emerging illicit drugs of abuse
DESCRIPTION
Emerging illicit drugs of abuseTRANSCRIPT
The legal highs
Dr Ioana Vlad
• What are they?
• How do patients present?
• How do we treat?
• What is all the fuss about?
Synthetic / emerging drugs
Issues
- readily available in retail stores and online
- cheap
- highly attractive packaging
- perceived as safe drugs
- party pills / herbal highs / legal highs /
nutritional supplements
- not easily detectable in urine or blood
samples
• Synthetic cannabinoids
• Synthetic cathinones
• Novel psychedelics / synthetic LSD
Synthetic / emerging drugs
Synthetic cannabinoids
Synthetic cannabinoids
• Usually marketed as incense sticks
• Smoked or ingested “with a carrier high in fat content”
• Labeled “not for human consumption”
Synthetic cannabinoids
• Spice• K2• Happy Tiger Incense• Blueberry spice• Purple rush• Banana cream nuke• Kronic
Synthetic cannabinoids ( ~ 460)
• structurally different from THC but same effect on cannabinoid receptors
Naphthoylindoles
JWH-018JWH-081JWH-250 AM-2201JWH-073JWH -200
CP-47497CP 47CP 497
Cyclohexylphenoles
Synthetic cannabinoids
• 1984 John Huffman University of Clemson (USA)
• 2004 “Spice” appeared in London - The Psyche Deli company
Advertised effects
• Euphoria / relaxation / laughter / feelings of joy
Clinical presentations
• Agitation / paranoid psychosis
• Seizures
• Nausea, vomiting
• Acute kidney injury
• Hypokalaemia / hyperglycaemia
• Hyperthermia
• SVT / cardiomyopathy / acute LVF / AMI
• Hypertension
Synthetic cathinones
- chemically similar to cathinone foundin the khat plant ofeastern Africa
- manufactured in China
Synthetic cathinones
- tablets or powder / swallowed, snorted or
injected
- most common - 3,4
methylenedioxypyrovalerone (MDPV),
mephedrone, methylone
3, 4-Methylenedioxypyrovalerone (MDPV) & other synthetic cathinones
effects similar to cocaine
/ amphetamines / MDMA
- sometimes labeled as
legal cocaine or legal
amphetamines
Developed in the 1960s for the
treatment of chronic fatigue, but
abandoned due to abuse and dependence
1969: Boehringer Ingelheim files a patent application for MDPV
2005: MDPV on recreational drugs markets and mentioned on
Drugs forum
MDPV timeline
2007: first seizure of MDPV as a recreational drug, by customs
officials in Germany (shipped from China)
2009: MDPV made illegal in Denmark
2010: UK
2011: USA, Australia
MDPV timeline
Sold as bath salts / insect repellant / research
chemical / plant food
Sold mostly on the internet,
but can also be found in adult
or herbal shops
Labeled “not for human consumption.”
Red DoveBlue SilkCloud NineOcean SnowLunar WaveVanilla Sky Ivory WaveWhite LightningScarfacePurple WaveStar DustHurricane Charlie
Euphoric
Anorectic
Aphrodisiac
Anxiogenic
Increases alertness
Inhibits sleep
Advertised effects
Advertised effects
“ Swim says he finds MDPV a wonderful compund for getting
things done, like cleaning the flat, getting long boring e-mails
written and sent and working through shitloads of Uni-grade
maths at hyperspeed. The lack of euphoria is almost concieved
as positive by SWIM as it doesn't distract him from the task at
hand."
"...lower doses of MDPV produces a clarity of thought far
superior to just about every other stimulant I've ever tried."
Clinical presentation dopamine-noadrenaline reuptake inhibitors (NDRI)
- Agitation / aggression / paranoid delusions with
violent behaviour / increased
alertness/awareness / insomnia
- Headache, confusion, seizures
- Movement disorders - bruxism / muscle spasms
- Abdominal pain
- Rhabdomyolysis, renal failure; hyponatraemia
- Tachycardia, hypertension, vasoconstriction –
STEMI
- Tachyarrhythmias
- Hyperthermia
quick onset
peak effects for 3 - 4 hours
tachycardia, hypertension, and mild
stimulation last 6 - 8 hours
MDPV
α-pyrrolidinopropiophenone (α-PPP)
- detected in Germany in seized "ecstasy" tablets
4'-methyl-α-pyrrolidinopropiophenone (MPPP)
- Germany late 1990s / early 2000s
3',4'-methylenedioxy-α-pyrrolidinopropiophenone (MDPPP)
- Germany late 1990s / early 2000s - imitation ecstasy pills
MDPV’s chemical ‘cousins’
• Naphyrone / O-2482 / naphthylpyrovalerone
– “Cosmic Blast” - marketed as a jewelrycleaner
– triple reuptake inhibitor (serotonin / noradr / dopamine)
– anecdotal reports of prolonged toxicity and severe hyperthermia
• Pentedrone, Alpha-PVP, 3,4-DMMC
Gen 2, 3 etc. of “bath salts”
What are the issues with MDPV?
What are the issues with MDPV?
"MDPV is the most compulsive drug swim has ever
done, he just can't stop hitting that pipe, it's worse
than fucking crack! He's been at it since 11am, 16
hours ago, and in that time he's done 150mg so far,
solely via the pipe, far too much!! He's still got over
300mg left, aargh!!! ...He's not even sure if he's still
enjoying it, don't think he is, but still he can't stop
hitting that pipe for some reason (though he does
know why really, dopamine = reward innit). Bloody
strange substance! Any swimer fancy coming round
and freeing swim of this bloody pipe?"
What are the issues with MDPV?
"MDPV is like the bastard with a whip you've got to
obey or you get hurt. Then you obey and get hurt
even worse. Finally, it's "Thank you sir may I have
another... thank you sir, may I have another... thank
you sir, may I have another..." and you wonder why
you've come to enjoy feeling like shit nearly every
waking moment. You vow never to touch MDPV again,
then an hour or two after it wears off you find yourself
eagerly using MDPV."
Novel psychedelics / NBOMe
Alexander Shulgin Albert Hofmann
Novel psychedelics / NBOMe
25B-NBOMe / 25I-NBOMe
derivatives of the 2C family of phenethylamine psychedelics
very potent partial agonists 5HT – 2A receptor
snorted or dissolved into a liquid and placed on blotter paper under the tongue
Novel psychedelics or synthetic LSD
90s – replacement for ecstasy
Colourful hallucinations
Feelings of empathy
Feelings of closeness with
others
Advertised effects
Effects
• Aggitation / extreme behaviours
• Tahycardia, hypertension
• Hyperthermia
• Seizures
• Metabolic acidosis
• Multiorgan failure
Effects
- onset ~15 min
- may last 6-10 hours
- active at very low
doses
Treatment
- Supportive care - benzodiazepines for agitation, seizures, tachycardia, and hypertension
- Significant hyperthemia may require passive or active cooling
- Consider checking electrolytes, renal and liver
function tests, cardiac markers, CK
- Observe until resolution of abnormal vital signs,
vomiting, and psychiatric symptoms
Legislation issues
- June 2011 – synthetic cannabinoids banned in
WA / QLD / VIC and then federal
- October 2011 – MDPV banned in USA and most
European countries
- February 2012 – WA bans MDPV
The problem: drugs could only be added to
the list once identified
DMECMethedroneEthedrone3-MOMC2-FMC2-FEC3-FMC3-FEC3-CMC3-BMCFlephedrone4-FECBrephedroneFMMC2,5-DMOMCbk-MDA2,3-MDMCMethyloneEthyloneO-2384α-PVP (O-2387)
4-MeMABP4-Me-NEB4-MethoxybuphedroneButyloneEutyloneBMDBbk-DMBDB5-Methylmethylone5-Methylethylone2-Methylbutylone5-MethylbutylonePentyloneMMPMEPbk-Methiopropamineα-Phthalimidopropiophenoneα-PPPα-PBPEDMC3,4-DMMC
• Urine drug screens will not pick them up
• Blood tests available
– Expensive
– Only for identified structures
Legislation issues
- Sept 2013 – NSW law banning “manufacture,
supply and advertising of psychoactive
substances (schedule 9)”
Take home messages
- drugs of abuse are forever changing
- manipulation of basic chemical
structures to avoid legal ramifications
- the classes of drugs more important than
names
- effects: psychoactive and sympathomimetic
- symptomatic management
-BZDs are a useful adjunct