Emerging Trends in Drug Abuse

1. Emerging Trends in Drug Abuse Joshua Pruitt, MD, FAAEM February 6, 2014

2. What’s New • E-Cigarettes • “Krokodil” • “N-bomb” • “Syrup,” “Purple Drank,” “Sizzurp,” “Lean” • “Molly” • Salvia Divinorum

3. What’s ‘Sort-of’ New • K-2/Synthetic Cannabinoids • Bath Salts, MDPV, Khat • Energy drinks

4. E-cigarettes • Battery-operated devices marketed as “safer” than traditional cigarettes • Produce flavored nicotine aerosol/steam that looks and feels like tobacco smoke • No tar or other chemicals from burning tobacco leaves • Still require a chemical diluent that has an unknown safety profile

5. E-cigarettes

6. “Krokodil” • Cheap heroin substitute • Desomorphine (Heroin is diacetylmorphine) • Made by combining codeine tablets with toxic chemicals (i.e., lighter fluid, industrial cleaners) • More powerful than heroin with a shorter duration • Causes gray/green scaly flesh at site of injection, thus the name • Injection sites often become gangrenous • Average life-span after beginning use is 2 years

7. “Krokodil”

8. “N-bomb,” “Legal Acid,” “Smiles,” “25I,” “25C,” “25B” • Three closely-related synthetic hallucinogens • Substitute for LSD or mescaline • Serotonin stimulant, more powerful than LSD • Can cause seizure, MI, respiratory depression/arrest, death • 19 related deaths in US between 3/2012 and 8/2013

9. “N-bomb,” “Legal Acid,” “Smiles,” “25I,” “25C,” “25B”

10. “Syrup,” “Purple Drank,” “Sizzurp,” “Lean” • Phenergan w/codeine plus soda (Actavis) • May include hard candies • Celebrated in rap music • High risk of respiratorydepression and CNSdepression • Deaths from prescription opioids now outnumber deaths from all other drugs

11. “Syrup,” “Purple Drank,” “Sizzurp,” “Lean” • Implicated in the deaths of DJ Screw and Pimp C

12. “Syrup,” “Purple Drank,” “Sizzurp,” “Lean” • Overdose symptoms related to promethazine and codeine • Promethazine – CNS depression, anticholinergic • Tachycardia, altered mental status, delirium • Codeine – CNS depression, respiratory depression • Miosis, bradypnea/apnea, hypoventilation • Seizures highly unusual and usually related to hypoxia

13. “Syrup,” “Purple Drank,” “Sizzurp,” “Lean”

14. “Molly”

15. “Molly” • Slang for “molecular” • Refers to pure crystalline powder form of MDMA (Ecstasy) • Sold in capsules • Celebrated in rap/hip-hop music • Produces energy and euphoria • May cause hyperthermia, confusion, depression, sleep problems

16. “Molly” • Symptoms often mixed toxidrome due to co-ingestions

17. “Molly”

18. Salvia • Highly selective kappa-opioid receptor agonist • Originated with Mexican Mazatec shamanism • Hallucinogen with psychedelic/dissociative effects • Taken by smoking, no real effects from ingestion

19. Salvia • Intoxication effects • Uncontrollable laughter • Vivid reliving of past memories • Sensation of motion or being pulled by something • Visions of membranes or other 2-D surfaces • Merging with or becoming objects • Overlapping realities, such as being in two places at once

20. Salvia

21. “K-2,” “Spice,” Synthetic Cannabinoids • Very diverse class of drugs • Bind to the cannabinoid receptor • Similar effects to marijuana • Often more intense effects • Include hallucinogenic and psychedelic effects

22. “K-2,” “Spice,” Synthetic Cannabinoids • Reported effects

23. K-2/Synthetic Cannabinoids

24. Bath Salts, MDPV, Khat • Synthetic cathinones • Function as dopamine-norepinephrine reuptake inhibitors • Four times more potent than Ritalin or Concerta • Duration of action 3-4 hours, with after-effects lasting as long as 6-8 hours

25. Bath Salts, MDPV, Khat

26. Bath Salts, MDPV, Khat • Amateur chemists change the chemical composition of the “bath salt” and make it nearly impossible for regulation to keep up with production. • Mortality rate from “excited delirium” estimated at 8-14%, most die while in police custody • Treatment is supportive • Benzo’s, restraints if necessary, watch for rhabdo

27. Bath Salts, MDPV, Khat

28. Bath Salts, MDPV, Khat

29. Energy Drinks • Drinks like Red Bull, Rock Star, Monster • Contain caffeine and other legal stimulants (guarana, ginseng) • Can contain 75 to >200 mg of caffeine per serving • 34 mg per serving in Coke • 55 mg per serving in Mt. Dew • If it says “no caffeine,” then it uses guarana, which is the same as caffeine

30. Energy Drinks • 5-hour energy advertises “no crash,” but that relates to the sugar crash • Contains artificial sweeteners • Short term problems • Increased heart rate, palpitations • Hypertension • Dehydration • Sleep problems

31. Energy Drinks • Some may have 2 servings per can • When used occasionally, not necessarily dangerous • Think of them as highly caffeinated drinks • Combination with alcohol • The stimulant effect of the energy drink can mask how intoxicated someone is • Can give the drinker the impression they are not impaired • Research shows that people drink more and have higher BALs when they combine alcohol and caffeine

32. Energy Drinks • ER visits related to energy drink consumption • 10,068 in 2007; 20,783 in 2011 • 60% of patients drank energy drink alone • 27% of patients combined with prescription drugs • 13% combined with alcohol • 10% combined with illegal drugs • 9% combined with prescription stimulants

33. Questions