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Clinical Experience of Novel Psychoactive Substances Dr Richard Stevenson

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Legal Highs & Lows. Clinical Experience of Novel Psychoactive Substances Dr Richard Stevenson. Background. Legal Highs -> Novel Psychoactive Substances 41 new substances in 2010 alone Diverse collection of compounds Piperazines Cathinones Synthetic cannabinoids Isolated compounds - PowerPoint PPT Presentation


Page 1: Legal Highs & Lows

Clinical Experience of Novel Psychoactive Substances

Dr Richard Stevenson

Page 2: Legal Highs & Lows

BackgroundLegal Highs -> Novel Psychoactive

Substances41 new substances in 2010 aloneDiverse collection of compounds

PiperazinesCathinonesSynthetic cannabinoidsIsolated compounds

Recreational problem identified in 2008/2009Varying legal status

Page 3: Legal Highs & Lows

GRI Emergency Dept Experience12 AMT22 synthetic cannabinoids3 cathinone2 methoxetamine1 salvia

9 life threatening toxicities

Page 4: Legal Highs & Lows

Why are people taking them?Legal statusPerception of safetyDifficult to detect

Point of care urine testingOdourless

AvailabilityInternet“Head shops”

Sold as other drugs

Page 5: Legal Highs & Lows



Page 6: Legal Highs & Lows

Common ProblemsLack of reliable data“Not what is says on the tin”DosageInter-individual variabilityTime of onset to effectPolysubstance misuseInteractions ?

Page 7: Legal Highs & Lows

Challenges in Clinical CareAcute

Identification of xenobioticLack of toxicological data

Mechanism of action Duration Clinical effects

Appropriate treatmentChronic

Long term psychological effectsLong term physical effects

Page 8: Legal Highs & Lows

CathinonesSynthetic variations of natural cathinones in KhatMephedrone, methedrone, naphyroneIvory wave, meow-meow, bubbles, ocean snow,

NRGSympathetic Toxidrome

↑HR, RR, BP, tempTremor, agitation, paranoia, hallucinations, seizures***duration 24 – 48 hours***

TreatmentsBenzodiazepines +/- haloperidol

Page 9: Legal Highs & Lows
Page 10: Legal Highs & Lows

PiperazinesDeveloped in 1950s – anti-helminthic agentsBZP “Benzo Fury”

Neurotransmitter release/reuptake inhibitionPhenylpiperazines

Direct serotonin receptor activationReversal of serotonin uptake

ClinicallySympathetic toxidromeSerotonin toxicity?

Page 11: Legal Highs & Lows

Synthetic CannabinoidsAnnihilation, Black Mamba, Spice, K2Structurally dissimilar to THCHerbal material sprayed with chemicalsClinical effects

Nausea +++CollapseSome psychotropic effects

Page 12: Legal Highs & Lows

MethoextamineStructurally similar to ketamineNMDA receptor agonistClinically (dose related)

Excitation, tachycardia, euphoriaHallucinationsDissociationProlonged neurological effects - ataxia

Supportive management

Page 13: Legal Highs & Lows

AMT/5-ITAMT – Alphamethyltryptamine5-IT – 5-aminopropylindoleAMT researched as antidepressant in 1960’sNon-specific MAOI

Hallucinations +++Psychomotor agitation +++Serotonin toxicity

High risk of toxicity

Page 14: Legal Highs & Lows

Serotonin ToxicityExposure to a

serotonergic drugClinical features



musculoskeletal system

Page 15: Legal Highs & Lows

Treatment of Serotonin ToxcityMorbidity & Mortality related to

hyperthermiaTemp ≥40 oCDuration

ConsequencesRhabdomyolysisAcute kidney injuryAcidosisCerebral damage

Page 16: Legal Highs & Lows

Treatment of Serotonin ToxicityAggressive coolingAntipyretics do not work!Control muscular activity

High dose benzodiazepinesHaloperidol for severe non-responders

Appropriate fluid controlBP control agentsAnaesthesia with muscle paralysis

Page 17: Legal Highs & Lows

The Future?Market flooded with NPSDifficult to legislate/controlLong term effects?