Welcome to a discussion of SYNTHETIC DRUGS, synthetic drug culture and some of the unique problems Teens bring with them… Your local resources: Dr. Thomas Walters, MD, Medical Director Don Hassett, MA, CASAC, CPP, Director of Prevention CASA Council on Alcohol and Substance Abuse of Livingston County Sources: We gratefully acknowledge the following institutions and sources: NFLIS, National Forensic Laboratory Information System DEA Upstate New York Poison Center NCADD, Rochester DAWN Drug Abuse Warning Network With specific public material originally developed by: Alexander Garrard, PharmD Clinical Toxicologist Upstate New York Poison Center Issue: Language -With the hundreds of new drugs (or are they “chemicals”) of abuse in use in various regions of this and other countries we will mostly be looking at these 2 categories of mind altering substances, as teens understand them: BATH SALTS/ HERBAL INCENSE and Spice/ K-2, K-3 The remarketing via street names is already changing and expanding even this basic classification. Note: At the end of this presentation you will find a comprehensive list of chemical names along with their sexy street names , understand that the formulations will continually change. We will cover: •Synthetics –specifically, spice & bath salts •Their origins •Chemical make up & derivations •Prevention and management Issues relevant to: language & terminology drug purity cultural appeal for teens a couple of Case presentation, management •Regional to NY, varieties & names •How synthetics fit teen culture •How they fit into the addiction paradigm Do we know enough to judge how addictive these chemicals are? Does addictiveness depend on social & genetic factors? •Some of the grass roots marketing strategy •Handouts: # 1 drug street names; #2 packaging & pictures; #3 simplified text on Spice, suitable for parent/student information. As if terminology isn’t enough of an obfuscation, consider: Very few street drugs are 100% pure Many are adulterated or contaminated Most discussion will be over pure presentation Shrub to Bath Salts? Catha Edulis Khat plant geography What is khat? Cathinone active alkaloid in khat leaves Chewing popular in middle east Produces amphetamine-like sympathomimetic symptoms What are bath salts? Synthetic cathinone derivatives Synthesized as early as 1928 and studied for medical use Methcathinone Mephedrone Bupropion only cathinone with medical indication MDPV, mephedrone, buphedrone, pentedrone, methylone, 4MEC, 4MePPP, αPVP, etc Structures! Pharmacology Similar to amphetamines Affect dopamine, serotonin, and norepinephrine Neuronal stimulation due to increased postsynaptic catecholamines Increased release of catecholamines Blockade of pre-synaptic uptake and storage Reduced MAO activity Indirect glutamate pathway stimulation End result: increased chemicals in the synapse causing increased effects How supplied? Powder, capsules, and tablets Insufflation, ingestion, IV use, and rectal use Mephedrone: 100 – 200 mg MDPV: 10 – 15 mg Effects within 30 mins; lasts up to 7+ hours Patient Case 30 yo male admits to using 1 – 2 grams of bath salts daily x 2 months VS: 187/93 P129 R12-16 T 98 Presents to ED “shaky and anxious” and hallucinating Administered lorazepam Patient returns to baseline 24 hours later Patient Case 26 yo male presents to ED after injecting bath salts Found agitated, altered, violent and combative and foaming at the mouth by EMS VS: 148/66 P175 T 106.3 (rectally) Patient intubated with RSI and aggressive cooling measures instituted CK peaked at 235,377 U/L (normal < 170 U/L) Patient Case 40 yo male injected unknown amount of “bath salts” Became aggressive, uncontrollable, delusional, removed all his clothing, and violent behavior Tazed by police and had be physically restrained by EMS VS: P 164 131/72 R24 rectal temp 105.4 Declared brain dead 42 hours after presentation after complicated ICU stay Clinical Manifestations Agitation (53.3%) Tachycardia (40%) Hypertension (20%) Seizures (20%) Palpitations (13.3%) Hallucinations/delusions Paranoia Renal failure? Cannibalism? Death Clinical Manifestations 45% of patients experience symptoms beyond 24 hours post exposure 30% have symptoms > 48 hours post exposure Are there adulterants present or contaminants? Management Protect yourself! Difficult to manage patients and unpredictable behavior ABCs No antidote GI decon? BZDs, BZDs, and more BZDs for agitation DPH likely won’t be effective Haloperidol could be problematic Management All BZDs work the same Increase frequency of chloride channel opening leading to hyperpolarization Only works in conjunction with GABA Diazepam Midazolam Lorazepam IV Quick (min) Quick (min) 5 – 20 min IM Unpredictable 5 – 10 min 20 – 30 min Single dose Short Short Long Repeated Doses Long Intermediate Long Onset Duration Management What if BZDs do not work? No real ceiling to BZD doses Respiratory depression Haloperidol Anticholinergic QTc prolongation Risk vs benefits Bring product into ED Synthetic Cannabinoids Where did it come from? 1960s: research into THC-like compounds Analgesic and anti-inflammatory minus psychotropic effects Recognized as drugs of abuse in early 2000’s in Europe Dr. JW Huffman researched THC analogues for use in cancer and AIDS patients Developer of JWH compounds HU-210 from Hebrew University What are they? Synthetic cannabinoids which work on the CB1 and CB2 receptor like THC Marketed as herbal incense, herbal smoking blends, potpourri, etc. Spice, K2, Mr. Nice Guy, Legal Funk, Tai Fun, Zen Ultra, Smoke, Chaos Mint, etc. Misleading packaging Not for human consumption Commonly smoked What’s in them? Pharmacology Effects likely from mixture of herbs and actual synthetic compounds Baybean, Beach bean, Dwarf skullcap, red clover, vanilla, honey, wild dagga and more Affects CB1 and CB2 receptors found in CNS/PNS Responsible for elevating mood, anxiety, cognition Responsible for reducing inflammation induced pain HU-210 100-800x more potent than THC Patient Case 21 yo male smoked some K2 earlier in evening Presents to ED tachycardic, dilated pupils and with myoclonic jerking Given BZDs and symptoms resolved over 8 hours Patient Case 48 yo man had generalized seizure within 30 minutes of ingesting a synthetic marijuanalike product Initial vital signs were: pulse, 106/min; BP, 140/88 mmHg; respirations, 22/min GCMS confirmed substance to be JWH-018 Patient Case 35 yo male admits to smoking legal weed 90 minutes ago C/o chest pain and dizziness Supportive care instituted Patient leaves AMA Clinical Manifestation Most information from case reports and case series Psychiatric effects predominate Anxiety, paranoia, agitation, delusions, and psychosis Physical manifestations Tachycardia, HTN, diaphoresis, seizures, and ???? The good ol’ standard addictive drugs are still here. We don’t yet fully understand how the new drugs fit the user’s needs. It is clear that they fit the network of illegal drug trade and electronic marketing of chemicals both illegal & legal. NFLIS analyzes drug samples. Here is what they are finding by region… NFLIS drug samples analyzed 1,660,216 drug reports were submitted to State and local forensic laboratories in the United States from January 1 through December 31, 2011 Nationally, in 2011 Cannabis/THC was the most frequently identified drug (536,630 reports), followed by: Cocaine (333,645 reports), Methamphetamine (160,960 reports), and Heroin (119,765 reports). More recently from 2010 to 2011, reports of clonazepam, buprenorphine, and amphetamine increased significantly at the national level. Regionally, reports of oxycodone, hydrocodone, alprazolam, and clonazepam increased significantly in all four U.S. census regions from the period of 2001 through 2011. Reports of buprenorphine increased significantly in the Midwest, and amphetamine reports increased significantly in the Midwest, Northeast, and South. 34 NFLIS data contd. Some current, partial, context for what we should be seeing in clinics. From 2010 to 2011, reports increased significantly In the Northeast oxycodone , buprenorphine Amphetamin BUT Cannabis/THC and cocaine reports decreased significantly In 2011, more than 70% of narcotic analgesic reports were oxycodone or hydrocodone. (while) Alprazolam accounted for 52% of identified tranquilizers and depressants. Among identified/Hallucinogens, MDMA accounted for 23% of reports. 35 2001 – 2011 (long term Trends) Reports of cocaine decreased significantly from the period of 2001 through 2011 in all four U.S. census regions. While cannabis/THC reports increased significantly in the Northeast. 36 Foxy Methoxy: Tryptamines Will Not Fade Away 5-methoxy-N,Ndiisopropyltryptamine (5-MeO-DIPT) was ranked among the 25 most frequently identified drug samples Foxy Methoxy: Tryptamines Will Not Fade Away In 2011, for the first time ever, 5-methoxy-N,Ndiisopropyltryptamine (5-MeO-DIPT) was ranked among the 25 most frequently identified drugs in NFLIS. With over 3,000 estimated drug reports, it was the only Tryptamine to make the list. In addition to the NFLIS State and local data, 5-MeO-DIPT was one of the top 10 drugs reported by the DEA. Abused for its hallucinogenic-like effects, 5-MeO DIPT is often administrated orally as tablets, capsules, or powder forms at doses ranging from 6 to 20 milligrams. Other routes of administration include smoking and snorting. It produces subjective effects with an onset of about 20 to 30 minutes, a peak at about 1 to 1.5 hours, and a duration of about 3 to 6 hours. Subjects who have been administered 5-MeO-DIPT are talkative and disinhibited with dilated pupils. High doses of 5-MeO-DIPT produce nausea, jaw clenching, muscle tension, and overt hallucinations with both auditory and visual distortions. The abuse of hallucinogenic substances in all-night dance parties (raves) and other venues was a major problem in the United States in the late 1990s and early 2000s. As DEA controlled various Phenethylamines and tryptamines, more designer drugs would appear. Sold as “Foxy” or “Foxy Methoxy,” the abuse of 5-MeO-DIPT began to spread in 1999. For the next four years, it was encountered by law enforcement agencies in several States. In 2003, DEA temporarily added 5-MeO-DIPT to Schedule I of the CSA to avoid imminent hazard to public safety. In 2004, this action was made permanent. Between 2010 and 2011, the number of 5MeO-DIPT reports increased nearly 36-fold. From 2009 to 2011, the change was 56-fold. It has been found in combination with N-benzylpiperazine (BZP); 1-(3-trifluoromethylphenyl)-piperazine (TFMPP); 3,4methylenedioxymethamphetamine (MDMA); and various synthetic cathinones. More intelligence gathering will be needed to discover why 5-MeO-DIPT has made such a resurgence. 37 About: Bath salts, research chemicals, plant food May have originated in China and India In foreign use for about two years Powder Snorted, smoked or injected Made of MDPV – Methylenedioxyprovalerone Methylone Mephedrone 38 Not your Mum’s Bath Salts? So – what are Bath Salts anyway? They are a man-made, chemical (as opposed to organic) stimulant drug. Generally, stimulants are a class of drugs that elevate mood, increase feelings of well-being and increase energy and alertness. Amphetamines, or speed, are an example of stimulant drugs. The technical term for Bath Salts is “substituted cathinone.” Khat is a plant that is cultivated and used in East Africa and the Middle East. It has a stimulant effect on the user and can be quite dangerous. Substituted cathinones are synthetic, concentrated versions of the stimulant chemical in Khat. Methylenedioxypyrovalerone (MDPV), mephedrone and methylone are the chemicals most often found in “Bath Salts.” They can be ingested orally or snorted through the nose. 39 Bath Salts are also called… Zoom Tranquility Ivory wave lady bubbles dove vanilla sky Bliss White Girl is good for cooking like crack Tranquility, better when smoked in powder form NRG not good cooked, better placed in mouth, tastes like vanilla 40 Roch/Buff/Syracuse markets: Molly an analogue of MDMA Believed on the street to be “pure MDMA” Manufactured in Europe and Asia for US 41 Begin by looking at why kids might choose Salts… • For energy / alternative to illegal stimulants • Perceived to be legal • Not picked up on standard drug tests • Available at retail outlets: convenience stores; head shops; online …they are trying to stay as legal as possible! Prevention messages, parental messages have been aimed at avoiding illegal behavior, and this is now a driver for synthetics. 42 It’s “New & Improved”… Drugs such as synthetics, not known to be used by addicts can be used “off label” with out incurring the social stigma usually associated with street drugs such as cocaine or even alcohol. So no stigma and doesn’t attract any attention from parents. Actually Tide has been a ingredient in drug manufacturing for several years. Product labeling “legal, not for human consumption” means you can’t be busted for holding. Dilemma: when, in an “underground culture” mind altering drugs are relabeled as insecticide (to allow for legal importation and retail sales), young adults realistically could assume any insecticide might get them high? 44 Again, the Effects of “Bath Salts” would look like: • Very severe paranoia that sometimes causes users to harm themselves or others. • Speed of onset – 15 minutes; Length of high – 4-6 hours • Long term effects: Unknown • Effects reported to Poison Control Centers – Suicidal thoughts – Agitation; Combative/Violent; • Confusion – Hallucinations / psychosis – Increased heart rate; Hypertension; Chest Pain – Death or serious injury users can’t know except via trial or reputation, contents or dosage 45 Calls To Poison Control Centers for Human Exposure to Bath Salts, 2010 to January 2012 100% 90% 80% 70% 60% 20ooo 50% 20000.002 40% 20000.00 30% 20% 10% 0% 2010 2011 2012 46 Poison control centers show dramatic increase in ingestion over very short period for bath salts –but beginning to flatten out. In 2010, poison centers received 304 calls about exposures to Bath Salts. That number rose dramatically in 2011 when poison centers received 6,138 calls. In early 2011, calls closed in each month* spiked through June, then gradually declined and was level in November and December 2011 and January 2012. 47 Synthetic Marijuana = Spice, K-2,and analogues K2 or "Spice" is a mixture of herbs or dried, shredded plant material that is typically sprayed with chemicals that are similar to THC, the psychoactive ingredients in marijuana. JWJ-018 (or J dub) Name refers to a key ingredient research chemical 48 Synthetic (420) marijuana also known locally as: K2 Spice Genie blaze red dawn 420 blue 49 More signs of use • Loss of physical control • Lack of pain response • Increased agitation • Pale skin • Seizures • Vomiting • Profuse sweating • Uncontrolled / spastic body movements • Elevated blood pressure, heart rate, and palpitations 50 Physical effects • Onset – 3-5 minutes • Length of duration – 1-8 hours • Short-term effects: In addition to physical signs of use, users may experience: – Dysphoria – the opposite of euphoria – Paranoia – similar to PCP / Angel Dust – Delusions, hallucinations and increased agitation • Long-term effects: Unknown May report morbid and depressive mental state 51 High School seniors, an important demographic coming your way... one in 10 high school seniors used synthetic marijuana in the prior year (MTF) Area students are being suspended for use but Schools have been late in the detection game Its not usually illegal No testing to confirm Paraphernalia is disguised from parental observation At 11.4 percent, the annual prevalence of synthetic marijuana is: 41 percent greater than Vicodin (8.1 percent) Four times greater than inhalants (3.2 percent) Four times greater than cocaine (2.9 percent) Eight times greater than meth (1.4 percent) 52 Bath Salts Synthetic Marijuana Calls to poison control centers for exposure to synthetic marijuana doubled between 2010 and 2011 and is on track to rise again in 2012. 5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Series 1 Series 2 Series 3 Category Category Category Category 1 2 3 4 53 NCAD-rs.org Embedded video, 15 minutes 54 NFLIS report Feb 22, 2013 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits In Brief In 2011, there were 5.1 million drug-related emergency department (ED) visits; about one half (49 percent) were attributed to drug misuse or abuse with a nearly equal percentage (45 percent) attributed to adverse drug reactions ED visits involving use of illicit drugs were relatively stable from 2004 (991,640 visits) to 2009 (974,392 visits) but increased from 2009 to 2011 (1,252,500 visits); between 2009 and 2011, the rate of visits involving illicit stimulants increased 68 percent, and the rate of visits involving marijuana rose 19 percent ED visits involving misuse or abuse of pharmaceuticals increased from 2004 (626,470 visits) through 2011 (1,428,145 visits); the most commonly involved drugs were anti-anxiety and insomnia medications and narcotic pain relievers (160.9 and 134.8 visits per 100,000 population, respectively) ED visits involving adverse reactions to drugs increased from 1,250,377 visits in 2005 to 2,287,271 visits in 2009; however, no increase occurred between 2009 and 2011 (2,301,059 visits) 55 (DAWN Rept_ )Figure 2 Table. Rates of Emergency Department (ED) Visits Involving Illicit Drugs among Patients Aged 12 to 24 per 100,000 Population, by Age Group: 2011 Illicit Drugs Persons Aged 12 to 17 Persons Aged 18 to 20 Persons Aged 21 to 24 Marijuana* 240.2 443.8 446.9 Heroin** 8.5 134.6 266.1 Cocaine** 23.5 112.5 214.4 Illicit Stimulants** 23.5 89.8 141.5 Synthetic Cannabinoids** 30.2 60.8 16.3 * The differences between those aged 12 to 17 and the two older age groups were statistically significant at the .05 level. **All differences between age groups were statistically significant at the .05 level. Source: 2011 SAMHSA Drug Abuse Warning Network (DAWN). Visits Involving Synthetic Cannabinoids Synthetic cannabinoids first appeared in DAWN records in 2009, but there were too few visits to be reported. By 2010, ED visits involving synthetic cannabinoids rose to a reportable level for the Nation (3.7 visits per 100,000 population).6 By 2011, there were 9.2 visits per 100,000 population involving synthetic cannabinoids across all age groups—about a 150 percent increase (data not shown). The rate of visits involving synthetic cannabinoids was highest among patients aged 18 to 20 (60.8 visits per 100,000 population), followed by patients aged 12 to 17 (30.2 visits per 100,000 population) (Figure 2). 56 Drugs of abuse and SEXY street names 1-[3-(Trifluoro-methyl)-phenyl]piperazine)] (Street Names: “TFMPP” or “Molly”. Often found in combination with BZP: “A2”, “Legal E” or “Legal X”) 2,5-Dimethoxy-4-(n)-propylthiophenethylamine (2C-T-7) (Street Names: Blue Mystic, T7, Beautiful, Tripstay, Tweety-Bird Mescaline) 3,4-Methylenedioxymethamphetamine (Street Names: MDMA, Ecstasy, XTC, E, X, Beans, Adams) 4-Bromo-2,5dimethoxyphenethylamine (Street Names: 2C-B, Nexus, 2’s, Toonies, Bromo, Spectrum, Venus) 4-Iodo-2,5-Dimethoxyphenethylamine (Street Names: 2C-I, i) 4-Methylmethcathinone (Mephedrone) (Street Names: 4-MMC, meow meow, m-CAT, bounce, bubbles, mad cow) 5-Methoxy-N,N-Diisopropyltryptamine (Street Names: Foxy, or Foxy methoxy) Alpha-Methyltryptamine (Street Name: Spirals) Anabolic Steroids (Street Names: Arnolds, Gym Candy, Pumpers, Roids, Stackers, Weight Trainers, Gear, and Juice) Benzodiazepines (Street Names: Benzos, Downers, Nerve Pills, Tranks) N-Benzylpiperazine (Street Names: BZP, A2, Legal E or Legal X) Buprenorphine (Trade Names: Buprenex®, Suboxone®, Subutex®) 57 Carisoprodol (Trade name: Soma®) Clenbuterol (Street Names: Clen) Cocaine (Street Names: Coke, Snow, Crack, Rock) Cyclobenzaprine (Trade Name: Flexeril®, Amrix®) Dextromethorphan (Street Names: DXM, CCC, Triple C, Skittles, Robo, Poor Man's PCP) N,N-Dimethyltryptamine (DMT) d-Lysergic Acid Diethylamide (Street Names: LSD, Acid, Blotter Acid, Window Pane) Fentanyl (Trade names: Actiq®, Fentora™, Duragesic®) Fospropofol (Lusedra®) Gamma Hydroxybutyric Acid (Street Name: GHB, Liquid Ecstasy, Liquid X, Goop, Georgia Home Boy, Easy Lay) Human Growth Hormone (Trade Names: Genotropin®, Humatrope®, Norditropin®, Nutropin®, Saizen®, Serostim®) Hydrocodone (Trade Names: Vicodin®, Lortab®, Lorcet-HD®, Hycodan®, Vicoprofen®) Hydromorphone (Trade name: Dilaudid®; Street Names: Dust, Juice, Smack, D, Footballs) ®) 58 Jimson Weed (Datura stramonium) (Street Names: Thornapple, stinkweed, locoweed, augushka, ditch weed, devil's snare, devil's seed, devil's trumpet, Korean morning glory, Jamestown weed, angel's trumpet, beelzebub's twinkie, madhatter, and crazy tea.) Ketamine (Street Names: Special K, "K", Kit Kat, Cat Valium) Kava (Other Names: Ava, Intoxicating Pepper, Kawa Kawa, Kew, Sakau, Tonga, Yangona) Khat (Street Names: Khat, Qat, Kat, Chat, Miraa, Quaadka) Kratom (Mitragyna specious korth) (Street Names: Thang, Kakuam, Thom, Ketum, Biak) Levamisole (Ergamisol®) Methamphetamine (Trade Name: Desoxyn®; Street Names: Meth, Speed, Crystal, Glass, Ice, Crank, Yaba) Methadone (Trade Names: Methadose®, Dolophine®; Street Names: Fizzies, Amidone, Chocolate Chip Cookies) 3,4-Methylenedioxypyrovalerone (MDPV) (Street Names: "bath salts," "Ivory Wave," "plant fertilizer," "Vanilla Sky," "Energy-1") Methylphenidate (Trade Names: Ritalin- (IR, LA, and SR), Concerta, Metadate- (CD and ER), Methylin- (IR and ER) and Focalin- (IR and ER)) Nalbuphine Hydrochloride (Trade Name: Nubain®) 59 Oxycodone (Trade Names: Tylox®, Percodan®, OxyContin®) Oxymorphone (Trade Names: Opana®, Opana ER®; Street Names: Blue Heaven, Blues, Mrs. O, New Blues, Octagons, Oranges, Orgasna IR, OM, Pink, Pink Heaven, Pink Lady, Pink O, Stop Signs, and The O Bomb) Phencyclidine (Street Names: PCP, Angel Dust, Supergrass, Boat, Tic Tac, Zoom, Shermans) Propofol (Diprivan®) Salvia Divinorum and Salvinorin A (Street Names: Maria Pastora, Sage of the Seers, Diviner’s Sage, Salvia, Sally-D, Magic Mint) Spice/K2 Cannabinoids CP 47,497 and homologues 2-[(1R,3S)-3-hydroxycyclohexyl]-5-(2-methyloctan-2-yl)phenol HU-210, [(6aR,10aR)-9-(hydroxymethyl)-6,6-dimethyl-3-(2-methyloctan-2-yl)-6a,7,10, 10a-tetrahydrobenzo[c] chromen-1-ol)] JWH-018, 1-Pentyl-3-(1-naphthoyl)indole JWH-073 1-Butyl-3-(1-naphthoyl)indole UR-144 and XLR11 (TCMP-018; KM-X1) and XLR11 (5-F-UR-144) Tramadol (Trade Name: Ultram 60 Much information is simply not known, but for trial and error. The prospect that these chemicals will ever be studied by researchers rather than experienced by teens is not likely. The cultural appeal of shared highs via blogging & tweeting, a invisible web based order system, and a virtual supply of mixtures has produced a lot of momentum.