EAPA - Virginia Summer Institute for Addiction Studies

Report
Designer Drugs
An Awareness Presentation
Kristine Nutt, LCSW, LCAS, CSI
Disclaimer
 This presentation is meant to provide basic awareness
information on herbal incense products and bath salts.
 There are hundreds of products being smoked for
cannabis-like effects
 Manufacturers constantly change product ingredients
and market products under new names to circumvent
the law.
 Constantly moving target
 Product names and lists, as well as the list of synthetic
cannabinoids, in this presentation are not all inclusive.
“SMILES” 
“SMILES”
• 2C-1 Hallucinogen synthetic drug
• Part of the 2C family of drugs
• Powder or Pill form
• Often mixed with chocolate and candy
• Schedule 1 class of drug
• According to LAPD, there has been an increase of overdose deaths
from this drug recently. Popular with teens and college students.
• Formulas were published in book “PiHKAL: A
chemical Love Story” (Transform Press, 1991)
“Smiles” 
• Dessa Bergen-Cisco, a Professor of Public
Health at Syracuse University stated,
“Basically, it’s a pure and potent form of
ecstasy or MDMA”.
• Effects are compared to a potent combination
of MDMA and LSD with terrifying
hallucinations and overwhelming anxiety.
• Overdoses have been reported in California,
Ohio, and other states.
“Smiles”
“SMILES” 
• Recently in the news due to Johnny Lewis, 28,
who was known for his role in the television
show, “Sons of Anarchy” killed 81 year old
landlady and her cat before jumping to his death.
No evidence of drugs were found in his system.
• One 17 year old in North Dakota overdosed and
was observed shaking, growling, and foaming at
the mouth. Another teen died the night before
from this drug.
• Does not show up on toxicology screens.
Effects
•
•
•
•
•
•
•
Anxiety leading to panic attacks.
Nausea and Vomiting.
Terrifying auditory and visual hallucinations.
Increased heart rate. Can cause strokes
Can cause seizures and kidney failure
Elevated body temperature.
Giddiness, Empathy, and Relaxed State.
Bath Salts Video Clip
BATH SALTS
• Derivatives of cathinone
found naturally in the
herbal stimulant khat.
• Part of phenethylamine
family that includes,
amphetamines,
methamphetamine, and
ecstasy.
BATH SALTS
• First developed in research labs and became a popular
party drug in Europe and UK
• Spread overseas around 2008, and began to show up
mostly in states like Louisiana, Kentucky, and
Tennessee. Some had regional names like “Hurricane
Charlie” and “Bayou”.
• Other product names include Bliss, Blizzard, Blue
Silk, Ivory Snow, Vanilla Sky and Ivory Wave.
• Became highly publicized with the cannibalistic
attack in Miami and other reports of violence.
BATH SALTS
BATH SALTS
BATH SALTS
Marketing
 Sold commercially as bath salts, plant fertilizer, toy cleaner,
pond cleaner, cell phone cleaner, jewelry cleaner, insect
repellant, glass cleaner, toilet cleaner, and ladybug attractant.
 Sold as tablets, capsules, and white or beige crystals/powder.
Capsules may be sold in combination with caffeine or
amphetamine. Has been sold as ecstasy.
 Sold mainly on the internet buy also in “head shops”,
convenience stores, and gas stations. Some people have
bought on e-bay. Low cost and readily available.
 It is not the stuff you find at Bath and Body Works!!!
BATH SALTS
Marketed as legal
alternative to LSD,
cocaine, ecstasy, and
methamphetamine.
Labeled not for
human consumption
but the sole purpose
is human
consumption.
Video of Bath Salts Sale
Chemical Makeup
• There are several synthetic cathinones. The most
common found in “Bath Salts” are MDPV
(methylenendioxypyrovalerone), mephedrone(4MMC), or methylone. Found in 98% of tested
products.
• Advertised as above 95% purity but samples tested in
Italy were only 40 – 50% pure. Some purchased
online had benzocaine, lidocaine, and caffeine.
Users truly don’t know what they are getting or how
much.
Bath Salts
 Costs anywhere from $40 - $100 per gram.
 Taken orally, IV, nasal inhalation,
intramuscular, or rectally. Snorting and
swallowing are the most common. Users may
combine 2 methods (oral and inhalation) to
obtain more rapid and prolonged effects.
 High risk for overdose due to packages
containing varying amounts of the chemicals.
BATH SALTS
Marketed as legal
alternative to LSD,
cocaine, and
amphetamines. May
imply safety for user.
Labeled not for
human consumption
but that is the sole
purpose!
Naphyrone
• Referred to as “Cosmic Blast” and marketed as
jewelry cleaner. Contains MDPV and Naphydrone.
Reuptake inhibitor of serotonin.
• Stays in system for long periods. Body temperatures
of up to 107 degrees have been reported.
BATH SALTS
Users do not know
how much or what
they are getting.
Package labeling
implies “relaxation”
but not stimulant
effects.
Video Effects
Trends in Use
• Mostly males with a mean age of mid-late twenties.
• 2012 Monitoring the Future Survey reported .9%
annual prevalence of use among students in grades
8,10, and 12 combined.
• Google Trends (2013) showed rapid increase in
Internet searches for “buy Mephedrone” in Europe
and “bath salts” in the U.S. in 2012.
MDPV
• Phenethylamine and norephinephrinedopamine reuptake inhibitor. Hallucinogenic
effects. Lasts longer than Mephedrone or
Methylone.
• Similar form of this was developed in 1960’s
to treat chronic fatigue syndrome but rejected
due to issues with dependency.
• Doses of 5 - 20 mg can produce effects with
oral and inhalation.
Mephedrone
• Derived from cathinone and increases dopamine,
serotonin, and norephinephrine levels.
• Users report longer and better high than cocaine.
Users report it is like using cocaine and ecstasy
together. Effects last about an hour. Known as
meow-meow.
• Users usually ingest capsules, dissolve in water,
snort, or use rectally (bombing).
Methylone
• Stimulant in the phenethylamine class. More
potency in terms of serotonin reuptake
inhibition. Similar structure to MDMA.
• After oral, nasal, or rectal use, effects occur
within 20 minutes, and last about 2 hours.
• *Low concentrations of endogenous phenethylamine
have been found in people with ADHD and high
concentrations have correlation with incidence of
schizophrenia.
Bath salts vs. Cocaine/Meth
• Like Amphetamines, Bath Salts release dopamine from
cells, while blocking the reuptake of dopamine into the
cell similar to cocaine.
• MDPV is ten times stronger than cocaine.
• Taking Bath Salts is like taking Cocaine and Meth
together.
• Time delay – MDPV is able to cross blood-brain barrier
which may impact onset of action and toxicity.
•
Pbs.org – September 2012
Bath Salts and The Brain
•
Why Do People Use Them?
•
•
•
•
Increased energy, alertness, and concentration.
Sexual stimulation and mood enhancement.
Decreased appetite and need for sleep.
Low cost and advertised to users as “they will
never fail a drug test”.
• Readily available and accessible.
Effects
• Patients reporting to ER’s have cardiovascular
complications, such as tachycardia, chest pains,
and hypertension.
• Dizziness, jaw clenching, and confusion.
• Body temperatures of up to 107 degrees have
been reported. Often people take their clothes off.
• Jerking eye movements and foaming at the mouth
have been reported. Vomiting and nosebleeds.
• Restlessness and inability to sit still.
• Insomnia – sleep deprivation * - Some people
take Xanex and other drugs to try to sleep.
EFFECTS
• Auditory and Visual Hallucinations with common
themes of monsters, demons, aliens, and God.
This leads to paranoid delusions and violent
behavior in response to hallucinations.
• Irritability, suicidal ideation, self-harm behaviors,
and prolonged anxiety. “Excited Delirium”.
• Begin 10 – 20 minutes, peak 45 – 90, last 2-3
hours then decrease. Users reported effects after
24 hours. Nonpsychiatric symptoms usually
resolve in 1 to several days, but psychosis can
persist.
Concerns
 A Marquette County, Michigan ER reported 35 admissions
from November 2010 to March 2011. This prompted Law
Enforcement to seize all bath salts from a local convenience
store. The products tested all contained MDPV.
 17 out of 35 were hospitalized. Median age was 28 years
(range 20 -55 years). One death reported. 63% used by
injection.
 54% were Men, 69% self-reported a history of drug abuse,
46% or 16 patients had a history of mental illness(bipolar
disorder, schizophrenia and depression), and 17% reported
suicidal thoughts/attempts related to use of bath salts.

“Morbidity and Mortality Weekly Report, Vol 60, May 20, 2011, 624 - 627
Concerns
• According to the Bangor Daily News, domestic violence calls
have increased in Maine due to use of Bath Salts.
• Cookeville Regional Medical Center in TN has treated over
160 people since 2010.
Dangers and Dependency
 A research study led by UNC professor CJ Malanga,
MD found that Mephedrone, like cocaine, has a high
potential for abuse and addiction.
 Study by Scripps Research Institute in California
suggests that Bath Salts are more addictive than Meth.
Rats averaged 60 level presses for meth versus 600 for
MDPV. Some even pressed 3000 times for a single hit.
Exhibited obsessive behavior, such as, licking, biting,
and sniffing their cages.
NIDA.org 2012 Sydney Herald 2013.
Acute Toxicity of Substituted Cathinone Product.
Use Compiled From 2 US Case Series Reports (n = 271)*
• Signs and Symptoms
• Agitation
• Tachycardia
• Combative violent behavior
• Delusions/hallucinations
• Paranoia
• Confusion
• Seizures tremor
• Drowsiness
• Hypertension
• Paranoia
• Mydriasis
• Myoclonus
• Chest pain
Percentage
66-82
56-63
57
40
36
34
29
23
17-23
20
13-20
19
17
Dangers
• Users report repeated dosing and binging over
several days leading to tolerance.
• Acute toxicity may be linked to larger binge
consumption, using multiple substances, and
other individual use patterns.
Legality
 The Synthetic Drug Prevention Act signed by
President Obama on July 9, 2012. This act
bans 29 chemicals found in Bath Salts and
Synthetic THC and makes them Schedule I.
 States will have to incorporate these into their
drug scheduling list and update the list as new
substances are discovered.
Operation “Logjam”
Operation logjam
• July 26, Operation “Logjam” seized 5 million
packets of synthetics and arrested 90 people in
a nationwide effort to crackdown on these
drugs.
• Tested products contained anywhere from 17
milligrams to 2000 milligrams of chemicals.
Poison Control Center Data
CALLS TO POISON CONTROL: 304 in 2010,
6,138 in 2011, 2065 in 2012,
Ages <6 to over 59. Most ages 20 – 29.
January – 228/301
July – 361/680
February – 230/487
August – 173/602
March – 264/639
September – 119/512
April – 285/600
October – 98/401
May – 295/720
November – 86(2012)
June – 415/743
December – 78(2012)
www. aapnc.org 1-800-222-1222
TREAMENT
• Often eat up Emergency Room resources as it
takes multiple nurses and doctors to treat users.
• Difficult to know what someone has taken
unless they self-report or someone else reports.
• Does not show up on typical toxicology
screens and can not be detected by drug dogs.
There are now drug tests that do test for Bath
Salts. Ammon labs, Redwood Toxicology,
and Dominion Diagnostic offer these drug
screens.
TREATMENT
• Low dose antipsychotics to treat psychosis
• Benzodiazepines, usually Ativan, to decrease
agitation is first treatment.
• Ten to twenty times the normal dose of sedatives
have been used.
• Try to avoid using restraints, but speak
reassuringly to people who are agitated and
paranoid
• Move to a quiet room with low light to help calm
patient.
• Avoid loud noises and try medications prior to
restraint.
TREATMENT
• Monitor the person for depression and suicidal
ideation even after they have stopped using the
drug. Address both mental health and addiction
issues. Follow guidelines for treatment of
stimulant users.
• Psychotic symptoms often persist after treatment
• Enhance coping skills to assist the person in
dealing with anger and other emotions.
• Train staff to deal with specialized issues and
incorporate questions into intake and assessment.
Movie Madness
• BATH SALT ZOMBIES
• Available on DVD February 19
• is a new horror film directed and co-written
by Dustin Wayde Mills (Puppet Monster
Massacre, Zombie A-Hole, Ballad of Skinless
Pete) and produced and co-written by Clint
Weiler of Aggronautix. The
movie sensationalizes the recent bath
salt epidemic and the attacks surrounding
them
“Zombie Apocalypse”
• The shocking wave of attacks associated with
Bath Salts has sparked fears of a real-life
zombie outbreak in the south. This led to The
Center for Disease Control and Prevention
releasing a statement saying it is not aware of
any virus that can cause zombie-like
behaviour.
What next?
• Partnerships and networks between the
community and law enforcement have made an
impact in the sale and distribution of this drug.
• Education regarding the dangers of Bath Salts.
Spice / K2
What is Spice and K2?
• Spice and K2 refer to commercially available
products sprayed with chemicals called synthetic
cannabinoids. These products claim to be a
mixture of herbs but often do not have herbs in
them. They include other ingredients that are
unknown and not listed.
• Many have warning labels as not intended for
human consumption, but are solely intended for
human consumption. Marketed as incense.
Resembles potpourri.
Synthetic Cannabinoids
• Synthetic Cannabinoid products are
manufactured in Asia and sold in US in many
different arenas (gas stations, liquor stores,
smoke shops and internet)
• Sold under different brand names: “K2, Spice,
Spice Gold, Spice Black, Mr. Nice Guy,
Yucatan Fire and many others”
• Since the national ban on five synthetic
cannabinoids, new brand names have
developed, such as K2 Sky, K3, and K4
What is a Synthetic Cannabinoid?
• A class of synthetic substances that bind to the
cannabinoid receptors(CB1 and CB2) in the body.
When used they create a high similar to THC.
Bind more strongly than THC. There are
hundreds of synthetic cannabinoids.
• Used in an attempt to avoid laws that make
marijuana illegal. National Ban on five
cannabinoids began in March 2011.
History of Spice and K2?
 The cannabinoid-like chemicals were first
developed in research laboratories to study receptors
in the body and brain and for other research
purposes. The five banned cannabinoids are JWH018, 073, 200, CP 47, and 497.
 JWH-018 was first made in 1995 by Dr. John
Walter Huffman at Clemson University.
Manufacturers read research and copied it to
produce this cannabinoid and marketed it for
commercial distribution.
 Brand “Spice” was released in 2004 and gained
popularity in 2006.
Spice and K2
 The company that started the “Spice” line went from
assets of 65,000 Euros in 2006 to 899,000 Euros in
2007. Spice was the dominant brand until 2008.
Then competing brands like “K2” hit the market.
Now there are many distributors of these products.
 Rick Broider with North America Herbal Incense
Trade Association estimates profits at 5 billion per
year.
 In 2011, Redwood Toxicology Lab developed testing
for six synthetic cannabinoid chemicals. 72 hours for
urine and 24 – 48 for saliva.
Spice Products
•
•
•
•
•
•
•
Spice
Spice Gold
Spice Diamond
Spice Tropical Synergy
Spice Arctic Synergy
Spice Gold Spirit
PEP Spice
Many Faces of Spice
K-2/SPICE
Other Herbal Incense Products
 Genie
 Yucatan Fire
 Dream
 Ex-ses
 Blaze
 Spike 99
 Blaze
 Spark
 Fusion
 MANY others!
Spice Ingredients
 One or more synthetic cannabinoid compounds. Can
be different mix each time.
 JWH-018, CP 47, 497, C8, JWH-073, and JWH250 have been found most often in spice products.
 Other legal substances such as Pink Lotus, Dwarf
Skullcap, Indian Warrior, and Lion’s Tail
 Potentiate or add to effects
 Create different effects between products
 Many have psychoactive effects on their own
 Some used as marijuana substitutes in the past.
 Cost $30 - $40 per 3 gram bag.
Other Synthetic Cannabinoids
HU named after Hebrew University where they were created.
• HU-210
– Various studies show it is anywhere from 66-800 times more potent
than ∆9 THC1
– Schedule I under CSA: Illegal in U.S.
• HU-211
– Studies tentatively show no ∆9 THC-like effects
– Used to research treatment of brain damage related to stroke, brain
trauma, glaucoma, and multiple sclerosis
• HU-311
– Has potent antineoplastic and antiproliferative
activity (cancer fighting drug)
1
J. Med. Chem.35 (11): 2065–9.
BIZARRO - ZENCENSE
BIZARRO
Bizarro
• At a glance:
• Out of all the varieties of incense that I have burned,
a fairly large number, Bizarro is my personal favorite.
That being said, I wouldn’t recommend Bizarro to
just anyone. It is for experienced users and is not to
be underestimated. As with other brands of herbal
potpourri, the psychoactive effects from Bizarro
should not be set alongside cannabis. They are much
more intense and harder to control. Bizarro is a great
brand of incense if used correctly, but it can also
render terrifying experiences to those who dive in too
fast.
Synthetic Cannabinoids
 CP 47,497 and analogues (CP Created by Pfizer)
 3 to 28 times more potent than ∆9 THC
 CP 55,940
 45 times more potent than ∆9 THC
 JWH-015
 JWH-018 4-5 x more potent than THC and same
chemical structure shared with known cancer
causing agents.
 JWH-073
 WIN 55,212-2 (WIN is for Sterling Winthrop)
 Used to research treatment for Alzheimer's
 Effects milder and don’t last as long as ∆9 THC
Other Herbal Incense Ingredients (Not all
 Baybean
 Blue Lotus
 Lion's Tail
 Lousewort
 Indian Warrior
 Dwarf Scullcap
 Maconha Brava
 Indian Pennyworth
 Clove
 Hops
 Tribulus Terrestris
inclusive)
 Pink Lotus
 Marsh Mallow
 Red Clover
 Rose
 Vanilla and Honey
 Fly Agaric
 Siberian Motherwort
 Damiana
 Stevia Leaf
 Lemon Grass
 Turnera diffusa
Many other legal herbs and herbal extracts are used to enhance aroma, potency
Dangers of K-2/Spice Video
Why Do People Use It?
• Legal substitute to marijuana
• Herbal incense products are
smoked or snorted for marijuana-like effects
• Other reasons: increase creativity, reduce
stress, experience euphoria, increase personal
insight, and increase appreciation for the arts
• There are numerous blogs and websites the
provide users the opportunity to share
experiences.
Effects
• Marijuana-like effects: euphoria, giddiness,
silliness, bloodshot eyes, impaired short-term
memory and concentration, and “munchies.”
• Other common effects: cotton mouth, light
sensitivity, a warm sensation in the limbs, dry
eyes, paranoia, light headedness, auditory and
visual hallucinations, painless head pressure, time
distortion, panic attacks, delirium, impaired
coordination, and sleeplessness
• Onset/duration: 5-10 minutes, and effects vary
from 2 hours for JWH and 5-6 for CP. Can get
high off a hit or two.
Effects
• A number of users experience hangover-like
effects the morning after use including dry
mouth, intense headaches
• Depending on the product, inhaled smoke is as
harsh as marijuana smoke
– Taste can vary from a very bad to sickly sweet.
Effects
• One hospital reported a patient with a 1-3 gram
a day habit and severe withdrawal symptoms
(tremors, headache, nausea, vomiting and
depression).
Dangers
 Linked to 16 cases of kidney failure. All but one
experienced nausea and vomiting. Twelve
reported abdominal, back, and neck pain. All but
one were male and had healthy kidneys. Age
range was 15 – 33. Traced to Spice Gold, Mad
Monkey, Mr. Happy, Clown Legal, and Lava
brand.
 Another study found these products may create
psychosis in patients with no history of psychiatric
disorder.
 Overdose potential from unknown amounts and
ingredients in products.
ABC News, Nick Wasson , M.D. February 2013
Dangers
Poison Control Centers had 112 calls in 2009, 2906
in 2010, 6,959 in 2011, and 5200 by December 31,
2012.
 Users are experimenting with combining different
products, which can dramatically change or
increase the effects. These cannabinoids were
created for experimental use. Not tested on
people. No one knows long term effects of these
products.
Dangers
• JWH-018 and others, have a shared chemical
structure with cancer causing agents, according
to NIDA.
• A hospital in Kansas reported 8-10 people
hospitalized in one month after smoking the
products with hallucinations, seizures and
bleeding from the nose and mouth.
• Three teens ages 16 and 18, showed up in ER
with anxiety, agitation, excessive sweating,
and inability to speak.
Dangers
• Kids’ brains are still developing.
• Across the US, people are showing up in
emergency rooms with aggressive and unusual
behavior. Suicides have been reported.
• A NIDA study stated 11% of school seniors
have used Spice/K-2 in 2011. Second most
frequently used drug after THC.
• Medical personnel often don’t know what they
are dealing with unless the person self-reports.
DANGERS
Appearance
• Most herbal incenses
appear as an olive
green leafy material
very similar in
appearance to
marijuana, oregano
Paraphernalia
• Herbal incense smokers will use the same or
similar products used by marijuana smokers
– Pipes, bongs, hookahs
– Rolling papers
– Blunts (hollowed out cigars packed with product)
• Herbal incense specific paraphernalia
– Vapor Genie
– Grinders (to further grind into a finer mixture)
Hookah
Vapor Genie
Grinders
Controlled Substances Act
 In Nov. 2010, the USDEA moved to ban 5 synthetic
cannabinoids, placing them in Schedule I status due to
high potential for abuse, and no known medical
benefits. The ban would be in effect for one year.
 The ban was delayed due to companies stating the ban
was unconstitutional.
 On March 1, 2011 the National Ban was enacted.
 This means that is illegal to possess and sell products
containing these.
 Before the ban, 15 states had already taken action to
control one or more of these five chemicals.
Challenges - Manufacturing
• Manufacturing occurs in countries where
synthetic cannabinoids are legal.
• As detection catches up with manufacturing,
makers will alter ingredients. They are using
new ingredients which are not illegal at this
time.
• Federal bans target larger distributors. States
will need to go after smaller distributors.
Challenges - Marketing
• Product will not cause positive drug test
• “There's never been a case reported by our clients
that any of our Herbal Smoke Blends caused them
to fail a test”
• “YOU'LL NEVER FAIL A DRUG TEST”
• Why would this be an issue for a product
marketed as incense and not for human
consumption?
Challenges - Marketing
• Ingredients1
– Synthetic cannabinoids not listed
– Listed ingredients are not necessarily in the
product
– Consumers don’t know what they are actually
getting
– Raises questions of consumer protection and
product misrepresentation
1 Understanding
the ‘Spice’ Phenomenon Thematic Paper, European Monitoring Centre for Drugs
and Drug Addiction, 2009, Portugal
ENERGY DRINKS
ENERGY DRINKS
• American Association of Poison Control Centers –
(www.aapnc.org) urges the public to use caution
using these products.
• Highly concentrated amounts of sugar, caffeine, and
other ingredients. Was mixed with alcohol in the past
and sold next to bath salts.
• Caution for children and adolescents. Children
should not have it and adolescents should not have
more than 100 mg of caffeine per day = one cup of
coffee*
*Journal of Pediatrics
Energy Drinks
• Due to labels, it is often hard to know how much
caffeine is in the drink.
• Drinks contain natural caffeine-containing
ingredients that are not separately listed, such as,
yerba mate, cacao, and guarana.
• These drinks are considered dietary supplements
and not regulated by the FDA so there is no limit
to amount of caffeine that can be in them.
• Drinking too many at one time or too fast ……..
EFFECTS
•
•
•
•
•
•
•
•
•
Nausea and vomiting
Seizures
Insomnia
Kidney Problems
Delirium
Mood Changes
Headache
Increased BP
Altered and increased heart rhythm
Withdrawal
Chest Pains
Dehydration
Sweating
BATH SALTS & ENERGY
DRINKS
• A 28 year old man was found passed out in a random person’s
driveway, and was taken to the hospital. It was discovered that
the man had overdosed on energy drinks and bath salts.
• According to a report by the Caledonia Police, officers found
the man lying on the floor of his van.
• An individual said he found the van in his own driveway. The
individual stated the engine was off and that no keys were
found in the ignition. The victim was found slouched over the
steering wheel. There was a cell phone in the man’s
possession, and the last dialed contact was that of his mother.
POISON CONTROL
CENTER
• 2607 calls to Poison Control Centers related to
the use of Energy Drinks through October 31,
2012
Resources
• Life Center of Galax is equipped to
treat persons using these substances.
Our confidential referral and
assessment number is 1-800-3456998. We are available 24/7 to speak
with anyone.
Thank You

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