use & Misuse 43(6): 803-818, 2008. (52 refs.)

This article examines the varied perceptions of the substance miraa/khat in Kenya, from strong approval in the Nyambene Hills region where it is cultivated to the strong disapproval evident in its frequent denunciation in various segments of Kenyan society. Perceptions are colored by various local and global discourses, and it is argued that of great importance is "war on drugs" rhetoric, which allows the conflation of miraa with other substances also termed "drugs"; much of the Kenyan miraa debate revolves around just how miraa should be categorized and to whether it can be labeled a "drug." War-on-drugs rhetoric is countered by those more enamored of the substance by discourse in which its use is labeled "traditional," "cool," and an "economic miracle.".

Carrier NCM. Kenyan Khat. Leiden: Brill Publishing, 2007

This ethnographic work traces the use of Kenyan khat - a plant widely chewed as mild stimulant across East Africa, and in East African immigrant communities throughout Europe and the US. It follows the process of production in the Nyambene Hills to consumers in Kenya and then throughout the world. It describes the economic, social and cultural significance of the substance, and the way in which khat is situated in East African social life.

de Ridder S; Eerens F; Hofstra L. Khat rings twice: Khat-induced thrombosis in two vascular territories. Netherlands Heart Journal 15(7-8): 269-270, 2007. (0 refs.)

The stimulant herbal drug Khat has long been known in East Africa and the Arabian peninsula. The habit of showing it has spread to ethnic communities world-wide. This is a case report of a 28 year old African male admitted to an emergency department with chest pain, somnolence and apparent aphasia, which developed after chewing Khat. ECG showed clear signs of inferoposterolateral myocardial infarction. In addition an MRI angiogram showed cerebral infarction due to an occluded left middle cerebral artery. Previous reports suggested that increased myocardial oxygen demand in combination with coronary vasoconstriction could be a major contributing factor to the cardiovascular complications associated with Khat use. This case suggests that increased thrombogenecity could be a key factor.

Dupont HJBH; Kaplan CD; Verbraeck HT; Braam RV; van de Wijngaart GV. Killing time: Drug and alcohol problems among asylum seekers in the Netherlands. International Journal of Drug Policy 16(1): 27-36, 2005. (30 refs.)

In the Netherlands, procedures for obtaining eventual refugee status normally take several years. This long period of uncertainty has been identified as a significant variable in psychological health complaints related to post-migration stress. Drug and alcohol problems were examined in a convenience sample of key figures in asylum seeker communities (N = 21) selected from three Dutch Asylum Seeker Centres (AZCs). A qualitative analysis of drug and alcohol use drawn from semi-structured, cross-sectional interviews was conducted to provide a description and explanations of variations in the drug use careers and drug use patterns of asylum seekers. Drug and alcohol use patterns were found to be often a continuation of standards, values and traditions from the country of origin and four types of drug culture emerged: abstinence, opium, khat and alcohol. Although psychological expectations and cultural background differed, our main finding was a hypothetical causal mechanism where use patterns have a similar function across groups as a means of "killing time". "Killing time" involved countering the psychosocial distress of the asylum-seeking process and uncertainties about the future as well as past trauma. Several possible education and policy interventions were identified. We hypothesise post-migration and cultural expectation factors that continue between the country of origin and the host country are more significant than past trauma in accounting for drug and alcohol use patterns in the asylum seeker population.

Falkowski CL. Drug abuse trends in the Minneapolis/St. Paul metropolitan area. IN: Community Epidemiology Work Group, eds. Epidemiologic Trends in Drug Abuse. Volume I: Proceedings of the International Epidemiology Work Group on Drug Abuse. June 1999. Bethesda MD: National Institute on Drug Abuse, 1999. pp. 127-130. (0 refs.)

Cocaine and marijuana prominent positions as illicit drugs of abuse in the Minneapolis/St. Paul metro area, although cocaine overdose deaths decreased in 1998, as did treatment admissions for both cocaine and marijuana. For the fourth consecutive year, marijuana treatment admissions outnumbered those for cocaine, and half of the patients were younger than 18. Marijuana abuse increased among Minnesota youth: in 1998, 30 percent of 12th graders and 24 percent of 9th graders reported past-year marijuana use. As in other midwestern cities, methamphetamine abuse, manufacture, and distribution escalated in 1998. All law enforcement agencies reported substantial growth in the methamphetamine-related activity, and for some metro law enforcement agencies, methamphetamine seizures and arrests surpassed those for cocaine. Dextromethorphan (DXM), gamma-hydroxybutyrate (GHB), ketamine, and khat continued to surface as new, emerging drugs of abuse. Injecting drug use was the soul contributing factor in 12 percent of the adult and adolescent AIDS cases diagnosed in Minnesota in 1998.

Public Domain

Feyissa AM; Kelly JP. A review of the neuropharmacological properties of khat. (review). Progress in Neuro-psychopharmacology & Biological Psychiatry 32(5): 1147-1166, 2008. (185 refs.)

Background: The psychostimulant khat (Catha edulis Forsk), is a herbal drug cultivated and chewed as a recreational and socializing drug in East Africa and the Arabian Peninsula for centuries. Due to increasing air transportation and the loosening of customs restrictions, it is now readily available in the Western Countries mainly used by immigrants from khat growing areas causing a concern to policy-makers. Objective: We conducted this review to further gain an insight to the neuropharmacological effects of khat. Methodology: PubMed search engine with key terms 'khat' or 'qat' or 'mirra' or'qaad/jaad' or 'cathinone' was used to obtain articles relevant to khat chewing. In total 284 English written articles published from 1959 to 2007 were screened. Results: Most of the studies focused on cathinone, the postulated active psychostimulant alkaloid in khat. There were few studies which investigated the entire plant extract in either in vitro or animal studies. In the majority of the studies it was reported that both cathinone and cathine, another psychoactive constituent, have actions that are similar to those of amphetamine. Conclusions: It seems that the well investigated khat alkaloids have many features similar to amphetamines; however there is a need for a more thorough examination of khat itself in well designed in vitro, animal and human studies with a range of comparator drugs before confirming the claim that khat is a "natural amphetamine".

Gebissa E. Scourge of life or an economic lifeline? Public discourses on khat (Catha edulis) in Ethiopia. Substance Use & Misuse 43(6): 784-802, 2008. (55 refs.)

Until the turn of the 20th century, only the religious and political elite of the city of Harer in eastern Ethiopia chewed khat. Its consumption has since spread to all regions of Ethiopia and all social groups, irrespective of religious affiliation, gender category, and age bracket, have taken up the habit. In a few decades khat has been transformed from a shrub grown for domestic consumption to the region's predominant cash crop; from a substance chewed on religious and cultural occasions to a visible and pervasive social habit; from a product sold in local markets to the most profitable commodity, whose trade involves millions of farmers, traders, and other service providers in the Horn of Africa and the Arabian Peninsula. The growing importance of khat has engendered a heated national debate in Ethiopia concerning the legal status of the plant. Opponents contend that khat is a health hazard with deleterious socioeconomic consequences and seek a complete ban to curb its "evil influence" on the country's youth and future. Others oppose any policy that ignores khat's micro- and macroeconomic benefits. This article outlines the positions the protagonists in this debate have staked out, critically evaluates their merits, and concludes by urging a public discourse on how to use the prosperity that the khat industry has generated to engender a sustainable economic development.

Gelaye B; Philpart M; Goshu M; Berhane Y; Fitzpatrick AL; Williams MA. Anger expression, negative life events and violent behaviour among male college students in Ethiopia. Scandinavian Journal of Public Health 36(5): 538-545, 2008. (41 refs.)

Aims: To assess the prevalence of violent behaviour and to identify risk factors associated with violent behaviour among male college students in Ethiopia. Methods: A cross-sectional study among 1294 male college students in Awassa, Ethiopia was conducted in June 2006. A self-administered questionnaire was used to collect information concerning violent acts, anger expression, and sociodemographic and lifestyle characteristics. Multivariable logistic regression procedures were used to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Results: More than half of the students (54.3%) reported committing at least one act of physical violence during the current academic year. Academic year of studies, use of khat, a natural stimulant with amphetamine-like effects, anger proneness and stressful life events were statistically significant covariates associated with committing acts of violence. Seniors, as compared with freshmen, were less likely to admit violent behaviour (OR=0.46; 95% CI 0.30-0.71). Those who reported using khat were more likely to report committing violent acts (OR= 1.46, 95% CI 1.02-2.08) than were non-users. Students with moderate levels of anger expression (scores of 11-14) were 3.40 times more likely to report committing acts of violence (OR=3.40; 95% CI 2.42-4.79) than were those with low levels of anger expression (scores < 11). For students with high levels of anger expression (>= 15 scores), the corresponding OR was 7.62 (95% CI 5.15-11.29). Participants who had experienced >= 4 negative life events during the current academic year were more likely (OR=2.41; 95% CI 1.58-3.69) to report violent behaviour than were those with fewer stressful life events. Conclusions: Screening for violent behaviour and violence prevention programmes, particularly those in educational settings, should include strategies that address students' stressful life events, anger management, and substance use.

Graziani M; Milella MS; Nencini P. Khat chewing from the pharmacological point of view: An update. (review). Substance Use & Misuse 43(6): 762-783, 2008. (142 refs.)

Khat chewing is deeply rooted in the every day life of people living in the Horn of Africa and in South Arabia, where Catha edulis is endemic. Considered little more than an exotic habit producing just mild pharmacological effects, systematic investigations on its active principles have instead lead to the isolation and chemical characterization of cathinone, a compound structurally related to amphetamine. Three decades of intense experimental and clinical research on khat have depicted a consistently clear picture of its pharmacological and toxicological effects.

Griffiths P; Gossop M; Wickenden S; Dunworth J; Harris K; Lloyd C. A transcultural pattern of drug use: Qat (khat) in the UK. British Journal of Psychiatry 170(3): 281-284, 1997. (12 refs.)

Background: This study investigates patterns of qat use among 207 Somalis living in London. Method: Subjects were recruited using privileged access interviewing. Somalian interviewers were recruited who shared the same culture as the subjects. Data were collected by means of a structured interview. Results: One hundred and sixty-two subjects (78%) had used qat. The majority (76%) used more qat than in Somalia. Some users reported moderate dependence; a minority reported severe problems. Adverse psychological effects included sleep problems, anxiety and depression. Medical problems associated with qat use were rare. Conclusions: Qat users who continue to use this drug when transplanted from a traditional context may experience difficulties. Qat use can also be seen as playing a positive role in supporting the cultural identity of the Somalian community. Severe problems were rarely reported. Qat consumption should be considered when addressing health-related topics with patients from those communities in which qat use is common.

Hassan NA; Gunaid AA; El-Khally FM; Murray-Lyon IM. The effect of chewing Khat leaves on human mood. Saudi Medical Journal 23(7): 850-853, 2002. (24 refs.)

Objective: Chewing fresh leaves of the Khat plant (Catha edulis), represents a widespread habit with a deep-rooted sociocultural tradition in Yemen. Khat is chewed for its central stimulant properties and to dispel feeling of fatigue and its use is believed to be associated with disturbance of mood. We studied the effect of chewing Khat leaves on human mood by using a standard questionnaire method, the Hospital Anxiety and Depression scale. Methods: A prospective study was conducted in the Faculty of Medicine and Health Sciences, University of Sana'a during the period January to June 2000. It comprised of 200 healthy volunteers, interviewed on 2 occasions a week apart. Subjects either chewed Khat at least 3 hours daily for 3 days or abstained from chewing for at least 7 days prior to mood assessment using the Hospital Anxiety and Depression scale. Subjects were studied in random order. Results: Using the Hospital Anxiety and Depression scale, there was a significant increase (P < 0.0001) of median score on the scale indicating mood disturbance during the Khat-arm of the study as compared to the control-arm. The effect was particularly evident shortly after the Khat session. Reactive depression symptoms were predominant. Conclusion: Khat chewing did result in functional mood disorder. This effect is believed to be caused by the sympathomimetic action of cathinone on the central nervous system. The clinical implication of this study is that Khat-chewing might exacerbate symptoms in patients with pre-existing psychiatric disease.

Hassan NAGM; Gunaid AA; El Khally FMY; Murray-Lyon IM. The subjective effects of chewing Qat leaves in human volunteers. Annals of Saudi Medicine 22(1-2): 34-37, 2002. (14 refs.)

Background: Chewing the leaves of the Qat plant (Catha edulis) for their pleasurable central stimulant effect is a habit that is widespread in Yemen and certain areas of East Africa. The use of the Qat leaves is believed to cause a variety of gastrointestinal and genito-urinary symptoms as well as sleep disturbance. We studied the subjective effects of chewing Qat leaves in human volunteers. Subjects and Methods: This prospective study included 1600 healthy adult male subjects who chewed Qat, and a similar number of 1600 subjects who never chewed Qat serving as control. Subjects in the Qat group chewed Qat for at least four hours daily for three successive days before answering a questionnaire. Results: The study revealed that the prevalence of gastrointestinal (GI) symptoms (epigastric bloating, belching and abdominal distension) and genito-urinary symptoms (weak stream of micturition, post-chewing urethral discharge) were significantly higher (P<0.0001) among Qat-chewing subjects than controls. Similarly, central nervous system (CNS) symptoms such as anorexia, insomnia (delayed bedtime), late wake-up the next morning and low work performance the next day, were significantly higher in Qat chewers (P<0.0001). Stepwise multivariate logistic regression analysis revealed that GI symptoms which were significant in univariate analysis were no longer significant, whereas CNS and genito-urinary symptoms remained significant (P<0.0001). Conclusion: This study confirms that Qat chewing induces anorexia, weak stream of micturition, post-chewing urethral discharge and insomnia (delayed bedtime), which result in late wake-up next morning and low work performance the next day. These effects are believed to be caused by the central and peripheral actions of cathinone and cathine in the Qat leaves.

Kebede D; Alem A; Mitike G; Enquselassie F; Berhane F; Abebe Y et al. Khat and alcohol use and risky sex behaviour among in-school and out-of-school youth in Ethiopia. BMC Public Health 5: ar109, 2005. (34 refs.)

Background: Khat (an evergreen plant with amphetamine-like properties) and alcohol are widely consumed among the youth of Ethiopia. However, their relationship to risky sexual behaviour is not well described. This study was conducted to describe the magnitude of risky sexual behaviour (unprotected sex and early initiation of sexual activity) and its association with khat and alcohol consumption in Ethiopian youths. Methods: A probabilistic national sample of 20,434 in-school and out-of-school youths aged between 15 and 24 years of age was selected and interviewed regarding their sexual behavior and substance use. Results: Over 20% of out-of-school youth had unprotected sex during the 12-month period prior to interview compared to 1.4% of in-school youth. Daily Khat intake was also associated with unprotected sex: adjusted OR (95% CI) = 2.26 (1.92, 2.67). There was a significant and linear association between alcohol intake and unprotected sex, with those using alcohol daily having a three fold increased odds compared to those not using it: adj. OR (95% CI) = 3.05 (2.38, 3.91). Use of substances other than khat was not associated with unprotected sex, but was associated with initiation of sexual activity: adj. OR (95% CI) = 2.54 (1.84, 3.51). Conclusion: A substantial proportion of out-of-school youth engage in risky sex. The use of khat and alcohol and other substances is significantly and independently associated with risky sexual behaviour among Ethiopian youths.

Khawaja M; Al-Nsour M; Saad G. Khat (Catha edulis) chewing during pregnancy in Yemen: Findings from a national population survey. Maternal and Child Health Journal 12(3): 308-312, 2008. (37 refs.)

Aims: This study examines the prevalence of khat chewing among women during pregnancy and some of the risk factors for this habit in Yemen. Methods: Survey data on 7,343 ever-married women from the Yemen Demographic and Maternal and Health Survey (YDMHS), conducted in 1997 are used. Women who had a live birth during the 5 years preceding the survey were asked if they chewed khat during each of their pregnancies (=1) or not (=0). Associations between chewing khat and socio-demographic risk factors were assessed using odds ratios from binary logistic regression models. Results: About 40.7% of women surveyed reported chewing khat while pregnant during the 5 years before the survey. Old age, no education, rural residence, living in mountainous regions, and low wealth were significant risk factors for chewing khat. Conclusions: Khat chewing during pregnancy is highly prevalent in Yemen. Socio-economically disadvantaged women were more likely to chew khat than other women.

Klein A. Khat in the neighbourhood: Local government responses to Khat use in a London community. Substance Use & Misuse 43(6): 819-831, 2008. (17 refs.)

There is increasing fear among the general public about khat, its use and users, and associated crime. In many English cities, neighborhoods with growing Somali populations and emerging khat-using scenes and markets have to find ways of managing the impact of the negative image of khat. This case study describes and analyzes how a local municipal authority can respond constructively by generating an evidence base, engaging in consultation, and endeavoring to identify the actual relationship between reported criminality and public nuisance and the alleged patterns of use and distribution of khat. It is argued that it is important to frame the khat in the community not as a "drug problem" but as a wider public health issue, for which appropriate solutions can be developed.

Lukandu OM; Costea DE; Neppelberg E; Johannessen AC; Vintermyr OK. Khat (Catha edulis) induces reactive oxygen species and apoptosis in normal human oral keratinocytes and fibroblasts. Toxicological Sciences 103(2): 311-324, 2008. (39 refs.)

Khat chewing is widely practiced in Eastern Africa and the Middle East. Khat is genotoxic to cells within the oral mucosa, and several studies have suggested an association between khat use and oral lesions like hyperkeratosis and oral cancer. This study investigated the mechanism of khat-induced cytotoxicity using primary normal human oral keratinocytes (NOK) and fibroblasts (NOF). Khat induced rounding up of cells, plasma membrane blebbing, and condensation of nuclear chromatin within 3-6 h of exposure. The cells also showed externalization of phosphatidylserine and fragmentation of DNA. Morphological and biochemical features were compatible with cell death by apoptosis. Khat also induced an increase in cytosolic reactive oxygen species (ROS) and a depletion of intracellular glutathione (GSH) within 1 h of exposure. Antioxidants reduced ROS generation, GSH depletion and delayed the onset of cytotoxicity in both cell types. Generally, NOF cells were more sensitive to khat-induced cytotoxicity than NOK cells. These effects were elicited at concentrations of khat expected to occur in the oral cavity during khat chewing. In summary, khat induced apoptotic cell death in primary normal oral keratinocytes and fibroblasts by an early effect on mechanisms that regulate oxidative stress.

MacDonald D. Drugs in Southern Africa: An overview. (review). Drugs: Education, Prevention and Policy 3(2): 127-144, 1996. (61 refs.)

This article presents an overview of the availability and supply of various types of drug and patterns of drug use in southern Africa, a region of the developing world currently experiencing a marked period of transition. The socioeconomic diversity and multi-faceted cultural dualism so characteristic of the region are reflected in patterns and levels of drug consumption. While alcohol, both licit and illicit, is still the major drug of abuse, others including methaquolone, solvents, khat and pharmaceuticals are reported to be increasingly abused, and illegal drugs in transit through the regions, such as cocaine and heroine, are more likely to be consumed locally. Available data suggest that the cultivation of cannabis as an export commodity is also increasing. Traditional cultural uses of this drug, however, illustrate the problem of controlling drugs and preventing their abuses within the context of modernizing post-colonial societies. The development of relevant community-led drug prevention strategies, social policies and legislation needs to be attuned to the cultural complexities and socioeconomic realities of rite region, rather than to northern paradigms of drug control based predominantly on legal prohibitionism.

Marker P; Krogdahl A. Plasma cell gingivitis apparently related to the use of khat: Report of a case. British Dental Journal 192(6): 311-313, 2002. (15 refs.)

Plasma cell gingivitis (PCG) is characterized by massive infiltration of plasma cells into the subepithelial tissue. It is a rare condition; the cause of which is still not fully understood. A case of PCG is reported in the mandibular gingiva probably caused by chewing khat. This report is the first, as far as we know, that relates PCG to the use of khat. The histological examination revealed infiltration of polyclonal plasma cells without signs of fungus, tuberculosis or malignancy. It is concluded that the changes were compatible with an allergic-like reaction. The patient, a 30-year-old immigrant from Somalia, revealed in a subsequent consultation that he regularly used khat. The leaves are placed in the buccal sulcus. The PCG disappeared within two weeks of the use of khat being discontinued. Dental surgeons (periodontists) in Europe and the New World will, due to increasing immigration from Africa and the Arabian Peninsula, meet more patients who regularly use khat. This means that PCG and other khat related intraoral changes will become more common in the future.

Milanovic B. Qat expenditures in Yemen and Djibouti: An empirical analysis. Journal of African Economies 17(5): 661-687, 2008. (29 refs.)

Using household surveys from Yemen and Djibouti, the paper analyses determinants of qat consumptions in two countries. The results confirm huge importance of qat in daily life: with between one-half (in Djibouti) and 70% (in Yemen) of all households reporting at least one user. But in Yemen, qat consumption is remarkably flat across income groups, age, and between rural and urban areas. Qat is a normal good and there is no indication that its use substitutes for food. In Djibouti, however, qat consumption increases with income, and appears to act as a substitute for food consumption. In both countries however there is a strong gender bias in the use: men are much more likely to use qat than women.

Murray CDR; Le Roux CW; Emmanuel AV; Halket JM; Przyborowska AM; Kamm MA et al. The effect of Khat (Catha edulis) as an appetite suppressant is independent of ghrelin and PYY secretion. Appetite 51(3): 747-750, 2008. (17 refs.)

Background: The leaves of the khat plant (Catha edulis) are chewed for their pleasurable effects. Chewing releases cathinone which may decrease appetite through an unknown mechanism. Levels of the peptide ghrelin increase with hunger and decrease immediately post-prandially, while peptide YY is released following a meal. We hypothesised that the anorexigenic effects of khat may be mediated through changes in these hormones. Materials and methods: Six habitual khat chewers attended on two separate occasions. For a period of 3 h they chewed either khat leaves or lettuce. Blood pressure (BP) and pulse rate (PR) were monitored throughout, as were subjective assessments of hunger and fullness. Plasma samples were analysed for cathinone, ghrelin and PYY levels. Results: Chewing khat significantly decreased subjective feelings of hunger and increased fullness (p < 0.05) but had no effect on ghrelin and PYY levels. Khat led to an increase in cathinone levels as well as an increase in BP and PR. Cathinone levels correlated positively with fullness and pulse rate and negatively with hunger. Conclusions: Chewing khat decreases subjective feelings of hunger and increases systemic sympathetic tone, but has no effect on ghrelin and PYY levels. We conclude that the anorexigenic effect of khat may be secondary to central mechanisms mediated via cathinone.

Nabuzoka D; Badhadhe FA. Use and perceptions of Khat among young Somalis in a UK city. Addiction Research 8(1): 5-26, 2000. ( 21 refs.)

This study examined patterns of use, perceptions, associated effects and problems of using Khat by a sample of young Somalis (N=94) in Sheffield, UK. Findings indicate that khat chewing has a social dimension, occupies a significant proportion of one's time and may be associated with other drugs. Most respondents considered khat to be a problem among Somalis with some negative health and social effects but rationalised usage citing personal pressures, socio-cultural and emotional problems faced as a result of dislocation from the country of origin, and need for recreation. Social intervention including counselling, health education and advice about khat was seen as necessary. It is suggested that excessive khat consumption among Somalis in UK should be seen in the wider context of a people dislocated from their country of origin as facilitating a deviant pattern of drug abuse. The findings are preliminary but have implications for future research and intervention.

Nielen RJ; van der Heijden FMMA; Tuinier S; Verhoeven WMA. Khat and mushrooms associated with psychosis. World Journal of Biological Psychiatry 5(1): 49-53, 2004. (41 refs.)

Objective: This paper describes two cases with khat- and two with psilocybin-induced psychoses and draws attention to the medical and social consequences of the use of these drugs. Method: Two male patients are presented who developed relapsing and short-lasting psychotic episodes after chewing khat leaves. In addition, two male patients are reported who showed an acute exacerbation of psychosis after ingestion of psilocybin mushrooms. In addition, a review of the literature is presented. Results: The khat-induced psychotic symptoms disappeared without any treatment within one week. One of the patients with a psilocybin-induced psychosis was treated with risperidone. In the other, symptomatology subsided in a few days. No somatic medical complications occurred. Conclusion: Adequate psychiatric diagnosis and treatment of the psychoses and the negative social consequences of the use of these drugs are stressed as well as the delineation from functional psychoses in cases of chronic use. The latter applies to patients with psychiatric comorbidity in particular.

Numan N. Exploration of adverse psychological symptoms in Yemeni khat users by the Symptoms Checklist-90 (SCL-90). Addiction 99(1): 61-65, 2004. (46 refs.)

Aim: The present study was aimed at assessing associations between psychological symptoms and khat use in the Yemeni population. Setting: The survey was performed in 2000/2001, in different zones including three urban and three rural areas. Participants: The survey was carried out in 800 Yemeni adults (15-76), both male and female, representing mainly urban populations of students, state employees and housewives. Design: A cross-sectional survey was undertaken using face-to-face interviews and no preset selection criteria regarding profession, socio-economic status, age or gender. Measurement: The Symptoms Checklist-90 (SCL-90) was used containing 90 items, which cover nine scales of the following domains: somatization, depression, anxiety, phobia, hostility, interpersonal sensitivity, obsessive-compulsive, hostility, interpersonal sensitivity, paranoia and psychoticism. Details of khat use and socio-demographic data were also collected. Findings: At least one life-time episode of khat use was reported in 81.6% of men and 43.3% of women. Male users tended to use more frequently. The incidence of adverse psychological symptoms was not greater in khat users; in fact, there was a negative association between the incidence of phobic symptoms and khat use. Conclusions: Khat use is very common in the Yemeni population, particularly men, but it is not associated with adverse psychological symptoms.

Odejide AO. Status of drug use/abuse in Africa: A review. International Journal of Mental Health and Addiction 4(2): 87-102, 2006. (51 refs.)

The history of psychoactive substance use in Africa is relatively short except for the reports on the use of traditional substances such as alcohol, cannabis and khat. The introduction of prescription drugs to Africa drastically increased the availability and use of psychoactive substances. This notwithstanding, alcohol, cannabis and khat still remain the most common substances of abuse in Africa. More recently, trafficking in heroin and cocaine has made narcotic drugs easily available across Africa despite the existing legal control measures. Complications arising from the use/abuse of psychoactive substances often draw public attention to their deleterious effects, which culminate in drug control policy formulation. This paper highlights the contribution of poverty, political instability, social unrest and refugee problems to the rapid spread of psychoactive substance use/abuse in Africa particularly among the youth. The review also points to a possible linkage between psychoactive drug use and HIV infection. At present in Africa, systematic evidence-based drug information is sparse. Also, drug policies are skewed towards formal control measures that may not encourage community participation. Poor funding, insufficient skilled health personnel, poor laboratory facilities, inadequate treatment facilities, and lack of political will are some of the impediments to controlling substance use/abuse in Africa. The paper argues that well-coordinated civil society participation is necessary in the control of drug problems in Africa in order to achieve a balance between supply and demand reduction efforts.

Odenwald M; Hinkel H; Schauer E; Neuner F; Schauer M; Elbert TR et al. The consumption of khat and other drugs in Somali combatants: A cross-sectional study. PLoS Medicine 4(12): 1959-1972, 2007. (74 refs.)

Background: For more than a decade, most parts of Somalia have not been under the control of any type of government. This "failure of state'' is complete in the central and southern regions and most apparent in Mogadishu, which had been for a long period in the hands of warlords deploying their private militias in a battle for resources. In contrast, the northern part of Somalia has had relatively stable control under regional administrations, which are, however, not internationally recognized. The present study provides information about drug abuse among active security personnel and militia with an emphasis on regional differences in relation to the lack of central governmental control-to our knowledge the first account on this topic. Methods and Findings Trained local interviewers conducted a total of 8,723 interviews of armed personnel in seven convenience samples in different regions of Somalia; 587 (6.3%) respondents discontinued the interview and 12 (0.001%) were excluded for other reasons. We assessed basic sociodemographic information, self-reported khat use, and how respondents perceived the use of khat, cannabis (which includes both hashish and marijuana), psychoactive tablets (e. g., benzodiazepines), alcohol, solvents, and hemp seeds in their units. The cautious interpretation of our data suggest that sociodemographic characteristics and drug use among military personnel differ substantially between northern and southern/central Somalia. In total, 36.4% (99% confidence interval [CI] 19.3%-57.7%) of respondents reported khat use in the week before the interview, whereas in some regions of southern/central Somalia khat use, especially excessive use, was reported more frequently. Self-reported khat use differed substantially from the perceived use in units. According to the perception of respondents, the most frequent form of drug use is khat chewing (on average, 70.1% in previous week, 99% CI 63.6%-76.5%), followed by smoking cannabis (10.7%, 99% CI 0%-30.4%), ingesting psychoactive tablets (8.5%, 99% CI 0%-24.4%), drinking alcohol (5.3%, 99% CI 0%-13.8%), inhaling solvents (1.8%, 99% CI 0%-5.1%), and eating hemp seeds (0.6%, 99% CI 0%-2.0%). Perceived use of khat differs little between northern and southern Somalia, but perceived use of other drugs reaches alarmingly high levels in some regions of the south, especially related to smoking cannabis and using psychoactive tablets. Conclusions: Our data suggest that drug use has quantitatively and qualitatively changed over the course of conflicts in southern Somalia, as current patterns are in contrast to traditional use. Although future studies using random sampling methods need to confirm our results, we hypothesize that drug-related problems of armed staff and other vulnerable groups in southern Somalia has reached proportions formerly unknown to the country, especially as we believe that any biases in our data would lead to an underestimation of actual drug use. We recommend that future disarmament, demobilization, and reintegration (DDR) programs need to be prepared to deal with significant drug-related problems in Somalia.

Patel NB. Mechanism of action of cathinone: The active ingredient of khat (Catha edulis). East African Medical Journal 77(6): 329-332, 2000. (28 refs.)

Objective: To review the current understanding of the mechanism of action of cathinone, the active ingredient of khat, Data source: Published experimental studies on the nature and action and effect of cathinone on the central nervous system both in animals and humans, Data extraction: Data was taken from work published on the mechanism of action of cathinone and also from work where the action of cathinone and amphetamine was compared. Data synthesis: Data from various studies on cathinone was compared for common themes with regards to its action and similarity with the known mechanism of action of amphetamine. Conclusion: The experimental work shows that cathinone is a liable substance, structually related to amphetamine, and similarly to amphetamine, increases the levels of dopamine in the brain by acting on the cathecholaminergic synaspes, Hence the psychostimulant effect of khat can be accounted for by the mechanism of cathinone, which is considered to be its main active ingredient.

Patel SL. Attitudes to khat use within the Somali community in England. Drugs: Education, Prevention and Policy 15(1): 37-53, 2008. (44 refs.)

Recently there has been considerable interest in the use of the stimulant substance khat by community groups originally from East Africa and now settled in the UK. The use of khat for socializing and recreation has existed for years and it is considered a legitimate substance. The most recent study of self-reported khat use within the Somali community in England has shown some subtle changes in the pattern of khat use, but it was mostly an activity that respondents carried out in moderation. However, the issue of the cultural legitimacy of khat use and its effects on individuals, families and society in general remains a debated issue. The study by Patel, Wright, and Gammampila (2005) showed that there are divided attitudes within the Somali community about khat; there were those who perceive khat use as a harmful activity and those who feel that it has an important social function and keeps the community together.

Pennings EJM; Opperhuizen A; van Amsterdam JGC. Risk assessment of khat use in the Netherlands: A review based on adverse health effects, prevalence, criminal involvement and public order. (editorial). Regulatory Toxicology and Pharmacology 52(3): 199-207, 2008. (110 refs.)

In preparing a decision about the legal status of khat in the Netherlands, the Dutch Minister of Health requested CAM (Coordination point Assessment and Monitoring new drugs) to assess the overall risk of khat in the Netherlands. The present paper is a redraft of a report which formed the scientific basis of the risk evaluation procedure (October 2007). This report reviews the scientific data about khat available in the international literature. In addition, the report contains some information specific for the Netherlands (prevalence, availability of khat and public order aspects). The main psychoactive compounds in khat leaves are cathine and cathinone, which are some 2- to 10-fold less active than amphetamine. Acute health problems are rarely seen, and are Usually related with malnutrition, social and financial problems. Khat has a low addictive potential. Chronic toxicity of khat is modest when used in low amounts, whereas at high levels, khat use is associated with adverse effects, like hypertension, heart rhythm disorders, insomnia and loss of appetite. in addition, khat users show a higher prevalence of cancers in the digestive tract. At population level, khat does not lead to specific health risks in the Netherlands, as its use is confined to East-African immigrants. A relationship between khat use and psychiatric disorders has been suggested, but the reports are contradictory, and such studies are presumably heavily confounded by posttraumatic and social stress. In the Netherlands (and other countries), khat use occasionally leads to minor disturbance of civil order in the public domain (loud talking, spitting), but is not related to criminal activities. Following the assessment, CAM estimated the overall risk potential of khat use in the Netherlands as very low. A similar conclusion may be drawn for countries with a comparable prevalence of khat use and khat related public order disturbance.

Rassool GH. An overview of psychoactive drugs. IN: Rassool GH, ed. Substance Use and Misuse: Nature, Context and Clinical Interventions. London: Blackwell Science, 1998. pp. 38-53. (6 refs.)

This chapter in a textbook for nurses offers an overview of the nature and effects of psychoactive substances. The chapter is organized by drug class --- opiates, cannabis, stimulants, hypnosedatives, hallucinogens, ecstasy, anabolic steroids, inhalants, over-the-counter preparations, as well as khat, ketamine, GHB. There is a brief description of each drug, its therapeutic and illicit uses, legal status, acute and chronic effects.

Ross MW; McCurdy SA; Kilonzo GP; Williams ML; Leshabari MT. Drug use careers and blood-borne pathogen risk behavior in male and female Tanzanian heroin injectors. American Journal of Tropical Medicine and Hygiene 79(3): 338-343, 2008. (12 refs.)

Injection drug use in sub-Saharan Africa is a relatively new phenomenon that expands the repertoire of human immunodeficiency virus (HIV)-associated risk behaviors in Africa. We carried out a study of 537 injection drug users (56% men and 44% women) in Dar es Salaam, Tanzania, to examine their HIV risk behaviors and their drug-using careers that had culminated in injecting heroin. Data were collected in 2005-2006 using the Swahili version of the Tanzanian AIDS Prevention Project questionnaire. Marijuana, alcohol, and heroin were the first drugs reported for both men and women. Most drug milestones appeared in a similar order for men and women. Mandrax, khat, and injecting appeared close to one another in chronological time for both men and women, suggesting they were introduced into the country and appeared on the drug scene at about the same (real) time. Drug careers for women were shorter than for men, and time from first use of heroin to first injection was shorter for women. Years of injecting suggested that injecting had increased in males approximately five years prior to data collection, with males injecting earlier, but females being increasingly introduced to injecting in the previous two years. Injecting appears at a mean of five years (men) and three years (women) into their heroin-using career. Heroin use appears to occur in binges, with women being more likely to have sex during a binge. In this sample, more than 90% of women but only 2% of men reported ever trading sex for money. More than 90% of men and women reported using new needles for injection. These data confirm that heroin injecting is well established in large cities in east Africa, and that HIV prevention in the region must now include drug injectors and other drug users.

Royal Canadian Mounted Police. Drug Situation Report 2005. Ottawa: Royal Canadian Mounted Police, 2006. (0 refs.)

This report deals provides a strategic overview of the illicit drug trade in Canada. Separate sections are directed to cocaine, heroin, opium, cannabis derivatives, ecstasy/MDMA, methamphetamine, other synthetic drugs (ketamine and GHB, and other controlled drugs), khat. It also includes a section on precursor chemicals, concludes with a summary of drug offenses. Drug seizure data is provided in an appendix. For each of the sections on drugs, key findings related to the substances are outlined, along with the level of demand, the drug source, the means of smuggling, trafficking patterns within the country, and major seizures.

Scheifele C; Nassar A; Reichart PA. Prevalence of oral cancer and potentially malignant lesions among shammah users in Yemen. Oral Oncology 43(1): 42-50, 2007. (32 refs.)

The purpose of this study was to assess the prevalence of oral precancerous lesions and squamous cell carcinoma (OSCC) in Yemeni users of shammah, a traditional smokeless tobacco habit known in the Arabian Peninsula. The study group comprised 199 male and one female shammah users who were interviewed via a standardised questionnaire and clinically examined in 48 Yemeni villages and cities. Cases with oral leukoplakia (OL) or mucosal burns (MB) were compared with users without any lesion. MB were detected in 31%, of which 46.8% were located on the tongue or floor of the mouth, and OL in 27%, of which 59.2% were located in the same region. In addition, two cases (1%) of apparent OSCC were identified. Statistically significant increased OR (95% CI) of OL were (a) 6.91 (2.66-17.95) for an average duration of the respective shammah application > 5 min.; (b) 4.90 (1.99-12.08) for a daily frequency of those applications > 10; and (c) 4.22 (1.43-12.43) for a daily duration > 6 h of chewing qat, also a traditional habit in Yemen. Likewise, decreased OR were (a) 0.39 (0.18-0.85) for rinsing the mouth after the shammah application; (b) 0.36 (0.17-0.78) for successful attempts to stop the use in the past; and (c) 0.26 (0.09-0.72) for existing knowledge about the carcinogenicity of shammah that was present in only 19% overall. In conclusion, evidence was shown for a significant association between the prevalence of OL and the daily duration of shammah application in a dose-dependent manner. An appropriate public health program might help to reduce this potential OSCC burden in shammah users.

Stevenson M; Fitzgerald J; Banwell C. Chewing as a social act: Cultural displacement and khat consumption in East African communities of Melbourne. Drug and Alcohol Review 15(1): 73-82, 1996. (19 refs.)

In this paper we present a review of practices surrounding the consumption of khat (Catha edulis) within recent migrant communities in Melbourne from East Africa. Cultures in East Africa and the Arabian Peninsular have used khat as a stimulant since the seventh century and the practice of coming together to chew the leaves of the khat plant has acquired unique cultural importance. Based on focus-group interviews the research examines transformations taking place in the meaning of khat for East African communities within their experiences of displacement and considers how the arrival of khat might be managed in the Australian context. Emphasis is given to indigenous models and the cultural context of practices surrounding khat. This anthropology of khat use in Melbourne summarizes issues such as who chews it, traditional settings for khat gatherings, culturally defined effects of the leaf, health effects, beliefs and attitudes, levels of use, gendered attitudes and questions of dependence. These issues raise questions regarding the reception of indigenous substance use within a state that claims to be multicultural.

Toennes SW; Kauert GF. Driving under the influence of khat-alkaloid concentrations and observations in forensic cases. Forensic Science International 140(1): 85-90, 2004. (25 refs.)

The use of the herbal stimulant khat (Catha edulis FORSK) is maintained by immigrants from countries where it is part of their cultural life (Arabian Peninsula and eastern Africa). In western countries the drug and its effects are largely unknown and no experience in evaluating impairment symptoms due to the khat-alkaloids, e.g. cathinone, cathine and norephedrine exists. Blood and urine samples from khat users involved in 19 cases of suspected driving under the influence of drugs were analysed and correlated with the results of medical examination and police officer reports. In 3 cases impaired driving and in 10 cases marked impairment of psychophysical functions was observed such as effects on the nervous system (slow pupil reaction to light, dry mouth, increased heart-rate), trembling, restlessness/nervousness, daze/apathy/dullness, impairment of attention, walking and standing on one leg. However, the alkaloid concentrations assayed in blood did not correlate with the impairment symptoms. Apart from an acute phase of indirect sympathomimetic action the development of habituation and withdrawal symptoms must also be considered in explaining the diversity of effects observed. From these results it can be concluded that chewing khat may severely impair driving ability, but may also be without noticeable effects.

Toennes SW; Kauert GF. Excretion and detection of cathinone, cathine, and phenylpropanolamine in urine after kath chewing. Clinical Chemistry 48(10): 1715-1719, 2002. (21 refs.)

Introduction: The stimulating herbal drug kath is uncommon in most countries, and information on its detection and interpretation of analytical results is limited. Therefore, a study with kath was carried out to compare the efficiencies of different analytical techniques used to detect drug use. Methods: Four volunteers chewed kath leaves for 1 h; urine samples were collected up to 80 It afterward and analyzed by the Abbott fluorescence polarization immunoassay (FPIA), the Mahsan-AMP300 on- site immunoassay, the Bio-Rad Remedi HS HPLC system with photodiode array detection (DAD), and gas chromatography-mass spectrometry (GC- MS). Results: FPIA gave negative results, whereas positive results were obtained with the Mahsan test during the first day. With HPLC, one peak could be observed up to 50 It, but its DAD spectrum could not be identified by the system. Further investigations indicated that the kath alkaloids coeluted and produced a mixed DAD spectrum. With GC- MS, the specific kath ingredient cathinone was detected up to 26 h, whereas cathine and norephedrine were still detectable in the last samples. Maximum concentrations of cathinone, cathine, and norephedrine in urine samples from the study were 2.5, 20, and 30 mg/L, respectively, whereas in authentic cases the concentrations were much higher. Conclusion: GC-MS is superior to the screening techniques Mahsan- AMP300 and Remedi with respect to specificity and sensitivity for the detection of kath use in urine.

WHO Expert Committee on Drug Dependence. WHO Expert Committee on Drug Dependence. Thirty-Third Report by WHO. Geneva Switzerland: World Health Organization, 2003. (14 refs.)

This report provides an overview of the review criteria for scheduling, essentially established in 1961, that serve as a classification schema for psychoactive substance. It then provides a critical review of amfepramone; amineptine; buprenorphine, delta-9-tetrahydrocannabinol, and tramadol. It also offers a "pre-review" of ketamine, zaleplon, zopiclone, butorphanol; oripavine; and khat. For each of these there is summary of pharmacology, therapeutic use, abuse potential, similarity to known substances and effects on the central nervous system.

Zaghloul A; Abdalla A; El Gammal H; Moselhy H. The consequences of khat use: A review of literature. (review). European Journal of Psychiatry 17(2): 77-86, 2003. (42 refs.)

Khat is an evergreen tree, which grows in certain areas of East Africa and the Arabian Peninsula. The leaves of the khat have stimulating effect, and therefore chewed habitually by many people living in the area where it grows. Due to the availability of air transport, this drug has made its appearance in Western Europe and in the USA. In this article we will review all the issues related to khat consequences and its use and abuse in different areas of the world.