Download - You Smoked What? or Emerging Drugs of Abuse
7/9/2018
1
You Smoked What?or
Emerging Drugs of Abuse
Francis L. Counselman, MD, CPE, FACEPEVMS Distinguished Professor and Chairman
Department of Emergency MedicineEastern Virginia Medical School
Overview
• There will always be new drugs
• Most new drugs involve manipulation of existing chemical structures
• Most new synthetic drugs have
psychoactive and
sympathomimetic
effects
Psychoactive Effects
Alterations in perception, mood or consciousness
Sympathomimetic Effects
• Mydriasis
• Increased heart rate and arrhythmias
• Increased blood pressure
• Increased respiratory rate
• Diaphoresis
• Hyperthermia
• Agitation
• Seizure
Overview
• Synthetic cathinones / Bath Salts
• Synthetic cannabinoids / Spice and K2
• Piperazines / Legal X
• Phenethylamines / 2C
• Kratom / Thang
• Salvia / Sally D
Overview
• Most purchased over Internet
• No quality control
• May not be drug you think
• May not be appropriate dose
• Most contain
adulterants
7/9/2018
2
Synthetic Cathinones
Bath Salts Vanilla Sky
Cloud 9 MCAT
Bubbles Explosion
White Lightning
Synthetic Cathinones
• From leaves of khat plants
• Chewing khat very popular
• First reported in U.S. in 2007
• “Not for human consumption”
• Made illegal in U.S.
in 2011
Users
• Male (68%)
• <30yo (54%)
• 2700 U.K. dance club frequenters: 54%
• 1.3% by H.S. seniors in 2012
Synthetic Cathinones
• Snorting (48%) followed by oral ingestion (29%)
• Occasional IV, IM, PR
• Average onset w/in 30 minutes
• Peak effect 45 to 90 minutes
• Duration up to
3 hours
Synthetic Cathinones
• Cardiac: Tachycardia, palpitations, HTN, chest pain
• Psychiatric: Agitation, aggression, confusion
• Neurologic: Seizures
Synthetic Cathinones
• Euphoria, talkativeness
• Visual, auditory or tactile hallucinations
• Nausea, vomiting, abdominal pain
• Mydriasis, burred vision
• Hyperthermia
• Rhabdomylosis
7/9/2018
3
Testing
• Based on presentation
• UDS usually negative
• Occasionally false positive for amphetamines (structurally similar)
Other Effects
• Metaboloic acidosis
• Hypoatremia
• Rhabdomyolsis
• Acute renal failure
Evaluation
• Cardiac monitor
• ECG
• Basic metabolic profile
• Urinalysis
• Urine pregnancy
test
• IV access
Treatment
• No antidote
• Symptom based
• Benzodiazephenes IV
- Lorazepam
• Restraints
• Supportive care
• Low-stimulation
environment
Synthetic Cannabinoids
Spice K2
Blaze Bliss
Black Mamba Aztec fire
Happy Tiger Incense
7/9/2018
4
Synthetic Cannabinoids
• Marketed as incense, air freshner
• Gained popularity as legal alternative to weed
• Other biological herbs mixed in
• Minimal packaging
information
Synthetic Cannabinoids
• Mixture of dried vegetable matter with
SC sprayed onto it
• Contains many substances
• Usually smoked
Synthetic Cannabinoids
• First appeared in U.S. in 2009
• Given Schedule I status March 2011
• All SCs stimulate cannabinoid receptors
• Hundred of SCs exist
• Varying degree of clinical presentations
• Typical user: Male in teens to early 20’s
• 2012 survey: 11.3% of H.S. seniors used
• Clenbuterol
Synthetic Cannabinoids
• Tachycardia
• Agitation
• Vomiting
• Confusion
• Hypertension
• Hallucinations
• Mydriasis
Testing
• Based on presentation
• UDS usually negative
• Commercial labs
7/9/2018
5
Evaluation
• Cardiac monitor
• ECG
• Basic metabolic profile
• Urinalysis
• Urine pregnancy test
• IV access
Treatment
• No antidote
• Symptom based
• Benzodiazepines IV
• Supportive care
• Low-stimulation
environment
Piperazines
Smileys Legal X
BZP ESP
Silver Bullet Happy Pills
The Good Stuff
Piperazines
Overview• No natural counterpart
• Initially antihelminthic, then antidepressant
• Used in pill, powder or liquid form
• Typical user: young male
• Illegal in the U.S.
• Most common active substance found in drugs purchased over Internet
Piperazines
• Time of onset and duration variable
• Usually lasts 6 to 8 hours
• Most presentations involve sympathomimetic effects
• Benzyl and
Phenyl
Piperazines
• Headache
• Anxiety
• Palpitations
• Diaphoresis
• Shortness of
breath
• Confusion
• Hallucinations
7/9/2018
6
Testing
• Based on presentation
• UDS may be false positive for amphetamines
Evaluation
• Cardiac monitor
• ECG
• Basic metabolic panel
• Urinalysis
• Urine pregnancy test
• IV access
Treatment
• No antidote
• Symptom based
• Benzodiazepines IV
• Supportive care
• Low-stimulation
environment
Phenethylamines
2C Toonies
Erox Bromo
Spectrum Venus
Phenethylamines
• PIHKAL: A Chemical Love Story
Alexander Shulgin, PhD
7/9/2018
7
Phenethylamines
• Both stimulant and hallucinogenic effects
• Snorting
Onset 5 – 15 mins
DOA 2 – 4 hours
• Oral
Onset 1 – 2.5 hours
DOA 5 – 7 hours
Phenethylamines
• Typical user: young males with h/o polydrugabuse
• Most are Schedule I
• New compounds constantly being developed
Phenethylamines
• Euphoria
• Hallucinations
• Agitation
• Nausea/Vomiting
• Tachycardia
• Hypertension
• Seizures
Testing
• Based on presentation
• Not detected on most drug screens
Evaluation
• Cardiac monitor
• ECG
• Basic metabolic profile
• Urinalysis
• Urine pregnancy test
• IV access
7/9/2018
8
Treatment
• No antidote
• Symptom based
• Benzodiazepines IV
• Supportive care
• Low-stimulation
environment
Kratom
Thang Thom
Blak Ketum
Kratom
• From tree in SE Asia – Mitragyna species
• Used by Thai and Malaysian manual workers for euphoria, stimulation, analgesia
• Used to help opioid withdrawal
• Smoked or ingested as a tea
• Available as leaves, powder, extract, encapsulated powder
Kratom
• No Federal law against
• Some states have outlawed
Kratom
• Dose dependent
• Low dose: stimulation, increased alertness, talkativeness, increased physical energy
• High dose: opiate and sedative effects
• Onset of action: 5-10 minutes
• Duration of action: 2-5 hours
Kratom
• Mitragynine 10x more potent than morphine
• Most patients present to the ED as opioid overdose or opioid withdrawal
• Kratom withdrawal and opioid withdrawal indistinguishable
7/9/2018
9
Kratom and Salmonella
• May 2018; 199 people infected
• 41 states
• 38% required hospitalization
• Recall initiated
Kratom and Salmonella
• Consider in young patients with presenting with fever, nausea, diarrhea, or crampy
abdominal pain
Testing
• Based on clinical presentation
• Not detected on ordinary drug screens
Evaluation
• Cardiac monitor
• ECG
• Basic metabolic panel
• Urinalysis
• Urine pregnancy test
• IV access
Treatment
• No antidote
• No report of naloxone working
• Symptom based
• Benzodiazepines IV
• Supportive care
7/9/2018
10
Salvia
Sally D Seer’s Sage
Mystic Sage Magic Mint
Salvia
• 100s of species
• Salvia divinorum plant in Mexico
• Used during religious ceremonies
• Enables speaking with Virgin Mary
Salvia
• Most commonly smoked
• Can be ingested as a tea or chewed plant leaves
• Bought over Internet as
prepackaged crushed leaves
Salvia
• Illegal in Delaware, Florida, Illinois, Kansas, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Ohio, Oklahoma, South Dakota, Tennessee and Virginia
Legal Everywhere Else
Salvia
• Primarily hallucinogenic effects
• Different from LSD or Magic Mushrooms
• Most potent natural hallucinogenic
• Stimulates kappa opioid receptors:
- Perceptual distortions
- Altered sense of self
- Altered sense of environment
Clinical Effects
• Onset of action 30sec – 10min
• DOA: approx 30 min
• “Union of the senses”:
- Visual synesthesia
- Tactile synesthesia
• Completely lose orientation
7/9/2018
11
Salvia
• Visual and tactile synesthesia
• “You see things and feel them in your body”
• “You can see everything going on in the room, but can see it through my skin, not through my eyes”
Testing
• Based on clinical presentation
• Will not be detected on standard drug tests
Treatment
• Very short acting
• Symptom based
• Supportive care
Rarely present to
Emergency Department
Take Home Messages
• Even if ask, the patient may not know what they actually ingested
• Poor historians, altered sensorium
• Most of the new drugs cause sympathomimetic and psychoactive effects
• Look for toxidromes
• May present as trauma
Take Home Messages
• ABCs
• Cardiac monitor
• Treat symptoms
• IV benzodiazepines
• Quiet environment
• Determine if recreational mishap or suicide attempt
7/9/2018
12
Take Home Message
• IV NS for hypotension or rhabdomyolysis
• Monitor core temperature
- Mist, fanning
- Antipyretics not useful
• GI decontamination / AC not useful
Majority will do well