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New Drugs of Abuse: Bath Salts and Synthetic Cannabinoids

New Drugs of Abuse: Bath Salts and Synthetic Cannabinoids. Bruce D. Anderson, PharmD , DABAT Director of Operations Associate Professor University of Maryland School of Pharmacy. Objectives. Know what the commonly encountered substances called “bath salts” usually contain

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New Drugs of Abuse: Bath Salts and Synthetic Cannabinoids

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  1. New Drugs of Abuse: Bath Salts and Synthetic Cannabinoids Bruce D. Anderson, PharmD, DABAT Director of Operations Associate Professor University of Maryland School of Pharmacy

  2. Objectives • Know what the commonly encountered substances called “bath salts” usually contain • Understand the basic pharmacology of bath salts and synthetic cannabinoids • Be able to describe the usual acute clinical effects from users of bath salts and from synthetic cannabinoids • Be able to describe the potential psychiatric impact of bath salts use

  3. Who am I and Why am I Here?

  4. MPC Overview • Service program of the University of Maryland School of Pharmacy since 1972 • First year of operations, received 5,600 calls • In 2012, MPC received ~62,000 calls

  5. MPC: (continued) • Open 24 hours/day • Staffed by pharmacists & nurses • Nationally certified Specialists in Poison Information

  6. MPC: Overview • Board certified Medical Director • Board certified Director • Masters in Public Health faculty • Additional consultants available

  7. Other Functions • Recognition and prevention of exposures through community education and outreach • Professional education to optimize patient care

  8. MPC: Overview • Data collection/reporting nationally • Research to optimize patient care *

  9. What’s the Mission? • The mission of the Maryland Poison Center is to decrease the cost and complexity of poisoning and overdose care while maintaining and/or improving patient outcomes.

  10. Bottom Line • Save Lives • Save Dollars

  11. Bottom Line (continued) • Save lives by providing emergency triage and treatment information to all callers. • Save dollars by managing vast majority of patients (~75%) safely and inexpensively at home.

  12. Fiscal Impact: • Last year, ~29,432 poisoning patients were safely managed at home. • Usual charge for ED evaluation and treatment: ~$1,000 per patient • Estimated cost savings:~$29,432,000 per year

  13. What the heck are “bath salts???

  14. The “Natural” Amphetamine • Cathinone; “Khat” • Catha edulis • Native to Africa • Amphetamine like alkaloid • Chewed for the effects Ann Pharmacother2012;46:436-441.

  15. In the Market http://www.whitehouse.gov/ondcp/ondcp-fact-sheets/synthetic-drugs-k2-spice-bath-salts. Accessed 7 Dec 2012.

  16. Former Fox TV Chair Beaten by Police http://www.nj.com/business/index.ssf/2012/10/bath_salts_used_by_deutsche_ba.html

  17. Man Tries to Bite Police http://www.huffingtonpost.com/2012/06/05/brandon-deleon-high-on-cloud-9_n_1570560.html

  18. Man Attacks Elderly Woman with a Shovel http://www.huffingtonpost.com/2012/06/25/robert-william-white-la-bath-salts_n_1624688.html

  19. Woman Has Baby, Goes on Rampage http://www.huffingtonpost.com/2012/07/06/carla-murphy-had-baby-smoked-bath-salts_n_1653979.html

  20. So… what is in “bath salts”? • Methylenedioxypyrovalerone (MDPV) • Mephedrone • Methylone • Methcathinone • Alpha-pyrillidonopropiophenone (α-PPP) • Others

  21. Synthetic Cathinones Cathinone Beta ketonated amphetamines N-alkylatedcathinones Ring substituted methylenedioxy-phenethylamines ClinToxicol 2011;49:705-719.

  22. Structures and Similarities Gerona RR, Wu AHB. Bath salts. Clin Lab Medicine 2012;32(3):415-27.

  23. Audience Question: What synthetic cathinone derivative carries a legal medical indication for use the U.S. and Europe?

  24. Answer: Bupropion • Substituted cathinone • Indications: • Depression • Smoking cessation Cathinone ClinToxicol 2011;49:705-719.

  25. Bath Salts: Pharmacology • Structurally similar to amphetamines and hallucinogenic amphetamines (e.g., MDMA) as well as cathinones • Functionally closer in effect to cocaine

  26. Clinical Effects • See typical stimulant effects • Hallucinogenic activity • Behavioral changes are common; may be persistent

  27. Spiller HA et al. Clinical experience with and analytical confirmation of bath salts and legal highs in the United States. ClinToxicol 2011;49:499-505.

  28. Management: Bath Salts Exposures • Airway, Breathing, Circulation • Charcoal: only for substantial, recent ingestions • Calm environment • Benzodiazepines • Symptomatic care

  29. Typical Case: Bath Salts • 38 year old presents to ED with altered mental status • Hyperverbal, talking out of his head and making no sense • BP 160s/100s; HR 120s; unable to get EKG • Hallucinating, sweating, agitated • Given 10 mg haloperidol, 2 mg lorazepam, 20 mg ziprazidone, 10 mg olanzepine without response; in 4 point restraints • Admitted to ICU, placed on dexmedetomidine; remains confused, agitated, diaphoretic, hypertensive • 3 hours later, the patient is A&O * 3, VSS, just observing.

  30. Bath Salts in Maryland 2011 2012 Maryland Poison Center

  31. Where to Buy? http://ivory-wave.com/

  32. Where to Buy? http://legalhighs.net63.net/product.php?id_product=19

  33. Regulation Status ClinToxicol2012;50:911-1164. http://www.justice.gov/dea/druginfo/drug_data_sheets/Bath_Salts.pdf. Accessed 7 Dec 2012. http://www.deadiversion.usdoj.gov/drugs_concern/mdpv.pdf. Accessed 7 Dec 2012. http://www.govtrack.us/congress/bills/112/s3189. Accessed 7 Dec 2012.

  34. Banned But Replaced http://www.fridayflyer.com/2012/10/05/banned-bath-salts-replaced-with-new-products

  35. Replaced by…What??? http://www.ncbi.nlm.nih.gov/pubmed/22528592

  36. Synthetic Cannabinoids • What are they? • What are the effects on people?

  37. Synthetic Cannabinoids http://sfgyc.com/k2-and-spice-now-illegal-tools-for-parents/2012/07/03/ http://www.noozhawk.com/article/053112_police_wary_florida_face_eating_incident/ http://www.mystoresupplier.com/L-A-SPICE-HERBAL-INCENSE-1-5-GRAM-32-COUNT-p/af079.htm

  38. Synthetic Cannabinoids: MPC

  39. Synthetic Cannabinoids: Effects • Altered mental status • Paranoia • Psychosis • Seizures • Tachycardia • Hypertension • Nausea and vomiting • Loss of consciousness • Acute pain • Hypokalemia • Acute kidney injury Bhanushali GK, Jain G, Fatima H, et al. AKI associated with synthetic cannabinoids: a case series. Clin J Am ScoNephrol 2012;ePud ahead of print Dec 14.

  40. Typical Case: Synthetic Cannabinoids • Call from ED regarding a 15 year old who presents after smoking synthetic cannabinoids • On presentation, patient was combative, screaming, and hallucinating • Treated with haloperidol and alprazolam • After 4 hours of observation, patients symptoms subsided and he was discharged home.

  41. Synthetic Cannabinoids • Why use? • avoid urine drug screen tests • Thought to be “safe” alternative to marijuana • Avoid going to a drug dealer

  42. Synthetic Cannabinoids • Synthetic Drug Abuse Prevention Act of 2012 Specified “cannabinimimetic agents” as Schedule I substances • Producers have changed formulations to avoid the law and are still selling online, convenience stores and in head shops

  43. Number of cases Time Cases of intentional abuse or misuse of synthetic cannabinoids reported to the Maryland Poison Center over time.

  44. Synthetic Cannabinoids • Management: Supportive care (ABC’s) • NOTE: Symptoms may persist

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