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Will They Turn You into a Will They Turn You into a Zombie? Zombie? What Clinicians Need to What Clinicians Need to Know about Synthetic Drugs Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION
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Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

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Page 1: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

Will They Turn You into a Zombie?Will They Turn You into a Zombie?What Clinicians Need to Know about What Clinicians Need to Know about

Synthetic DrugsSynthetic DrugsTRAINER’S NAMETRAINING DATE

TRAINING LOCATION

Page 2: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

Training CollaboratorsTraining Collaborators

• Gulf Coast Addiction Technology Transfer Center–University of Texas, School of Social

Work• Pacific Southwest Addiction Technology

Transfer Center–UCLA Integrated Substance Abuse

Programs2

Page 3: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

Special AcknowledgementsSpecial Acknowledgements• Dr. Volker Auwaerter, University Medical Center

Freiburg, Germany• Dr. Michael Bauman, Intramural Research Program,

NIDA• Dr. Raimondo Bruno, University of Tasmania• Mathias Forrester, Texas Department of State

Health Services• Dr. Paul Griffiths, EMCDDA• James Hall, Nova Southeastern University• Dr. Barry Logan, National Medical Services Labs, Inc.

3

Page 4: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

IntroductionsIntroductions

Briefly tell us:• What is your name?• Where do you work and what you do there?• Who is your favorite musician or performer?• What is one reason you decided to attend this

training session?

4

Page 5: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

Educational Objectives Educational Objectives At the end of this presentation, participants will be able to:At the end of this presentation, participants will be able to:

1. Identify the key characteristics and effects of synthetic drugs, most notably synthetic cannabinoids and synthetic cathinones.

2. Describe the current information available on the availability and patterns of synthetic drug use in the United States.

3. Explain strategies for communicating the dangers involved with synthetic drug use.

5

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““Tales of Bath Salts and Zombie Tales of Bath Salts and Zombie CannibalismCannibalism””

• Bath Salts made headlines in summer 2012 when a story of possible cannibalism was reported in Miami, FL

• The Miami-Dade Medical Examiner found no traces of bath salts, LSD, or synthetic marijuana in the perpetrator's system

• The sole psychoactive substance detected was cannabis (marijuana)

6

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AN INTRODUCTION TO KEY AN INTRODUCTION TO KEY TERMS AND DEFINITIONSTERMS AND DEFINITIONS

7

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How Psychoactive Substances WorkHow Psychoactive Substances Work• Because of their chemical

structure, alcohol and drugs have dramatic effects on neurotransmitters in CNS.

• Effects on:– Mental processes– Behavior– Perception– Alertness

SOURCE: NIDA. (2010). Drugs, Brains, and Behavior: The Science of Addiction. 8

Page 9: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

Commonly Used Psychoactive SubstancesCommonly Used Psychoactive Substances

SOURCE: National Institute on Drug Abuse.SOURCE: National Institute on Drug Abuse.

SUBSTANCE EFFECTSAlcohol

(liquor, beer, wine)euphoria, stimulation, relaxation,

lower inhibitions, drowsiness

Cannabinoids (marijuana, hashish)

euphoria, relaxations, slowed reaction time, distorted perception

Opioids (heroin, opium, many pain meds)

euphoria, drowsiness, sedation

Stimulants (cocaine, methamphetamine)

exhilaration, energy

Club Drugs (MDMA/Ecstasy, GHB)

hallucinations, tactile sensitivity, lowered inhibition

Dissociative Drugs (Ketamine, PCP, DXM)

feel separated from body, delirium, impaired motor function

Hallucinogens(LSD, Mescaline)

hallucinations, altered perception9

Page 10: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

““Designer” Psychoactive SubstancesDesigner” Psychoactive Substances

SOURCE: http://www.drugs-forum.com. 10

Page 11: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

““Designer” Psychoactive SubstancesDesigner” Psychoactive SubstancesTwo classes: 1. Stimulants: mephedrone, MPDV, piperazines, “bath

salts”2. Psychedelics: 2C-B, mescaline, DMT, etc.Differences in users:1. Stimulant users similar to other ecstasy users; (shifting to

mephedrone and MPDV due to shortage of Ecstasy?)2. Psychedelic users started ecstasy use earlier; were more

frequent users; used multiple substances; had more legal, mental health, and social problems.

SOURCE: Bruno et al. (2012). Drug and Alcohol Dependence, 124(1-2), 19-25. 11

Page 12: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

Examples of Major Stimulant DrugsExamples of Major Stimulant DrugsDRUG NAME DESCRIPTIONMephedrone 4-methyl-methcathinone; “Miaow”

Similar to cocaine and MDMA (ecstasy)Methylone β-MDMA: 3,4-methylenedioxy-

methcathinone; “Explosion”Similar to cocaine and MDMA (ecstasy)

MDPV 3,4-methylenedioxyprovalerone; MDPV; “NRG-1” (Brandt, 2010); “Ivory Wave”Stimulant with rapid onset; 2-4 hour duration of action

BZP 1-benzyl-piperazoneSimilar to amphetamine1/10 potency of d-methamphetamine

SOURCE: Slide courtesy of R. Bruno et al., 2011, with revisions by James Hall, 2012. 12

Page 13: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

Examples of Major Psychedelic DrugsExamples of Major Psychedelic DrugsDRUG NAME DESCRIPTION

2C-I Phenethylamine, via PiHKAL; stimulant and hallucinogenSlow onset (1 hr); long duration of action (8-10 hr.)

2C-B Phenethylamine, via PiHKAL; visualsFaster onset (1 hr.); shorter duration than 2C-I

5-MeO-DMT Tryptamine; naturally occurring (toad, shamantic brews)Smoked: almost immediate, very intense, short effect (<30 min)

DMT Tryptamine; naturally occurringSmoked: almost immediate, very intense, short effect (<20 min)

SOURCE: Slide courtesy of R. Bruno et al., 2011, with revisions by James Hall, 2012. 13

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Why People Use Psychoactive SubstancesWhy People Use Psychoactive SubstancesWhy Start?

• Experimental• Peer Pressure• Medical

Why Continue? • Relieve

stress/pain• Function better• Have fun/relax• Cope with mental

health disordersSOURCE: NIDA. (2010). Drugs, Brains, and Behavior: The Science of Addiction. 14

Page 15: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

After repeated drug use, “deciding” to use After repeated drug use, “deciding” to use drugs is no longer voluntary becausedrugs is no longer voluntary because

DRUGS CHANGE THE BRAIN!DRUGS CHANGE THE BRAIN!

SOURCE: NIDA. (2010). Drugs, Brains, and Behavior: The Science of Addiction. 15

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Substance Use Disorder (SUD)Substance Use Disorder (SUD)

The language we use matters

Addiction

Abuse

Addict

Substance Misuse

Chemical DependenceDependence

Recreational userDrug Addict

AlcoholicAbuser

Risky user

Substance abuse

16

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What is a Substance Use Disorder?What is a Substance Use Disorder?• A substance use disorder (SUD) is a continuum of

problematic use of substances:– On one end of the continuum are people who are

using at risky levels. They may not be having problems yet, but are at risk of developing them if current level of use continues.

– On the other end, SUD is a complex, chronic, relapsing brain disease characterized by compulsive, and at times, uncontrollable drug craving, seeking, and use that persist even in the face of extremely negative consequences.

SOURCE: NIDA. (2010). Drugs, Brains, and Behavior: The Science of Addiction. 17

Page 18: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

Some Additional Important TerminologySome Additional Important Terminology

• Psychological craving

• Tolerance

• Withdrawal symptoms

18

Page 19: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

Psychological CravingPsychological Craving

• Psychological craving is a strong desire or urge to use drugs. Cravings are most apparent during drug withdrawal.

19

Page 20: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

ToleranceTolerance• Tolerance is a state in which a person no

longer responds to a drug as they did before, and a higher dose is required to achieve the same effect.

SOURCE: Krasnegor, N.A. (Ed.). (1978). Behavioral Tolerance: Research and Treatment Implications, NIDA Research Monograph 18. Rockville, MD: Department of Health, Education, and Welfare.

SOURCE: Krasnegor, N.A. (Ed.). (1978). Behavioral Tolerance: Research and Treatment Implications, NIDA Research Monograph 18. Rockville, MD: Department of Health, Education, and Welfare. 20

Page 21: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

WithdrawalWithdrawal

The following symptoms may occur when drug use is reduced or discontinued:

• Tremors, chills• Cramps• Emotional problems• Cognitive and attention deficits• Hallucinations• Convulsions• Death

SOURCE: APA. (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. SOURCE: APA. (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. 21

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A REVIEW OF SYNTHETIC A REVIEW OF SYNTHETIC CANNABINOIDS AND SYNTHETIC CANNABINOIDS AND SYNTHETIC

CATHINONESCATHINONES

22

Page 23: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

Synthetic Synthetic DrugsDrugs

• Not really “Spice,” “Bath Salts,” or “Incense”

• Chemically-based; not plant derived• Complex chemistry• Constantly changing to “stay legal”• Need to prove “intended to use” to

convict in some areas23

Page 24: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

Marijuana (Cannabis)Marijuana (Cannabis)• Often called pot, grass, reefer, MJ, weed, herb• A mixture of the dried, shredded leaves, stems,

seeds, and flowers of Cannabis sativa—the hemp plant• Most commonly used drug in the U.S.• Delta-9-tetrahydrocannabinol (THC) is the main active

ingredient in marijuana• Common effects include: euphoria, relaxation, heightened

sensory perception, laughter, altered perception of time, and increased appetite

• May also produce anxiety, fear, distrust, or panic, and can lead to severe mental health problems for some users.

SOURCE: NIDA. (2010). NIDA DrugFacts: Marijuana. 24

Page 25: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

Synthetic Cannabinoids (a.k.a. Spice)Synthetic Cannabinoids (a.k.a. Spice)

• Wide variety of herbal mixtures• Marketed as “safe” alternatives to marijuana• Brand names include: K2, fake weed, Yucatan

Fire, Skunk, Moon Rocks• Labeled “not for human consumption”• Contain dried, shredded plant material

and chemical additives that are responsible for their psychoactive effects.

SOURCE: NIDA. (2012). NIDA DrugFacts: Spice (Synthetic Marijuana). 25

Page 26: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

Synthetic Cannabinoids (Spice)Synthetic Cannabinoids (Spice)

• Mainly abused by smoking (alone or with marijuana); may also be prepared as an herbal infusion for drinking.

• The five active chemicals most frequently found in “Spice” products have been classified by the DEA as Schedule I controlled substances, making them illegal to buy, sell, or possess.

SOURCE: NIDA. (2012). NIDA DrugFacts: Spice (Synthetic Marijuana). 26

Page 27: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

Synthetic Cannabinoids: Synthetic Cannabinoids: The Major CompoundsThe Major Compounds

N

R2O

R1

R3

a) Naphthoylindoles

JWH-018 JWH-073

JWH-398 JWH-200

JWH-081 JWH-015

JWH-122 JWH-210

JWH-019 JWH-007

5-Fluoropentyl-JWH-122

b) Cyclohexylphenoles

OH

OHR1

R2

R3 R4

CP-47,497-C8

AM-2201 JWH-020

JWH-387 AM-1220

JWH-412

SOURCE: Agudelo et al. (2012). Effects of Synthetic Cannabinoids on the Blood Brain Barrier, Presented at 74th Annual CPDD.27

Page 28: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

JWH-018/073 arrived early and have come and gone.

JWH-250 arrived a little later and has also cycled out.

JWH-081 was part of a second wave that has already completed its cycle.

JWH-122 was part of the same wave but has persisted in popularity and is part of the current scene.

AM-2201 was part of the same second wave and has gained in popularity, probably currently the most prevalent.

JWH-022 and JWH-210 are showing signs of increasing popularity.

Recent emergent drugs are the adamantoyl (AM-1248) and tetramethylcyclopropyl (XLR-11 and UR-144) indoles which are ahead of the latest attempts to schedule these drug classes.

SOURCE: Logan, B.K. (2012). Testing Strategies to Monitor Novel/Emerging/Designer Drug Use in At-Risk Populations, Presented at 74th Annual CPDD.

The Emergence of The Emergence of Synthetic CannabinoidsSynthetic Cannabinoids

28

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Timeline of Synthetic Timeline of Synthetic Cannabinoids and Spice ProductsCannabinoids and Spice Products

SOURCE: Fattore & Fratta. (2011). Frontiers in Behavioral Neuroscience, 5(60), 1-12. 29

Page 30: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

Factors Associated with Spice Factors Associated with Spice Products’ PopularityProducts’ Popularity

• They induce psychoactive effects• They are readily available in retail stores

and online • The packaging is highly attractive• They are perceived as safe drugs• They are not easily detectable in urine and

blood samples

SOURCE: Fattore & Fratta. (2011). Frontiers in Behavioral Neuroscience, 5(60), 1-12. 30

Page 31: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

KhatKhat

• Pronounced “cot”• Stimulant drug derived from a shrub (Catha

edulis) native to East Africa and southern Arabia

• Use is considered illegal, because one of its chemical constituents, cathinone, is a Schedule I drug

• Khat found in the U.S. often comes in by mail from Africa

SOURCE: NIDA. (2011). NIDA DrugFacts: Khat. 31

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Synthetic Cathinones:Synthetic Cathinones:“Bath Salts” “Bath Salts” • Could be MDPV, 4-MMC,

mephedrone, or methylone• Sold on-line with little info on

ingredients, dosage, etc.• Advertised as legal highs, legal meth, cocaine, or ecstasy• Taken orally or by inhaling• Serious side effects include tachycardia, hypertension,

confusion or psychosis, nausea, convulsions• Labeled “not for human consumption” to get around

laws prohibiting sales or possession

SOURCE: Wood & Dargan. (2012). Therapeutic Drug Monitoring, 34, 363-367. 32

Page 33: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

Synthetic Cathinones are Synthetic Cathinones are -keto (‘bk’) -keto (‘bk’) Analogs of AmphetamineAnalogs of Amphetamine

N CH3

HO

CH3

Methcathinone

N CH3

HO

CH3

4-Methylmethcathinone(Mephedrone)

H3C

N CH3

H

CH3

Methamphetamine

N

O

O

O

3,4-Methylenedioxypyrovalerone(MDPV)

N

O

CH3

O

O

3,4-Methylenedioxmethcathinone(Methylone)

CH3

H

33

Page 34: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

Sources and Continuing AvailabilitySources and Continuing Availability• A number of synthetic marijuana and bath salt

products appear to originate overseas and are manufactured in the absence of quality controls and devoid of governmental regulatory oversight.

• The large profits from sales, plus the fact that these chemicals can be easily synthesized to stay one step ahead of control, indicate there is no incentive to discontinue retail distribution of synthetic cannabinoid products under the current statutory and regulatory scheme.

SOURCES: ONDCP, 2012; EMCDDA, 2011. 34

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Federal Efforts to Ban Synthetic DrugsFederal Efforts to Ban Synthetic Drugs• Mar 2011: Five synthetic cannabinoids were temporarily

categorized as Schedule I substances under the CSA. • Oct 2011: DEA exercised its emergency scheduling

authority to control some of the synthetic substances used to manufacture bath salts; these synthetic stimulants are now designated as Schedule I substances.

• Dec 2011: House of Representatives approves the Synthetic Drug Control Act (HR 1254).

• July 2012: Congress passed and President Obama signed the Synthetic Drug Abuse Prevention Act.

SOURCE: ONDCP, 2012. 35

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Texas Poison Control Exposures and Texas Poison Control Exposures and Effect of ControlsEffect of Controls

Synthetic Cannabis Synthetic Cathinones

SOURCE: Forrester, M.B. (2012). Synthetic Cannabinoids (Marijuana Homologs) Reported to the Texas Poison Control Network Update, September 4, 2012; and Synthetic Cathinones (Bath Salts) Reported to the Texas Poison Center Network Update, September 4, 2012. Austin, TX: Texas Department of State Health Services, monthly update. 36

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THE EFFECTS OF SYNTHETIC THE EFFECTS OF SYNTHETIC CANNABINOIDS AND SYNTHETIC CANNABINOIDS AND SYNTHETIC

CATHINONESCATHINONES

37

Page 38: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

“People high on these drugs can get very agitated and violent, exhibit psychosis, and severe behavior changes…some have been admitted to psychiatric hospitals and have

experienced continued neurological and psychological effects.”

(Dr. Rick Dart, AAPCC President)

SOURCE: Dimond, D. This Spice Can Kill You. Posted 8/8/12 at 2:49 p.m. 38

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Cannabis vs. Cannabinoids: Effects Cannabis vs. Cannabinoids: Effects Seen in Clinical CasesSeen in Clinical Cases

• Most symptoms are similar to cannabis intoxication:– Tachycardia– Reddened eyes– Anxiousness– Mild sedation– Hallucinations– Acute psychosis– Memory deficits

• Symptoms not typically seen after cannabis intoxication:– Seizures– Hypokalemia– Hypertension– Nausea/vomiting– Agitation– Violent behavior– Coma

SOURCES: Hermanns-Clausen et al. (In Press), Addiction; Rosenbaum et al. (2012). Journal of Medical Toxicology; Forrester et al. (2011). Journal of Addictive Disease; Schneir et al. (2011). Journal of Emergency Medicine. 39

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Agitation 82%

Combative/Violent behavior 57%

Tachycardia 56%

Hallucinations 40%

Paranoia 36%

Confusion 34%

Myoclonus/Movement disorders 19%

Hypertension 17%

Chest pain 17%

CPK elevations 9%

Clinical Symptoms of Synthetic Cathinone Clinical Symptoms of Synthetic Cathinone Use in Patients Admitted to the Use in Patients Admitted to the Emergency Department (N=236)Emergency Department (N=236)

SOURCE: Spiller et al. (2011). Clinical Toxicology, 49, 499-505. 40

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THE EPIDEMIOLOGY THE EPIDEMIOLOGY OF SYNTHETIC OF SYNTHETIC DRUG USEDRUG USE

41

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Calls Received by U.S. Poison Control Calls Received by U.S. Poison Control Centers for Human Exposure to Synthetic Centers for Human Exposure to Synthetic

Marijuana, 2010 to July 2012Marijuana, 2010 to July 2012

SOURCE: American Association of Poison Control Centers, Spice Data, updated August 2012.

2,906

6,959

The number of calls in 2011 were more than double that in 2010

3,821

2010 Jan-July 2012201142

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Emerging Drug Items Identified in U.S. Emerging Drug Items Identified in U.S. NFLIS Tox Labs: 2010 – 1/2 2012 NFLIS Tox Labs: 2010 – 1/2 2012

(1/2 2012 incomplete)(1/2 2012 incomplete)

SOURCE: U.S. DEA, Office of Diversion Control, NFLIS data, 2012. 43

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44

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Synthetic Cannabinoid Varieties Synthetic Cannabinoid Varieties 20102010

SOURCE: U.S. DEA, Office of Diversion Control, NFLIS data, 2010. 45

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Synthetic Cannabinoid Varieties Synthetic Cannabinoid Varieties 20112011

JWH-25012%

SOURCE: U.S. DEA, Office of Diversion Control, NFLIS data, 2011. 46

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Synthetic Cannabinoid Varieties Synthetic Cannabinoid Varieties 2012 (through 8/27/12)2012 (through 8/27/12)

SOURCE: U.S. DEA, Office of Diversion Control, NFLIS data, 2012. 47

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Calls Received by U.S. Poison Control Calls Received by U.S. Poison Control Centers for Human Exposure to Bath Centers for Human Exposure to Bath

Salts, 2010 to July 2012Salts, 2010 to July 2012

SOURCE: American Association of Poison Control Centers, Bath Salts Data, updated August 30, 2012.

304

6,138

The number of calls in 2011 were over 20 times that in 2010

2,078

2010 2011 Jan-July 201248

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Synthetic Cathinone Varieties Synthetic Cathinone Varieties 20102010

SOURCE: U.S. DEA, Office of Diversion Control, NFLIS data, 2010. 49

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Synthetic Cathinone Varieties Synthetic Cathinone Varieties 20112011

SOURCE: U.S. DEA, Office of Diversion Control, NFLIS data, 2011. 50

Page 51: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

Synthetic Cathinone Varieties Synthetic Cathinone Varieties 2012 (through 8/27/12)2012 (through 8/27/12)

SOURCE: U.S. DEA, Office of Diversion Control, NFLIS data, 2012. 51

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• Lack of availability of the reference standard for new drugs

• Variable quality of reference standards• Lack of purity and labeled internal standards• Chemical similarity of new

drugs within a class requires great care with identification

• Sensitivity (correctly IDs the drug)

Challenges with Challenges with Chromatography ScreeningChromatography Screening

SOURCE: Logan et al. (2012). Journal of Forensic Sciences, 57(5), 1168-1180. 52

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OTHER NOTABLE SYNTHETIC OTHER NOTABLE SYNTHETIC DRUGS – “NEW AND OLD”DRUGS – “NEW AND OLD”

53

Page 54: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs TRAINER’S NAME TRAINING DATE TRAINING LOCATION.

MDMA (Ecstasy)MDMA (Ecstasy)

• 3, 4-methylenedioxy-methamphetamine• Street terms: Adam, E, X, XTC, love drug, Molly • A synthetic, psychoactive drug with both

stimulant and hallucinogenic properties similar to methamphetamine and mescaline

• Adverse effects: enhanced physical activity, sweating, lack of coordination, mental confusion, jaw clenching, hyperthermia, and agitation

NIDA. (2010). NIDA InfoFacts: MDMA (Ecstasy). 54

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Glimpses of the Current Glimpses of the Current MDMA SituationMDMA Situation

• Australian EDRS reports drop in MDMA use from 52% in 2003 to 27% in 2011.

• Both Australia and UK report MDMA “drought.”

• Shift from PMK to safrole to make MDMA.

• Some experts predict return of high quality MDMA but from China, not BeneLux sources.

SOURCE: http://www.ecstasydata.org/stats_substance_by_year.php. 55

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Party Drugs Identified by U.S. Party Drugs Identified by U.S. Toxicology Labs: 2005-2011Toxicology Labs: 2005-2011

SOURCE: U.S. DEA, Office of Diversion Control, NFLIS data analysis by J.C. Maxwell. 56

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2C-Phenethylamine2C-Phenethylamine

• A broad range of compounds that share a common phenylethan-2-amine structure.

• Some are naturally occurring neurotransmitters (Dopamine and Epinephrine), while others are psychoactive stimulants (Amphetamine), entactogens (MDMA), or hallucinogens (the 2C-X series of compounds).

• 2 C-X can be snorted or dissolved into a liquid and placed on blotter paper under the tongue.

• May last 6-10 hours; onset takes 15 min -120 to 2 hours.

• Reports of seizures and renal failure.

SOURCE: U.S. DEA, Office of Diversion Control. (2012). National Forensic Laboratory Information System Special Report: Emerging 2C-Phenethylamines, Piperazines, and Trypamines in NFLIS, 2006-2011. 57

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Spread of 2C-Phenethylamine Spread of 2C-Phenethylamine throughout the United Statesthroughout the United States

SOURCE: U.S. DEA, Office of Diversion Control. (2012). National Forensic Laboratory Information System Special Report: Emerging 2C-Phenethylamines, Piperazines, and Trypamines in NFLIS, 2006-2011. 58

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PiperazinesPiperazines• Frenzy, Bliss, Charge, Herbal ecstasy, A2, Legal Z, Legal E.• Mainly available over internet and sold as ecstasy pills

that are “safe.”• Two classes: (1) benzylpiperazines (BZP) and (2)

phenylpiperazines (TFMPP).• Mimics effects of ecstasy (MDMA); dangerous with

seizure disorders, psychiatric illness, or coronary disease. • Adverse events included hypertension, reduced

consciousness, psychotic episode, hallucinations, tachycardia, hyperthermia, coma. Could be toxic if combined with MDMA or amphetamines.

SOURCE: Arbo, Bastos, & Carmo. (2012). Drug and Alcohol Dependence, 122(3), 165-258. 59

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BZP & TFMPPBZP & TFMPPBenzylopiperazine (BZP) and trifluoromethyl-phenylpiperazine (TFMPP) identified in US Toxicology Labs (NFLIS).

BZP TFMPP2007 274 1062008 4,252 1,5322009 8,943 2,8252010 5,216 1,6472011 3,536 1,225½ 2012 1,082 367

SOURCE: U.S. DEA, Office of Diversion Control, NFLIS data analysis by J.C. Maxwell. 60

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A Few Other Psychoactive A Few Other Psychoactive Substances to Throw in the Mix…Substances to Throw in the Mix…

• Kratom – opioid-like effects• Salvia divinorum – hallucinogenic

effects• Methoxetamine – “legal ketamine”

SOURCE: Rosenbaum et al. (2012). Journal of Medical Toxicology, 8(1), 15-32. 61

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PhencyclidinePhencyclidine

• PCP, Angel Dust, Killer Weed• Dissolved in embalming fluid (“Fry,”

“Amp,” “Water, Water”)• Swallowed, sniffed, smoked on joints

dipped in “Fry”• Users report out-of-body strength

SOURCE: NIDA. (2009). NIDA Drug Facts: Hallucinogens – LSD, Peyote, Psilocybin, and PCP. 62

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PCP Indicators in Texas: PCP Indicators in Texas: 1998-20111998-2011

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What is DXMDXM? ? DextromethorphanDextromethorphan is a psychoactive drug found in common over the counter cough medicines.

SOURCE: NIDA. (2001). NIDA Research Report Series: Hallucinogens and Dissociative Drugs. 64

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Past Month Use of Coricidin®: Past Month Use of Coricidin®: Texas Secondary School Survey Texas Secondary School Survey

2004-20102004-2010

SOURCE: Texas Department of State Health Services (DSHS), data analysis by J.C. Maxwell. 65

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Dextromethorphan (DXM)Dextromethorphan (DXM)• Dextromethorphan’s slang names include “Robo”.• At high doses, may produce dissociative

hallucinations (distance from reality, visual effects with eyes open and closed; perceptual changes, drug liking, mystical-type experiences similar to use of psilocybin.

• Can also produce tachycardia, hypertension, agitation, ataxia, and psychosis at high doses.

• Users of DXM engage in “dose dependent” behaviors in which they try to gauge the amount of the drug they take to produce the desired effects, which they call “plateaus”. Plateau is the mildest effect and the 5th plateau will guarantee a trip to the hospital.

SOURCES: Reissig et al. (2012). Psychopharmacology, 223(1), 1-15; http://dxm.darkridge.com/text/beginners.htm. 66

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CASE EXAMPLES, SAMPLE CASE EXAMPLES, SAMPLE TREATMENT PROTOCOLS, AND TREATMENT PROTOCOLS, AND

CONCLUDING THOUGHTSCONCLUDING THOUGHTS

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Case Example #1Case Example #1You are a professional in a setting working with youth (e.g., counselor, educator, tutor, etc.). During your normal duties, you overhear a group of youth talking about their interest in trying bath salts or spice.

1.What messages would you want to communicate?2.What strategies would you use to maintain trust but also being able to point out the possible dangers from using one of these synthetic drugs? 3.What initial assessment questions would you want to ask?4.What alternative activities would you explore to using these drugs?

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Case Example #2Case Example #2A sixteen year old male presents to your office with serious paranoia. He is screaming erratically, and inconsolable. You take him to a dark, quiet examination room, and restrain him for his and your safety. Once he calms down, and you inquire about his substance use history, he admits to trying spice at a friend’s house party three weeks ago. He said he usually smokes pot, but because he is searching for a part-time job, he decided to try spice instead, because his friends told him it wouldn’t come up on a drug screen. He only tried it one time, and does not report any other substance use except occasional use of beer and vodka and “pills of some sort.”

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Case Example #2, continuedCase Example #2, continued

1. What additional information do you want to know?

2. What safety issues need to be addressed?3. What kind of intervention does this youth

need?4. Do you believe that he has used only once? 5. What do you say about his use of beer and

pills?

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Bath Salts in MichiganBath Salts in MichiganCase Report – MMWR, May 2011Case Report – MMWR, May 2011

• First report to summarize epidemiology of bath salt ED cases

• Based on 35 people who had ingested, inhaled, or injected bath salts and subsequently visited a Michigan Emergency Department (ED) between 11/13/10 and 3/31/11

• Patients presented with hypertension, tachycardia, tremors, motor automatisms, mydriasis, delusions, and paranoia

• No relationship found between route of administration and severity of illness

SOURCE: Cheng, Yeo, Brown, & Regan. (2012). American Academy of Emergency Medicine, 19(2), 19-22. 72

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Sample Clinical Treatment Protocol Sample Clinical Treatment Protocol for Synthetic Cannabinoid Usersfor Synthetic Cannabinoid Users

• Direct individual to emergency room via ambulance

• Consult a regional Poison Control Center• Acute management consists of:

– Supportive care with the use of benzodiazepines, if needed, to control agitation and anxiety

– Observe until resolution of abnormal vital signs, vomiting, and psychiatric symptoms

SOURCE: Cheng, Yeo, Brown, & Regan. (2012). American Academy of Emergency Medicine, 19(2), 19-22. 73

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Sample Clinical Treatment Protocol Sample Clinical Treatment Protocol for Synthetic Cathinone Usersfor Synthetic Cathinone Users

• Supportive care• Aggressive sedation with benzodiazepines (for

agitation, seizures, tachycardia, and hypertension)

• Significant hyperthemia may require passive or active cooling.

• Lab studies including electrolytes, renal and liver function tests, cardiac markers, and creatine kinase should be considered.

SOURCE: Cheng, Yeo, Brown, & Regan. (2012). American Academy of Emergency Medicine, 19(2), 19-22. 74

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What do you do if someone has taken What do you do if someone has taken a Spice Product or Bath Salts?a Spice Product or Bath Salts?

• Call your local poison center at 1-800-222-1222– 57 poison centers around the country have

experts waiting to answer your call. – Experts can help you decide whether someone

can be treated at home, or whether he or she must go to a hospital.

• Dial 9-1-1 immediately if they:– Stop breathing– Collapse– Have a seizure

SOURCE: American Association of Poison Control Centers (AAPCC). (2012). Facts about Bath Salts.

…or if they have taken one of these and are having physical symptoms or behaving in a way that is concerning to you

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In Summary: Key PointsIn Summary: Key Points• Despite widespread Internet availability and use

among certain populations, health care providers remain largely unfamiliar with Spice products and Bath Salts.

• Research is needed to better understand the side effects and long-term consequences associated with the use of synthetic cannabinoids and synthetic cathinones

• More toxicological identification of these new drugs, more information on the sources of them, as well as their distribution and patterns of use is needed to curtail future increases in use.

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Resources for Continued LearningResources for Continued Learning

• American Association of Poison Control Centers, www.aapcc.org

• Drug Enforcement Administration, www.dea.usdoj.gov

• European Monitoring Centre for Drugs and Drug Addiction, www.emcdda.europa.eu

• National Institute on Drug Abuse, www.nida.nih.gov• Office of National Drug Control Policy,

www.ondcp.org • Refer to the Synthetic Drugs Reference List**

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Thank you for your time!Thank you for your time!For more information:

Jane C. Maxwell: [email protected] Rutkowski: [email protected] E. Freese: [email protected]

Gulf Coast ATTC: http://www.attcnetwork.org/gulfcoastPacific Southwest ATTC: http://www.psattc.org 78