Tales of Bath Salts and Legal Marijuana : TheRapidExpansion OfNewDesignerStreetDrugs

1. Tales of Bath Salts and Legal Marijuana: TheRapidExpansionOfNewDesignerStreetDrugs jay lance kovar, md,facep tcep 2012

2. Objectives • Review new synthetic substances of abuse • Discuss pharmacology and clinical presentations • Identify EMS and ER treatment options for care

3. Bath Salts • Bath Salts • synthetic product • contains hallucinogenic, mind-altering chemicals • similar in structure to those also found in cocaine and ecstasy • depending on which brand or form is purchased.

4. Bath Salts • Sold as: • a bath salt, • or plant food • Labeled: • “for novelty use only” • “not for human consumption” • to by- pass FDA regulations-not being sold as food or drug product. • Sold in: • either 250 or 500 mg packets depending on brand or form purchased.

5. Bath Salts Ivory Wave is the most popular brand of this product • Vanilla Sky • Fly • Snow • Ivory • Charge • Ivory Coast • Purple Wave • Cristalius • Magic • Ocean Blue • Columbian Salts • Bolivian Salts • Ocean Burst • Lunar Wave • Lady Bubbles • Arctic Blast • Sextacy • Disco • Snow Leopard • Natural NRG • Tranquility

6. What’s in it? • MDPV (methylene-dioxy-pyro-valerone) usually referred to as pyro-valerone, (Super Coke) • powerful psychoactive chemical similar to Ritalin • acts as a stimulant that inhibits re-uptake of dopamine & norepinephrine • minimal effects on serotonin levels. • most versions of these products as containing Lidocaine • may also contain similar components to 2-DPMP or MDMA (aka ecstasy).

7. Purposely designed in a way that will mimic the effects of: • Cocaine • Crack • Ecstasy • Most often used by snorting.

8. Where can I find it? • It is sold most frequently • on-line • tobacco/smoke shops • as a novelty item “not for human consumption” • $30 for a small package • in bulk (50-100 packets) for a discount rate. Bath salts have increased in “club scene” use as ecstasy availability and use have declined

9. What’s the prevalence? • Poison Control calls 2009 0 • Poison Control calls 2010 303 • Poison Control calls 2011 4,100

10. What’s the purity? • Samples seized from different regions reveal a great deal of variance despite the same labels and producers

11. Pharmacology • Multiple manufactures sources • Vary in purity, concentration, and fillers • Sold in • packages 50mg to 200mg • vials 500mg • Consumed • orally, rectal, insufflated, injected, or smoked

12. Phamacology Effects • Onset, peak, and duration depends upon route Major source seems to be China, routed through New Orleans and out I-10 corridor • Houston #1 • Montgomery County Top 10

13. Why is it popular? • Effects of amphetamines, cocaine, and ecstacy without hangover, comedown, or depression commonly following the use of those drugs • Elevates mood, decreases hostility, raises energy levels, improves sense of well-being, improves attentions span and attention to detail, euphoria, empathy, and sexual stimulation.

14. Appears to be extremely addictive with many users reporting an “almost uncontrollable urge for another hit” immediately, stating that its effects are several times stronger than cocaine when snorted.

15. Downside • Acute psychosis • Severe anxiety, paranoia, agitation, bizzarre behavior, tremors, persecutory hallucinations • Sympathetic overdrive • Palpitations, shortness of breath, diaphoresis, hot flashes, headaches, hyperthermia, overwhelming thirst • Bruxism

16. Side effects • muscular pain/spasms • emotional fragility • acute paranoid psychosis • sore jaw • kidney failure • loss of bowel control • intense high followed by painful hangover • suppressed appetite

17. “It’s legal” • K2

18. K2/Spice products are a mixture of herbal/spice plant products sprayed with potent psychotropic drugs • often contaminated with unidentified toxic substances which contribute to various adverse health effects • cause hallucinogenic effects similar to effects of PCP. • Marketed under variety of names • K2, Spice, Pep Spice, Spice Silver, Spice Gold, Spice Diamond, Smoke, Sence, Skunk, Yucatan Fire, Genie & Zohai • sold in variety of colors/flavors- usually sold in foil packaging

19. K2/Spice Health Risks • Symptoms/Side-Effects may include: • mimics marijuana “high” (often induced more quickly/more intense than “real” marijuana) • hallucinations • seizures/tremors • coma/unconsciousness • vomiting • numbness/tingling

20. K2/Spice Health Risks • Symptoms/Side-Effects may include: • increased respiration rate • elevated blood pressure (reported up to 200/100) • elevated heart rate (reported up to rate of 150) • increased level of anxiety/agitation leading to panic attacks (possible suicide attempts)

21. Depending on synthetic compound in specific commercial brand, can be anywhere from 4 times to over 100 times more potent than marijuana (THC) • Sold in tobacco shops, head shops, and convenience stores • Sold as “incense” marked “not for human consumption”

22. Price averages $45 for 3 grams (about equal to 3 sugar packets)-higher than good grade marijuana • Most often smoked but can be mixed in with food or drink • Most likely users: • 14-27 yr. olds • Prisoners/probationers • Military (use now banned by all military branches)

23. Creation of K2/Spice • Developed by Dr. John W. Huffman, a Clemson University professor, as part of research for National Institute for Drug Abuse (NIDA) on endogenous cannabinoid receptors-but never tested on humans nor approved by FDA • “It is like Russian roulette to use these drugs. We don’t know a darn thing about them for real.” “It shouldn’t be out there.” • JWH-018 & many of its “cousins” such as HU-210/211, JWH-073 & CP 47/497 found in these drugs have a chemical structure shared with known cancer-causing agents. • All effects of K2/Spice drugs may not be known for very long time because of long time period that body stores them.

24. ????????????????????? • Nothing is known about metabolism of the chemical compounds in K2/Spice drugs • some may be toxic • pharmacologically active-differing from batch to batch in kind/amount applied • higher risk of accidental overdosing which has already been seen • increase numbers of ER incidents reported

25. ????????????????????? • There are hundreds more of these chemical compounds containing strong, active cannabinoid receptors agonists so can be safely assumed that further such substances will appear on market soon if not banned • Increasing challenges for toxicology testing, law enforcement and medical professionals. • Causing difficulties for law enforcement agencies, probation & parole, as well as drug courts due to difficulties in testing for presence • one lab test now known to detect it in system but at cost of $50 & will probably not test positive for all the known variations

26. National Institute for Drug Abuse “hijacking the part of the brain important for many major functions: temperature control, food intake, perception, memory and problem solving. Many people taking these high-potency drugs are affecting important functions throughout their bodies-hormone functions for example.” Drugs may involve acute toxicity levels, possibly long term, as well as impacting cannabinoid receptors that regulate body’s immune system.

27. On the rise • Source primarily Mid-West US • Recent increase in sales from app. $1000 daily up to $10, 000 daily. • Rapid and powerful addiction on a level not usually found among smokers of “real” marijuana. • Recently linked to over 352 nationwide emergency room incidents • suicide attempts, extremely elevated heart rate/blood pressure, comas, seizures, and anxiety attacks.

28. What about your patient?

29. Is this Excited Delirium? • An imminently life threatening medical emergency… • Massive release of epinephrine, norepinephrine, dopamine, serotonin in the body and brain. • Severe delirium and agitation

30. Recognizing Excited Delirium • Agitation or Excitement = Increased activity and intensity • Aggressive, threatening or combative – gets worse when challenged or injured • Amazing feats of strength • Pressured loud incoherent speech • Sweating (or loss of sweating late) • Dilated pupils/less reactive to light • Rapid breathing

31. Recognizing Excited Delirium • Delirium = Confusion • Disoriented • Person, place, time, purpose • Rapid onset over a short period of recent time • “He just started acting strange” • Easily distracted/lack of focus • Decreased awareness and perception • Rapid changes in emotions (laughter, anger, sadness)

32. Recognizing Excited Delirium • Psychotic = bizarre behavior • Thought content inappropriate for circumstances • Hallucinations (visual or auditory) • Delusions (grandeur, paranoia or reference) • Flight of ideas/tangential thinking • Makes you feel uncomfortable

33. Bad Behavior: Other Reasons • Alcohol intoxication or withdrawal • Other drug use problems • Example: Cocaine psychosis • Pure psychiatric disease • Head injury • Dementia (Alzheimer’s Disease) • Hypoglycemia • Hyperthyroidism

34. ED presentations • Combative • Self destructive • Homicidal/suicidal • Agitation followed by severe depression

35. ED presentations • Differential • PCP • LSD • Cocaine • Methamphetamines • Alcohol • Hypoglycemia • Hypoxia • Head trauma • CNS infection

36. The Work Up • Urine Tox • r/o routine street drugs + “polypharmacy” • BMP • Hypoglycemia, metabolic acidosis • CBC • Infection and anemia • CT Head • Intracranial hemorrhage, hydrocephalus • 12 lead EKG • Biomarkers, myoglobin, lactic acid • Temperature monitoring

37. Treatment Options No Antidote Supportive therapies • Sympathetic Overdrive • Alpha and beta receptor stimulation • Sustained endogenous norepinephrine release • Beta blocker caution? • Metabolic dysfunction • Hepatic metabolism of bath salts • Hyperthermia

38. Treatment Options No Antidote Supportive therapies • Psychosis • Benzodiazepines • Versed, Valium, Ativan • Antipsychotics • Haldol, Inapsine • Geodon • Ketamine

39. Disposition • Unpredictable dose and duration • Psychiatric evaluation when clear • Home • Jail • Psychiatric facility

40. Status of K2/Spice • Many European countries ban sale and use • Kansas was first state to ban use • 15 states so far to officially ban the sale & use of these products statewide. • October 2011 DEA made it illeagal to possess or sell the chemicals or products containing the chemicals found in bath salts in the US for 1 year pending a review of permanently banning them • Bath Salts are a Schedule 1 substance

41. Texas May 2011 • The Texas House passed a bill banning K2 or spice, a synthetic marijuana • The Texas Department of State Health Services outlawed the fake pot last month after the Drug Enforcement Agency issued an emergency ban for a year. • The possession of K2 a misdemeanor, but manufacturers and sellers would be charged with a felony effective September 2011

42. HB 2118, SB 331 Certain synthetic compounds deceptively labeled as “bath salts” and synthetic marijuana products (K2 or spice) have been added to Penalty Group 2 of the Texas Controlled Substances Act.

43. ANY QUESTIONS???