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Legal Highs & Lows

Legal Highs & Lows. Clinical Experience of Novel Psychoactive Substances Dr Richard Stevenson. Background. Legal Highs -> Novel Psychoactive Substances 41 new substances in 2010 alone Diverse collection of compounds Piperazines Cathinones Synthetic cannabinoids Isolated compounds

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Legal Highs & Lows

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  1. Legal Highs & Lows Clinical Experience of Novel Psychoactive Substances Dr Richard Stevenson

  2. Background • Legal Highs -> Novel Psychoactive Substances • 41 new substances in 2010 alone • Diverse collection of compounds • Piperazines • Cathinones • Synthetic cannabinoids • Isolated compounds • Recreational problem identified in 2008/2009 • Varying legal status

  3. GRI Emergency Dept Experience • 12 AMT • 22 synthetic cannabinoids • 3 cathinone • 2 methoxetamine • 1 salvia • 9 life threatening toxicities

  4. Why are people taking them? • Legal status • Perception of safety • Difficult to detect • Point of care urine testing • Odourless • Availability • Internet • “Head shops” • Sold as other drugs

  5. AMT 5-IT

  6. Common Problems • Lack of reliable data • “Not what is says on the tin” • Dosage • Inter-individual variability • Time of onset to effect • Polysubstance misuse • Interactions ?

  7. Challenges in Clinical Care • Acute • Identification of xenobiotic • Lack of toxicological data • Mechanism of action • Duration • Clinical effects • Appropriate treatment • Chronic • Long term psychological effects • Long term physical effects

  8. Cathinones • Synthetic variations of natural cathinones in Khat • Mephedrone, methedrone, naphyrone • Ivory wave, meow-meow, bubbles, ocean snow, NRG • Sympathetic Toxidrome • ↑HR, RR, BP, temp • Tremor, agitation, paranoia, hallucinations, seizures • ***duration 24 – 48 hours*** • Treatments • Benzodiazepines +/- haloperidol

  9. Piperazines • Developed in 1950s – anti-helminthic agents • BZP “Benzo Fury” • Neurotransmitter release/reuptake inhibition • Phenylpiperazines • Direct serotonin receptor activation • Reversal of serotonin uptake • Clinically • Sympathetic toxidrome • Serotonin toxicity?

  10. Synthetic Cannabinoids • Annihilation, Black Mamba, Spice, K2 • Structurally dissimilar to THC • Herbal material sprayed with chemicals • Clinical effects • Nausea +++ • Collapse • Some psychotropic effects

  11. Methoextamine • Structurally similar to ketamine • NMDA receptor agonist • Clinically (dose related) • Excitation, tachycardia, euphoria • Hallucinations • Dissociation • Prolonged neurological effects - ataxia • Supportive management

  12. AMT/5-IT • AMT – Alphamethyltryptamine • 5-IT – 5-aminopropylindole • AMT researched as antidepressant in 1960’s • Non-specific MAOI • Hallucinations +++ • Psychomotor agitation +++ • Serotonin toxicity • High risk of toxicity

  13. Serotonin Toxicity • Exposure to a serotonergic drug • Clinical features • Confusion • Autonomic instability • Hyperkinetic musculoskeletal system

  14. Treatment of Serotonin Toxcity • Morbidity & Mortality related to hyperthermia • Temp ≥40 oC • Duration • Consequences • Rhabdomyolysis • Acute kidney injury • Acidosis • Cerebral damage

  15. Treatment of Serotonin Toxicity • Aggressive cooling • Antipyretics do not work! • Control muscular activity • High dose benzodiazepines • Haloperidol for severe non-responders • Appropriate fluid control • BP control agents • Anaesthesia with muscle paralysis

  16. The Future? • Market flooded with NPS • Difficult to legislate/control • Long term effects?

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