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Designer Drugs Toxicity Management and Impact on South Dakota Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

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Page 1: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Designer DrugsToxicity Management and Impact on South Dakota

Billie Bartel, PharmDSanford Aberdeen Medical CenterAberdeen, SD

Page 2: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Disclosures

I have had no financial relationship over the past 12 months with any commercial sponsor with a vested interest in this presentation.

Page 3: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Objectives

Describe the mechanism of action and toxicity profile of designer drugs

Identify treatment approaches to adverse reactions to designer drugs

Describe the impact of designer drug use in South Dakota

Page 5: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Accessibility

Page 6: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Why do we need to know about this?

Use is widespread

Recognize and manage the intoxication syndromes

Educate patients about their potential dangers May be more

dangerous that substances they want to imitate!

Page 7: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

National Association of Poison ControlsDesigner Drug Calls

Marketing geared toward young consumers

Social media involvement

Page 9: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Synthetic Cannabinoids

K2 Spice SCs Krypton Aztec Fire Bombay Blue Fake Weed Yucatan Fire No More Mr. Nice Guy Mr. Smiley Eclipse Black Mamba

Page 10: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Synthetic Cannabinoids

Marketed as “legal marijuana”

Chemical sprayed on plant material

Route of ingestion: Inhalation (smoke) Ingestion (food, tea)

Available in 1, 3, 9, 30 gm packages 1 gm = 3 “servings”

or rolled joints 1 gm = $20

Discount for buying in “bulk”

Page 11: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Appearance

Chemicals usually in powder form and dissolved into solvents then sprayed onto dried plant material

Imprecise methods of manufacturing results in variable potencies Risk of “hot spots”

Page 12: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Reported Use of Synthetic Cannabinoids

Year Number of Calls

2010 2,906

2011 6,959

2012 5,225

2013 2,668

2014 3,680

2015 (as of September 23) 6,189

American Association of Poison Control Centers:Number of calls regarding human exposures to synthetic cannabinoids

Page 13: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Reported Use of Synthetic Cannabinoids 2015

Page 14: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Mechanism of Action

Bind to same receptors in the brain as tetrahydrocannabinol (THC)

Full agonist to cannabinoid (CB)-1 and CB-2 receptors No ceiling of dose

effect

Page 15: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Desired Effects

Alteration in mood Dissociative state

Timing: Onset: 10 mins Duration: 2-6 hours

Page 16: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Adverse Effects

Anxiety/agitation Psychosis

Paranoia Hallucinations Delusions

Depression Suicidal

thoughts/actions Seizures Loss of

consciousness

Nausea/vomiting Tachycardia Hypertension Diaphoresis Muscle spasms Tremors AKI

Long term effects of use not known Risk of withdrawal

effects

Page 17: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Treatment

Supportive care Monitor vitals Protection, limit stimuli Fluids Antiemetics Benzodiazepines Diphenhydramine

Clinical effects last < 8 hours in most users

Page 18: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Identification of Ingestion

Not as important as treating symptoms

Does not cross-react with THC on standard urine drug screen

Some private and reference labs have capacity to compare tests with some reference compounds For example: “Substance consistent

with…”

Page 19: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Synthetic Cathinones

Bath salts Ivory Wave, Vanilla

Sky M-cat Meow-meow

Page 20: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Synthetic Cathinones

Designer stimulant

Synthetic derivatives of cathinone Leaves of the Khat Plant▪ Mephedrone▪ Methylene-

dioxypyrovalerone (MDPV)▪ Methylone

Supplied as a powder and compressed into crystals

Route of ingestion: Nasal Oral IV or IM injection

Sold in 300-500mg package < 10mg considered

normal “dose” Cost: 1gm = $50

Page 21: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Reported Use of Synthetic Cathinones

Year Number of Calls

2009 0

2010 3.2

2011 6,138

2012 2691

2013 995

2014 582

2015 (as of August 31) 377

American Association of Poison Control Centers:Number of calls regarding human exposures to synthetic cathinones

Page 22: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Molecular Structure

Bupropion

MDMA (Ecstasy)

Page 23: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Mechanism of Action

Increase brain levels of stimulatory neurotransmitters Serotonin: elevate mood and cause

calming effect Norepinephrine: increase alertness,

concentration, motivation Dopamine: increases pleasure

Page 24: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Desired Effects

Euphoric high with rush Similar to cocaine,

ecstasy or methamphetamine

Increased: Energy Concentration Sociability Libido Sense of well-being

Timing: Onset: 5-20 mins Peak: 45-90 mins Duration: 2-4 hours ▪ Then decrease over

6-12 hours

Page 25: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Adverse Effects

Agitation* Psychosis:

Paranoia Hallucinations Delusions

Seizures

Long term effects unknown Risk of tolerance,

dependence, withdrawal effects

Hyperthermia Diaphoresis Muscle spasms Bruxism Palpitations Tachycardia Hypertension Arrhythmias/

myocarditis Hyponatremia Rhabdomyolysis

Page 26: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Treatment

Supportive care Monitor vitals Protection, limit stimuli Fluids Benzodiazepines Diphenhydramine Vasodilators

Ensure staff and patient safety

Page 27: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Identification of Ingestion

No cross-reactivity with amphetamines

Labs can compare substances with references Cathinone Methcathinone MDPV Mephadrone

Page 29: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Synthetic Hallucinogens

2C phenethylamine derivative Similar to LSD

Supplied as a blotter, powder, or spray

Route of ingestion: Nasal Buccal/SL IV injection Inhalation of vapor Orally active?

50-1500 mcg or “cap” dosing

Page 31: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Desired Effects

Euphoria Physical and

mental stimulation Increased

empathy Hallucinations Depersonalization

Timing: Onset: rapid Peak: 20 mins Duration: 3-13

hours

Page 32: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Adverse Effects

Agitation/aggression

Confusion Hallucinations Delirium Paranoia Violence Seizures

Hyperthermia Mydriasis Hyperreflexia/clonus Tachycardia Hypertension Metabolic acidosis Rhabdomyolysis Acute kidney injury

High risk of overdose

Page 33: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Treatment

Supportive care IV fluids Correct metabolic abnormalities Benzodiazepines Antipsychotics Diphenhydramine Dialysis

Clinical effects last 4-10 hours After-effects last 1-7 days

Page 34: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Designer Drug Toxicity Work-up

EKG Labs:

CBC CMP Serial cardiac enzymes CK level Pregnancy test

Assess for co-ingestions: Urine Toxicology Ethanol APAP and salicylate levels Other prescription medications?

Page 35: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Designer Drug Clinical Signs/Symptoms

Body System Finding Drug(s)

General Hyperthermia Cathinones, hallucinogens

Head & neck Bruxism Cathinones

Cardiac TachycardiaHypertensionChest pain

All classesAll classesCannabinoids, cathinones

Renal Acute kidney injury

Cannabinoids

Gastrointestinal Nausea/vomitingAcute hepatitis

CannabinoidsAll classes

Musculoskeletal

Muscle spasmsRhabdomyolysis

Cathinones (cannabinoids less)Cathinones, hallucinogens

Skin DiaphoresisEcchymosis

CathinonesHallucinogens

Neurologic ClonusSeizures

HallucinogensAll classes

Psychiatric AgitationHallucinationsPsychosis

All classesAll classesAll classes

Page 36: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Desomorphine

Krokodil Crocodile Zoombie Drug Russian Magic

Page 39: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Treatment

Supportive care Naloxone Antibiotics if indicated

Average survival from first use of desomorphine is ~2 years

Page 40: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Designer Drug Legislation Synthetic Drug

Abuse Prevention Act of 2012

Adds 31 compounds to the FDA Schedule 1 class 9 Cathinone-based

compounds 20 Cannabinoid-

based compounds

Page 41: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

South Dakota Legislation

2012: Synthetic designer drugs added to list of controlled substances prohibiting the unauthorized manufacture, distribution, counterfeiting or possession of substances with high potential for abuse as a felony

2014: Annual bill to update list of substances on the controlled substance schedule

Page 42: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Operation Log Jam

Page 43: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Operation Log Jam

Nationwide synthetic drug takedown in July 2012 91 individuals arrested 4.8 million packets of synthetic cannabinoids

seized▪ Plus products to produce 13.6 million more

167,000 packets of synthetic cathinones seized▪ Plus products to produce 392,000 more

Sioux Falls, SD:▪ 3 tobacco shops closed temporarily

Page 45: Billie Bartel, PharmD Sanford Aberdeen Medical Center Aberdeen, SD

Drug testing in SD

May 2012: South Dakota Public Health Laboratory received grant to improve ability to test for suspected illegal synthetic drugs Compare case samples to drug test

standards that contain known characteristics of banned compounds

Money from drug control fund