1. Designer Drugs An Awareness Presentation
Kristine Nutt, LCSW, LCAS, CSI

2. Disclaimer Constantly moving target
This presentation is meant to provide basic awareness information on herbal incense products and bath salts.
There are hundreds of products being smoked for cannabis-like effects
Manufacturers constantly change product ingredients and market products under new names to circumvent the law.
Constantly moving target
Product names and lists, as well as the list of synthetic cannabinoids, in this presentation are not all inclusive.

3. “SMILES” 

4. “SMILES” 2C-1 Hallucinogen synthetic drug
Part of the 2C family of drugs
Powder or Pill form
Often mixed with chocolate and candy
Schedule 1 class of drug
According to LAPD, there has been an increase of overdose deaths from this drug recently. Popular with teens and college students.
Formulas were published in book “PiHKAL: A chemical Love Story” (Transform Press, 1991)

5. “Smiles” 
Dessa Bergen-Cisco, a Professor of Public Health at Syracuse University stated, “Basically, it’s a pure and potent form of ecstasy or MDMA”.
Effects are compared to a potent combination of MDMA and LSD with terrifying hallucinations and overwhelming anxiety.
Overdoses have been reported in California, Ohio, and other states.

6. “Smiles”

7. “SMILES” 
Recently in the news due to Johnny Lewis, 28, who was known for his role in the television show, “Sons of Anarchy” killed 81 year old landlady and her cat before jumping to his death. No evidence of drugs were found in his system.
One 17 year old in North Dakota overdosed and was observed shaking, growling, and foaming at the mouth. Another teen died the night before from this drug.
Does not show up on toxicology screens.

8. Effects Anxiety leading to panic attacks. Nausea and Vomiting.
Terrifying auditory and visual hallucinations.
Increased heart rate. Can cause strokes
Can cause seizures and kidney failure
Elevated body temperature.
Giddiness, Empathy, and Relaxed State.

9. Bath Salts Video Clip

10. BATH SALTS
Derivatives of cathinone found naturally in the herbal stimulant khat.
Part of phenethylamine family that includes, amphetamines, methamphetamine, and ecstasy.

11. BATH SALTS
First developed in research labs and became a popular party drug in Europe and UK
Spread overseas around 2008, and began to show up mostly in states like Louisiana, Kentucky, and Tennessee. Some had regional names like “Hurricane Charlie” and “Bayou”.
Other product names include Bliss, Blizzard, Blue Silk, Ivory Snow, Vanilla Sky and Ivory Wave.
Became highly publicized with the cannibalistic attack in Miami and other reports of violence.

12. BATH SALTS

13. BATH SALTS

14. BATH SALTS

15. Marketing
Sold commercially as bath salts, plant fertilizer, toy cleaner, pond cleaner, cell phone cleaner, jewelry cleaner, insect repellant, glass cleaner, toilet cleaner, and ladybug attractant.
Sold as tablets, capsules, and white or beige crystals/powder. Capsules may be sold in combination with caffeine or amphetamine. Has been sold as ecstasy.
Sold mainly on the internet buy also in “head shops”, convenience stores, and gas stations. Some people have bought on e-bay. Low cost and readily available.
It is not the stuff you find at Bath and Body Works!!!

16. BATH SALTS
Marketed as legal alternative to LSD, cocaine, ecstasy, and methamphetamine.
Labeled not for human consumption but the sole purpose is human consumption.

17. Video of Bath Salts Sale

18. Chemical Makeup
There are several synthetic cathinones. The most common found in “Bath Salts” are MDPV (methylenendioxypyrovalerone), mephedrone(4-MMC), or methylone. Found in 98% of tested products.
Advertised as above 95% purity but samples tested in Italy were only 40 – 50% pure. Some purchased online had benzocaine, lidocaine, and caffeine. Users truly don’t know what they are getting or how much.

19. Bath Salts Costs anywhere from $40 - $100 per gram.
Taken orally, IV, nasal inhalation, intramuscular, or rectally. Snorting and swallowing are the most common. Users may combine 2 methods (oral and inhalation) to obtain more rapid and prolonged effects.
High risk for overdose due to packages containing varying amounts of the chemicals.

20. BATH SALTS
Marketed as legal alternative to LSD, cocaine, and amphetamines. May imply safety for user.
Labeled not for human consumption but that is the sole purpose!

21. Naphyrone
Referred to as “Cosmic Blast” and marketed as jewelry cleaner. Contains MDPV and Naphydrone. Reuptake inhibitor of serotonin.
Stays in system for long periods. Body temperatures of up to 107 degrees have been reported.

22. BATH SALTS
Users do not know how much or what they are getting.
Package labeling implies “relaxation” but not stimulant effects.

23. Video Effects

24. Trends in Use Mostly males with a mean age of mid-late twenties.
2012 Monitoring the Future Survey reported .9% annual prevalence of use among students in grades 8,10, and 12 combined.
Google Trends (2013) showed rapid increase in Internet searches for “buy Mephedrone” in Europe and “bath salts” in the U.S. in 2012.

25. MDPV
Phenethylamine and norephinephrine-dopamine reuptake inhibitor. Hallucinogenic effects. Lasts longer than Mephedrone or Methylone.
Similar form of this was developed in 1960’s to treat chronic fatigue syndrome but rejected due to issues with dependency.
Doses of mg can produce effects with oral and inhalation.

26. Mephedrone
Derived from cathinone and increases dopamine, serotonin, and norephinephrine levels.
Users report longer and better high than cocaine. Users report it is like using cocaine and ecstasy together. Effects last about an hour. Known as meow-meow.
Users usually ingest capsules, dissolve in water, snort, or use rectally (bombing).

27. Methylone
Stimulant in the phenethylamine class. More potency in terms of serotonin reuptake inhibition. Similar structure to MDMA.
After oral, nasal, or rectal use, effects occur within 20 minutes, and last about 2 hours.
*Low concentrations of endogenous phenethylamine have been found in people with ADHD and high concentrations have correlation with incidence of schizophrenia.

28. Bath salts vs. Cocaine/Meth
Like Amphetamines, Bath Salts release dopamine from cells, while blocking the reuptake of dopamine into the cell similar to cocaine.
MDPV is ten times stronger than cocaine.
Taking Bath Salts is like taking Cocaine and Meth together.
Time delay – MDPV is able to cross blood-brain barrier which may impact onset of action and toxicity.
Pbs.org – September 2012

29. Bath Salts and The Brain

30. Why Do People Use Them?
Increased energy, alertness, and concentration.
Sexual stimulation and mood enhancement.
Decreased appetite and need for sleep.
Low cost and advertised to users as “they will never fail a drug test”.
Readily available and accessible.

31. Effects
Patients reporting to ER’s have cardiovascular complications, such as tachycardia, chest pains, and hypertension.
Dizziness, jaw clenching, and confusion.
Body temperatures of up to 107 degrees have been reported. Often people take their clothes off.
Jerking eye movements and foaming at the mouth have been reported. Vomiting and nosebleeds.
Restlessness and inability to sit still.
Insomnia – sleep deprivation * - Some people take Xanex and other drugs to try to sleep.

32. EFFECTS
Auditory and Visual Hallucinations with common themes of monsters, demons, aliens, and God. This leads to paranoid delusions and violent behavior in response to hallucinations.
Irritability, suicidal ideation, self-harm behaviors, and prolonged anxiety. “Excited Delirium”.
Begin 10 – 20 minutes, peak 45 – 90, last 2-3 hours then decrease. Users reported effects after 24 hours. Nonpsychiatric symptoms usually resolve in 1 to several days, but psychosis can persist.

33. Concerns
A Marquette County, Michigan ER reported 35 admissions from November 2010 to March This prompted Law Enforcement to seize all bath salts from a local convenience store. The products tested all contained MDPV.
17 out of 35 were hospitalized. Median age was 28 years (range years). One death reported. 63% used by injection.
54% were Men, 69% self-reported a history of drug abuse, 46% or 16 patients had a history of mental illness(bipolar disorder, schizophrenia and depression), and 17% reported suicidal thoughts/attempts related to use of bath salts.
“Morbidity and Mortality Weekly Report, Vol 60, May 20, 2011,

34. Concerns
According to the Bangor Daily News, domestic violence calls have increased in Maine due to use of Bath Salts.
Cookeville Regional Medical Center in TN has treated over 160 people since 2010.

35. Dangers and Dependency
A research study led by UNC professor CJ Malanga, MD found that Mephedrone, like cocaine, has a high potential for abuse and addiction.
Study by Scripps Research Institute in California suggests that Bath Salts are more addictive than Meth. Rats averaged 60 level presses for meth versus 600 for MDPV. Some even pressed 3000 times for a single hit. Exhibited obsessive behavior, such as, licking, biting, and sniffing their cages.
NIDA.org Sydney Herald 2013.

36. Acute Toxicity of Substituted Cathinone Product.
Use Compiled From 2 US Case Series Reports (n = 271)*
Signs and Symptoms Percentage
Agitation
Tachycardia
Combative violent behavior 57
Delusions/hallucinations
Paranoia
Confusion
Seizures tremor
Drowsiness
Hypertension
Paranoia
Mydriasis
Myoclonus
Chest pain

37. Dangers
Users report repeated dosing and binging over several days leading to tolerance.
Acute toxicity may be linked to larger binge consumption, using multiple substances, and other individual use patterns.
Journal of Addiction Medicine, May/June 2013

38. Legality
The Synthetic Drug Prevention Act signed by President Obama on July 9, This act bans 29 chemicals found in Bath Salts and Synthetic THC and makes them Schedule I.
States will have to incorporate these into their drug scheduling list and update the list as new substances are discovered.

39. Operation “Logjam”

40. Operation logjam
July 26, Operation “Logjam” seized 5 million packets of synthetics and arrested 90 people in a nationwide effort to crackdown on these drugs.
Tested products contained anywhere from 17 milligrams to 2000 milligrams of chemicals.

41. Poison Control Center Data
CALLS TO POISON CONTROL: 304 in 2010, 6,138 in 2011, in 2012,
Ages <6 to over 59. Most ages 20 – 29.
January – 228/301 July – 361/680
February – 230/487 August – 173/602
March – 264/639 September – 119/512
April – 285/600 October – 98/401
May – 295/720 November – 86(2012)
June – 415/743 December – 78(2012)
www. aapnc.org

42. TREAMENT
Often eat up Emergency Room resources as it takes multiple nurses and doctors to treat users.
Difficult to know what someone has taken unless they self-report or someone else reports.
Does not show up on typical toxicology screens and can not be detected by drug dogs. There are now drug tests that do test for Bath Salts. Ammon labs, Redwood Toxicology, and Dominion Diagnostic offer these drug screens.

43. TREATMENT Low dose antipsychotics to treat psychosis
Benzodiazepines, usually Ativan, to decrease agitation is first treatment.
Ten to twenty times the normal dose of sedatives have been used.
Try to avoid using restraints, but speak reassuringly to people who are agitated and paranoid
Move to a quiet room with low light to help calm patient.
Avoid loud noises and try medications prior to restraint.

44. TREATMENT
Monitor the person for depression and suicidal ideation even after they have stopped using the drug. Address both mental health and addiction issues. Follow guidelines for treatment of stimulant users.
Psychotic symptoms often persist after treatment
Enhance coping skills to assist the person in dealing with anger and other emotions.
Train staff to deal with specialized issues and incorporate questions into intake and assessment.

45. Movie Madness BATH SALT ZOMBIES Available on DVD February 19
is a new horror film directed and co-written by Dustin Wayde Mills (Puppet Monster Massacre, Zombie A-Hole, Ballad of Skinless Pete) and produced and co-written by Clint Weiler of Aggronautix. The movie sensationalizes the recent bath salt  epidemic and the attacks surrounding them

46. “Zombie Apocalypse”
The shocking wave of attacks associated with Bath Salts has sparked fears of a real-life zombie outbreak in the south. This led to The Center for Disease Control and Prevention releasing a statement saying it is not aware of any virus that can cause zombie-like behaviour.

47. What next?
Partnerships and networks between the community and law enforcement have made an impact in the sale and distribution of this drug.
Education regarding the dangers of Bath Salts.

48. Spice / K2

49. What is Spice and K2?
Spice and K2 refer to commercially available products sprayed with chemicals called synthetic cannabinoids. These products claim to be a mixture of herbs but often do not have herbs in them. They include other ingredients that are unknown and not listed.
Many have warning labels as not intended for human consumption, but are solely intended for human consumption. Marketed as incense. Resembles potpourri.

50. Synthetic Cannabinoids
Synthetic Cannabinoid products are manufactured in Asia and sold in US in many different arenas (gas stations, liquor stores, smoke shops and internet)
Sold under different brand names: “K2, Spice, Spice Gold, Spice Black, Mr. Nice Guy, Yucatan Fire and many others”
Since the national ban on five synthetic cannabinoids, new brand names have developed, such as K2 Sky, K3, and K4

51. What is a Synthetic Cannabinoid?
A class of synthetic substances that bind to the cannabinoid receptors(CB1 and CB2) in the body. When used they create a high similar to THC. Bind more strongly than THC. There are hundreds of synthetic cannabinoids.
Used in an attempt to avoid laws that make marijuana illegal. National Ban on five cannabinoids began in March

52. History of Spice and K2?
The cannabinoid-like chemicals were first developed in research laboratories to study receptors in the body and brain and for other research purposes. The five banned cannabinoids are JWH-018, 073, 200, CP 47, and 497.
JWH-018 was first made in 1995 by Dr. John Walter Huffman at Clemson University. Manufacturers read research and copied it to produce this cannabinoid and marketed it for commercial distribution.
Brand “Spice” was released in 2004 and gained popularity in 2006.

53. Spice and K2
The company that started the “Spice” line went from assets of 65,000 Euros in 2006 to 899,000 Euros in Spice was the dominant brand until Then competing brands like “K2” hit the market. Now there are many distributors of these products.
Rick Broider with North America Herbal Incense Trade Association estimates profits at 5 billion per year.
In 2011, Redwood Toxicology Lab developed testing for six synthetic cannabinoid chemicals. 72 hours for urine and 24 – 48 for saliva.

54. Spice Products Spice Spice Gold Spice Diamond Spice Tropical Synergy
Spice Arctic Synergy
Spice Gold Spirit
PEP Spice

56. Many Faces of Spice

57. K-2/SPICE

58. Other Herbal Incense Products
Genie
Yucatan Fire
Dream
Ex-ses
Blaze
Spike 99
Blaze
Spark
Fusion
MANY others!

59. Spice Ingredients
One or more synthetic cannabinoid compounds. Can be different mix each time.
JWH-018, CP 47, 497, C8, JWH-073, and JWH-250 have been found most often in spice products.
Other legal substances such as Pink Lotus, Dwarf Skullcap, Indian Warrior, and Lion’s Tail
Potentiate or add to effects
Create different effects between products
Many have psychoactive effects on their own
Some used as marijuana substitutes in the past.
Cost $30 - $40 per 3 gram bag.

60. Other Synthetic Cannabinoids
HU named after Hebrew University where they were created.
HU-210
Various studies show it is anywhere from times more potent than ∆9 THC1
Schedule I under CSA: Illegal in U.S.
HU-211
Studies tentatively show no ∆9 THC-like effects
Used to research treatment of brain damage related to stroke, brain trauma, glaucoma, and multiple sclerosis
HU-311
Has potent antineoplastic and antiproliferative activity (cancer fighting drug)
1 J. Med. Chem.35 (11): 2065–9.

61. BIZARRO - ZENCENSE

62. BIZARRO

63. Bizarro
At a glance:
Out of all the varieties of incense that I have burned, a fairly large number, Bizarro is my personal favorite. That being said, I wouldn’t recommend Bizarro to just anyone. It is for experienced users and is not to be underestimated. As with other brands of herbal potpourri, the psychoactive effects from Bizarro should not be set alongside cannabis. They are much more intense and harder to control. Bizarro is a great brand of incense if used correctly, but it can also render terrifying experiences to those who dive in too fast.

64. Synthetic Cannabinoids
CP 47,497 and analogues (CP Created by Pfizer)
3 to 28 times more potent than ∆9 THC
CP 55,940
45 times more potent than ∆9 THC
JWH-015
JWH x more potent than THC and same chemical structure shared with known cancer causing agents.
JWH-073
WIN 55,212-2 (WIN is for Sterling Winthrop)
Used to research treatment for Alzheimer's
Effects milder and don’t last as long as ∆9 THC

65. Other Herbal Incense Ingredients (Not all inclusive)
Baybean
Blue Lotus
Lion's Tail
Lousewort
Indian Warrior
Dwarf Scullcap
Maconha Brava
Indian Pennyworth
Clove
Hops
Tribulus Terrestris
Pink Lotus
Marsh Mallow
Red Clover
Rose
Vanilla and Honey
Fly Agaric
Siberian Motherwort
Damiana
Stevia Leaf
Lemon Grass
Turnera diffusa
Many other legal herbs and herbal extracts are used to enhance aroma, potency

66. Dangers of K-2/Spice Video

67. Why Do People Use It? Legal substitute to marijuana
Herbal incense products are
smoked or snorted for marijuana-like effects
Other reasons: increase creativity, reduce stress, experience euphoria, increase personal insight, and increase appreciation for the arts
There are numerous blogs and websites the provide users the opportunity to share experiences.

68. Effects
Marijuana-like effects: euphoria, giddiness, silliness, bloodshot eyes, impaired short-term memory and concentration, and “munchies.”
Other common effects: cotton mouth, light sensitivity, a warm sensation in the limbs, dry eyes, paranoia, light headedness, auditory and visual hallucinations, painless head pressure, time distortion, panic attacks, delirium, impaired coordination, and sleeplessness
Onset/duration: 5-10 minutes, and effects vary from 2 hours for JWH and 5-6 for CP. Can get high off a hit or two.

69. Effects
A number of users experience hangover-like effects the morning after use including dry mouth, intense headaches
Depending on the product, inhaled smoke is as harsh as marijuana smoke
Taste can vary from a very bad to sickly sweet.

70. Effects
One hospital reported a patient with a 1-3 gram a day habit and severe withdrawal symptoms (tremors, headache, nausea, vomiting and depression).

71. Dangers
Linked to 16 cases of kidney failure. All but one experienced nausea and vomiting. Twelve reported abdominal, back, and neck pain. All but one were male and had healthy kidneys. Age range was 15 – 33. Traced to Spice Gold, Mad Monkey, Mr. Happy, Clown Legal, and Lava brand.
Another study found these products may create psychosis in patients with no history of psychiatric disorder.
Overdose potential from unknown amounts and ingredients in products.
ABC News, Nick Wasson , M.D. February 2013

72. Dangers
Poison Control Centers had 112 calls in 2009, in 2010, 6,959 in 2011, and 5200 by December 31, 2012.
Users are experimenting with combining different products, which can dramatically change or increase the effects. These cannabinoids were created for experimental use. Not tested on people. No one knows long term effects of these products.

73. Dangers
JWH-018 and others, have a shared chemical structure with cancer causing agents, according to NIDA.
A hospital in Kansas reported 8-10 people hospitalized in one month after smoking the products with hallucinations, seizures and bleeding from the nose and mouth.
Three teens ages 16 and 18, showed up in ER with anxiety, agitation, excessive sweating, and inability to speak.

74. Dangers Kids’ brains are still developing.
Across the US, people are showing up in emergency rooms with aggressive and unusual behavior. Suicides have been reported.
A NIDA study stated 11% of school seniors have used Spice/K-2 in Second most frequently used drug after THC.
Medical personnel often don’t know what they are dealing with unless the person self-reports.

75. DANGERS

76. Appearance
Most herbal incenses appear as an olive green leafy material very similar in appearance to marijuana, oregano

77. Paraphernalia
Herbal incense smokers will use the same or similar products used by marijuana smokers
Pipes, bongs, hookahs
Rolling papers
Blunts (hollowed out cigars packed with product)
Herbal incense specific paraphernalia
Vapor Genie
Grinders (to further grind into a finer mixture)

78. Hookah

79. Vapor Genie
Grinders

80. Controlled Substances Act
In Nov , the USDEA moved to ban 5 synthetic cannabinoids, placing them in Schedule I status due to high potential for abuse, and no known medical benefits. The ban would be in effect for one year.
The ban was delayed due to companies stating the ban was unconstitutional.
On March 1, 2011 the National Ban was enacted.
This means that is illegal to possess and sell products containing these.
Before the ban, 15 states had already taken action to control one or more of these five chemicals.

81. Challenges - Manufacturing
Manufacturing occurs in countries where synthetic cannabinoids are legal.
As detection catches up with manufacturing, makers will alter ingredients. They are using new ingredients which are not illegal at this time.
Federal bans target larger distributors. States will need to go after smaller distributors.

82. Challenges - Marketing
Product will not cause positive drug test
“There's never been a case reported by our clients that any of our Herbal Smoke Blends caused them to fail a test”
“YOU'LL NEVER FAIL A DRUG TEST”
Why would this be an issue for a product marketed as incense and not for human consumption?

83. Challenges - Marketing
Ingredients1
Synthetic cannabinoids not listed
Listed ingredients are not necessarily in the product
Consumers don’t know what they are actually getting
Raises questions of consumer protection and product misrepresentation
1 Understanding the ‘Spice’ Phenomenon Thematic Paper, European Monitoring Centre for Drugs and Drug Addiction, 2009, Portugal

84. ENERGY DRINKS

85. ENERGY DRINKS
American Association of Poison Control Centers – ( urges the public to use caution using these products.
Highly concentrated amounts of sugar, caffeine, and other ingredients. Was mixed with alcohol in the past and sold next to bath salts.
Caution for children and adolescents. Children should not have it and adolescents should not have more than 100 mg of caffeine per day = one cup of coffee*
*Journal of Pediatrics

86. Energy Drinks
Due to labels, it is often hard to know how much caffeine is in the drink.
Drinks contain natural caffeine-containing ingredients that are not separately listed, such as, yerba mate, cacao, and guarana.
These drinks are considered dietary supplements and not regulated by the FDA so there is no limit to amount of caffeine that can be in them.
Drinking too many at one time or too fast ……..

87. EFFECTS Nausea and vomiting Seizures Insomnia Kidney Problems
Delirium Mood Changes
Headache Increased BP
Altered and increased heart rhythm
Withdrawal
Chest Pains
Dehydration
Sweating

88. BATH SALTS & ENERGY DRINKS
A 28 year old man was found passed out in a random person’s driveway, and was taken to the hospital. It was discovered that the man had overdosed on energy drinks and bath salts.
According to a report by the Caledonia Police, officers found the man lying on the floor of his van.
An individual said he found the van in his own driveway. The individual stated the engine was off and that no keys were found in the ignition. The victim was found slouched over the steering wheel. There was a cell phone in the man’s possession, and the last dialed contact was that of his mother.

89. POISON CONTROL CENTER
2607 calls to Poison Control Centers related to the use of Energy Drinks through October 31, 2012

90. Resources
Life Center of Galax is equipped to treat persons using these substances. Our confidential referral and assessment number is We are available 24/7 to speak with anyone.

91. Thank You