You Smoked What? or Emerging Drugs of Abuse

7/9/2018

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You Smoked What?or

Emerging Drugs of Abuse

Francis L. Counselman, MD, CPE, FACEPEVMS Distinguished Professor and Chairman

Department of Emergency MedicineEastern Virginia Medical School

Overview

• There will always be new drugs

• Most new drugs involve manipulation of existing chemical structures

• Most new synthetic drugs have

psychoactive and

sympathomimetic

effects

Psychoactive Effects

Alterations in perception, mood or consciousness

Sympathomimetic Effects

• Mydriasis

• Increased heart rate and arrhythmias

• Increased blood pressure

• Increased respiratory rate

• Diaphoresis

• Hyperthermia

• Agitation

• Seizure

Overview

• Synthetic cathinones / Bath Salts

• Synthetic cannabinoids / Spice and K2

• Piperazines / Legal X

• Phenethylamines / 2C

• Kratom / Thang

• Salvia / Sally D

Overview

• Most purchased over Internet

• No quality control

• May not be drug you think

• May not be appropriate dose

• Most contain

adulterants

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Synthetic Cathinones

Bath Salts Vanilla Sky

Cloud 9 MCAT

Bubbles Explosion

White Lightning


• From leaves of khat plants

• Chewing khat very popular

• First reported in U.S. in 2007

• “Not for human consumption”

• Made illegal in U.S.

in 2011

Users

• Male (68%)

• <30yo (54%)

• 2700 U.K. dance club frequenters: 54%

• 1.3% by H.S. seniors in 2012


• Snorting (48%) followed by oral ingestion (29%)

• Occasional IV, IM, PR

• Average onset w/in 30 minutes

• Peak effect 45 to 90 minutes

• Duration up to

3 hours


• Cardiac: Tachycardia, palpitations, HTN, chest pain

• Psychiatric: Agitation, aggression, confusion

• Neurologic: Seizures


• Euphoria, talkativeness

• Visual, auditory or tactile hallucinations

• Nausea, vomiting, abdominal pain

• Mydriasis, burred vision

• Hyperthermia

• Rhabdomylosis

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Testing

• Based on presentation

• UDS usually negative

• Occasionally false positive for amphetamines (structurally similar)

Other Effects

• Metaboloic acidosis

• Hypoatremia

• Rhabdomyolsis

• Acute renal failure

Evaluation

• Cardiac monitor

• ECG

• Basic metabolic profile

• Urinalysis

• Urine pregnancy

test

• IV access

Treatment

• No antidote

• Symptom based

• Benzodiazephenes IV

- Lorazepam

• Restraints

• Supportive care

• Low-stimulation

environment

Synthetic Cannabinoids

Spice K2

Blaze Bliss

Black Mamba Aztec fire

Happy Tiger Incense

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• Marketed as incense, air freshner

• Gained popularity as legal alternative to weed

• Other biological herbs mixed in

• Minimal packaging

information


• Mixture of dried vegetable matter with

SC sprayed onto it

• Contains many substances

• Usually smoked


• First appeared in U.S. in 2009

• Given Schedule I status March 2011

• All SCs stimulate cannabinoid receptors

• Hundred of SCs exist

• Varying degree of clinical presentations

• Typical user: Male in teens to early 20’s

• 2012 survey: 11.3% of H.S. seniors used

• Clenbuterol


• Tachycardia

• Agitation

• Vomiting

• Confusion

• Hypertension

• Hallucinations

• Mydriasis

Testing


• UDS usually negative

• Commercial labs

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Evaluation

• Cardiac monitor

• ECG


• Urinalysis

• Urine pregnancy test

• IV access

Treatment

• No antidote

• Symptom based

• Benzodiazepines IV

• Supportive care

• Low-stimulation

environment

Piperazines

Smileys Legal X

BZP ESP

Silver Bullet Happy Pills

The Good Stuff

Piperazines

Overview• No natural counterpart

• Initially antihelminthic, then antidepressant

• Used in pill, powder or liquid form

• Typical user: young male

• Illegal in the U.S.

• Most common active substance found in drugs purchased over Internet

Piperazines

• Time of onset and duration variable

• Usually lasts 6 to 8 hours

• Most presentations involve sympathomimetic effects

• Benzyl and

Phenyl

Piperazines

• Headache

• Anxiety

• Palpitations

• Diaphoresis

• Shortness of

breath

• Confusion

• Hallucinations

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Testing


• UDS may be false positive for amphetamines

Evaluation

• Cardiac monitor

• ECG

• Basic metabolic panel

• Urinalysis


• IV access

Treatment

• No antidote

• Symptom based


• Supportive care

• Low-stimulation

environment

Phenethylamines

2C Toonies

Erox Bromo

Spectrum Venus

Phenethylamines

• PIHKAL: A Chemical Love Story

Alexander Shulgin, PhD

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Phenethylamines

• Both stimulant and hallucinogenic effects

• Snorting

Onset 5 – 15 mins

DOA 2 – 4 hours

• Oral

Onset 1 – 2.5 hours

DOA 5 – 7 hours

Phenethylamines

• Typical user: young males with h/o polydrugabuse

• Most are Schedule I

• New compounds constantly being developed

Phenethylamines

• Euphoria

• Hallucinations

• Agitation

• Nausea/Vomiting

• Tachycardia

• Hypertension

• Seizures

Testing


• Not detected on most drug screens

Evaluation

• Cardiac monitor

• ECG


• Urinalysis


• IV access

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Treatment

• No antidote

• Symptom based


• Supportive care

• Low-stimulation

environment

Kratom

Thang Thom

Blak Ketum

Kratom

• From tree in SE Asia – Mitragyna species

• Used by Thai and Malaysian manual workers for euphoria, stimulation, analgesia

• Used to help opioid withdrawal

• Smoked or ingested as a tea

• Available as leaves, powder, extract, encapsulated powder

Kratom

• No Federal law against

• Some states have outlawed

Kratom

• Dose dependent

• Low dose: stimulation, increased alertness, talkativeness, increased physical energy

• High dose: opiate and sedative effects

• Onset of action: 5-10 minutes

• Duration of action: 2-5 hours

Kratom

• Mitragynine 10x more potent than morphine

• Most patients present to the ED as opioid overdose or opioid withdrawal

• Kratom withdrawal and opioid withdrawal indistinguishable

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Kratom and Salmonella

• May 2018; 199 people infected

• 41 states

• 38% required hospitalization

• Recall initiated

Kratom and Salmonella

• Consider in young patients with presenting with fever, nausea, diarrhea, or crampy

abdominal pain

Testing

• Based on clinical presentation

• Not detected on ordinary drug screens

Evaluation

• Cardiac monitor

• ECG

• Basic metabolic panel

• Urinalysis


• IV access

Treatment

• No antidote

• No report of naloxone working

• Symptom based


• Supportive care

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Salvia

Sally D Seer’s Sage

Mystic Sage Magic Mint

Salvia

• 100s of species

• Salvia divinorum plant in Mexico

• Used during religious ceremonies

• Enables speaking with Virgin Mary

Salvia

• Most commonly smoked

• Can be ingested as a tea or chewed plant leaves

• Bought over Internet as

prepackaged crushed leaves

Salvia

• Illegal in Delaware, Florida, Illinois, Kansas, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Ohio, Oklahoma, South Dakota, Tennessee and Virginia

Legal Everywhere Else

Salvia

• Primarily hallucinogenic effects

• Different from LSD or Magic Mushrooms

• Most potent natural hallucinogenic

• Stimulates kappa opioid receptors:

- Perceptual distortions

- Altered sense of self

- Altered sense of environment

Clinical Effects

• Onset of action 30sec – 10min

• DOA: approx 30 min

• “Union of the senses”:

- Visual synesthesia

- Tactile synesthesia

• Completely lose orientation

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Salvia

• Visual and tactile synesthesia

• “You see things and feel them in your body”

• “You can see everything going on in the room, but can see it through my skin, not through my eyes”

Testing

• Based on clinical presentation

• Will not be detected on standard drug tests

Treatment

• Very short acting

• Symptom based

• Supportive care

Rarely present to

Emergency Department

Take Home Messages

• Even if ask, the patient may not know what they actually ingested

• Poor historians, altered sensorium

• Most of the new drugs cause sympathomimetic and psychoactive effects

• Look for toxidromes

• May present as trauma

Take Home Messages

• ABCs

• Cardiac monitor

• Treat symptoms

• IV benzodiazepines

• Quiet environment

• Determine if recreational mishap or suicide attempt

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Take Home Message

• IV NS for hypotension or rhabdomyolysis

• Monitor core temperature

- Mist, fanning

- Antipyretics not useful

• GI decontamination / AC not useful

Majority will do well

Documents

You Smoked What? or Emerging Drugs of Abuse