Update in Toxicology 2013 K2, Spice, Bath Salts, & the New
Designer Drugs K2, Spice, Bath Salts, & the New Designer Drugs
William Hurley, MD FACEP William Hurley, MD FACEP Harborview
Medical Center Harborview Medical Center Washington Poison Center
Washington Poison Center [email protected][email protected] (800)
222-1222 (800) 709-0911
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Update in Toxicology 2013 Goal Goal Increase knowledge in
management of the poisoned patient Objectives Objectives Describe
manifestations & management of the stimulant syndrome List new
designer drugs, their mechanisms, & their sources Designer
Drugs
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Tox Update 2012
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Designer Drugs
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Poisoning Case A 20 year-old female is found agitated &
confused by family in her dormitory room. A 20 year-old female is
found agitated & confused by family in her dormitory room. She
has no significant past medical history, but the family suspects
she has been experimenting with alcohol & marijuana since
starting school. She has no significant past medical history, but
the family suspects she has been experimenting with alcohol &
marijuana since starting school. She is agitated & aggressively
ordering care providers to leave her exam room. Family explains
this is not like her at all. She is agitated & aggressively
ordering care providers to leave her exam room. Family explains
this is not like her at all. She is tachycardic, hypertensive, hot,
& diaphoretic She is tachycardic, hypertensive, hot, &
diaphoretic (P 128, BP 180/110) How would you manage this
encounter? How would you manage this encounter?
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20 Year Old Female Anxious & Agitated Initial Evaluation ?
Initial Evaluation ? Designer Drugs
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20 Year Old Female Anxious & Agitated Mental Status Mental
Status A A B B C C D D E E Designer Drugs
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20 Year Old Female Anxious & Agitated Mental Status Mental
Status A Open & Protected ? A Open & Protected ? B
Ventilating & Oxygenating ? B Ventilating & Oxygenating ? C
Rhythm, Perfusion ? C Rhythm, Perfusion ? D - Disability / Seizures
D - Disability / Seizures Decontamination, Dextrose ?
Decontamination, Dextrose ? E Exposure, Elimination ? E Exposure,
Elimination ? Poison Center 1-800-222-1222 Poison Center
1-800-222-1222 Designer Drugs
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Initial Management WA Poison Center WA Poison Center
1-800-222-1222 1-800-222-1222 1-800-709-0911 1-800-709-0911 Airway
Airway Breathing Breathing Circulation Circulation 80% of
poisonings Disability/Decontamination Disability/Decontamination
90% of poisonings Exposure/Elimination Exposure/Elimination
Antidotes 100% of poisonings Designer Drugs
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20 Year Old Female Anxious & Agitated Agitated, responding
to loud verbal Agitated, responding to loud verbal A Open with
intact gag reflex A Open with intact gag reflex B - RR 20-24 /
minute, clear lungs B - RR 20-24 / minute, clear lungs C -
Tachycardic (Sinus - 130s) C - Tachycardic (Sinus - 130s)
Hypertensive (180/110) Hypertensive (180/110) D - No Seizure,
Glucose 108 D - No Seizure, Glucose 108 Decontamination?
Decontamination? E Elimination? E Elimination? Designer Drugs
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Poisoning Management ABCDE ABCDE Safety Net Safety Net IV,
Monitors (ECG & O2) Focused History Focused History What, when,
why, what has been done? What else is available? Focused Physical
Examination Focused Physical Examination Toxicologic Syndrome?
Designer Drugs
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Toxicologic Syndromes Asphyxiant Asphyxiant Cholinergic
Cholinergic Anticholinergic Anticholinergic Cyclic Antidepressant
Cyclic Antidepressant Opiod Opiod Sedative Sedative Stimulant
Stimulant Hallucinogenic Hallucinogenic Serotonergic Serotonergic
Hepatotoxic Hepatotoxic Heavy Metal Heavy Metal Irritant gas
Irritant gas Caustic Caustic Salicylates Salicylates Toxic Alcohols
Toxic Alcohols Hydrocarbons Hydrocarbons Calcium antagonists
Calcium antagonists Designer Drugs
Spice Case Roomate produces packets of incense purchased at a
local head shop. Roomate produces packets of incense purchased at a
local head shop. Designer Drugs
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Spice Case A 20 year-old female crazy A 20 year-old female
crazy Begins screaming & struggling Begins screaming &
struggling Attempting IV Has 3 minute seizure Management?
Management? Designer Drugs
Cannabinoids Spice products - Europe in 2004 Spice products -
Europe in 2004 Herbal smoking blend Herbal smoking blend Not for
Human Consumption Not for Human Consumption Synthetic agents,
created to simulate effects of cannabis Synthetic agents, created
to simulate effects of cannabis CNS cannabinoid receptors CNS
cannabinoid receptors Derived from cathinones (Khat) Derived from
cathinones (Khat) Designer Drugs
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Cannabinoids Sold in small packets Sold in small packets
Variety of names Variety of names K2, Spice Gold, Spice Diamond,
Spice Silver, Spice of Life Retail U. S. $25-$40 Retail U. S.
$25-$40 Designer Drugs
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Plant & Herbal Blends Marketed as incense Marketed as
incense Desire for legal high Desire for legal high Ability to
avoid detection on drugs- of-abuse testing (THC) Ability to avoid
detection on drugs- of-abuse testing (THC) Designer Drugs
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Whats up with the Eye? Designer Drugs
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Whats up with the Eye? Wide-open-eye imprint Wide-open-eye
imprint Allusion to Dune Allusion to Dune Fictional drug Melange
Fictional drug Melange Called the spice Called the spice Excessive
use caused blue sclera Excessive use caused blue sclera Designer
Drugs
Synthetic Cannabinoids Synthesized 1960s at Hebrew University
(HU) Synthesized 1960s at Hebrew University (HU) HU-210 Pfizer
1970s; Cyclohexylphenol series Pfizer 1970s; Cyclohexylphenol
series J W Huffman (JWH) 80s J W Huffman (JWH) 80s JWH-018,
JWH-073, JWH-200 Designer Drugs
European Experience Within weeks of regulatory control Within
weeks of regulatory control Non-prohibited cannabinoids found in
products Non-prohibited cannabinoids found in products Structures
heterogeneous Structures heterogeneous No THC rxn Designer
Drugs
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Synthetic Cannabinoids 2010 U.S. DEA, Office of Diversion
Control JWH 73 11% JWH 250 13%
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U.S. DEA Activity March, 2011 March, 2011 Temporary Schedule I
Temporary Schedule I unsafe, highly abused, no medical usage Five
synthetic cannabinoids Five synthetic cannabinoids JWH-018,
JWH-073, JWH-200 CP-47,497 & Cannabicyclohexanol HU-210 all
ready Schedule I Designer Drugs
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Synthetic Cannabinoids 2011 U.S. DEA, Office of Diversion
Control JWH 250 12% JWH 210 9% JWH-122 12% JWH-18 14% AM-2201
29%
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Synthetic Drug Abuse Prevention Act of 2012 Signed into law
July 9, 2012 Signed into law July 9, 2012 Adds certain classes of
synthetic cannabinoids & two substituted cathinonesmephedrone
and MDPV to the federal controlled substances act. Adds certain
classes of synthetic cannabinoids & two substituted
cathinonesmephedrone and MDPV to the federal controlled substances
act. Designer Drugs
Stimulant Toxicity Clinical Management Central inhibition of
catecholamine reuptake Central inhibition of catecholamine reuptake
Benzodiazepines (GABA receptor agonists) 0.1-0.2 mg/kg Diazepam IV
(5-10 mg) 0.1-0.2 mg/kg Diazepam IV (5-10 mg) 0.05 mg/kg Lorazepam
or Midazolam IV or IM (2-5 mg) 0.05 mg/kg Lorazepam or Midazolam IV
or IM (2-5 mg) Repeat every 5-10 minutes for seizures, every 10
minutes until calm Repeat every 5-10 minutes for seizures, every 10
minutes until calm Neuroleptics (monitor the QT interval) 2-5 mg IM
or slow IV Haloperidol or Droperidol 2-5 mg IM or slow IV
Haloperidol or Droperidol Designer Drugs
Spice Case A 20 year-old female crazy A 20 year-old female
crazy Tachycardic, hypertensive, warm, & wet Tachycardic,
hypertensive, warm, & wet (P 140, BP 185/110) Diazepam 5 mg IV
X 2 Diazepam 5 mg IV X 2 Temp 104.4 o Temp 104.4 o Urine reddish
brown IV NS with 2 amps NaHCO 3 Designer Drugs
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Spice Case CT head negative CT head negative Urine Tox negative
Urine Tox negative Admitted ICU Admitted ICU Continuous EEG
monitoring Awakens next morning Awakens next morning Admits binge
of Spice Peak CPK 14,000 No renal failure Discharged home intact
day #3 Designer Drugs
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Smoking Bath Salts 26 y.o. male agitated & confused 26 y.o.
male agitated & confused 3 day binge 3 day binge Smoking
Bolivian Bath Salts Roomate found him face-down on floor Roomate
found him face-down on floor Designer Drugs
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26 Year Old Male Agitated & Confused Management?
Management? Designer Drugs
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Initial Management WA Poison Center WA Poison Center
1-800-222-1222 1-800-222-1222 1-800-709-0911 1-800-709-0911 Airway
Airway Breathing Breathing Circulation Circulation 80% of
poisonings Disability/Decontamination Disability/Decontamination
90% of poisonings Exposure/Elimination Exposure/Elimination
Antidotes 100% of poisonings Designer Drugs
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26 Year Old Male Agitated & Confused Agitated, responding
to loud verbal Agitated, responding to loud verbal A Open with
intact gag reflex A Open with intact gag reflex B - RR 28 / minute,
clear lungs B - RR 28 / minute, clear lungs C - Tachycardic (Sinus
- 130s) C - Tachycardic (Sinus - 130s) Hypertensive (160/100)
Hypertensive (160/100) D - No Seizure, Glucose 120 D - No Seizure,
Glucose 120 Decontamination? Decontamination? E Elimination? E
Elimination? Designer Drugs
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Bath Salts Case Agitated, responds to loud verbal stimuli
Agitated, responds to loud verbal stimuli No trauma No trauma
Pupils 6 mm Pupils 6 mm P 130 BP 160/100 P 130 BP 160/100
Diaphoretic & Hot Diaphoretic & Hot Designer Drugs
Bath Salts White Ice, Ocean Snow, Lunar Wave, Purple Wave,
Ivory Wave, Ivory Soft, Vanilla Sky, Bliss White Ice, Ocean Snow,
Lunar Wave, Purple Wave, Ivory Wave, Ivory Soft, Vanilla Sky, Bliss
$20 packets from convenience stores, truck stops & via Internet
$20 packets from convenience stores, truck stops & via Internet
Designer Drugs
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Bath Salts - Compounds Very similar to amphetamines Very
similar to amphetamines Side effects largely the same we see with
amphetamines in large dose Side effects largely the same we see
with amphetamines in large dose Jeffrey Baldwin, University of
Nebraska Medical Center Typically snorted, smoked, injected
Typically snorted, smoked, injected Can be mixed with water as a
beverage Can be mixed with water as a beverage Designer Drugs
Mephedrone - Europe Cathinone derivative Cathinone derivative
Marketed as plant feeder not for human consumption Marketed as
plant feeder not for human consumption Potentially addictive &
Potentially addictive & Increasingly popular legal substitute
for cocaine & ecstasy Increasingly popular legal substitute for
cocaine & ecstasy Designer Drugs
Bath Salts Case Agitated for 18 hours at hospital Agitated for
18 hours at hospital Tachycardia resolves with IV benzos &
fluids Tachycardia resolves with IV benzos & fluids Temp 104.1
Temp 104.1 Urine (+) benzos only Urine (+) benzos only CK Peak 6500
CK Peak 6500 Designer Drugs
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Cannabinoids & Bath Salts 2010 - 2011 Designer Drugs Olives
TD, et al. Bath salts: the ivory wave of trouble. West J Emerg Med.
2012 Feb;13(1):58-62.
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Bath Salts - Banned DEA Temporary Schedule I (Oct 2011) DEA
Temporary Schedule I (Oct 2011) Up to 12 months for permanent
Louisiana, Florida, North Dakota, WA Louisiana, Florida, North
Dakota, WA New York, Kentucky, Mississippi - Pending PC calls fell
with Louisiana ban PC calls fell with Louisiana ban Now ordering by
Internet Shipping to Mississippi Executive Health February 04, 2011
Executive Health February 04, 2011 Designer Drugs
New Rave (2 C agents) Minneapolis, MN 17 March 2011
Minneapolis, MN 17 March 2011 Eleven hospitalized (16-21 y.o.) 2
critical, 1 dead Konawa, OK 7 May 2011 Konawa, OK 7 May 2011 Seven
hospitalized (19-20 y.o.) 2 critical, 1 dead
2,5-dimethoxy-4-ethyl-phenethylamine
2,5-dimethoxy-4-ethyl-phenethylamine Designer Drugs
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2, 5, I-NBOMe Deaths Erowid.org (Extracts) March 2012 Adult
male South Australia March 2012 Adult male South Australia
2C-I-NBOMe & 2C-B-NBOMe (MVC) June 2012 17 & 18 yo males MN
June 2012 17 & 18 yo males MN Mixed 25i with chocolate candy
July 2012 - 25 yo female, NC July 2012 - 25 yo female, NC 25i
pills, died >12 hours after ingestion Designer Drugs 2011
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2 Ci Blotter Paper Designer Drugs
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2 C-I Designer Drugs
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Phenethylamines Chemical NameStreet Name 3,4,5-trimethoxy-
phenethylamine Mescaline 2C-E 2,5-dimethoxy-4-ethyl- phenethylamine
Europa 2C-B 2,5-dimethoxy-4-bromo- phenethylamine Bees, Bromo,
Bromo mescaline, Nexus, Spectrum, Toonies, Venus 2C-I
2,5-dimethoxy-4-iodo- phenethylamine N-Bomb 2C-T7 2,5-dimethoxy-4-
propylthio-phenethylamine Blue Mystic, Vanilla Aroma Designer
Drugs
Phenethylamines Legal control Legal control 2C-B & 2C-T7
Schedule I 2C-E & 2C-I - not scheduled controlled substance
analogs controlled substance analogs Bad trips ?alleviated by
SSRIs? Bad trips ?alleviated by SSRIs? Not studied nor recommended
Designer Drugs
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Stimulant Agents Cocaine Cocaine Amphetamines Amphetamines
Decongestants Decongestants Beta Stimulators Beta Stimulators
Withdrawal States Withdrawal States Cannabinoids Cannabinoids Bath
Salts Bath Salts Phenethylamines Phenethylamines 2 CE & 2 CI
Designer Drugs
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Stimulant Agents Mechanisms of Action Central inhibition of
catecholamine reuptake Central inhibition of catecholamine reuptake
Epinephrine, norepinephrine Peripheral stimulation of alpha &
beta receptors Peripheral stimulation of alpha & beta receptors
Additional effects (nuances) Additional effects (nuances) Na
channel / local anesthetic (cocaine) Serotonin reuptake inhibition
(MDMA) Designer Drugs
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Poisoning Management ABCDE Poison Center (1-800-222-1222) ABCDE
Poison Center (1-800-222-1222) Safety Net Safety Net IV, Monitors
(ECG & O2) Focused History Focused History What, when, why,
what has been done? What else is available? Focused Physical
Examination Focused Physical Examination Toxicologic Syndrome?
Laboratory Studies? Laboratory Studies? Designer Drugs
Stimulant Toxicity - Key Points Central & Peripheral
catecholamine surge Central & Peripheral catecholamine surge
Characteristic clinical toxicological syndrome Specific agents
Specific agents Cocaine, amphetamines, decongestants, cannabinoids,
Mephedrone, MDPV, phenethylamines Often unavailable for
decontamination & detection Treat the patient, not the agent
Importance - reduce severity of poisoning (avoid complications)
Importance - reduce severity of poisoning (avoid complications)
Benzodiazepines & Hyperthermia prevention Designer Drugs
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Spice References Gunderson EW, et al. "Spice" and "K2" herbal
highs: a case series and systematic review of the clinical effects
and biopsychosocial implications of synthetic cannabinoid use in
humans. Am J Addict. 2012 Jul-Aug;21(4):320-6. Simmons JR, et al.
Intoxication from smoking "spice. Ann Emerg Med. 2011
Feb;57(2):187-8. Vardakou I, et al. Spice drugs as a new trend:
mode of action, identification & legislation. Toxicol Lett 2010
Sep 1;197(3):157-62. Schneir AB, et al. "Spice" Girls: Synthetic
Cannabinoid Intoxication. J Emerg Med 2010 Dec 15. Designer
Drugs
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Bath Salts - References Designer Drugs o Borek HA, et al.
Hyperthermia and multiorgan failure after abuse of "bath salts"
containing 3,4-methylenedioxypyrovalerone. Ann Emerg Med. 2012
Jul;60(1):103-5. o Prosser JM, Nelson LS. The toxicology of bath
salts: a review of synthetic cathinones. J Med Toxicol. 2012
Mar;8(1):33-42. o Murray BL, et al. Death following recreational
use of designer drug "bath salts" containing
3,4-Methylenedioxypyrovalerone (MDPV). J Med Toxicol. 2012
Mar;8(1):69-75. o Kasick DP, et al. "Bath salt" ingestion leading
to severe intoxication delirium: two cases and a brief review of
the emergence of mephedrone use. Am J Drug Alc Abuse. 2012
Mar;38(2):176-80. o Emergency department visits after use of a drug
sold as "bath salts"--Michigan, November 13, 2010-March 31, 2011.
MMWR 2011 May 20;60(19):624-7. o Psychonaut WebMapping Research
Group, Mephedrone Report, Institute of Psychiatry, King's College
London, London, UK (2009).
Slide 87
Update in Toxicology 2013 Goal Goal Increase knowledge in
management of the poisoned patient Objectives Objectives Describe
manifestations & management of the stimulant syndrome List new
designer drugs, their mechanisms, & their sources Designer
Drugs
Slide 88
Update in Toxicology 2013 K2, Spice, Bath Salts, & the New
Designer Drugs K2, Spice, Bath Salts, & the New Designer Drugs
William Hurley, MD FACEP William Hurley, MD FACEP Harborview
Medical Center Harborview Medical Center Washington Poison Center
Washington Poison Center [email protected][email protected] (800)
222-1222 (800) 709-0911