“Novel Psychoactive Substances”What to know and what to doWhat to know and what to doWhat to know and what to doWhat to know and what to do

RCP Northern

Update in Medicine

27th November 2017

Dr Simon Hill

Disclosures

• I have no financial disclosures

• All images are either:

– Freely reusable under creative commons

– Used with permission

– My own

Objectives

1. Define ‘NPS’

2. Make the case that this an important problem

3. Provide a structured approach to patient

assessment

4. Outline acute patient management

5. Discuss novel fentanyls

6. Provide take home messages

7. Provide self assessment

WHAT ARE THEY?

Legal Legal Legal Legal HighsHighsHighsHighs‘‘‘‘Designer drugs’Designer drugs’Designer drugs’Designer drugs’

‘Research Chemicals’‘Research Chemicals’‘Research Chemicals’‘Research Chemicals’‘Party pills‘Party pills‘Party pills‘Party pills’’’’

‘Novel Psychoactive ‘Novel Psychoactive ‘Novel Psychoactive ‘Novel Psychoactive Substances’Substances’Substances’Substances’

Novel Psychoactive Substances

(NPS)

• Formal definition– Harmful substances not controlled by UN Conventions

• A practical definition– ‘New stuff’

• May have been legal

• Modified classical drugs

• Unknown pharmacology, toxicity, safety

• Quite a variety– >500 different chemicals

IS THIS IMPORTANT?

Mortality

2011 2012 2013 2014 2015 2016

NPS 31 55 63 82 114 123

Source: ONS. Deaths related to drug poisoning in England and Wales: 2016 registrations

Mortality

2011 2012 2013 2014 2015 2016

All 2652 2597 2955 3346 3674 3744

NPS 31 55 63 82 114 123

Mortality

2011 2012 2013 2014 2015 2016

All 2652 2597 2955 3346 3674 3744

NPS 31 55 63 82 114 123

Cocaine 112 139 169 247 320 371

Heroin /

Morphine

596 579 765 962 1201 1209

MDMA 13 31 43 50 57 n/a

Cannabis 7 14 11 28 21 n/a

Age-standardised mortality rate for deaths related to

drug misuse, by country and region, registered in 2016

Newcastle NPS activity – January 2016

• North East Ambulance Service reported– 263 calls in January 2016 linked to ‘legal highs’

– 97 in February – after a range of targeted activity

• Police reported– 225 calls linked to ‘legal highs’ in January

– 71 between 1 Feb and 21 Feb

• Hospital involvement mainly dealt with by acute

services

PATIENT ASSESSMENT &

MANAGEMENT

Why might it be helpful to know what

they took?

• Risk assessment

– Location and duration of care

– Anticipate complications

– Guide specific management

• Differential diagnosis

– Acute psychosis, thyrotoxicosis, sepsis, encephalopathy, encephalitis, phaeochromocytoma, withdrawal syndromes

What did they take?

The problem with Products

• Constituents vary

• Quality

• Multiple chemicals

Testing

• Immunoassays

– Availability

– Limited scope

– False negatives

– False positives

• LC-MS/MS

– Availability

– Cost

Toxidrome approach

Stimulant Depressant

HallucinogenSynthetic

cannabinoid

NPS

Stimulants

Presentation

• Pill, snorted powder, IV

• Agitated, paranoid, violent

• Chest pain

• BP 185/113

• HR 126/min

• Dilated pupils

• Catecholamine excess

Stimulants

NPS Examples

• Substituted amphetamines

• Cathinones

– Mephedrone

– MDPV

• NBOMe

• Ethylphenidate

Stimulant

Management

• Benzodiazepines

• Aggressive cooling

• Critical care

• Manage agitation

Caution

• Serotonin syndrome

• Hyperthermia / MOF

• Vasoconstriction & Vascular

complications

• Agitation / Psychosis

• Beta-blocker caution

Depressant

Presentation

• Tablets, ‘Blues’, IV

• GCS 8/15

• Respiratory rate 9/ min

• pH 7.22, PaC02 8.9

• Opioid or GABA receptor

agonism

NPS Examples

• Opioids

– Fentanil derivatives

– AH-7921, U47700

• Benzodiazepines

– Etizolam, Diclazepam

• Dissociatives

– Methoxetamine

Depressant

Management

• Airway management

• Naloxone 400microg IV

• Flumazenil with caution

Caution

• Oxygen

• Early discharge

• Novel opioids / naloxone

failure

• Flumazenil

Hallucinogen

Presentation

• Visual, auditory, tactile

• Behavioural

• Few physiological changes

– Tachycardia

– Mydriasis

– Hyperthermia

– Platelet dysfunction

• Serotonin 2a receptor agonism

NPS Examples

• 1p-LSD

• AMT

• NBOMe

Hallucinogen

Management

• Calm & keep safe

• Benzodiazepines

• Antipsychotics

Caution

• Agitation / Psychosis

• Ketamine

• AMT

Hallucinogen

SCRA

Presentation

• Smoked

• Reduced GCS

• Respiratory depression

• Acidosis

• Agitation/psychosis

• CVS disturbance

– Tachy or bradycardia

• Seizure

• Mydriasis

NPS Examples

• MDMB-CHMICA

• AB-FUBINACA

• AKB-48

SCRA

Management

• Calm & keep safe

• Benzodiazepines

• Airway protection

• Manage acidosis

Caution

• Mental health disturbances

• Reduced GCS

• Acidosis

• Social

IONA study

• 24 sites in the UK

• Severe toxicity due to suspected NPS

• Consent

• Clinical data collection

• Linked-anonymised

• Bio-fluid analysis by non-targeted LC-MS/MS

CI - Professor Simon Thomas

Fentanyl derivatives

EMCDDA notifications – fentanyls

Example: Illicit drug overdose deaths with

fentanyl detected, British Columbia , Canada

Rodent toxicology data

Take home messages

• No “legal highs” since PSA 2016

• People take drugs, you probably won’t know which on admission

• Use a Toxidromes approach to risk assess and manage– Stimulant

– Depressant

– Hallucinogen

– SCRA

• Hyperthermia, CVS derangement and acute mental health disturbances require caution

• Fentanyl derivatives of increasing concern

• NPIS can help

TOXBASE®

Image attributions

• http://freeforcommercialuse.org/photos/cup-coffee/

• https://pixabay.com/en/cigarette-smoking-smoke-ash-1359562/

• Guardian – written permission

• 2.0 Graham Richardson from Plymouth, England. https://commons.wikimedia.org/wiki/File:SWAS-ambo-shout.jpg

• 2.0 Ivaan Kotulsky via Toronto History from Toronto, Canada.https://commons.wikimedia.org/wiki/File:Man_lying_on_street.jpg

• NPIS annual report 2014/15 front cover

• https://commons.wikimedia.org/wiki/File:Ketamine.JPG

• Nutschig at the English language wikipedia. https://commons.wikimedia.org/wiki/File:Dilated_pupils_2006_(cropped).jpg

• moodygroove at the English language wikipedia. https://commons.wikimedia.org/wiki/File:SinusTach.jpg

• https://commons.wikimedia.org/wiki/File:Trippy.jpg

• https://commons.wikimedia.org/wiki/File:25C-NBOMe_blotter.jpg

• https://commons.wikimedia.org/wiki/File:USMC-100201-M-3762C-001.jpg

SELF ASSESSMENT

Toxidromes: self-assessmentConnect the presentation with the correct Toxidrome

Presentation

• Homeless. GCS 9/15, mydriasis, smoked ‘something’, PaC02 6.8

• Violent, HR 145/min, Temp 41.2°C

• GCS 15/15, HR 96/min, says ‘I can smell colours’

• GCS 3/15 paramedic but improved to 15 without treatment after 1 hour. Has been raped, HR 52/min

Toxidrome

• Stimulant

• Depressant

• Hallucinogen

• SCRA

True or false?

1. The duration of action of naloxone is longer than the

effects of novel opioids

2. Ketamine is the first line agent for severe agitation due to

NPS

3. If intubation and ventilation is required for stimulant

toxicity avoid fentanils in anaesthesia / sedation

4. Heroin remains the most potent abused opioid

5. SCRA can cause respiratory drive suppression

6. If a novel opioid is suspected increase naloxone initial dose

to 2g IV

7. NPS use is less common in those with mental health

problems

True or false?

1. The duration of action of naloxone is longer than the

effects of novel opioids False

2. Ketamine is the first line agent for severe agitation due to

NPS False

3. If intubation and ventilation is required for stimulant

toxicity avoid fentanils in anaesthesia / sedation True

4. Heroin remains the most potent abused opioid False

5. SCRA can cause respiratory drive suppression True

6. If a novel opioid is suspected increase naloxone initial dose

to 2g IV False

7. NPS use is less common in those with mental health

problems False