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/SpiceExpectations or goals for this workshop
3 Objectives History and background of “new synthetic designer drugs” Epidemiology and current trendsEffects and dangers of these drugsHow sold, what they look like and how usedLegal, prevention and treatment issues
5 Designer Drugs: Background Trend started in late 1970’sDrugs of abuse are classified by DEADrugs of abuse work according to structureAnalogsCan “design” an analog to have same or similar activity but not listed as a “controlled substance”Not subject to legal penalties and restrictions5
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.66
7 Federal Drug Schedules Federal Controlled Substances Act (CSA) of 1970Schedule 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 AbuseExplain that penalties are more severe the lower the schedule number.SOURCE: ATTC National Office, CONNECT to Fight Prescription Drug Abuse.7
8 Designer Drugsdesigner 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 lawsBeing manufactured in other countriesMany “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 outlets10
11 Web Sites www.erowid.org www.lycaeum.org www.hightimes.com 11
13 Herbal IncenseCrushed non-psychoactive herbal plant matter treated with one or more synthetic cannabinoidsFirst 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 K2K2 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 marijuanaK2 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 K2For $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 itNow do but extra expense and only some labsSmokable 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 SpiceK2 contains synthetic chemicals, known as JWH-018 and JWH-073, that mimic THC by acting on the cannabinoid receptors in the brainOther analogs detectedHU-210AM-2201CP-47, CP-497, C6, C8, C9The 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 2012Year #2, 906Year #6,959Year 2012 up to May 31 #2,883Prior 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 productsLeaf can be: marshmallow leaf, parsley, etc.Sprayed with synthetic cannabinoidsMarketed as incense and “not for human consumption”No regulations to list ingredients or age requirements to purchaseAs 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 FactTests show that even the same brand may have different drugs– in different amounts-at different timesUser has no way of knowing what or how much they are takingOne 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 sDr. 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 ImpactRetailers 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 purchaseSame notes as TOT
23 HU-211 and HU-2101Ki values are and 0.52 nM at cloned human CB1 and CB2 receptors respectively (http://www.tocris.com/dispprod.php?ItemId=2257)
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 structureIn 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 receptorsBehavioral pharmacology studies show that JWH-018 and JWH-073 both have Δ9-THC-like activity in animalsSame notes as TOT
25 Missouri K2 Administration Study Bob Welsh- PIIRB Human subjects approvalSix subjects smoked K2 SummitEach contained JWH-018 & JWH-073 or CP47, 497Subjects performed Standardized Field Sobriety Tests, cognitive tests & Drug Recognition Expert ExamBlood, urine and oral fluid collectedRecent 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 headednessBlurred visionAgitation, Motor restlessnessTime dilation (?)Theory in physics, time travelSelf 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 pressureLack of convergenceMovement of the two eyes so coordinated that the images of a single point fall on corresponding points of the two retinasNo horizontal or vertical gaze nystagmusPupils normal, muscle tone normalHere 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 tremorsLoss of balanceLoss of motor coordinationSelf 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 TachycardiaDry MouthFelt Impaired, subjective thought disruptionChanges in perceptionImpaired sense of timeMild anxiety, paranoiaSedation & Post-intoxication exhaustionEffects 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 attackAgain these effects are self reported from web sites and from ER staff reporting. Very subjectiveMain point is that it has a strong DYSPHORIA and yet users use a againSelf mutilation such as digging at tactile hallucinations, pulling hair etc.3030
31 On Line Reported K2 Effects Self mutilationParanoiaAuditory & visual hallucinationsDeliriumAgitationMore 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 effectsEuphoriaGiddinessSillinessImpaired short-term memory and concentrationIncreased 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 ProductsStraight from a web page of one of the most prolific web sites3333
34 K2 ProductsExamples of packing and if readable names such as Ninja and Black Mamba3434
35 How Diagnosis is MadeMainly supported by clinical history rather than presentation or mental status examDuration of intoxication or “high” is relatively short (30 min. or less)Do not typically present acutely intoxicated to an outpatient visitUnlike marijuana do not have a typical or signature smellThis 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 systemCrisis Centers, ER’s & Psychiatric HospitalsER’s are seeing and identifying more due to acute intoxicationToxicology testing continues to improveNot 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 usedNausea, vomiting, heart pounding like I am going to have a heart attackNot sure if I just said that, thought it, or read itTwo hours later will never take this againHere 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 tasteFive minutes feels like cannabisTen minutes like an intense cannabis highMore than three puffs might be too muchVery 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 incenseVarying potencyOverdosePresence of different cannabinoidsKnock-offsUser/environment characteristicsSet & setting, etc.
40 K2 Overview No quality control Manufacturing process may be associated with adverse effectsSubjective effects most closely resemble those of very powerful marijuanaAlmost complete lack of scientific studyStreet information very inconsistentReview 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 state40
41 K2 Treatment Issues High rates of addiction (K2info.org) Withdrawal due to physical addictionTreated with sedatives and clonidineBefore D/A treatment need to be medically and psychiatrically safe and stableResidual effects for weeks (or months) due to long half-life & fat storageMention that the K2info.org web site is an excellent resource to learn more about various aspectsResidual 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 professionalsSome 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 monthsDue to tolerance increased dose 10 foldFelt need to continue use dailyWhen unable to get drug experienced:Unrest, drug craving, nightmares, sweating, nausea, tremor, headache, high BP, tachycardiaMost 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 againWhen wanted to stop checked into hospitalExperienced classic withdrawal that lasted 7 daysSame 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 potHerbal incense blends are harshJWH-018 does not mix well with alcoholThe high last no more than 30 minutesThis 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 TestingMany labs have a test for the first generation JWH chemicalsIn February 2010, Redwood Labs, California developed a saliva test for JWH-018, JWH-073 and JWH-250Saliva and urine tests recently developed for second generation JWH’sRodney: 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 TestingFollowing 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 AdministrationMaryland no enactment yet for K2 as of Sept 25, 2012Local bans such as Ocean CityJuly 21, 2012 Bath Salts now Schedule I in Maryland
58 Bath SaltsToxic psychoactive drugs “disguised” or “pretending” to be “Bath Salts”They are NOTSome people have snorted real BS’sSome 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” AreIt 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 teaStimulation and euphoriaPart 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 stimulant62
63 Khat Coca ---------------cocaine Khat cathinone (Schedule I)Cathinones: Structure similar to amphetaminesEuphoriaAnorexiaStimulationDilated pupilsHypnagogic hallucinations when wearing offAnalogy 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 1929Rediscovered web site “The Hive”Was a replacement for EcstasySold as “plant food” & later “bath salts”Manufactured in clandestine labsMethylenedioxypyrpvalerone (MDPV)Known as substituted cathinones64
65 MDPV TimelineMDPV 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.
68 Mephedrone & MDPV Use Capsules, tablets or white granuels Can be swallowed, smoked, snorted, injectedProminent use in EuropeOut of 70 Dutch users of mephedrone, 58 described it as an overall pleasant experience and 12 described it as an unpleasant experience68
70 Mephedrone/MDPV Desired Effects Mental and physical stimulationEuphoria, mood liftFeelings of empathy, opennessIncrease in sociability, desire to talk with othersPleasurable rushingSense of being sped up70
71 Mephedrone/MDPV General Effects General change in consciousness (as with most psychoactives)Decreased appetitePupil dilationUnusual body sensations (facial flushing, chills, goosebumps, body energy)Change in body temperature regulationSweatingIncrease in heart rate and blood pressure71
72 Mephedrone/MDPV Toxic Effects Strong desire to re-dose, craving to recapture initial euphoric rushUncomfortable changes in body temperature (sweating/chills)Heart palpitations, sense of racing heartImpaired short term memoryInsomnia72
73 Mephedrone/MDPV Toxic Effects Severe paranoiaPsychosisHypersexualityAggressionHallucinationsAnxiety and depressionSeizures73
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 StoryMarch 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 shopRemember they are:PotentLethalHighly addictiveThere 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 themThe remeber points are crucial to understanding the dangers of these drugs77
78 One More StoryNovember 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 story78
79 Bath Salt DataAmerican Association of Poison Control Centers # of callsJune 9, 2012 reportYear #304Year #6,138Year 2012 to May #1,320
80 Berks PA County Head Shop Bust A variety of Bath Salts and K280
81 Same Head ShopMore- 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 addictionSimilar to PCP abuse/addictionStabilization and Safety highest prioritySafety of clientSafety of staff and others
83 Mephedrone/MDPV Treatment Issues If psychotic or dissociated need to medicateNeuroleptics:Haldol for emergency stabilizationAtypicals (Seroquel/Respirdol/etc.) for ongoing stabilizationDecease sensory exposure“Rock or Rave” medicineTalking down bad tripsDe-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 disturbanceThe disturbance develops over a short period of time (usually hours to days) and tends to fluctuate.
86 ED: Research FindingsExcited Delirium often involved psycho-stimulant drugsAmphetaminesamphetamine derivativesCocaineSometimes even the lack of having taken certain prescription drugs could cause a similar response behaviori.e. lithium in the case of manic depressants
87 ED: Research FindingsPsycho-stimulant drugs can produce a number of potentially lethal effectsPsycho-stimulant overdoses can causecardiovascular compromiseSeizureshyperthermia.
88 Mephedrone & MDPV Treatment Issues Once stable and safe be aware of cognitive impairmentMay need “tincture of time” to grasp recoverySupportive non threatening environmentScreen for COD (high probability)
89 Bath Salts OverviewThey 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 MDPVMDPV 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 AggressionAgitationBreathing difficultyBruxism (grinding teeth)ConfusionDizzinessExtreme anxiety sometimes progressing to violent behaviorFits and delusionsHallucinationsHeadacheHypertension (high blood pressure)Increased alertness/awarenessIncreased body temperature, chills, sweatingInsomniaKidney painLack of appetiteLiver failureLoss of bowel controlMuscle spasmsMuscle tensenessVasoconstriction (narrowing of the blood vessels)Nausea, stomach cramps, and digestive problemsNosebleedsPsychotic delusionsPupil dilationRenal failureRhabdomyolysis (release of muscle fiber contents [myoglobin] that could lead to kidney problems)Severe paranoiaSuicidal thoughtsTachycardia (rapid heartbeat)Tinnitus91
92 Dangers/Legal IssuesDr. 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 permanentOctober 1, 2012 Synthetic Drugs now listed as Schedule IAll substituted cathinones now Schedule IChemists 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 EducationSchools, parent groups, community groups, law enforcement, medical & treatment, etc.Legislation against precursor chemicalsLegislation making drugs Schedule IPatrick 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 stimulantsAtlantic Labs- Bensalem, PA Bath Salts $20.00 and K2 $15.00.Most labs now testingCheck with your lab97
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 treatmentProblem: labs report as high as 35-40% false negatives with on-siteOn-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 soon99
100 You May Ask What’s Next? Krokodil? 2C-1 or “Smiles” Kratom In Russia and Europe2C-1 or “Smiles”Yahoo reports 09/19/2012KratomHere today in Maryland & Mid-Atlantic StatesMarketed as “Natural” substitute for K2 & K3
101 Krokodil Opioid- desomorphine Result of attempt to extract codeine Injected can be used by other routesRussia & spreading through EuropeTissue breakdownHighly 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 WHATDoes this information mean to me professionally and personally?????
106 Objectives History and background of “new synthetic designer drugs” Epidemiology and current trendsEffects and dangers of these drugsHow sold, what they look like and how usedPrevention and treatment issues