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Emerging Trends in Drug Abuse Joshua Pruitt, MD, FAAEM February 6, 2014

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Whats New E-Cigarettes Krokodil N-bomb Syrup, Purple Drank, Sizzurp, Lean Molly Salvia Divinorum

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Whats Sort-of New K-2/Synthetic Cannabinoids Bath Salts, MDPV, Khat Energy drinks

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E-cigarettes Battery-operated devices marketed as safer than traditional cigarettes Produce flavored nicotine aerosol/steam that looks and feels like tobacco smoke No tar or other chemicals from burning tobacco leaves Still require a chemical diluent that has an unknown safety profile

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E-cigarettes

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Krokodil Cheap heroin substitute Desomorphine (Heroin is diacetylmorphine) Made by combining codeine tablets with toxic chemicals (i.e., lighter fluid, industrial cleaners) More powerful than heroin with a shorter duration Causes gray/green scaly flesh at site of injection, thus the name Injection sites often become gangrenous Average life-span after beginning use is 2 years

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Krokodil

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N-bomb, Legal Acid, Smiles, 25I, 25C, 25B Three closely-related synthetic hallucinogens Substitute for LSD or mescaline Serotonin stimulant, more powerful than LSD Can cause seizure, MI, respiratory depression/arrest, death 19 related deaths in US between 3/2012 and 8/2013

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N-bomb, Legal Acid, Smiles, 25I, 25C, 25B

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Syrup, Purple Drank, Sizzurp, Lean Phenergan w/codeine plus soda (Actavis) May include hard candies Celebrated in rap music High risk of respiratory depression and CNS depression Deaths from prescription opioids now outnumber deaths from all other drugs

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Syrup, Purple Drank, Sizzurp, Lean Implicated in the deaths of DJ Screw and Pimp C

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Syrup, Purple Drank, Sizzurp, Lean Overdose symptoms related to promethazine and codeine Promethazine CNS depression, anticholinergic Tachycardia, altered mental status, delirium Codeine CNS depression, respiratory depression Miosis, bradypnea/apnea, hypoventilation Seizures highly unusual and usually related to hypoxia

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Syrup, Purple Drank, Sizzurp, Lean

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Molly

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Slang for molecular Refers to pure crystalline powder form of MDMA (Ecstasy) Sold in capsules Celebrated in rap/hip-hop music Produces energy and euphoria May cause hyperthermia, confusion, depression, sleep problems

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Molly Symptoms often mixed toxidrome due to co- ingestions CNS effectsCV effectsGI effectsDerm effects AMSPalpitationsDry mouthDiaphoresis SeizuresChest painNausea/vomitingPiloerection RestlessnessCramping AgitationDental effectsAnorexiaGU effects HyperthermiaBruxismUrinary retention SyncopeEnamel erosionSexual dysfunction Ataxia

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Molly

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Salvia Highly selective kappa-opioid receptor agonist Originated with Mexican Mazatec shamanism Hallucinogen with psychedelic/dissociative effects Taken by smoking, no real effects from ingestion

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Salvia Intoxication effects Uncontrollable laughter Vivid reliving of past memories Sensation of motion or being pulled by something Visions of membranes or other 2-D surfaces Merging with or becoming objects Overlapping realities, such as being in two places at once

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Salvia

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K-2, Spice, Synthetic Cannabinoids Very diverse class of drugs Bind to the cannabinoid receptor Similar effects to marijuana Often more intense effects Include hallucinogenic and psychedelic effects

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K-2, Spice, Synthetic Cannabinoids Reported effects Impaired driving incidentsSuicide attempts Increased anxietyPanic attacks PalpitationsRespiratory complications AggressionMood instability Altered perceptionParanoia

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K-2/Synthetic Cannabinoids

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Bath Salts, MDPV, Khat Synthetic cathinones Function as dopamine-norepinephrine reuptake inhibitors Four times more potent than Ritalin or Concerta Duration of action 3-4 hours, with after-effects lasting as long as 6-8 hours

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Bath Salts, MDPV, Khat CNS/Psych effectsCV effectsRespiratory effectsRenal/GI effects AggressionHypertensionTachypneaTransaminitis AgitationVasoconstrictionRespiratory alkalosisUrinary incontinence ConfusionTachycardiaFecal incontinence Extreme anxietyChest painNausea/vomiting HallucinationsRhabdomyolysis HyperthermiaAKI Delusions Paranoia Suicidal ideations

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Bath Salts, MDPV, Khat Amateur chemists change the chemical composition of the bath salt and make it nearly impossible for regulation to keep up with production. Mortality rate from excited delirium estimated at 8-14%, most die while in police custody Treatment is supportive Benzos, restraints if necessary, watch for rhabdo

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Bath Salts, MDPV, Khat Elevated temperature Agitated delirium Respiratory arrest DEATH

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Bath Salts, MDPV, Khat

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Energy Drinks Drinks like Red Bull, Rock Star, Monster Contain caffeine and other legal stimulants (guarana, ginseng) Can contain 75 to >200 mg of caffeine per serving 34 mg per serving in Coke 55 mg per serving in Mt. Dew If it says no caffeine, then it uses guarana, which is the same as caffeine

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Energy Drinks 5-hour energy advertises no crash, but that relates to the sugar crash Contains artificial sweeteners Short term problems Increased heart rate, palpitations Hypertension Dehydration Sleep problems

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Energy Drinks Some may have 2 servings per can When used occasionally, not necessarily dangerous Think of them as highly caffeinated drinks Combination with alcohol The stimulant effect of the energy drink can mask how intoxicated someone is Can give the drinker the impression they are not impaired Research shows that people drink more and have higher BALs when they combine alcohol and caffeine

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Energy Drinks ER visits related to energy drink consumption 10,068 in 2007; 20,783 in 2011 60% of patients drank energy drink alone 27% of patients combined with prescription drugs 13% combined with alcohol 10% combined with illegal drugs 9% combined with prescription stimulants

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Questions