Synthetics -slide show AA MSPP

Welcome to a discussion of
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
CASA Council on Alcohol and Substance Abuse of
Livingston County
We gratefully acknowledge the following institutions and
NFLIS, National Forensic Laboratory Information System
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
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
 MDPV, mephedrone, buphedrone,
pentedrone, methylone, 4MEC, 4MePPP, αPVP, etc
 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
 Administered lorazepam
 Patient returns to baseline 24 hours later
Patient Case
 26 yo male presents to ED after injecting bath
 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%)
Renal failure?
Clinical Manifestations
 45% of patients
experience symptoms
beyond 24 hours post
 30% have symptoms >
48 hours post exposure
 Are there adulterants
present or
 Protect yourself!
 Difficult to manage patients and unpredictable
 ABCs
 No antidote
 GI decon?
 BZDs, BZDs, and more BZDs for agitation
 DPH likely won’t be effective
 Haloperidol could be problematic
 All BZDs work the same
 Increase frequency of chloride channel opening
leading to hyperpolarization
 Only works in conjunction with GABA
Quick (min)
Quick (min)
5 – 20 min
5 – 10 min
20 – 30 min
Single dose
Repeated Doses
 What if BZDs do not work?
 No real ceiling to BZD doses
Respiratory depression
 Haloperidol
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?
 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
 Presents to ED tachycardic, dilated pupils and
with myoclonic jerking
 Given BZDs and symptoms resolved over 8
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
 Psychiatric effects predominate
 Anxiety, paranoia, agitation, delusions, and
 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
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.
 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
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 ,
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.
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.
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
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.
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
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.
Bath Salts
are also called…
 Zoom
 Tranquility
 Ivory wave
lady bubbles
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
Roch/Buff/Syracuse markets:
 Molly an analogue of MDMA
 Believed on the street to be “pure MDMA”
 Manufactured in Europe and Asia for US
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
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?
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
Calls To Poison Control Centers for Human
Exposure to Bath Salts, 2010 to January 2012
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
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
Synthetic (420) marijuana
also known locally as:
 K2
 Spice
 Genie
red dawn
 blue
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
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
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)
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.
Series 1
Series 2
Series 3
Category Category Category Category
 Embedded video, 15 minutes
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)
(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
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
**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).
Drugs of abuse and SEXY street names
(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)
(Street Names: MDMA, Ecstasy, XTC, E, X, Beans, Adams)
(Street Names: 2C-B, Nexus, 2’s, Toonies, Bromo, Spectrum, Venus)
(Street Names: 2C-I, i)
4-Methylmethcathinone (Mephedrone)
(Street Names: 4-MMC, meow meow, m-CAT, bounce, bubbles, mad cow)
(Street Names: Foxy, or Foxy methoxy)
(Street Name: Spirals)
Anabolic Steroids
(Street Names: Arnolds, Gym Candy, Pumpers, Roids, Stackers, Weight Trainers, Gear, and Juice)
(Street Names: Benzos, Downers, Nerve Pills, Tranks)
(Street Names: BZP, A2, Legal E or Legal X)
(Trade Names: Buprenex®, Suboxone®, Subutex®)
(Trade name: Soma®)
(Street Names: Clen)
(Street Names: Coke, Snow, Crack, Rock)
(Trade Name: Flexeril®, Amrix®)
(Street Names: DXM, CCC, Triple C, Skittles, Robo, Poor Man's PCP)
d-Lysergic Acid Diethylamide
(Street Names: LSD, Acid, Blotter Acid, Window Pane)
(Trade names: Actiq®, Fentora™, Duragesic®)
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®)
(Trade Names: Vicodin®, Lortab®, Lorcet-HD®, Hycodan®, Vicoprofen®)
(Trade name: Dilaudid®; Street Names: Dust, Juice, Smack, D, Footballs)
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.)
(Street Names: Special K, "K", Kit Kat, Cat Valium)
(Other Names: Ava, Intoxicating Pepper, Kawa Kawa, Kew, Sakau, Tonga, Yangona)
(Street Names: Khat, Qat, Kat, Chat, Miraa, Quaadka)
Kratom (Mitragyna specious korth)
(Street Names: Thang, Kakuam, Thom, Ketum, Biak)
(Trade Name: Desoxyn®; Street Names: Meth, Speed, Crystal, Glass, Ice, Crank, Yaba)
(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")
(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®)
(Trade Names: Tylox®, Percodan®, OxyContin®)
(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)
(Street Names: PCP, Angel Dust, Supergrass, Boat, Tic Tac, Zoom, Shermans)
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)
(Trade Name: Ultram
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.

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