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Northern New England Poison Center Teen Poisonings

from RX Drugs to K2, Salvia and Monster

Karen E. Simone, PharmD, DABATsimonk@mmc.org

207-662-7221

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Contents

• Overview of poisoning (abuse, suicide, other)

• Types of teen substance abuse poisonings

• Most commonly abuse substances (by teens)

• Substances used in teen suicide attempts

• Information about the substances abused

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Northern New England Poison Center Staff

• Physicians board-certified in Toxicology

• PharmD board-certified in Toxicology

• Nurses nationally-certified in Poison Information

• Nurses in Training

• Nurse Educators, some with Public Health Masters

• EMTs and other providers (under supervision)

• Administrative, including toxicsurveillance specialist

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Northern New England Hotline Calls

Human Poisonings30%

Confirmed Non-Exposures

<1%

Animal Poisonings2%

Questions68%

N = 107,533

ME, NH, VT; 2009

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Types of PoisoningsHotline Call Reasons

• Unintentional– General, environmental, misuse, therapeutic error,

occupational, food poisoning, bite/sting• Intentional

– Abuse, misuse, suicide attempt• Other

– Malicious, tampering/contamination, withdrawal• Adverse effect

– Drug, chemical, other• Unknown

– Drug, chemical, other

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Types of CallsQuestion Types

• Substance Abuse– Identification, effects, drug screens, withdrawal

• Medication– Pharmacology, adverse effects, interactions, withdrawal

• Toxicology– General, environmental, food poisoning, pregnancy/lactation

• Prevention/safety– Plants, lectures/health fairs, printed materials

• Occupation– Safety, monitoring

• Medical/legal/other– Drug, chemical, other

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Poisonings in Teens 13 - 18 years

Unintentional47%

Suicide Attempt24%

Substance Abuse/Withdrawal12%

Other Intentional11%

Adverse /reaction3%

Malicious/tampering2%

Unknown1%

ME from July 2009 - June 2010

N=926

Unintentional: 26% therapeutic error 29% misuse

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Substance Abuse/Withdrawal

Dextromethorphan21%

Stimulants/street drugs18%

Analgesics (opioid mostly)12%

Alcohol10%

Inhalants6%

Antidepressants5%

Plants/mushrooms4%

Other9%

Sedatives/hypnotics9%

Antihistamines6%

N=156 substances

Children under 19 years

ME from July 2009 - June 2010

Alcohol: Mostly unknown beverage, some vodka and tequila, Listerine spray and hand sanitizer

Inhalants: Keyboard cleaner, disc cleaner, spray paint, markers, helium, nail polish remover, fire extinguisher

Plants: Nutmeg (3), kratom (1)

Substance Abuse

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Stimulants and Street Drugs

Marijuana35%

ADHD Medications29%

Caffeine (pills/drinks)14%

Ecstasy and related11%

K27%

Cocaine4%

N=28

Children under 19 years

ME from July 2009 - June 2010

Substance Abuse

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Analgesics

Buprenorphine (Suboxone)21%

Acetaminophen (Tylenol)17%

Oxycodone (OxyContin, Percocet)

17%

Codeine11%

Ibuprofen (Motrin)11%

Tramadol (Ultram)11%

Hydrocodone (Vicodin, Lortab)6%

Unknown opioid6%

N=18

Children under 19 years

ME from July 2009 - June 2010

Substance Abuse

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Sedatives/Hypnotics

Benzodiazepine (Xanax, Ativan, Valium, Klonopin)

43%

Zolpidem (Ambien)36%

Antipsychotic21%

N=14

Children under 19 years

ME from July 2009 - June 2010

Substance Abuse

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Suicide Attempts

Analgesics31%

Antidepressants19%

Sedatives/hypnotics13%

Other9%

Antihistamines6%

Cough and cold5%

Alcohols4%

Stimulants/street drugs4%

Anticonvulsants3%

Vitamins2%

Antibiotics2%

Cardiovascular2%

N=336 substances

Children under 19 years

ME from July 2009 - June 2010Suicide Attempts

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Analgesics

NSAIAs (ibuprofen, naproxen)35%

Acetaminophen (Tylenol)30%

Aspirin10%

Opioids9%

Acetaminophen with (diphenhydramine, caffeine,

menstrual)9%

Acetaminophen and Aspirin6%

Other (phenazopyridine)1%

N=106 substances

Children under 19 years

ME from July 2009 - June 2010

Suicide Attempts

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PCP (Phenycyclidine)-like• Dextromethorphan (DXM) +/- antihistamine

– Slang: DXM, RoboTrip or Triple C

– Products: Robitussin DM, Coricidin HBP for Cough and Cold, others

• Dissociative analgesic/anesthetic in overdose– Caused by metabolite – dextrorphan

– Dissociation of thalamoneocortical from limbic systems

• Drowsiness or agitation – Coma or seizures possible but not common

• Vertical or rotary nystagmus may be present

• Large or small pupils possible

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Amphetamines• Amphetamine brand names: Adderall,

Dexedrine, Vyvanse

• Amphetamine-like brand names: Ritalin, Concerta, Methylin, Focalin

• Medical concerns:– Increased heart rate and blood pressure (irregular

heart rhythm, heart attack, stroke)– Increased body temperature– Seizures– Psychosis– Addiction

Similar to cocaine

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What do all of these products have in common?

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Caffeine

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Caffeine – Dietary SupplementsYellow Swarm Extreme Energizer by Yellow Jacket

• Yellow Swarm Extreme Energizer, Yellow Jacket• Ephedra Free, • Herbal Dietary Supplement, • Extreme Energy. • Yellow Swarm Extreme Energizer is a proprietary blend of herbs that

combines Green Tea Extract, Yerba Mate, Guarana, Capsicum and Kola Nut. Yellow Swarm (Yellow Jacket) provides you with an extreme boost of energy when you need it.

• Supplement FactsServing Size: 1 capsule Amount Per Serving % Daily Value Caffeine (anhydrous) 300mgProprietary Blend 211mgGreen Tea Extract 60% (Leaves)(4.5 mg Caffeine Alkaloids),Yerba Mate (leaves), Guarana (Seeds),Capsicum Annuum (fruit), Kola Nut (seeds)(<1 mg Caffeine Group Alkaloids),Ginseng (Root)

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Caffeine Content:• Tea (green-black) 40-50mg/8oz• Coffee 100mg/8oz• Starbucks Grande 330mg/16oz• Coca-Cola Classic 35mg/12oz• Mountain Dew 54mg/12oz• Red Bull 76mg/8.3oz• Monster 160mg/16oz• No Doz 200mg/tablet

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What effects can occur?• Stomach: upset stomach and vomiting,

sometimes abdominal pain and diarrhea

• Nervous System: anxiety, agitation, irritability, tremor, headache, dizziness, hallucinations (not common) and seizures

• Heart: rapid heartbeat, increased blood pressure, chest pain and irregular rhythms

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Energy Drinks - Teenage Problem?

• Large amounts are available in forms marketed to teens and young adults.

• Teens and young adults often lack the good judgment to limit dosing.

• Some ingest up to 5 cans of energy drink (equivalent to 8 cups of coffee) in one sitting.

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What about caffeinewith alcohol?

• More risky behaviors (possibly)

• Not safer to drive: performance not significantly better, in some ways worse

• May not realize unsafe to drive: may have false sense of ability to drive safely

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What about carbs and calories?

• Sobe Adrenaline Rush 16 oz (2 servings):– Calories: 260

– Carbs: 68 g (22%) with 66 g as sugars

• Red Bull 8.3 oz (1 serving) – double if 16.9 oz: – Calories: 110

– Carbs: 28 g (9%) with 27 g as sugars

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Which has more carbs?

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Winner – Most Carbs• Sobe Adrenaline Rush 16 oz (2 servings):

– Calories: 260– Carbs: 68 g (22%) with 66 g as sugars

• Starbuck’s Grande Latte 16 oz: – Calories: 280– Carbs: 36 (12%) with 34 g as sugars

• Krispy Kreme Donut – Chocolate Iced Kreme Filled: – Calories: 350– Carbs: 39 g (13%) with 23 g as sugars

• McDonald’s Big Mac: – Calories: 540– Carbs: 45 g (15%) with 9 g as sugars

Caloric intake (16 – 18 yrs): 1800 – 2400 (females), 2400 – 3200 (males)

Coke and Pepsi have ~ 40 g carbs

per 12 oz (150 calories)

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Mushrooms (Shrooms)• Timing:

– Onset: 10 – 30 minutes

– Duration: 4 – 5 hours

– Back to normal: 6 – 12 hours

• Effects:– Fast heart rate, increased blood pressure, large

pupils, dry mouth, nausea/vomiting

– Uncontrollable laughter, vivid hallucinations (bright colors and shapes)

– Loss of sense of time, meditative

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Salvia divinorum• Names:

– Diviner’s sage, magic mint, Maria Pastoria• Use:

– Ceremonial healing– Divination rituals– An entheogen (“that which causes god to be within a

person”)• Component: salvinorin A

– Type: ?dissociative hallucinogen? • Similar to: PCP, ketamine and DXM

– Mechanism: Opioid kappa agonist• Similar to: butorphanol (Stadol®) and pentazocine (Talwin®)

– Dose: 100 – 200 mcg

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Salvia divinorum• Routes:

– Oral: Chew leaves or drink extract from fresh leaves• Onset: 5 – 10 minutes• Peak: 1 hour• Duration: 2 hours

– Inhalation: Smoke dried leaves• Onset: 30 seconds• Peak: 5 – 10 minutes• Duration: 20 – 30 minutes

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Salvia divinorum

• Hallucinogenic effects:– Type: out of body experience, entering another

reality, time and space displacement

– Effects: altered perceptions, hallucinations, ataxia, depersonalization, hysterical laughter, incoherent speech, unconsciousness

– Onset/duration: rapid/an hour or so

– Dose relationship (inhalation):• Hallucinations: 0.2 – 0.5 mg

• Out-of-body experience: > 1 mg

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K2 (Spice, Spice Gold)• Synthetic cannabinoid (JWH-

018 and JWH-073)

• Anticipate similar effects to marijuana

• Probably not illegal yet

• Not anticipated to cross with marijuana screens

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K2 (Spice, Spice Gold)

• Rapid heart rate, elevated blood pressure

• Anxiety/agitation/hallucinations

• Drowsiness/slurred speech

• Vomiting

• Numbness/tingling, tremors/seizures

• Pale appearance, dilated pupils

Dried herbs sprayed with synthetic cannabinoid-like substance

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Kratom – per labelStimulant and Depressant?

Amazing legal high / herbal high!

Low dose: stimulating and euphoricHigh dose: sedative at higher doses

Plant: mitragyna

Active ingredient: mitragynine

Mechanism: stimulates delta opioid receptors

Effects:Calms the mind, lowers anxietyCauses to feel: happy, strong, and active, with a strong desire to do work

Onset: 5 - 10 minutes after use

Duration: several hours (longest with highest dose), positive afterglow effect possible 1 day after use

High dose effect: a state of blissful euphoria with the possibility of mild visuals

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Kratum (mambog) – per science• Mitragyna with mitragynine • Psychoactive, opioid substitute• Use: increase productivity and heat tolerance• “Therapeutic” effects:

– Onset 5 – 10 minutes after chewing leaves– Type: mild euphoria and stimulation

• Overdose:– Effects: nausea, vomiting, flushing, stupor, vertigo, giddiness, tremors of

face, extremities and tongue, rombergism (loss of positional sense –unable to balance standing with feet together and eyes closed)

• Chronic toxicity:– Effects: anorexia, weight loss, abdominal distension and constipation,

skin discoloration (dry, unhealthy, tan without sun OR pallor), (numbness and twitching)

• Withdrawal:– Effects: aggression, tearfulness, runny nose, muscle aches, “jerky”

motions