1. Current Trends K2/Spice, “Bath Salts” & Others
Ken Dickinson, M.S., R.Ph. 1

2. Introductions Presenters: Rodney & Ken Attendees
Experience with “Bath Salts” and K2/Spice
Expectations or goals for this workshop

3. Objectives History and background of “new synthetic designer drugs”
Epidemiology and current trends
Effects and dangers of these drugs
How sold, what they look like and how used
Legal, prevention and treatment issues

5. Designer Drugs: Background
Trend started in late 1970’s
Drugs of abuse are classified by DEA
Drugs of abuse work according to structure
Analogs
Can “design” an analog to have same or similar activity but not listed as a “controlled substance”
Not subject to legal penalties and restrictions 5

6. Mephedrone & Methamphetamine
Just using this as a visual example to show what we mean by analogs and to demonstrate that drugs of a similar structure have similar effects. Mephadrone on the left is one of main ingredients in Bath Salts and has similar structure to methamphetamine. Therefore similar effects. 6 6

7. Federal Drug Schedules
Federal Controlled Substances Act (CSA) of 1970
Schedule I: No medical use, high abuse potential (heroin)
Schedule II: Accepted medical use, high abuse potential (OxyContin, Ritalin)
Schedule III: Accepted medical use, less abuse potential than I or II (Vicodin)
Schedule IV: Accepted medical use, less abuse potential than I-III (Valium, Xanax)
Schedule V: Accepted medical use, lowest abuse potential (Robitussin AC)
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse
Explain that penalties are more severe the lower the schedule number.
SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse. 7

8. Designer Drugs
designer drugs  (in  designer drugs (chemistry)) ...to see a marginally different version appear, using substances not covered in the original law. In the United States this problem was addressed in the Anti-Drug Abuse Act of 1986, which contained a Controlled Substance Analogue Enforcement Act (commonly called the Designer Drug Act), which prohibited the manufacture of “substantially similar” analogues of banned chemicals. 8

9. Designer Drugs: Evolution
Internationally do not have such laws
Being manufactured in other countries
Many “designer drugs” do not test (+)
A way to “Beat the Bladder Police” 9

10. Designer Drugs Today’s trend Make an analog that is not listed in laws
Since legal can make an distribute as an everyday household product e.g. “Bath Salts” “Plant Food”, potpourri, incense, jewellery cleaner, hummingbird attractant, etc.
Then label “not for human consumption”
Market via social media and retail outlets 10

11. Web Sites www.erowid.org www.lycaeum.org www.hightimes.com 11

12. K2 Products 12

13. Herbal Incense
Crushed non-psychoactive herbal plant matter treated with one or more synthetic cannabinoids
First generation: “K2”, “Spice”, “Black Mamba”
Second generation “K3”, “Splice”, “Apocalypse”, “Cloud 10”, “Destiny”
The leaf used varies from Marshmallow leaf to catnip, tobacco, etc. A cheap leafy substance that will burn well. This leaf is then treated with the synthetic drug made in clandestine labs with the precursor chemicals being industrial solvents and other chemicals. The precursor chemicals usually originate in China and India and can be toxic.
There are an endless number of names used for these products here are a few. Who knows of others?? Ask for audience participation

14. Synthetic Marijuana (JWH- 018)
Known as Spice or K2
K2 originated at Clemson University, where researchers developed synthetic cannabinoids in an effort to create therapeutic drugs. But the cannabinoids also have effects akin to THC, the key ingredient in marijuana
K2 is largely created by individual sellers, it's anyone's guess what else is added to the mix.
Researchers were looking for a drug to be used medicinally that could provide therapeutic effects seen with the cannabinoids but would be an improvement over THC and possibly work better or have less side effects. The researchers tweeked the THC molecule and made synthetic versions that might be an improvement. Dr. Huffman at Clemson developed a molecule that would help people with a wasting disease such as cancer or HIV/AIDS. It increased appetite and showed promise in alleviating pain while boosting the immune system. He published his research and hence it was in a Journal and on the web. An entrepreneurial found chemist found it and replicated it. Since then many other “analogs” have been discovered and are being marketed. 14

15. K2
For $35, users can buy 3 grams of K2 "incense" with nothing more than a credit card or PayPal account.
Did not have drug test or it
Now do but extra expense and only some labs
Smokable herbal blends marketed as "legal highs" have become increasingly popular and as easy to buy as cigarettes. (before )
Initially was sold over the internet. Now cheaper in many areas and available in retail settings. Big attraction to this drug was that there was no drug test for it. Even now many do not test for it due to expense and lab availability. 15

16. K2 Spice
K2 contains synthetic chemicals, known as JWH-018 and JWH-073, that mimic THC by acting on the cannabinoid receptors in the brain
Other analogs detected
HU-210
AM-2201
CP-47, CP-497, C6, C8, C9
The JWH group of cannabinoids were the first to me made and marketed. Since then other groups of synthetic cannabinoids have be made and there are many, many analogues in each group. There maybe 100 or more psychoactive cannabinoids that could be sold as synthetic pot. 16

17. K2 Data American Association of Poison Control Centers
Reported in article June 2012
Year #2, 906
Year #6,959
Year 2012 up to May 31 #2,883
Prior to 2010 there were very few calls to poison control centers for K2. It is believed that even if there were they were not yet know to professionals and not documented. Similar numbers for Emergency Room visits. Before 2010 persons in ER’s displaying symptoms of K2 ingestion were documented as “psychosis of unknown origin”. Today with better awareness these people are identified as K2 or Bath Salts in ER’s. Poison Control staff now trained to identify when synthetic drugs are involved. Poison Control calls seem to have peaked in 2011 with numbers more than double what we saw in It appears 2012 numbers may be down due to laws and the closing of retail outlets.

18. Description of the Drug
Mixture of herbal and spice plant products
Leaf can be: marshmallow leaf, parsley, etc.
Sprayed with synthetic cannabinoids
Marketed as incense and “not for human consumption”
No regulations to list ingredients or age requirements to purchase
As mentioned earlier unknown variety of herbal and plants products used.. Since not sold as a product for human consumption they do not have to list ingredients. Also prior to new laws sellers were not breaking any laws since it came with “not for human consumption” warning. Not sold as food or drug products no reason for FAD, DEA and similar agencies to be involved.

19. Alarming Fact
Tests show that even the same brand may have different drugs– in different amounts-at different times
User has no way of knowing what or how much they are taking
One batch of a brand may contain entirely different herbs and active ingredients the next time purchased. Very unpredictable even when buying same package and brand. Studies has confirmed this. Who is in this photo and why? Demi Moore and she was found comatose with K2 packages laying around her. This drug appeals to many from different social and economic groups. Many marijuana smokers have been attracted to it thinking it would act like pot but not sh iow in urine tests. It does not act like pot people. Works much stronger. Our next slide addresses how these synthetics are different in activity

20. s
Dr. Huffman & Dr. Huestis (Chief of Chemistry/Drug Metabolism at National Institute for Drug Abuse) indicate that when taking these drugs, it is “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 body’s-hormone functions for example.”
Doctors also express concern that the drugs may involve acute toxicity levels, possibly long term, as well as impacting cannabinoid receptors that regulate body’s immune system.
Huffman is the person who first made these compounds and Huestis from NIDA is considered the leading expert on these drugs. This slide highlights the important fact that these drugs hijack important functions. This leads to life threatening issues such as hyperthermia, seizures, etc. Scientists are very concerned about the long term effects

21. K2 Impact
Retailers selling the drugs report a recent (2011) increase in sales from app. $1000 daily up to $10, 000 daily.
Medical reports indicate that K2/Spice drugs potentially result in users developing a rapid and powerful addiction on a level not usually found among smokers of “real” marijuana.
Recently linked (Dec 2011) to over 352 nationwide emergency room incidents-includes suicide attempts, extremely elevated heart rate/blood pressure, comas, seizures, and anxiety attacks.
A lot of profit motivates the retailers

22. Incense Emporium Online K2/Spice Ad (Current):
Note from the owners:  On Dec 24, the federal government banned certain ingredients commonly found in K2 - our products have been scientifically analyzed and certified not to contain any of the controlled ingredients, for more information please click on the "Contact Us" above. Thanks for being loyal Incense Emporium customers! 
 Buy 1 Get 1 FREE on all Herbal Incense!!! Buy whatever you HERBAL INCENSE would like and we will automatically double it when we package it for shipping.  It's that simple!  Buy 2, Get 4...Buy 5, Get 10...Buy 100, Get No Limits!!!  
$ for 2 ounces...that's only $65 per ounce!!! Our products are NOT FOR HUMAN CONSUMPTION  Must be 18 to purchase
Same notes as TOT

23. HU-211 and HU-2101
Ki values are and 0.52 nM at cloned human CB1 and CB2 receptors respectively (

24. JWH-073 and JWH-0181 JWH-018 and JWH-073
JWH-018 and JWH-073 are synthetic cannabinoid agonists without the classical cannabinoid chemical structure
In vitro studies show that JWH-018 and JWH-073 binds to the brain cannabinoid receptor CB1 with higher affinity than Δ9-THC which binds with almost equal affinity to CB1 and CB2 receptors
Behavioral pharmacology studies show that JWH-018 and JWH-073 both have Δ9-THC-like activity in animals
Same notes as TOT

25. Missouri K2 Administration Study
Bob Welsh- PI
IRB Human subjects approval
Six subjects smoked K2 Summit
Each contained JWH-018 & JWH-073 or CP47, 497
Subjects performed Standardized Field Sobriety Tests, cognitive tests & Drug Recognition Expert Exam
Blood, urine and oral fluid collected
Recent study shows that the scientific and human services communities are responding. Here is a study performed at Univ. of Missouri by the Principle Investigator Bob Welsh. This is an Institutional Review Board approved study and is valid. Small with only six subjects but it is more than we had.
They used a brand called “K2 Summit” that contained the most used compounds. In an effort to measure the effects and their impact the study performed the following tests: Standardized Filed Sobriety Test, Cognitive Tests, and the Drug Recognition Expert Exam. These provide good insight into the drugs effects on the individuals..
Toxicology was also perfomed to determine the drugs present, etc. the following slides are the results of this study.

26. K2 Study (cont’d) Onset of effects in about 2-3 minutes Dry mouth
Light headedness
Blurred vision
Agitation, Motor restlessness
Time dilation (?)
Theory in physics, time travel
Self explanatory except for the “time dilation”. This is a term used by the researcher and it pertains to the subjects feeling like they travel in time. They do not feel as if they are here now but in a different time and place.

27. K2 Study (cont’d) Drug Recognition Expert Exam
Increased pulse and blood pressure
Lack of convergence
Movement of the two eyes so coordinated that the images of a single point fall on corresponding points of the two retinas
No horizontal or vertical gaze nystagmus
Pupils normal, muscle tone normal
Here are the results for the Drug Recognition Expert Exam. This may be useful when confronting a person and not sure if they are drug influenced or not. Lack of convergence may be helpful.

28. K2 Study (cont’d) Field Sobriety Tests
3 to 4 inches of sway, leg body tremors
Loss of balance
Loss of motor coordination
Self explanatory regarding coordination and balance.
Note: the photo shows K2 packaged as “bud” form of marijuana. Marketed as higher potency

29. Missouri Study Self Reported K2 Effects
Tachycardia
Dry Mouth
Felt Impaired, subjective thought disruption
Changes in perception
Impaired sense of time
Mild anxiety, paranoia
Sedation & Post-intoxication exhaustion
Effects that have been reported via self reporting on web sites and user anecdotes. But this is a valid study not anecdotal information. Hopefully more studies will result in knowing more about these drugs.
Review the effects listed and comment on “feeling impaired”
Changes in perception another way of saying halluccinations?
Time distorted such as “time dilation” mentioned earlier

30. On Line Reported K2 Effects
Strong dysphoria -Panic attacks -Heavy body load -Extreme nausea -Fear, Panic, Anxiety -Strong aural hallucinations --Racing heart (higher doses)
Heart attack
Again these effects are self reported from web sites and from ER staff reporting. Very subjective
Main point is that it has a strong DYSPHORIA and yet users use a again
Self mutilation such as digging at tactile hallucinations, pulling hair etc. 30 30

31. On Line Reported K2 Effects
Self mutilation
Paranoia
Auditory & visual hallucinations
Delirium
Agitation
More effects but they are self reported on line. This is how we have obtained most information so far. These we are reporting are mentioned repeatedly and are recognized as true effects.

32. On Line Reported K2 Effects
Marijuana-like effects
Euphoria
Giddiness
Silliness
Impaired short-term memory and concentration
Increased appetite
“Most angiogenic substance I ever ingested”
More on-line. These have been accumulated by Ken by reviewing sites on line such as Erowid and Googling for K2 or Bath Salts “forums” and “Discussions”

33. K2 Products
Straight from a web page of one of the most prolific web sites 33 33

34. K2 Products
Examples of packing and if readable names such as Ninja and Black Mamba 34 34

35. How Diagnosis is Made
Mainly supported by clinical history rather than presentation or mental status exam
Duration of intoxication or “high” is relatively short (30 min. or less)
Do not typically present acutely intoxicated to an outpatient visit
Unlike marijuana do not have a typical or signature smell
This information was obtained from a study conducted by Danielle Castellanos, MD at Florida International Univeristy.
This study was conducted on adolescents and young adults

36. How Diagnosis is Made Usually access “system” via behavioral crisis
Criminal Justice system
Crisis Centers, ER’s & Psychiatric Hospitals
ER’s are seeing and identifying more due to acute intoxication
Toxicology testing continues to improve
Not usually coming directly into treatment for K2. They come in because of issues with other drugs or more often psychiatric or behavioral issues. Until recently users who became psychotic presented in Crisis Centers and Psych ER’s. But we didn’t have a test or know that these drugs were being used and persons were being discharged with a diagnosis of “ Psychosis – unknown cause”. Only to show up again with again no true diagnosis. Today ER’s know to look for and ask about K2 and Bath Salts. Today when detected many are now being referred to addiction treatment. Ken will discuss testing in some detail soon.

37. User Report #1 This is the worst experience I have ever had
The most angiogenic substance I have ever used
Nausea, vomiting, heart pounding like I am going to have a heart attack
Not sure if I just said that, thought it, or read it
Two hours later will never take this again
Here we will look at two different experiences to demonstrate the variety of experiences that users are reporting and that reinforces that it is so new and so unpredictable as to what and how much is in package or how much to use, etc.

38. User Report #2 Three individual hits from a small pipe
Organic, no chemical odor or taste
Five minutes feels like cannabis
Ten minutes like an intense cannabis high
More than three puffs might be too much
Very different experience for these three. Note they only had 3 puffs. Many smoke more than 3 puffs as a routine habit and get more intense results.

39. Why the Discrepancy in Reports?
Use of other drugs with incense
Varying potency
Overdose
Presence of different cannabinoids
Knock-offs
User/environment characteristics
Set & setting, etc.

40. K2 Overview No quality control
Manufacturing process may be associated with adverse effects
Subjective effects most closely resemble those of very powerful marijuana
Almost complete lack of scientific study
Street information very inconsistent
Review each line to summarize some of the key points regarding K2 and our understanding of it the web site at the bottom discusses the epidemiology of K2 in Maryland and it impact on that state 40

41. K2 Treatment Issues High rates of addiction (K2info.org)
Withdrawal due to physical addiction
Treated with sedatives and clonidine
Before D/A treatment need to be medically and psychiatrically safe and stable
Residual effects for weeks (or months) due to long half-life & fat storage
Mention that the K2info.org web site is an excellent resource to learn more about various aspects
Residual effects are of concern to us in treatment. Due to clients having these effects even after weeks or months of abstinence.
Just like bath salts these clients need to be cleared by both medical and psychiatric professionals
Some researchers report the physical dependence is powerful unlike THC and can produce a withdrawal much like seen with opiates or alcohol. 41

42. Withdrawal Case Study WebMD
German male 20 y.o. used Spice Gold daily for 8 months
Due to tolerance increased dose 10 fold
Felt need to continue use daily
When unable to get drug experienced:
Unrest, drug craving, nightmares, sweating, nausea, tremor, headache, high BP, tachycardia
Most information regarding withdrawal is anecdotal here information found on WebMD gives us a person who the reporters were able to follow over time and document his withdrawal symptoms. This gives us some idea regarding a withdrawal syndrome Note some of the characteristics of addiction are seen with K2 such as tolerance and the need to use daily.

43. Withdrawal Case Study Cont’d
Began using again
When wanted to stop checked into hospital
Experienced classic withdrawal that lasted 7 days
Same young man had the same withdrawal experience a second time.

44. K2 Harm Reduction Tips Not all incense blends are created equal.
JWH-018 is more expensive than real pot
Herbal incense blends are harsh
JWH-018 does not mix well with alcohol
The high last no more than 30 minutes
This is taken from a “harm reduction” web site. Warnings to those who are insistent upon using K2. Message as stated earlier in presentation is that they don’t know what they are getting. Dose? Ingedients? Etc. Information like this is shared on the web routinely for persons who we know from experience are not going to refrain from usage. 44

45. K2 Testing
Many labs have a test for the first generation JWH chemicals
In February 2010, Redwood Labs, California developed a saliva test for JWH-018, JWH-073 and JWH-250
Saliva and urine tests recently developed for second generation JWH’s
Rodney: I will cover this slide since I will be adding more information that I just found today. I will probably show some web sites that are very current.

46. K2 Testing
Following a single low dose exposure, synthetic cannabinoids can be detected up to 72 hours in human urine.
In case of chronic exposure the window of detection is much longer

47. Maryland Law: K2 & Bath Salts
On March 1, 2011, the possession and distribution of 5 synthetic cannabinoid compounds became illegal in the U.S. per an emergency ban by the U.S. Drug Enforcement Administration
Maryland no enactment yet for K2 as of Sept 25, 2012
Local bans such as Ocean City
July 21, 2012 Bath Salts now Schedule I in Maryland

49. Mitragyna Speciosa Used in: Local names: Malaysia Thailand Indonesia
Ithang
Biak Biak
Ketum
Kakuam

50. Kratom Pharmacology Mitragynine
Structurally similar to some hallucinogens
No hallucinogenic activity or effects
Acts on opioid receptors

52. Kratom & Opioid Treatment
Currently used for heroin and methadone dependence in some countries
New Zealand
Thailand
Used in detox to manage withdrawal symptoms from opioids

54. Kratom Seems to be a stimulant in lower doses
Mitragynine
Seems to be sedative in higher doses
7 hydroxymitragynine
Often produces a mixed effect
Onset 5 t o 10 minutes
Duration several hours

55. Kratom Side Effects Short term (immediate) Side effects Dry mouth
Increased or decrease urination
Loss of appetite
Nausea and/or vomiting
Side effects
Anorexia/weight loss
Depression
Addiction

57. Mephedrone (4-Methylmethcathinone)57

58. Bath Salts
Toxic psychoactive drugs “disguised” or “pretending” to be “Bath Salts”
They are NOT
Some people have snorted real BS’s
Some attendees in previous workshops have a hard time with understanding that Bath Salts is a disguise. These drugs are not true bath salts they are bath salts imposters. 58

59. “Bath Salts” Are
It is easy to make fun of Charlie Sheen so the package with him is used. There are hundred of photos on the web that can be use to show how bath salts are packaged. Here are just two. More will be shown during ther presentation. Take note that the package states 0.5 Gram. That is 1/10th of a teaspoonful. Who ever used 1/10th of a teaspoonful of bath salts in their bath? AND, it sells for $25 to $50 dollars a lot for bath salts. 59

60. What are Synthetic Cathinones?
Synthetic cathinones are related to the parent compound cathinone.
Since the mid-2000s, unregulated ring-substituted cathinone derivatives have appeared in the European and American recreational drugs market.

61. What are Synthetic Cathinones?
The most commonly available synthetic cathinones sold on the recreational market in the period up to 2012 appear to be 3, 4-Methylenedioxypyrovalerone (MDPV), mephedrone, and methylone.
These products are usually encountered as highly pure white or brown powders. Cathinone derivatives are claimed to have effects similar to those of cocaine, amphetamine or MDMA (ecstasy), but little is known of their detailed pharmacology.

62. Khat Native to tropical East Africa and the Arabian Peninsula
Fresh Leaves/tops chewed or consumed as tea
Stimulation and euphoria
Part of social culture in many countires (coffee, tea, coca or khat)
This analogous to cocaine and its use in South Central America Both Khat and Cocaine have been used for centuries by indigenous persons to those areas as a cultural stimulant 62

63. Khat Coca ---------------cocaine
Khat cathinone (Schedule I)
Cathinones: Structure similar to amphetamines
Euphoria
Anorexia
Stimulation
Dilated pupils
Hypnagogic hallucinations when wearing off
Analogy of cocaine and khat review the effects seen with khat and mention this is what we see with bath salts as explained in upcoming slides. 63

64. Mephedrone Background
Discovered 1929
Rediscovered web site “The Hive”
Was a replacement for Ecstasy
Sold as “plant food” & later “bath salts”
Manufactured in clandestine labs
Methylenedioxypyrpvalerone (MDPV)
Known as substituted cathinones 64

65. MDPV Timeline
MDPV was developed in the 1960s, and has been used for the treatment of chronic fatigue, but caused problems of abuse and dependence.
1969: Boehringer Ingelheim files a patent application for MDPV.
2005: MDPV appears as a recreational drug; first mention on Drugs-Forum.
2007: First seizure of MDPV as a recreational drug, by customs officials in the German state of Saxony. The drug had been shipped from China.
2008: First seizure of MDPV in the United States.

66. MDPV Timeline 2009: MDPV made illegal in Denmark.
2010: MDPV made a controlled drug in the UK, Sweden, Germany, Australia and Finland. First reports of the widespread retail marketing of 'bath salts' containing MDPV in the US. The US considers both Mephedrone (July, 2010) and MDPV (December, 2010) "a drug and chemical of concern".
2011& 2012: MDPV sale and possession are banned in most US states with legislation being introduced in Maryland an other states.

67. Mephedrone/MDPV Appearance
Distinctive odor
Fishy
Vanilla
Stale urine
Bleach
Circuit boards 67

68. Mephedrone & MDPV Use Capsules, tablets or white granuels
Can be swallowed, smoked, snorted, injected
Prominent use in Europe
Out of 70 Dutch users of mephedrone, 58 described it as an overall pleasant experience and 12 described it as an unpleasant experience 68

69. Mephedrone/MDPV Effects
Duration
Total 2 – 5 hours
Onset minutes
Coming up 15 – 30 minutes
Plateau 15 – 30 minutes
Coming down 30 – 90 minutes
After effects 2 – 4 hours 69

70. Mephedrone/MDPV Desired Effects
Mental and physical stimulation
Euphoria, mood lift
Feelings of empathy, openness
Increase in sociability, desire to talk with others
Pleasurable rushing
Sense of being sped up 70

71. Mephedrone/MDPV General Effects
General change in consciousness (as with most psychoactives)
Decreased appetite
Pupil dilation
Unusual body sensations (facial flushing, chills, goosebumps, body energy)
Change in body temperature regulation
Sweating
Increase in heart rate and blood pressure 71

72. Mephedrone/MDPV Toxic Effects
Strong desire to re-dose, craving to recapture initial euphoric rush
Uncomfortable changes in body temperature (sweating/chills)
Heart palpitations, sense of racing heart
Impaired short term memory
Insomnia 72

73. Mephedrone/MDPV Toxic Effects
Severe paranoia
Psychosis
Hypersexuality
Aggression
Hallucinations
Anxiety and depression
Seizures 73

74. PA Criminal Intelligence Center
February 2011, Schuylkill County: PSP, Schuylkill Haven members were attempting to serve a mental health warrant and noticed the subject was fidgety and talking very fast.
The subject admitted to taking methamphetamine earlier in the day and snorting two lines of TranQuility bath salts approximately three hours prior to PSP arrival.
The subject related he felt no pain, was invincible, and likened the effects to that of a cocaine overdose. He was unable to perform any field sobriety tests

75. PA Criminal Intelligence Center
February 2011, Lebanon County: PSP, Jonestown members responded to a burglary where a subject broke a window and jumped through a glass door.
After he was confronted by the occupant, the subject ran outside and kicked in a garage door.
While being interviewed by troopers, he jumped onto the hood of the patrol car, rolled off, and went into a fetal position. The subject was incoherent, claimed he was being electrocuted, and was eventually transported to the hospital.

76. Another PA Story
March 2011, two Pennsylvania men were found dead in the woods after missing for two weeks. Toxicology reports indicate that they had taken bath salts prior to their deaths. The bath salts probably led to their disorientation and they died from exposure and hypothermia.
These individuals were reported to be experienced outdoorsmen and yet died from hypothermia as a result of becoming disoriented- as experienced as they were (were law enforcement agents) 76

77. More Bath Salts Tragedy
January 2011, a 48 year old Florida woman was jailed after shed attacked and attempted to behead her 710 Y.O. mother with a machete. The woman was high on bath salts she purchased from a local head shop
Remember they are:
Potent
Lethal
Highly addictive
There are many, many stories like these, these are just some and you can skip over some if need to save time Just refer attendees to review them
The remeber points are crucial to understanding the dangers of these drugs 77

78. One More Story
November 2010-a 21 year old Louisiana man snorts a packet of Cloud 9 Bath salts and endures several days of delirium and paranoia. He cuts his own throat with a kitchen knife only to survive and then shoots himself later when he had visions of army soldiers swarming his house.
Powerful hallucinations, paranoid and psychosis are landmark characteristics as seen with this story 78

79. Bath Salt Data
American Association of Poison Control Centers # of calls
June 9, 2012 report
Year #304
Year #6,138
Year 2012 to May #1,320

80. Berks PA County Head Shop Bust
A variety of Bath Salts and K2 80

81. Same Head Shop
More- mostly K2 products. Another product we won’t detail today is Kratom which was found in this bust. Kratom is being marketed as a “new K2” in some markets. 81

82. Mephedrone/MDPV Treatment Issues
Similar to strong amphetamine addiction
Similar to PCP abuse/addiction
Stabilization and Safety highest priority
Safety of client
Safety of staff and others

83. Mephedrone/MDPV Treatment Issues
If psychotic or dissociated need to medicate
Neuroleptics:
Haldol for emergency stabilization
Atypicals (Seroquel/Respirdol/etc.) for ongoing stabilization
Decease sensory exposure
“Rock or Rave” medicine
Talking down bad trips
De-escalation techniques

84. Excited Delirium Delirium Defined:
Acute change in mental status characterized by impairment of attention.
Excited Delirium Defined:
Delirium with continuous agitation

85. Excited Delirium Diagnostic Criteria for Delirium
Disturbance of consciousness with reduced ability to focus, sustain, or shift attention.
A change in cognition such as memory deficit, disorientation, language disturbance
The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate.

86. ED: Research Findings
Excited Delirium often involved psycho-stimulant drugs
Amphetamines
amphetamine derivatives
Cocaine
Sometimes even the lack of having taken certain prescription drugs could cause a similar response behavior
i.e. lithium in the case of manic depressants

87. ED: Research Findings
Psycho-stimulant drugs can produce a number of potentially lethal effects
Psycho-stimulant overdoses can cause
cardiovascular compromise
Seizures
hyperthermia.

88. Mephedrone & MDPV Treatment Issues
Once stable and safe be aware of cognitive impairment
May need “tincture of time” to grasp recovery
Supportive non threatening environment
Screen for COD (high probability)

89. Bath Salts Overview
They are sold mostly on the internet, but can also be found in select shops locally.
They're known by a variety of names, including “Red Dove,” “Blue Silk,” “Zoom,” “Bloom,” “Cloud Nine,” “Ocean Snow,” “Lunar Wave,” “Vanilla Sky,” “Ivory Wave,” “White Lightning,” “Scarface” “Purple Wave,” “Blizzard,” “Star Dust,” “Lovey, Dovey,” “Snow Leopard,” “Aura,” and “Hurricane Charlie.”
While they have become popular under the guise of selling as ‘bath salts’, they are sometimes sold as other products such as insect repellant, or plant food with names like “Bonsai Grow” among others.

90. Effects of MDPV
MDPV is sometimes labeled online as legal cocaine or legal amphetamines.
The effects have a duration of roughly 3 to 4 hours, with after effects such as tachycardia, hypertension, and mild stimulation lasting from 6 to 8 hours.
High doses have been observed to cause intense, prolonged panic attacks in stimulant-intolerant users, and there are anecdotal reports of psychosis from sleep withdrawal and addiction at higher doses or more frequent dosing intervals.

91. Synthetic Cathinones Effects Summary Sheet
Aggression
Agitation
Breathing difficulty
Bruxism (grinding teeth)
Confusion
Dizziness
Extreme anxiety sometimes progressing to violent behavior
Fits and delusions
Hallucinations
Headache
Hypertension (high blood pressure)
Increased alertness/awareness
Increased body temperature, chills, sweating
Insomnia
Kidney pain
Lack of appetite
Liver failure
Loss of bowel control
Muscle spasms
Muscle tenseness
Vasoconstriction (narrowing of the blood vessels)
Nausea, stomach cramps, and digestive problems
Nosebleeds
Psychotic delusions
Pupil dilation
Renal failure
Rhabdomyolysis (release of muscle fiber contents [myoglobin] that could lead to kidney problems)
Severe paranoia
Suicidal thoughts
Tachycardia (rapid heartbeat)
Tinnitus 91

92. Dangers/Legal Issues
Dr. Volkow, the NIDA Director stated: “Because these products are relatively new to the drug abuse scene, our knowledge about their precise chemical composition and short- and long-term effects is limited.”
In February, 2011, Congressman Charles Schumer (D-NY) introduced legislation that would add bath salts to a list of federally controlled substances. September 7, 2011, finally saw this legislation in the form of a proposed temporary DEA ban.

93. Federal Ban Proposed on 09/7/2011
The United States Drug Enforcement Administration (DEA) is using its emergency scheduling authority to temporarily control three synthetic cathinones (Mephedrone, 3,4 methylenedioxypyrovalerone (MDPV) and Methylone).
Except as authorized by law, this action will make possessing and selling these chemicals or the products that contain them illegal in the U.S. for at least one year while the DEA and the United States Department of Health and Human Services (DHHS) further study whether these chemicals should be permanently controlled.

94. Synthetic Drug Abuse Prevention Act of 2012
July 10, 2012 President signed Law making temporary law permanent
October 1, 2012 Synthetic Drugs now listed as Schedule I
All substituted cathinones now Schedule I
Chemists working on making non-cathinone stimulants

95. National vs. State-by-State Bans
Just because a federal ban is enacted on a drug, it does not mean local authorities will take action on this drug.
States still need to enact legislation to ban the substances in order for state (then local) authorities to take action.
Federal bans will go after larger distributors, but it will be locally determined as to whether users and smaller, local distributors (such as non-chain convenience stores and gas stations) will be sought after without a state ban.

96. Prevention For K2 & Bath Salts
Heighten awareness via Education
Schools, parent groups, community groups, law enforcement, medical & treatment, etc.
Legislation against precursor chemicals
Legislation making drugs Schedule I
Patrick Meehan “Synthetic Drug Control Act”
Goes into effect October !!!
“Hit the retailers in their pocket book”
Civil suits by victims (users and families)
Authorities appealing to retailers with amnesty if stop and destroy

97. Urine Detection Information
Redwood Toxicology Laboratory shows currently they have detection for MDPV and Mephedrone. (see w.K2info.org/drugtesting)
June 11, 2012 Redwood expanded to test for #21 designer stimulants
Atlantic Labs- Bensalem, PA Bath Salts $20.00 and K2 $15.00.
Most labs now testing
Check with your lab 97

98. Urine Detection Information (Expanded to #21 June 2012)
Redwood has a 2 panel drug test (MDPV, Mephedrone) and a 14 panel drug test which tests for the following drugs:
BZP (Benzylpiperazine)
Butylone (β-keto-N-methylbenzodioxolylpropylamine, bk-MBDB)
Cathinone (Khat or Benzoylethanamine)
Ethylone (3,4-methylenedioxy-N-ethylcathinone, MDEC, bk-MDEA)
MBDB (Methylbenzodioxolylbutanamine, Methyl-J, “Eden”)
mCPP (meta-Chlorophenylpiperazine)
MDA (3,4-Methylenedioxyamphetamine, tenamfetamine)
MDEA (3,4-Methylenedioxy-N-ethylamphetamine, MDEA, MDE, “Eve”)
MDPV (Methylenedioxypyrovalerone, Cloud 9, Ivory Wave, White Lightning)
MDMA (3,4-Methylenedioxymethamphetamine, ecstasy, “E”, “X”)
Mephedrone (4-methylmethcathinone [4-MMC], 4-methylephedrone, “Meph”, “MCat”)
Methcathinone (α-methylamino-propiophenone, may be confused with mephedrone)
Methylone (3,4-methylenedioxy-N-methylcathinone, bk-MDMA, MDMC, “M1”)
TFMPP (3-Trifluoromethylphenylpiperazine, “Legal X”)

99. On-Site Testing Many labs now have available
On site may be useful in treatment
Problem: labs report as high as 35-40% false negatives with on-site
On-site shows no use but when testing for accuracy they send to lab for confirm and up to 40% tested positive.
On-site technology is being developed some labs sell it with a caution regarding its accuracy. Other labs expect to develop a more accurate product soon 99

100. You May Ask What’s Next? Krokodil? 2C-1 or “Smiles” Kratom
In Russia and Europe
2C-1 or “Smiles”
Yahoo reports 09/19/2012
Kratom
Here today in Maryland & Mid-Atlantic States
Marketed as “Natural” substitute for K2 & K3

101. Krokodil Opioid- desomorphine Result of attempt to extract codeine
Injected can be used by other routes
Russia & spreading through Europe
Tissue breakdown
Highly addicting- Usually fatal

105. Points to Ponder WHAT So WHAT Did I learn so far?
What do I think about it?
How do I feel about it?
So WHAT
Does this information mean to me professionally and personally?????

106. Objectives History and background of “new synthetic designer drugs”
Epidemiology and current trends
Effects and dangers of these drugs
How sold, what they look like and how used
Prevention and treatment issues