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International Journal of Drug Policy 22 (2011) 95–101

Contents lists available at ScienceDirect

International Journal of Drug Policy

journa l homepage: www.e lsev ier .com/ locate /drugpo

eview

ZP-party pills: A review of research on benzylpiperazine as a recreational drug

ruce M.Z. Cohena,∗, Rachael Butlerb

Department of Sociology, University of Auckland, Human Sciences Building, Room 920, 10 Symonds Street, Private Bag 92019, Auckland 1142, New ZealandSchool of Pharmacy, University of Auckland, New Zealand

r t i c l e i n f o

rticle history:eceived 26 July 2010eceived in revised form 20 October 2010ccepted 1 December 2010

eywords:ZParty pillsesigner drugsegal highserbals

a b s t r a c t

Background: BZP-party pills are yet another ‘designer drug’ which mimics the stimulant qualities ofamphetamines and MDMA/Ecstasy. As legal markets for the substance have developed in the last decade(especially amongst young people) so has public and governmental concern.Methods: This article provides a summary of the available international research on benzylpiperazine(BZP) and its popular use in the compound form known as ‘party pills’. Through performing an analysisof the available medical and social scientific literature, the review outlines current knowledge on thecompound, the prevalence of usage of BZP-party pills, as well as the associated harms, risks and rationalesfor use of the drug.Results: Despite moves towards legislative control of BZP-party pills, the evidence presented suggestslimited social and health harms associated with the drug, although research on long term effects isa significant gap in the literature. It also remains inconclusive as to whether BZP-party pills act as a‘gateway’ to illegal drugs or, conversely, play a role in harm reduction with illegal drug users turning to

legal alternatives; there is some evidence for both positions.Conclusion: With increasing controls of BZP-party pills, and with the increasing numbers of ‘legal highs’and new designer drugs on the market, we conclude that new legal alternatives will continue to surfaceto replace the drug in the future. Considering a harm reduction approach to drug taking, it is suggestedthat policy makers consider the creation of a legal holding category which restricts and regulates themarket in legal highs whilst the social and health harms associated with each drug can be thoroughly investigated.

ntroduction

As part of the recent growth in ‘legal highs’, benzylpiperazineBZP) was first used as a recreational substance in Europe in 1999European Monitoring Centre for Drugs and Drug Addiction, 2009;

ikstrom, Holmgren, & Ahlner, 2004); markets have since devel-ped in a number of countries including Bulgaria, the US, Australia,weden, Japan and South Africa. Between 2000 and 2008, however,ew Zealand was the only country to develop a significant legalarket for what has become known as ‘BZP-party pills’ (Bellamy,

007; Social Tonics Association of New Zealand, 2005; Wilkins &weetsur, 2010). During this period, the country also produced aumber of pieces of research on the drug which, together, makep a body of knowledge unmatched elsewhere in the world. This

as recently acknowledged in a risk assessment on BZP carried out

y the European Monitoring Centre for Drugs and Drug AddictionEMCDDA) (2009, p. 39) which stated, ‘without doubt, BZP haseen most prevalent in New Zealand . . . It is for this reason that

∗ Corresponding author. Tel.: +64 9 373 7599x89497; fax: +64 9 373 7439.E-mail address: b.cohen@auckland.ac.nz (B.M.Z. Cohen).

955-3959/$ – see front matter © 2011 Elsevier B.V. All rights reserved.oi:10.1016/j.drugpo.2010.12.002

© 2011 Elsevier B.V. All rights reserved.

much of the epidemiological and pharmacotoxicological data onBZP originate in that country’. A summation of the research fromNew Zealand as well as from other countries is outlined in this arti-cle. The legal trade in BZP-party pills was halted in New Zealand in2008 following the introduction of new government legislation, re-classifying this group of drugs as Class C1 and, consequently, mak-ing it illegal to manufacture, import, export, supply, sell or consumeBZP-party pills and related substances. By this point the BZP-partypill industry in New Zealand was worth an estimated NZ$50 million(approximately 22 million GBP) per year (Vince, 2006).

Method

Our goals for performing a literature search on BZP-party pillswere twofold. Firstly, there was a need to review and catalogue thestudies previously undertaken on the psychoactive properties ofthe drug (that is, studies that profiled the drug’s effect on humans

rather than articles related to BZP’s pharmacological and technicalqualities alone). Secondly, there was a need to retrieve scientificand grey literature which offered secondary analysis and furthercommentary of the available medical and social scientific literatureon the drug.

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Literature searches were performed using the databases JSTOR,INAHL, Sociological Abstracts, PsycINFO, IBSS (International Bib-

iography of the Social Sciences), Proquest, Project MUSE, Te Puna,nformit Database Collection, CSA Illumina, Expanded Academic,BSCOHost and MEDLINE for the period up to June 2010. In addi-ion, a search for peer reviewed and grey literature was undertakenia Google Scholar and through accessing relevant websites (forxample, government health agencies or drug-related sites). Key-ords utilised in this initial search were ‘bzp’, ‘benzylpiperazine’,

nd ‘party pill(s)’. Due to the low level of sociological literatureccessed, the search terms ‘herbal high(s)’, ‘designer drug(s)’, and

legal high(s)’ were added later. Following each search, titles andbstracts were screened by the reviewer (RB), and a decision wasade as to which studies met the inclusion criteria. Following this,

ull copies of the publications were accessed and reviewed. A totalf 82 scientific articles and grey literature reports were found ofirect relevance to BZP-party pills. Of this total, just nine originaledical or social research studies on the psychoactive effects of

he drug on humans were found. Three of the studies were clinical-ased trails, and all but one of the investigations (Sheridan & Butler,007) were quantitative-based. Six of the nine studies had beeneer-reviewed, whilst only two of the studies were based outsidef New Zealand. These research studies on BZP-party pills are sum-arised in Table 1. It should be noted that a randomised control

rial of BZP-party pills has never been successfully completed withumans. Likewise, there has never been a representative popula-ion study on BZP-party pills.

Whilst the information was selected and reviewed in an objec-ive manner, this is a narrative rather than a systematic review.he very limited literature available – as evidenced by some of theore sociologically orientated databases returning no results at allmeans that the authors were more reliant on grey literature. There

s still room, therefore, in a future review on BZP-party pills to per-orm a more systematic analysis of the published scientific material.t should be noted that much of the published research retrieveds concerned with BZP-party pills rather than BZP per se (that is,eproductions of the drug in pill form, rather than the compoundtself). This is reflected in the findings, with terminology adoptedhat reflects the original data source.

esults

he substance

It has been mistakenly reported in the scientific literaturend popular media that BZP was previously investigated as aotential antihelmic (Campbell, Cline, Evans, Lloyd, & Peck, 1973;ussell, 2006; Vince, 2006). It is likely that the confusion arisesue to the product’s similarity to ‘piperazine’, which is used as aorming agent (European Monitoring Centre for Drugs and Drugddiction, 2008). Another notable erroneous association with BZP

s its ‘herbal’ origins or ‘natural’ composition, despite the substanceeing entirely synthetic (Gee, Richardson, Woltersdorf, & Moore,005; Johnstone et al., 2007). Whilst it has no recognised medici-al use (European Monitoring Centre for Drugs and Drug Addiction,007), its potential as an antidepressant drug was explored in the970s (Advisory Council on the Misuse of Drugs, 2008; Campbellt al., 1973). However, it was rejected for this purpose due to itseported similarity to amphetamine, and for its abuse potentialCampbell et al., 1973; European Monitoring Centre for Drugs and

rug Addiction, 2007).

BZP is predominantly consumed in capsule or tablet formWilkins, Girling, Sweetsur, Huckle, & Huakau, 2006), as products

ore commonly known as ‘party pills’, ‘herbal highs’, ‘P.E.P. pills’,A2’ and ‘social tonics’ (European Monitoring Centre for Drugs and

al of Drug Policy 22 (2011) 95–101

Drug Addiction, 2007, 2009). Levels of BZP per pill can vary, witha typical dose per unit ranging between 50 and 200 mgs (personalcommunication, cited in European Monitoring Centre for Drugs andDrug Addiction, 2009). An analysis of levels of BZP in a range of‘party pill’ products identified differing BZP content of between28 and 133 mgs (with an average level of 65 mgs of BZP per pill)(Kenyon, Button, Ramsey, & Holt, 2007), although there have beenreports of increasing levels of BZP per pill (Dawkins, 2008) as wellas evidence of pills containing up to 1000 mgs of BZP (Gee et al.,2005) this is not believed to be commonplace. Following ingestion,it takes around two hours for the substance to take effect (Bye,Munro-Faure, Peck, & Young, 1973; Gee & Richardson, 2005). Inundertaking this literature review, only two peer reviewed clinicaltrials of the effects of BZP on humans were identified (Bye et al.,1973; Campbell et al., 1973); the results of both studies indicatethat BZP causes the same subjective and physiological effects asdexamphetamine (although much weaker, with BZP at around onetenth of the potency of dexamphetamine). The literature containsvarying reports on the duration of the substance, which has beenestimated to be anywhere between four and eight hours (ExpertAdvisory Committee on Drugs, 2004; Nikolova & Danchev, 2008;Wikstrom et al., 2004), and recent research suggests that BZP couldbe detected in the blood up to 30 h after ingestion (Antia, Lee, Kydd,Tingle, & Russell, 2009).

Whilst BZP forms the focus of this review, it should be notedthat ‘party pills’ are often made up of a blend of BZP and triflu-oromethylphenylpiperazine (TFMPP); when this is the case, theratio of BZP to TFMPP in such pills can range from 2:1 to 10:1(Thompson et al., 2006, p. 5). Both substances have been describedas ‘amphetamine-like compounds’ (Russell, 2006, p. 46), withTFMPP, like BZP, being legal to sell and consume in New Zealanduntil the change in legislation in 2008. The effects of using BZPand TFMPP (alone or in combination) are still under investigation(Antia, Tingle, & Russell, 2009), with Russell (2006, p. 47) noting thatthe effects on humans of taking TFMPP alone have never been sci-entifically investigated. The European Monitoring Centre for Drugsand Drug Addiction (2009, p. 59) have recently commented on thisBZP/TFMPP knowledge gap, stating that ‘it is not clear which factorsare solely due to BZP, which are solely due to TFMPP and which aredue to the mixture’. However, Antia (2009, p. 56; see also Russell,2006; Thompson et al., 2006) has supported the view that BZP has‘amphetamine-like effects . . . while TFMPP is said to reproduce thepsychedelic effects of MDMA and other empathogenic drugs’. Thereis an important implication here for the present review of BZP-party pills in that the effects of the two different compounds maybe confused, both by party pill users who may not know or remem-ber how much (if any) TFMPP was in the pills they took, and by theresearchers who have not, or are unable to, clearly differentiate theeffects of the two compounds in their studies.

Size of market

In 2008, it was reported that there were over 120 party pillbrands in New Zealand (Gee et al., 2008). The Social TonicsAssociation of New Zealand (2005) – an industry body represent-ing major manufacturers, retailers, distributors and marketers of‘social tonics’ including BZP products – claimed that eight millionservings (meaning ‘the number of pills or tablets used at one time’;for example, if the recommended dose is two pills, this is equivalentto one serving, Social Tonics Association of New Zealand, 2005, p. 6)of BZP-party pills and related products were sold between 2000 and

2005. The size or value of other international BZP-party pill mar-kets is currently unknown (Wilkins, Girling, & Sweetsur, 2007). In arisk assessment report on BZP, The European Monitoring Centre forDrugs and Drug Addiction (2009) note that whilst there has beensporadic seizures of BZP-party pills across the European Union in

B.M.Z. Cohen, R. Butler / International Journal of Drug Policy 22 (2011) 95–101 97

Table 1Summary of included studies.

Author (year) (country) Design Sample size and details Study description Main findings

Bye et al. (1973) (England) NRCT n = 24 volunteers (fromstaff of researchlaboratory); twogroups of 12, the firstaged 21–46 years (25%female), the secondaged 21–47 years (42%female).

Comparison of the effects of 1–7.5 mgdexamphetamine, 20–100 mg BZP and a dummydrug on performance tests and cardiovascularresponses. Both groups received all threesubstances under double-blind clinical conditions.The first group was tested on higher doses of bothcompounds.

Both drugs improved auditory vigilance(p < 0.05), and produced significant increasesin heart rate and systolic blood pressure (4 hafter taking at least 2.5 mg dexamphetamineor 50 mg BZP the increase in heart rate wassignificant at p < 0.01).

Campbell et al. (1973) (England) NRCT n = 18 drug users; splitinto multiple drugsusers aged 16–29 years(n = 10, 20% female)and amphetamineusers only aged 34–50years (n = 8, 100%female).

Comparison of the effects of 10 mgdexamphetamine, 100 mg BZP and a lactosedummy on performance tests and cardiovascularresponses. Both groups received all threesubstances under double-blind clinical conditions.

Both dexamphetamine and BZP increaseduser pulse rates (F = 18.17; p < 0.001) andtheir systolic and diastolic blood pressure(F = 3.82; p < 0.05). Unlike dexamphetamine,BZP produced dilation of the pupils(F = 10.85; p < 0.001).

Gee et al. (2005) (New Zealand) EDA n = 61 patients (80presentations)associated with ‘partypill’ use over a5-month period; aged15–36 years (male tofemale ratio of 1:1.3).

Investigation of the toxic effects of BZP-party pillsfor presenting cases at a hospital emergencydepartment in Christchurch. Self report formswere retrospectively analysed to identifyappropriate cases.

An average of 4.5 pills had been ingested bythe subjects. 15 toxic seizures wereidentified, though majority of the samplehad co-ingested other drugs. No differencesfound in the number of tablets consumedbetween patients who had seizures andthose who did not (an average of 4.3 versus4.55 pills in non-seizing patients), thoughthese results were not significant at the 0.5%level (p = 0.75). Seizures occurred in twocases where BZP-party pills alone wereconsumed.

Gee et al. (2008) (New Zealand) EDA n = 156 patients (178presentations) with‘possible BZP toxicity’identified over a27-month period; aged15–42 years (53%female).

Follow-up investigation of the toxic effects ofBZP-party pills for presenting cases at a hospitalemergency department in Christchurch. Self reportforms were retrospectively analysed to identifyappropriate cases.

An average of 3.9 pills had been ingested bythe subjects. Nearly one in five (33)presentations experienced seizures. Arelationship was found between increasedBZP levels and a higher frequency of seizures(CI 1.08–1.72), whilst the co-ingestion ofalcohol was associated with a reduction inthe incidence of seizures (CI 0.23–0.94).

Nicholson (2006) (New Zealand) QQ n = 1043 (all patientsand relativespresenting over a2-month period).

Anonymous survey at a hospital emergencydepartment in Waikato to investigate theprevalence, epidemiology and toxicity of ‘herbalparty pills’.

125 (12%) people had ‘ever taken a herbalparty pill’ (aged 16–43 years, 55% female).There was a tendency for this group not toread the instructions before ingestion (32%;CI 24.5–40.6%), to take more pills thanrecommended (32.8%; CI 25.2–41.5%) and toco-ingest alcohol (43.2%; CI 34.9–52%). Sixpeople had sought medical attention due toparty pill use, one reported experiencing aseizure.

Sheridan and Butler (2007) (NewZealand)a (Butler & Sheridan,2007; Sheridan & Butler, 2010)

QI n = 58 young people(16–24 years, 48%female) using ‘legalparty pills’ in thepreceding 12 months.Interviews wereconducted in Auckland(n = 43), Christchurch(n = 9) and Nelson(n = 6).

Exploration of young people’s use of, andexperiences with legal party pills.

On a single occasion subjects were taking upto six party pills, many were taking morethan the ‘recommended’ dose, and wereoften used in combination with alcohol. Thedrugs were mainly used for their stimulantand social effects. Others took them for theirmind/mood altering effects, to enhance theway they felt, or to experience specificfeelings of intoxication. Less frequentlynoted was the potential of party pills to actas an appetite suppressant and aid to weightloss, as well as an aid to wakefulness forcompleting periods of study.

Theron et al. (2007) (NewZealand)

EDA n = 26 presentations asa result of party pillingestion, for a 3-yearperiod.

Retrospective ‘overdose database’ analysis at anemergency department in Auckland to determinethe impact of party pills on overdose figures.

Party pill-related presentations increasedsignificantly from 1 in 2002 to 21 in 2004(p < 0.001). Overall, they had a minimalimpact on the department, with party pillpresentations in 2004 comprising just 1.5% ofthe total overdose database. Of the 21 casespresenting in 2004, none required medicaladmission.

Thompson et al. (2006) (NewZealand)a

RCT n = 64 volunteers (aged20 years or older) whohad previously usedBZP and/or TFMPP onthree or moreoccasions withoutserious adversereactions.

Double blind clinical trial to investigate the healtheffects of BZP/TFMPP alone and with alcohol.Subjects were randomly allocated to one of fourgroups: placebo group; alcohol group (taking six320 ml drinks – containing 30 ml of vodka on eachoccasion – given over a 3 h period); party pill group(taking 300 mg BZP/74 mg TFMPP over a 2 hperiod); combined party pill and alcohol group(taking both the BZP/TFMPP and vodka doses).

Study was abandoned due to concernsregarding health effects on the 35 subjectsinitially tested. Severe health effects wereexperienced by 4 of the 10 subjects (40%) inthe party pill group and 3 of the 7 (43%) inthe combined party pill and alcohol group. Incontrast, the placebo and alcohol groupsexperienced no serious adverse healtheffects.

98 B.M.Z. Cohen, R. Butler / International Journal of Drug Policy 22 (2011) 95–101

Table 1 (Continued)

Author (year) (country) Design Sample size and details Study description Main findings

Wilkins et al. (2006a) (NewZealand)a (Wilkins et al., 2007;Wilkins & Sweetsur, 2010)

QQ n = 2010 (aged 13–45years).

A random household telephone survey to providenational population statistics on the prevalence,patterns, and harms related to legal party pill use.

One in five of the sample (20.3%; CI18.4–22.3%) had ever used legal party pills,one in seven (293 respondents) had usedthem in the previous 12 months (15.3%; CI13.6–17.1%). This finding indicated thatBZP-party pills were the fourth mostcommonly used recreational substance(behind alcohol, tobacco and cannabis). Onein three (32.8%, CI 26.9–39.4%) drank ‘more’alcohol and nine out of 10 (86.4%, CI81.6–90.1%) used other substances with legalparty pills. ‘Last year’ party pill usersidentified health issues such as ‘poorappetite’ (41%), ‘hot/cold flushes’ (30%),‘heavy sweating’ (23%) and ‘stomachpains/nausea’ (22%) after taking the drug.Around 1% had accessed health services inthe past 12 months due to their party pill use.

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a Non-peer reviewed studies.

he past ten years it is difficult to assess whether this suggests anncrease in the market for the drug or the utilisation of BZP in theroduction of MDMA/Ecstasy pills.

The 2006 household survey on the prevalence of legal party pillsn New Zealand identified that levels of ‘lifetime’ use of ‘party pills’defined as having ‘ever tried’ the products) was highest amongsthose aged 18–29 years, with nearly half of 20–24 year olds hav-ng ever used ‘party pills’. In nearly all age groups, males were

ore likely than females to have used them (Wilkins, Girling, et al.,006; Wilkins et al., 2007). Beyond this, BZP-party pill users areot a homogeneous group (European Monitoring Centre for Drugsnd Drug Addiction, 2009). They include both illicit drug users andhose who choose not to use illegal drugs (European Monitoringentre for Drugs and Drug Addiction, 2009; Sheridan & Butler,007; Wilkins, Girling, et al., 2006), and come from a range ofocio-economic backgrounds (Wilkins et al., 2007). There have beeneports of shift workers and truck drivers using the substancesJohnstone et al., 2007), as well as students utilising them as a studyid (Butler & Sheridan, 2007; Sheridan & Butler, 2007).

atterns of usage

BZP is most commonly swallowed in tablet or capsule formButler & Sheridan, 2007; Wilkins, Girling, et al., 2006); there is alsoome evidence of intravenous use of the substance (Gee et al., 2005,008) as well as the powder from BZP-party pills being snorted orixed in drinks (Advisory Council on the Misuse of Drugs, 2008;

heridan & Butler, 2007; Wilkins, Girling, et al., 2006). Users typ-cally consume around two to three pills on one occasion (Butler

Sheridan, 2007; Wilkins, Girling, et al., 2006), although thereave been reports of people ingesting eight or more pills (Wilkins,irling, et al., 2006); hospital data reveals a higher numbers of pillseing consumed (Gee et al., 2008), however this is to be expectediven that this data includes people who accessed support due toheir BZP-party pill use. Nevertheless, evidence exists that manysers exceed the ‘recommended’ dose (packaging may state forxample ‘normal dose 1–2 tablets. Wait 2 hours between doses’;owever, no recommended dose actually exists as these are notedicinal products) (Butler & Sheridan, 2007; Gee et al., 2005;

ussell, 2006; Wilkins & Sweetsur, 2010). This may be due to initialoses failing to produce the level of ‘high’ sought (Butler & Sheridan,007; Gee et al., 2005; Russell, 2006). The legal status of BZP-partyills in New Zealand prior to 2008 and erroneous ‘herbal’ associa-ions, may also mean that users underestimated the strength of the

d clinical trial; QI, qualitative interviews; QQ, quantitative questionnaires; RCT,recorded; studies in brackets are meta-analyses from the original data.

products and took higher dosages (Sheridan & Butler, 2010). Onaverage, females generally consume fewer pills than males (Geeet al., 2008; Wilkins, Girling, et al., 2006).

The New Zealand household survey in 2006 reported that ‘pub-lic places’ – defined as ‘music concerts, on the street, at the beach orpark, pub, bar or at a dance party’ – were generally the most com-mon settings to use ‘party pills’ (Wilkins, Girling, et al., 2006). Giventhe substance’s stimulant and ‘Ecstasy-like’ effects (when com-bined with TFMPP), it is not surprising that users report using themat dance parties or ‘raves’ (Butler & Sheridan, 2007; Johnstone et al.,2007; Wilkins et al., 2007). Researchers have also highlighted thesimilarities between use of this drug and MDMA/Ecstasy; notably,extended periods of dancing in heated conditions and the use ofother drugs to manage the ‘comedown’ period (Butler & Sheridan,2007; Sheridan & Butler, 2007).

Motivations and rationalisations for usage

It was claimed by the New Zealand ‘party pill’ industry that BZPproducts provided a safe alternative to substances such as metham-phetamine, and thus played a harm minimisation role (Social TonicsAssociation of New Zealand, 2005). However, the New ZealandNational Drug Intelligence Bureau and Customs Service reported in2006 that they had no evidence of a decline or levelling off of use ofmethamphetamine (Expert Advisory Committee on Drugs, 2006b);hospital data did not support this argument either (Theron, Jansen,& Miles, 2007). Whilst subsequent research has indicated thatuse of methamphetamine has plateaued in New Zealand (Wilkins,Sweetsur, & Casswell, 2006), it is not possible to know what roleBZP-based products played in this. It is interesting to note that 44%of ‘lifetime’ ‘party pill’ users interviewed as part of the New Zealandhousehold survey in 2006 indicated that they ‘were using illicitdrugs but now mostly use legal party pills’. Yet Wilkins, Girling, et al.(2006) also found that one in seven reported that they had ‘startedout using legal party pills but now mostly use illegal drugs’. Thissuggests that, at least for some, BZP-party pills may act as a ‘gate-way’ drug. Nevertheless, we should show caution here, for recentresearch on the ‘gateway thesis’ in cross-national comparison sug-gests that risk factors (such as age of onset of drug taking) may be

more significant in predicting the move from ‘soft’ to ‘hard’ drugsfor young people than their use of any particular drug (Degenhardtet al., 2010).

With regards to BZP-party pills, it has been reported that avoid-ance of criminal prosecution has been a motivating factor for users

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f the substances (Expert Advisory Committee on Drugs, 2004;heridan & Butler, 2010; Wikstrom et al., 2004; Wilkins et al., 2007).round one in five users interviewed as part of the 2006 nationalousehold survey stated that the legal status of the substances wasne of things they most liked about ‘party pills’ (Wilkins, Girling, etl., 2006). Users have also reported liking the low cost of, and easyccess to, BZP products (Wilkins, Girling, et al., 2006). Other posi-ive associations with BZP-party pills, as identified by users, includets stimulant properties, and feelings of increased confidence andnhanced socialisation (Butler & Sheridan, 2007; Sheridan & Butler,007; Wilkins, Girling, et al., 2006). ‘Party pills’ containing BZP havelso been shown to improve driving performance several hoursfter dosing (Thompson et al., 2006).

ealth harms

Data from Wilkins, Girling, et al. (2006) suggested health con-erns for nearly half of ‘last year’ party pill users. Around one inve had suffered from ‘headaches’, ‘tremors/shakes’ and ‘poor con-entration’, whilst less than one percent reported ‘fits/seizures’.Psychological problems’ included ‘trouble sleeping’ (50%), ‘loss ofnergy’ (18%), ‘strange thoughts’ (16%) and ‘mood swings’ (15%).ery few respondents (around 1%) had accessed health services in

he last 12 months due to their ‘party pill’ use (Wilkins, Girling,t al., 2006; Wilkins et al., 2007).

This information can be supplemented from three emergencyepartment audits carried out in New Zealand (Gee et al., 2005,008; Theron et al., 2007). Gee et al. (2005) identified 15 toxiceizures from 80 presentations associated with party pill use, withany patients experiencing milder symptoms such as ‘palpita-

ions’, ‘vomiting’, ‘agitation’, ‘anxiety’ and ‘confusion’. An extensiono this research noted that some patients appeared to exhibit sensi-ivity to seemingly small doses of BZP (Gee et al., 2008). In contrast,heron et al. (2007) found that presentations due to party pill usead had a minimal impact on their emergency department’s over-ose database. The difference between the latter results and theore serious outcomes identified in the Christchurch studies (Gee

t al., 2005, 2008) has been attributed to regional differences in therug taking culture (Gee & Fountain, 2007), and the higher dosage

evels of BZP products sold in Christchurch (Theron et al., 2007).ilkins and Sweetsur (2010) analysed North and South Island BZP-

arty pill users (239 and 54 respondents, respectively) and foundifferences in harm (including ‘financial problems’); specifically,hey identified a student lifestyle – with associated higher levelsf other drug use – as a possible reason for this trend (Wilkins &weetsur, 2010).

There have been very few BZP-related deaths worldwideEuropean Monitoring Centre for Drugs and Drug Addiction, 2009).hese include six fatal cases reported in the literature (Balmelli,upferschmidt, Rentsch, & Schneemann, 2001; Elliott & Smith,008; Wikstrom et al., 2004), with two of these deaths being due tooad accidents, and one the result of a fall (Elliott & Smith, 2008). Inll instances, other drugs such as MDMA/Ecstasy and alcohol hadlso been ingested (Advisory Council on the Misuse of Drugs, 2008;uropean Monitoring Centre for Drugs and Drug Addiction, 2009);herefore, the role of BZP in these deaths is unknown.

There is limited data on the potential for dependence withegard to BZP (Advisory Council on the Misuse of Drugs, 2008;uropean Monitoring Centre for Drugs and Drug Addiction, 2009).hilst Wilkins et al. (2007) found little evidence of dependence,

ampbell et al. (1973) concluded that the substance was liable to

buse. Further, the Expert Advisory Committee on Drugs (EACD) –ho provide expert advice to the New Zealand Minister of Health

egarding drug classification issues – noted that there was somevidence that ‘BZP has the ability to create dependence in a verymall proportion of users’ (Expert Advisory Committee on Drugs,

al of Drug Policy 22 (2011) 95–101 99

2007, p. 6). These health concerns appeared to be confirmed whenThompson et al. (2006, p. 29) were forced to abandon their ran-dom control trial on BZP/TFMPP due to the ‘significant potentialrisk’ to participants. However, this study was subsequently criti-cised for the high levels of BZP/TFMPP given to subjects and thefact that the substances were ingested on an ‘empty stomach’. Thedegree of the seriousness of side effects experienced by subjectshas also been queried (Allen And Clarke Policy And RegulatorySpecialists Limited, 2007). The relatively short period that BZP hasbeen used as a recreational substance means that the long termhealth consequences of use are also unknown (Butler & Sheridan,2007; Expert Advisory Committee on Drugs, 2006a; Johnstone et al.,2007; Sheridan & Butler, 2007).

Social harms

An assessment of the health and social risks of BZP undertakenby The European Monitoring Centre for Drugs and Drug Addic-tion (EMCDDA) identified a dearth of information on the negativesocial consequences of BZP-party pill use (European MonitoringCentre for Drugs and Drug Addiction, 2009). They reported noevidence of use of the substance being linked to violence or anti-social behaviour. Aside from some seizures of BZP-party pills ina number of European countries they found no other evidenceof organised crime (European Monitoring Centre for Drugs andDrug Addiction, 2009). A subsequent review has reported simi-lar findings (see Advisory Council on the Misuse of Drugs, 2008).Whilst the EMCDDA assessment highlighted no serious social harmrelated to taking BZP-party pills, they cautioned that ‘the lack of evi-dence makes drawing any strong conclusions difficult’ (EuropeanMonitoring Centre for Drugs and Drug Addiction, 2009, p. 31).

In other research, BZP-party pill users have reported ‘energy andvitality’, ‘health’ and ‘financial position’ as the areas of life mostcommonly harmed by their use of the substance (Wilkins et al.,2007). Findings from the 2006 household survey in New Zealandalso indicated that only 1% of the sample believed that their legalBZP-party pill use had harmed their ‘children’s health or well-being’(Wilkins et al., 2007). Further, there have been reports of BZP-partypill users withdrawing from social interactions or work and studycommitments due to the negative after-effects of the substance(Sheridan & Butler, 2010).

BZP legislation

Internationally, BZP has been controlled or regulated to varyingdegrees. The US was one of the first countries to ban the substance(in 2002), followed by Australia (2006) and Japan (2006). Subse-quently, BZP has been controlled under drug control or equivalentlegislation in Ireland, Denmark, Sweden, Belgium, Estonia, Greece,Italy, Lithuania and Malta, whilst Spain and the Netherlands haveregulated BZP under their medicine-related legislation (EuropeanMonitoring Centre for Drugs and Drug Addiction, 2008). At the timeof writing, BZP is not a controlled substance in Canada. In NewZealand, BZP was uncontrolled until 2005 when it was reclassifiedas the first ‘restricted substance’ under a new regulatory regimeintroduced by the Misuse of Drugs Amendment Act 2005 (MDAA).The MDAA made it illegal to sell or supply the drug to anyoneless than 18 years of age. A ban on print and television advertis-ing, and the distribution of free samples, was also introduced atthis time. This decision was based on recommendations from theExpert Advisory Committee on Drugs (EACD) which concluded that

there was insufficient evidence to control the drug under currentlegislation (Dawkins, 2008). The new Act also included provisionsfor controlling the places from which restricted substances couldbe sold or supplied, as well as the labelling and packaging of theproducts. These latter provisions were never enacted, with Dawkins

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2008) suggesting that the cost involved in doing so was a key rea-on for this not happening. On 1 April 2008, following a reviewf the available evidence (the government commissioned threeesearch studies as part of this review process: Sheridan and Butler,007; Thompson et al., 2006; Wilkins, Girling, et al., 2006), BZP andelated phenylpiperazines (including TFMPP) were re-classifiednder Schedule 3, Part 1 (Class C1) of the Misuse of Drugs Act 1975,hus making it illegal to manufacture, import, export, supply, sellr consume BZP-party pills and related substances. Although the

restricted substance’ category created by the MDAA remains, therere no substances currently classified under this section of the Act.

Some other nations where BZP remains unregulated haveecently reviewed the status of BZP, and appear to be followingew Zealand’s model. The recent risk assessment of BZP under-

aken by the EMCDDA resulted in the EU council requesting EUountries to submit BZP to ‘control measures proportionate to theisks of the substance and criminal penalties in line with theirational laws’ within one year (European Monitoring Centre forrugs and Drug Addiction, 2008, p. 1). Following a review of BZPy the Advisory Council on the Misuse of Drugs (2008), the UK gov-rnment enacted legalisation on 23 December 2009 making BZPnd ‘substituted piperazines’ a Class C drug (the lowest level forcontrolled substance in the UK; fines and/or prison sentences

an be incurred for possession of or dealing in a Class C controlledubstance), placing them in the same Class as GHB, Ketamine andranquilizers.

iscussion

It may well be the case that, without its legal status, BZP-partyills loses its main advantage in the party drugs market as youngeople turn instead to other designer drugs such as MDMA/Ecstasy.ertainly there is evidence from New Zealand that the use ofDMA/Ecstasy has continued to grow over the last 10 years or so,

hough the impact of the criminalisation of BZP-party pills on thisrend is as yet unclear (Wilkins, Griffiths, & Sweetsur, 2010). Theres also a concern from such users that there has been a decline in theurity of MDMA/Ecstasy due to the stock pile of illegal BZP-partyills being either fraudulently sold as low potency MDMA/Ecstasyr used in the manufacture of the drug (for further discussion on these of piperazines in MDMA/Ecstasy pills see Winstock & Ramsey,010). BZP-party pills may well be confined to history and forgot-en, as the next ‘legal high’ appears on the market; ‘BZP-free partyills’ have already begun to emerge to fill this gap in the market

n some countries (Winstock & Ramsey, 2010). The significance ofhis literature review, then, has been not only to outline the evolu-ion of BZP-party pills as an interesting case study of mass designerrug taking, but to also highlight the burgeoning market for legallternatives to illegal designer drugs more generally. Regardless ofhe health risks, as one drug is criminalised another will emerge toeplace it (Vince, 2006).

Due to the recent development of global web-based market-ng and distribution networks, Winstock and Ramsey (2010, p.685) note that there has been a sizeable increase in the range,otency, profile and availability of ‘legal highs’. For policy makers,his is a challenge to traditional supply reduction strategies anduggests a need to re-think the impact and consequences of legal-sation. The current review has surveyed both the rationale and

otivations for mass BZP-party pill consumption as well as theotential health risks involved, highlighting the inconclusive and

ometimes contradictory nature of available research on the sub-tance. For example, the research tells us that BZP-party pills haveoth the potential for abuse and may act as a ‘gateway’ to more

llicit substances, yet it also informs us that the legality and per-eived safety of the product may play a harm reduction role with

al of Drug Policy 22 (2011) 95–101

illegal drug users taking party pills instead. Whilst ‘legal’ does notnecessarily mean ‘safe’, a broader range of responses to ‘legal highs’by policy makers are necessary. Following New Zealand’s exam-ple of the ‘restricted substance’ category in the Misuse of DrugsAmendment Act 2005, the former Chair of the UK’s Expert Advi-sory Committee on Drugs, Nutt (2010), suggests that the creationof a ‘holding category’ of drugs (a ‘Class D model’) would be a usefulstart. Appropriate regulation of each substance by the governmentwould be an intermediate step whilst thorough monitoring, test-ing and research on each substance was undertaken. The resultinginformation would allow the government to take an appropri-ate, informed decision on each new drug. Similarly, Winstock andRamsey (2010, p. 1686) call for the collection of internationaldata on ‘legal highs’ through ‘longitudinal integrated monitoringsystems’ (for example, collecting data from toxicology and treat-ment services) to assess the impact of legislation on drug-relatedharm.

Given the limited nature of the available research on BZP-party pills outlined, more research on the drug and its separatecompounds are necessary, both in terms of understanding the epi-demiology of the drug through representative population surveys,as well as conducting cohort studies which focus on the long-termhealth and social effects of BZP-party pill ingestion. These currentomissions will partly be rectified by an on-going cohort study beingcarried by one of the authors (BC) on BZP-party pill users in NewZealand.

Conclusion

In undertaking this literature review, it is apparent that muchof the published research on BZP-party pills has been undertakenin New Zealand (European Monitoring Centre for Drugs and DrugAddiction, 2009). This is not surprising given the size of the legalmarket which developed in this county prior to the substance beingbanned (Wilkins & Sweetsur, 2010). However, evidence of increas-ing international interest in the substance is noticeable in the bodyof literature emerging from other nations (Advisory Council on theMisuse of Drugs, 2008; European Monitoring Centre for Drugs andDrug Addiction, 2009; King & Van-Der Meer, 2001; Nikolova &Danchev, 2008; Wikstrom et al., 2004). Despite this, much of thedata is focussed on the health harms of the drug; there have beenfew sociological studies undertaken. The relative infancy of the drugmeans that longer term harms are not yet able to be observed.Whilst initially unregulated in many countries, there has been atrend towards prohibition of the substance. The impact of this isnot yet clear, although it has been hypothesised that it will lead tothe criminalisation of users and a potential increase in use of othersubstances (Sheridan & Butler, 2010). Regardless of the outcomeof controls on BZP-party pills, given the increasing trend towardsconsuming ‘legal highs’ and new ‘designer drugs’, it is possible thatother substances may replace it in the future. The socio-politicalfactors surrounding the criminalisation of BZP-party pills in NewZealand and the meanings of drug taking for users themselves willbe explored further in our ongoing research and future publications.

Funding

Funding for a Research Assistant (RB) to complete the initial lit-erature review for this article was provided by the University of

Auckland’s Faculty of Arts ‘Faculty Research Development Fund’,General Programme No. 3622727. The Faculty of Arts had no fur-ther role in the study design, collection, analysis, interpretation,or reporting of this research; they were also not involved in thedecision to submit this paper for publication.

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