psychotropic medications update plus synthetic & emerging drugs of abuse

Psychotropic Medications Update PLUS

Synthetic & Emerging Drugs of Abuse

Daniel Castellanos, MDAssistant Dean of Graduate Medical Education

Founding Chair, Department of Psychiatry & Behavioral Health Professor of Psychiatry & Behavioral Health and Pediatrics

Herbert Wertheim College of Medicine

Miami-Dade County Public SchoolsDivision of Exceptional Student Education

Clinical Behavioral ServicesE/BD Program Strategies and Interventions

January 8, 2016

2016

Disclosures

Consultant, Florida Medicaid Drug Therapy Management Program for Behavioral HealthUniversity of South Florida/AHCA

No other relevant financial disclosures

Castellanos 2016

Identify the names and indications for use of commonly prescribed psychotropic medications

Recognize the names and indications of newer FDA approved psychotropic medications

Identify the types of synthetic and emerging drugs of abuse, including “flakka”, ecstasy, synthetic cannabinoids, ketamine and others

Recognize the prevalence of use of these drugs

Recognize the psychoactive and physical effects secondary to use of these drugs

Learning Objectives

Castellanos 2016

Psychotropic Medications

Update2016

Castellanos 2016

Stimulants & Other Medications Used to Treat ADHD

Stimulants & Other

Medications Used to

Treat ADHD

FIU


Training

Castellanos 2016

FDA Max FDA Approved for ADHD

Children & AdolGeneric Name Brand Name® per day

Atomoxetine Strattera 100 mg Yes

Bupropion Wellbutrin SR/XL400 mg(SR) /

450(XL)No

Clonidine Catapres 0.4 mg No

Clonidine ER Kapvay 0.4 mg Yes

Dexmethylphenidate Focalin 20 mg Yes

Dexmethylphenidate XR Focalin XR 30 mg Yes

Dextroamphetamine Dexedrine 40 mg Yes

Guanfecine Tenex 4 mg No

Guanfecine ER Intuniv 4 mg Yes

Lisdexamphetamine Vyvanse 70 mg Yes

Methylphenidate

Daytrana Patch

Methylin

Ritalin

30 mg

60 mg

60 mg

Yes

Methylphenidate ER

Concerta

Metadate CD

Ritalin LA

Quillivant XR

72 mg

60 mg

60 mg

60 mg

Yes

Mixed Amphetamine salts Adderall 40 mg Yes

Mixed Amphetamine salts XR Adderall XR 30 mg Yes


Castellanos 2016

Castellanos 2016

FDA Max FDA Approved for ADHD

Children & AdolGeneric Name Brand Name® per day

Atomoxetine Strattera 100 mg Yes

Bupropion Wellbutrin SR/XL400 mg(SR) /

450(XL)No

Clonidine Catapres 0.4 mg No

Clonidine ER Kapvay 0.4 mg Yes

Dexmethylphenidate Focalin 20 mg Yes

Dexmethylphenidate XR Focalin XR 30 mg Yes

Dextroamphetamine Dexedrine 40 mg Yes

Guanfecine Tenex 4 mg No

Guanfecine ER Intuniv 4 mg Yes

Lisdexamphetamine Vyvanse 70 mg Yes

Methylphenidate

Daytrana Patch

Methylin

Ritalin

30 mg

60 mg

60 mg

Yes

Methylphenidate ER

Concerta

Metadate CD

Ritalin LA

Quillivant XR

72 mg

60 mg

60 mg

60 mg

Yes

Mixed Amphetamine salts Adderall 40 mg Yes

Mixed Amphetamine salts XR Adderall XR 30 mg Yes


Castellanos 2016

Antidepressants

Antidepressants

FIU


Training

Castellanos 2016

Generic Name Brand Name®FDA Max

per day

FDA Approved for

Major Depression in

Children & Adolescents

Bupropion Wellbutrin 450 mg No

Bupropion SR/XL Wellbutrin SR/XL 400 mg(SR) /

450(XL)No

Citalopram Celexa 40 mg No

Desvenlafaxine Pristiq 400 mg No

Doxepin Silenor 6 mg No

Duloxetine Cymbalta 120 mg No

Escitalopram Lexapro 20 mg Yes-Children & Adol (12-17)

Fluoxetine Prozac 80 mg Yes-Children & Adol (8-17)

Fluoxetine Sarafem 80 mg No

Fluvoxamine Luvox 300 mg No

Fluvoxamine CR Luvox CR 300 mg No

Levomilnacipran ER Fetzima 120 mg No

Mirtazapine Remeron 45 mg No

Paroxetine Paxil, Pexeva 50 mg No

Paroxetine CR Paxil CR 62.5 mg No

Selegiline Emsam patch 12 mg No

Sertraline Zoloft 200 mg No

Venlafaxine Effexor 375 mg No

Venlafaxine XR Effexor XR 225 mg No

Vilazodone Viibryd 40 mg No

Vortioxetine Brintellix 20 mg No

Antidepressants - Newer

Castellanos 2016

Generic Name Brand Name®

FDA Max

per day

FDA Approved for

Major Depression

Clomipramine Anafranil

200 mg

(children/adol)

250 mg (adults)

No

Doxepin Sinequan 300 mg Adults

Trazodone Desyrel 300 mg Adults

Amitryptiline Elavil 300 mg Adults

Nortryptiline Pamelor 200 mg Adults

Imipramine Tofranil 300 mg Adults

Antidepressants - Older

Castellanos 2016

Generic Name Brand Name®Bulimia

Nervosa

Generalized

Anxiety

Disorder

OCDPanic

DisorderPMDD PTSD

Social Anxiety

Disorder

Vortioxetine Brintellix

Citalopram Celexa

Duloxetine Cymbalta

Velanfaxine Effexor

Venlafaxine XR Effexor XR

Selegine Emsam patch

Fetzima Levomilnacipran CR

Escitalopram Lexapro

Fluvoxamine Luvox

Fluvoxamine CR Luvox CR

Paroxetine Paxil, Pexeva

Paroxetine CR Paxil CR

Desvenlafaxine Pristiq

Fluoxetine Prozac

Mirtazapine Remeron

Fluoxetine Serafem

Doxepin Silenor

Vilazodone Viibryd

Bupropion Wellbutrin

Bupropion SR/XL Wellbutrin SR/XL

Sertraline Zoloft

Antidepressants – Newer- FDA Indications Adults

Castellanos 2016

Antipsychotics

Antipsychotics

FIU

Psychotropic Medications Training

Castellanos 2016

Antipsychotics - Newer

* Long acting injection

Generic Name Brand Name® FDA Max per day

FDA Approved in

Children & Adolescents for

Schizophrenia Mania/Bipolar

Aripiprazole Abilify 30 mg Yes-Adolescents (13-17)Yes-Child & Adolescents

(10-17)

Aripiprazole Abilify Maintena* 400 mg/4 wks No No

Asenapine Saphris 20 mg NoYes-Child & Adolescents

(10-17)

Brexpiprazole Rexulti 4mg No No

Cariprazine Vraylar 6mg No No

Clozapine Clozaril 900 mg No No

Iloperidone Fanapt 24 mg No No

Lurasidone Latuda160 mg-Schizophrenia

120 mg-BPD DepressionNo No

Loxapine Adasuve 10 mg (Inhaled) No No

Olanzapine Zyprexa Relprevv*300 mg/2 wks or 405 mg/4

wksNo No

Olanzapine Zyprexa 20 mg Yes-Adolescents (13-17) Yes-Adolescents (13-17)

Paliperidone Invega 12 mg Yes-Adolescents (12-17) No

Paliperidone Invega Sustenna* 234 mg/4 wks No No

Paliperidone Invega Trinza* 819 mg/12 wks No No

Quetiapine Seroquel 800 mg Yes-Adolescents (13-17)Yes-Child & Adolescents

(10-17)

Risperidone Risperdal 6 mg Yes-Adolescents (13-17)Yes-Child & Adolescents

(10-17)

Risperidone Risperdal Consta* 50 mg/2 wks No No

Ziprasidone Geodon 160 mg No No

Castellanos 2016

Generic Name Brand Name® FDA Max per day

FDA Approved in

Children & Adolescents for

Schizophrenia Mania/Bipolar

ChlorpromazineNo current brand

name exists1,000 mg No No

FluphenazineNo current brand

name exists20 mg No No

Fluphenazine Prolixin Decanoate* 50 mg/2 wks No No

HaloperidolNo current brand


Haloperidol Haldol Decanoate* 200 mg/4 wks No No

Loxapine Loxitane 100 mg No No

PerphenazineNo current brand


Pimozide Orap 10 mg No No

ThioridazineNo current brand


Thiothixene Navane 50 mg No No

TrifluoperazineNo current brand


Antipsychotics - Older

* Long acting injection

Castellanos 2016

Generic Name Brand Name®Schizophrenia

(13-17 yo)

Bipolar I

Disorder

(10-17 yo)

Autism

Spectrum

Disorder

(6-17 yo)

Aripiprazole Abilify

Asenapine Saphris

Olanzapine Zyprexa 13-17 yo

Paliperidone Invega 12-17 yo

Quetiapine Seroquel

Risperidone Risperdal

Children & Adolescents & AntipsychoticsSummary of FDA Indications

Castellanos 2016

2013: 2 new antidepressants FDA approved:

Vortioxetine (Brintellix®)

Levomilnacipran CR (Fetzima®)

2014: 0

2015: Antipsychotics FDA approved:

Aripiprazole lauroxil (Aristada®) – use up to 6 wks Brexpiprazole (Rexulti®)

Cariprazine (Vraylar®)

Paliperidone (Invega Trinza®) – use every 12 wks

Digital Medicine…

ANew

Era is

Coming

Castellanos 2016

Digital medicine

Managing consumer health by the use of : Ingestible sensors Wearable and implantable physiological sensors Mobile communication technology Web-based patient communities

Represents a new and rapidly evolving paradigm in healthcare

Eg; Proteus Digital Health

Castellanos 2016

Digital medicine

Digital medications:

Contain the same medications available today

In addition, each pill also contains a tiny ingestible sensor which communicates about medication-taking behaviors in real time

Utilizes digital health feedback system

Castellanos 2016

Digital medicine

Digital medications II:

First application of the ingestion sensor is to measure a consumer’s adherence to oral medication therapy regimens (medication levels)

Other uses include how the body is responding (eg, blood pressure, pulse, etc) and many others

Will allow consumers, families & physicians to take appropriate action in response to a consumer’s adherence pattern and specific health metrics

Castellanos 2016

Digital medicine

Stretchable electronics (patches):

Contain sophisticated, integrated sensing systems

Possible functions: Transdermal delivery of medication Monitor therapeutic levels of medication Monitor various health functions: pulse; blood

pressure; stress; activity (including movements), etc Detect street drug levels Others

Castellanos 2016

Digital medicine


Castellanos 2016

Digital medicine


Synthetic&

Emerging Drugs

of Abuse

2016

Castellanos 2016

Identify the types of designer drugs, including “flakka”, ecstasy, synthetic cannabinoids and others

Recognize the prevalence of use of these drugs

Recognize the psychoactive and physical effects secondary to use of these drugs

Learning Objectives

Castellanos Intro Child & Adol Psychiatry 2015

Epidemiology/Prevalence

Castellanos 2016

Children aged

3-17 yrscurrently

had:

Source: MMWR, 2013

ADHD 6.8%

Behavioral or conduct

disorder 3.5%

Anxiety3.0%

Depression2.1%

Castellanos 2016

Epidemiology

Disorders in which the majority of cases begin in childhood:

ADHD (attention-deficit/hyperactivity disorder)

Autism Spectrum Disorders & Intellectual Disability

Anxiety Disorders

Oppositional Defiant Disorder (ODD)

Most of the childhood-onset disorders have more male than female cases

(Rutter M, Caspi A, Moffitt T, 2003)

Castellanos 2016

Lifetime Prevalence of Behavioral Health Disorders Adolescents

Source: Meriknagas,et al, 2010

Castellanos 2016

Epidemiology

Disorders that usually begin in adolescence:

Social anxiety disorder

Panic disorder

Substance use disorders

Depressive disorders

Anorexia nervosa & bulimia nervosa

Most adolescent disorders have more female than male cases (Rutter M, Caspi A, Moffitt T, 2003)

Castellanos 2016

Reported Drinking Patterns Among 8th, 10th & 12th Grade Students: 2013

Castellanos 2016

Past Month Use of Tobacco Products

Castellanos 2016

Top Drugs Among 8th & 12th Graders, Past Year Use

Castellanos 2016

Adolescents -Trends in Annual Prevalence of an Illicit Drug Use

Castellanos 2016

Annual Prevalence of Designer Drug Use by US 8th, 10th & 12th Graders, 2013

Source: Johnson LD et al, Monitoring the Future National Survey on Drug Use, 2014

%

Synthetic Marijuana

MDMA GHB Ketamine

0

1

2

3

4

5

6

7

8

4

1.1

7.4

3.6

7.9

4

11.4

8th

10th

12th%

Castellanos 2016

% of Florida High School Students who used Club Drugs* & Synthetic Marijuana,

2013

Lifetime Past 30 Days Lifetime Past 30 Days

Club Drugs* Synthetic Marijuana

*Ecstasy, Rohypnol, GHB, KetamineSource: 2013 Florida Youth Substance Abuse Survey

0

2

4

6

8

10

12

14

16

2.1

0.3unk unk

4.6

1.1unk unk

5.3

1.8

14.8

1.8

8th

10th

12th

Castellanos 2016

Thirty-Day Prevalence of Use of Various Types DrugsAges 19-30, 2014

Source: Monitoring the Future Survey Results on Drugs Use 1975-2014Castellanos 2016

Thirty-Day Prevalence of Use of Various Types DrugsAges 19-30 by gender, 2014

Source: Monitoring the Future Survey Results on Drugs Use 1975-2014Castellanos 2016

Adolescents Differ from Adults in Substances Most Abused

Castellanos 2016

Adults lifetime

prevalence

Source: Kessler, et al, National Comorbidity Survey, 2005

Any substance use disorder

14.6%

Any anxiety disorder

28.8%

Major depression16.6%

ADHD8.1%

PTSD6.8%

Bipolar Disorder

3.9%OCD1.6%

Castellanos 2016

The adolescent brain is often likened to a car with a fully functioning gas pedal (the reward system) but weak brakes (the prefrontal cortex).

Teenagers are highly motivated to pursue pleasurable rewards and avoid pain, but their judgment and decision-making skills are still limited.

Importance of

the Teenage

Years

Castellanos 2016

This affects their ability to weigh risks accurately and make sound decisions, including decisions about using drugs.

For these reasons, adolescents are a major target for prevention messages promoting healthy, drug-free behavior and giving young people encouragement and skills to avoid the temptations of experimenting with drugs.

Importance of

the Teenage

Years

Castellanos 2016

The teenage years are a critical window of vulnerability to substance use disorders, because the brain is still developing and malleable (a property known as neuroplasticity).

Some brain areas are less mature than others.

The parts of the brain that process feelings of reward and pain are the first to mature during childhood.

Importance of

the Teenage

Years

Castellanos 2016

What remains incompletely developed during the teen years are the prefrontal cortex and its connections to other brain regions.

The prefrontal cortex is responsible for assessing situations, making sound decisions, and controlling our emotions and impulses; typically this circuitry is not mature until a person is in his or her mid-20s.

Importance of

the Teenage

Years

Castellanos 2016

Images of Brain Development in Healthy Youth (Ages 5-20)

Themature brain regions at each developmental stage are indicated in blue/purple.

The prefrontal cortex, which governs judgment and self-control, is the last part of the brain to mature.

.

Castellanos 2016

Substance Related

& Addictive Disorders

Castellanos 2016

True or False?

The DSM-IV term Substance “dependence” was

replaced with Substance “addiction” in DSM-5.

Castellanos 2016

Substance Use

Disorders

Qualifiers used in the category: Use replaces both abuse and dependence Intoxication remains sameWithdrawal remains same

SUDs will be coded with DSM-IV substance dependence

codes

Castellanos 2016

Substance Use

Disorders (cont’d)

Alcohol

Opioid

Sedative, Hypnotic or Anxiolytic

Cocaine

Cannabis Use Disorder

Other Hallucinogen

Inhalant

Tobacco

Amphetamine

Phencyclidine

Castellanos 2016

Substance Use

Disorders

There are two major changes to the new DSM-5 criteria for substance use disorder:

“Recurrent legal problems” criterion for substance abuse has been deleted from DSM-5

A new criterion has been added: craving or a strong desire or urge to use a substance

Castellanos 2016

Substance Use

Disorder Criteria

1. Taking the substance in larger amounts or for longer than the you meant to

2. Wanting to cut down or stop using the substance but not managing to

3. Spending a lot of time getting, using, or recovering from use of the substance

4. Cravings and urges to use the substance

5. Not managing to do what you should at work, home or school, because of substance use

6. Continuing to use, even when it causes problems in relationships

Castellanos 2016

Substance Use

Disorder Criteria

7. Giving up important social, occupational or recreational activities because of substance use

8. Using substances again and again, even when it puts the you in danger

9. Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance

10. Needing more of the substance to get the effect you want (tolerance)

11. Development of withdrawal symptoms, which can be relieved by taking more of the substance

Castellanos 2016

Severity specifiers of the SUDs is based on the number of criteria endorsed: 2–3 criteria = mild disorder 4–5 criteria = moderate disorder 6 or more = severe disorder

Substance Use

DisorderCriteria

Castellanos 2016

Synthetic &

EmergingDrugs

Castellanos 2016

Overview of

the Problem

Designer and club drug use has increased in popularity over the past 2-4 years

Serious medical and psychiatric consequences can result

We have seen an increase in ED visits associated with use of these drugs

Castellanos 2016

Overview of

the Problem

The newest compounds on the street are chemically different than the first generation compounds.

They are potent, impairing and addictive, but their chemistry makes them invisible to older designer drug screens and traditional drug tests.

Data show newer designer drugs are increasingly associated with more medical complications and drug related deaths.

Although labeled as “not for human consumption,” these substances often come as a powder to be snorted, injected, smoked or vaped by users.

Castellanos 2016

Overview of

the Problem

While local retail sales of these now mostly illegal drugs have diminished, new venues of illicit distribution were appearing, ranging from online orders to courier delivery services, as street and club sales also continued.

Manufacturers are constantly coming up with new compounds to stay ahead of the law and avoid detection.

Castellanos 2016

Synthetic &

EmergingDrugs

GHB

Ketamine

Kratom

Dextromethorphan

Sizzurp

Prescription drugs

Ecstasy / MDMA

Synthetic Marijuana/Cannabinoids

Bath Salts / Flakka

Castellanos 2016

Castellanos 2016Castellanos 2016

Symptoms &

Management Issues

Synthetic &

Emerging Drugs

Castellanos 2016

Castellanos 2016

Synthetic and short-acting opioid analgesic

50-100 times more potent than morphine

Approved for managing acute or chronic pain associated with advanced cancer.

Most cases of fentanyl-related ED cases and deaths are linked to illicitly manufactured fentanyl and fentanyl analogs (non-pharmaceutical fentanyl -NPF)

Castellanos 2016

Effects include:

Nausea

Confusion

Constipation

Sedation

Unconsciousness

Respiratory depression and arrest

Coma

Euphoria

Drowsiness

Tolerance

Addiction.

Castellanos 2016

Centers for Disease Control and Prevention (CDC) and the DEA report increases in fentanyl-related unintentional overdose fatalities in multiple states

Overdoses involving fentanyl are on the rise

In 16 months we have had 51 deaths involving Flakka

Broward County had 53 deaths from fentanyl in 2014 and has passed that number in 2015

Castellanos 2016

Sizzurp

Castellanos 2016

History of

SizzurpOriginated in Houston, Texas

1960: It was first used by Blues singers in the in order to perform and continue to work

They used Robitussin with beer and then when wine coolers became popular they replaced it

1980-1990: The recipe was changed to use it with codeine promethazine cough syrup with a lemon lime soda and Jolly Ranchers

1990s: Made popular by a DJ in Houston and his music being played in a slow tempo as if they were on codeine and promethazine

This concoction caused his early death and it was then that is caught the attention of law enforcement

2012: It became popular in the hip hop community

Castellanos 2016

Other Names

Purple drank

Purple lean

Purple jelly

Texas Tea

Syrup

Castellanos 2016

Justin Bieber Guzzles High Quality Sizzurp1/19/2014 12:48 PM PST BY TMZ STAFF

Was Justin Bieber Drinking Sizzurp At

His 20th Birthday Celebration?By Sophie Miskiw in Lifestyle / Showbiz on 04 March 2014

What is sizzurp? Justin Bieber reportedly addicted to

dangerous drink favored by rappers like Lil WayneThe homemade concoction is well-known among young people due to its mention in hip-hop lyrics, and can even be deadly, experts say.BY Tracy Miller

NEW YORK DAILY NEWS

Thursday, January 23, 2014, 1:00 PM

Castellanos 2016

http://www.nydailynews.com/authors?author=Tracy-Miller

Overview of

Sizzurp

It’s a concoction which includes:Cough syrup with codeinePromethazineJolly Rancher candy or SkittlesSoda popUsually served in Styrofoam cup but also drank out

of the soda bottle

Castellanos 2016

Physical &

Psychoactive Effects

of Sizzurp

Slow reaction time

Sedation

Relaxation

Decreased respiratory rate

Weight gain

Tooth decay

Dizziness

Lethargy

Dissociative feeling

Motor skill impairment

Castellanos 2016

Dangers of

Sizzurp

Seizures when mixed with alcohol or if person prone to seizures

Shut-off of the respiratory center in the brain

Castellanos 2016

PrescriptionMedicati0ns

Castellanos 2016

The 2011 National Youth Risk Behavior Survey (YRBS) (www.cdc.gov/yrbss) found that 1 in 5 high school students in the US have ever taken a prescription drug, such as OxyContin, Percocet, Vicodin, Adderall, Ritalin, or Xanax, without a doctor’s prescription.

Nonmedical use

of prescription drugs

Castellanos 2016

Top Drugs Among 8th & 12th Graders, Past Year Use

Castellanos 2016

Castellanos 2016

Ecstasy

Castellanos 2016

Castellanos 2016

If you think its “Molly”

it may actually be methylone

or ethylone

Molly is the street name for the synthetic drug MDMA

It’s called Molly because of the capsule or powder form it comes in, as opposed to tabs

The presumption is that the “molecular” form, or Molly for short, is more pure

Many drugs sold as Ecstasy (MDMA) are really something else

Eg, finding of methylone or ethylone, key ingredients in bath salts

Most drug users don’t know who designed their drugs

Castellanos 2016

Emergency Room Visits,

Miami-Dade County

398 MDMA -involved ED visits for Miami-Dade County during 2011

Represents 2 percent of all ED visits among 6 categories of substances (cocaine, cannabinoids, illicit stimulants, MDMA, nonmedical use of prescription opioids & BZs

The 2011 total represented a 91 percent increase over the 209 MDMA reports in 2004

Castellanos 2016

Castellanos 2016

Ecstasy - MDMA

Castellanos 2016

Overview of

Ecstasy

MDMA 3,4 -methylenedioxymethamphetamine

Hallucinogenic amphetamine

Historical use in research and psychotherapy

DEA ban on MDMA in 1985

Castellanos 2016

Ecstasy- MDMA

MDMA doses range from 80 to 150 mg but doses as high as 300 mg have been detected.

Prices varies greatly. A single table is typically $10-25 but can cost as much as $50.

Onset 20 to 40 minutes

Effects last less than 24 hours

Street names: e, Adam, X, XTC, purest form MOLLY (Usually white pill or powder)

Castellanos 2016

Physical Effects

of Ecstasy /

MDMA

Castellanos 2016

Physical Effects

of Ecstasy /

MDMA

Neurological:

Increased restlessness

Motor tics

Headaches

Neurotoxicity - Damage of serotonin nerve endings

Cardiovascular:

Tachycardia

Arrhythmias

Hypertension

Castellanos 2016

Physical Effects

of Ecstasy /

MDMAOphthalmologic (eyes):

Nystagmus

Kidney:

Secondary to muscle breakdown (Rhabdomyolysis)

Muscular:

Bruxism (teeth grinding) & jaw clenching

Muscle rigidity & breakdown: Rhabdomyolysis (breakdown products of damaged muscle cells are released into the bloodstream) can lead to kidney problems

Castellanos 2016

Physical Effects

of Ecstasy /

MDMAOthers:

Decreased appetite

Elevated temperature (users frequently drink/carry bottles of water)

Hepatotoxicity (liver)

Castellanos 2016


of Ecstasy /

MDMA

Castellanos 2016


of Ecstasy /

MDMACognitive:Memory problems for at least 2 weeks after use

Altered time perception

Affect:

EuphoriaIncreased anxietyDepressed mood

Anhedonia

Castellanos 2016


of Ecstasy /

MDMABehavior:Increased energyDecreased aggressionDecreased defensiveness/disinhibitionLethargy

Perceptual:Changes in visual perceptions

Castellanos 2016


of Ecstasy /

MDMAOther:

Increased ability to interact with othersDecreased desire/motivation to perform mental or

physical tasksIncreased or decreased libido

Increased awareness of emotions

Castellanos 2016

Synthetic Cannabinoids

Castellanos 2016

Overview of


Product line marketed as incense, herbal or aromatic incense or potpourri

“Not for human consumption” All ingredients don’t have to be listed

Not “intended” for smoking but most of the products are smoked in hand-held pipes, water pipes or rolled in cigarette paper

Synthetic cannabinoid is sprayed on the product.

Manufacturers are substituting more potent synthetic cannabinoid products every day

Castellanos 2016

Synthetic Cannabinoids Crime Lab Cases in Florida: 2010-2014

0

200

400

600

800

1000

1200

1400

1600

1800

2000

2200

2010 2011 2012 2013 2014

AM-2201

XLR-11

AB-FUBINACA

PB-22

UR-144

AB-PINACA

Various JWH

All Other Cannabinoids

301

Nu

mb

er

of

Cri

me

La

b R

ep

ort

s

Source: Analysis of US DEA - National Forensic Laboratory System Data

9

1,209

2,087 1,996

Castellanos 2016

Castellanos 2016


Physical Effects

Castellanos 2016


Physical EffectsA number of users experience hangover-like

effects the morning after use including dry mouth, intense headaches

Depending on the product, inhaled smoke is as harsh as marijuana smoke:Taste can vary from a very bad to very sweet tasteOne user described the taste as “sickly sweet”

Ophthalmologic (eyes):Conjunctival injectionMydriasisPhotosensitivityDry eyes

Castellanos 2016


Physical EffectsNeuro-muscular:

Tremors Numbness A warm sensation in the limbs Muscle spasms Seizures Impaired coordination Headaches or painless head pressure Light headedness

Cardiovascular: Tachycardia Increased blood pressure

Castellanos 2016


Physical Effects

Gastrointestinal: Nausea, vomitingIncreased appetite (“munchies”)Dry mouth

Castellanos 2016


Physical Effects

Others:Insomnia Paleness of skinListlessness / Lack of interestSweating

Castellanos 2016

Synthetic CannabinoidsPsychoactive

Effects

Castellanos 2016



Mood changes:

Giddiness

Castellanos 2016



Mood changes:

Euphoria

Anxiety

Panic attacks

Irritability

Depression

Giddiness

Castellanos 2016


Effects Cognitive changes:

Impaired short term memory

Confusion

Cognitive dulling

Impairment of linear thinking

Time distortion

Castellanos 2016


Effects Behavioral changes:

Sedation

Excitability

Agitation

Aggression

Sleep Changes

Delirium

Castellanos 2016



Suicide:

Multiple reports connecting SC use and suicide can be found in the media and throughout the internet

Review of scientific literature discovered a handful of subjects in different studies and case reports describing suicide and suicidal behaviors with SC use

Relationship between SC use and suicide is unclear

Castellanos 2016


Effects Psychosis:

Hallucinations- auditory & visual

Disorganized thinking

Disorganized behavior

Delusions (paranoid)

Agitation

Aggression

Can be new onset or exacerbation of previously stable psychotic disorders

Psychotic symptoms may persist beyond acute intoxication

Castellanos 2016



Addiction/Dependence:

Research on the addictive properties of SCs has produced varying results.

Case reports and users report symptoms of dependence such as cravings, continued use despite knowledge of physical or psychological harm, tolerance and withdrawal symptoms.

SCs have been shown to cause greater dopamine release than MDMA and may therefore have a greater abuse liability.

SO….. SCs can be addictive and continued, heavy usage could result in withdrawal/dependency symptoms

Castellanos 2016

PsychosisNew onset Exacerbation of previously stable psychotic disorders

Extreme mood changes

Effects persist beyond acute intoxication

Tolerance, withdrawal & dependence may be associated with long term use

Summaryof

Dangers of


Castellanos 2016

Clinical

Presentations

Castellanos 2016

Acute Care

Presentation

Some clinical symptoms similar to cannabis intoxication:

Reddened eyes

Mild sedation

Euphoria

Giddiness

Paranoia

Perceptual distortions

Memory deficits

Impaired short-term memory

Castellanos 2016

Acute Care

PresentationPhysical symptoms not typically seen with cannabis intoxication:

Seizures

Hypokalemia

Palpitations

Hypertension

Respiratory difficulties

Abdominal/flank pain

Acute kidney injury

Nausea/vomiting

Coma

Castellanos 2016

Acute Care

Presentation

Psychoactive symptoms not typically seen with

cannabis intoxication:

Agitation

Violent behavior

Impulsivity

Disorganized thoughts

Auditory & visual hallucinations

Delusions, typically paranoid

Castellanos 2016

Office Presentation

Typically:

User not intoxicated at the time of office visit User typically denies use More readily agrees to tox screen/testing SCs not first drug used; most typically have used

marijuana before Living situation involves being monitored for use (eg,

teens who have found to be using marijuana)

Castellanos 2016

Bath Salts / Synthetic

Cathinones /Flakka

Castellanos 2016

History of

Bath Salts

First synthesized in the 1920s

In 2009-2010: they became popular in the underground market

2010: started to be marketed as “ not for human consumption”

2011: New York was one of the first states to ban the sale of Bath salts

2012: President Obama signed a bill that amended the Federal drug policy of the United States to ban “bath salts”

Castellanos 2016

History of

Bath Salts

Khat, a leafy plant native to East Africa and the Arabian Peninsula, is chewed for its stimulatory effects, mild euphoric and appetite suppression.

Khat is a natural cathinone.

First generation synthetic bath salts were comprised mainly of the synthetic cathinones mephedrone and MDPV (3,4 methylenedioxypyrovalerone).

These drugs were sometimes called the “poor man’s cocaine.”

Castellanos 2016

History of

Bath Salts

Bath salts or synthetic cathinones continue to evolve.

Newer bath salts have been comprised of methylone, ethylone and alpha-pvp (alpha-pyrrolidinopentiophenone).

In reality, we don’t know what is contained in these drugs.

Castellanos 2016

http://www.designerdrugtrends.org/documents/trendsreport2015_3.pdf Castellanos 2016

Ethylone Candy

Castellanos 2016

Include some of the latest designer drugs

Used as synthetic stimulants

Illegal in at least 41 states and pending legislation in the others

Poison Control Center has received over 4,000 calls last year

Bath Salts

Castellanos 2016

"Flakka” is the latest of these drugs to hit the street.

Flakka is thought to be mainly comprised of alpha-PVP, a novel psychoactive substance that has been on the recreational drug market since 2012.

Former street names include “Gravel”, which was allegedly alpha-PVP mixed with lorazepam, and other bath salts.

Flakka

Castellanos 2016

Flakka is sometimes called a “second generation” bath salt.

The chemical structures of these drugs are constantly changing.

We expect for a “newer” compound to replace flakka sometime in the future.

Flakka

Castellanos 2016

Typically sold as powder or crystals

Approx $3-$40

Routes of administration: Snorting Oral Injection Smoking Use with electronic cigarettes increasing

Desired effects last for a few hours

Adverse side effects can last from hours to days

Flakka

Castellanos 2016

Flakka Hospital Cases: Broward Health

0

20

40

60

80

100

120

140

160

180

12-19yrs

20-29yrs

30-39yrs

40-49yrs

50-59yrs

60-69yrs

70-79yrs

80-89yrs

90 yrs

10

177 180

98

44

10 2 1 1

Flakka Cases by Age

Nu

mb

er

of

Fla

kka C

ases

Mean Age = 33 years

Average Age = 35.4 years

Castellanos 2016

FlakkaDeathsBroward County, Florida

September, 2014 – June 15, 2015

Castellanos 2016

1 1 1

6

1

2

3 3

6

1

0

1

2

3

4

5

6

7

Sep Oct Nov Dec Jan Feb Mar Apr May Jun

2014 2015

Broward County Flakka Related Deaths By Month/Year (9/14 - 6/15)

# F

lak

ka

-Re

late

d D

ea

ths

Castellanos 2016

Physical Effects

of Flakka /

Bath Salts

Castellanos 2016

Physical Effects

of Flakka /

Bath SaltsPoor judgment and insight

Cardiovascular:Tachycardia Hypertension

Endocrine:

Increased temperature- Users will frequently remove some/all of clothing

Castellanos 2016

Physical Effects

of Flakka /

Bath SaltsMuscular:

Bruxism (teeth grinding) & jaw clenching

Muscle breakdown: Rhabdomyolysis (breakdown products of damaged muscle cells are released into the bloodstream) can lead to kidney problems

Muscle spasms

Difficulty with muscle coordination

Kidney:

Secondary to muscle breakdown (Rhabdomyolysis)

Castellanos 2016


of Flakka /

Bath Salts

Castellanos 2016


of Flakka /

Bath Salts

Behavior: Agitation

Increased body strength Aggression Impulsivity

Affect: Anger, irritability

Labile affect Blunting or flattening Distress

Castellanos 2016


of Flakka /

Bath Salts

Speech:

Yelling

Repetitive speech

Illogical speech

Psychosis:

Hallucinations

Paranoia

Delusions

“Excited delirium”

Castellanos 2016

What did you

observe on

this video?

Muscle spasm


Agitation

Labile, inappropriate affect

Yelling, speech difficulties

Distress

Impulsivity

Lack of Judgment and Insight

?Hallucinations

?Paranoia

?Delusions

Castellanos Designer & Emerging Drugs of Abuse 2015

What did you

observe on

this video?

Muscle spasm


Agitation

Gaze (“crazed look”)

Inappropriate affect

Yelling, speech difficulties

Distress

Impulsivity

Lack of Judgment and Insight

?Hallucinations

?Paranoia

?Delusions


Treatment/

Interventions

Castellanos 2016

Acute Treatment-

Intoxication

When multiple substances used, unclear which signs, symptoms are a result of which substance

Time of use to time of evaluation in ED varies; some symptoms persist others improve by the time the person is attended to in the ED

Literature:Is limited to anecdotal reports, single case reports, case

seriesFrequently based on self/family report of use; still limited

toxicological confirmation

Castellanos 2016

Acute treatment is supportive:

Fluids- Individuals seen in the ED usually require IV fluids

Lower body temperature (frequently also associated with agitation)

Address kidney functioning to prevent more serious kidney problems

Acute Treatment-

Intoxication

Castellanos 2016

Acute treatment is supportive:

Address agitation; aggression:Lorazepam is frequently used IM/IV/PO for acute

improvement Address psychosis:

Short term use of antipsychotic meds can be beneficialSometimes psychosis lingers or doesn’t remit

AcuteTreatment-

Intoxication

Castellanos 2016

Little or no research examining best treatment practices after the acute intoxication

Treatment:

Frequently needs to address use of multiple substances

Needs to be multimodal

Interventions are guided by the class the synthetic drug belongs to (eg, stimulants, hallucinogens)

Should address co-occurring psychiatric conditions (such as, psychosis if has not remitted after the acute intoxication)

OngoingTreatment

Castellanos 2016


Take Home Points

Become familiar with:Types of newer drugs being abused Clinical symptoms of presentation

Evidence based practices should guide your evaluation and management

Castellanos 2016


Parting Thoughts

Designer drug use will not go away.

New drugs will continue to emerge.

No matter how designer drugs evolve, we need to be ready

Castellanos 2016

psychotropic medications update plus synthetic & emerging drugs of abuse

Documents