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Update in Toxicology 2013 K2, Spice, Bath Salts, & the New Designer Drugs K2, Spice, Bath Salts, & the New Designer Drugs William Hurley, MD FACEP William.

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Presentation on theme: "Update in Toxicology 2013 K2, Spice, Bath Salts, & the New Designer Drugs K2, Spice, Bath Salts, & the New Designer Drugs William Hurley, MD FACEP William."— Presentation transcript:

1 Update in Toxicology 2013 K2, Spice, Bath Salts, & the New Designer Drugs K2, Spice, Bath Salts, & the New Designer Drugs William Hurley, MD FACEP William Hurley, MD FACEP Harborview Medical Center Harborview Medical Center Washington Poison Center Washington Poison Center –(800) –(800)

2 Update in Toxicology 2013 Goal Goal –Increase knowledge in management of the poisoned patient Objectives Objectives –Describe manifestations & management of the stimulant syndrome –List new designer drugs, their mechanisms, & their sources Designer Drugs

3 Tox Update 2012

4 Designer Drugs

5

6 Poisoning Case A 20 year-old female is found agitated & confused by family in her dormitory room. A 20 year-old female is found agitated & confused by family in her dormitory room. She has no significant past medical history, but the family suspects she has been “experimenting” with alcohol & marijuana since starting school. She has no significant past medical history, but the family suspects she has been “experimenting” with alcohol & marijuana since starting school. She is agitated & aggressively ordering care providers to leave her exam room. Family explains this is not like her at all. She is agitated & aggressively ordering care providers to leave her exam room. Family explains this is not like her at all. She is tachycardic, hypertensive, hot, & diaphoretic She is tachycardic, hypertensive, hot, & diaphoretic –(P 128, BP 180/110) How would you manage this encounter? How would you manage this encounter?

7 20 Year Old Female Anxious & Agitated Initial Evaluation ? Initial Evaluation ? Designer Drugs

8 20 Year Old Female Anxious & Agitated Mental Status Mental Status A – A – B – B – C – C – D – D – E – E – Designer Drugs

9 20 Year Old Female Anxious & Agitated Mental Status Mental Status A – Open & Protected ? A – Open & Protected ? B – Ventilating & Oxygenating ? B – Ventilating & Oxygenating ? C – Rhythm, Perfusion ? C – Rhythm, Perfusion ? D - Disability / Seizures D - Disability / Seizures Decontamination, Dextrose ? Decontamination, Dextrose ? E – Exposure, Elimination ? E – Exposure, Elimination ? Poison Center Poison Center Designer Drugs

10 Initial Management WA Poison Center WA Poison Center Airway Airway Breathing Breathing Circulation Circulation –80% of poisonings Disability/Decontamination Disability/Decontamination –90% of poisonings Exposure/Elimination Exposure/Elimination –Antidotes –100% of poisonings Designer Drugs

11 20 Year Old Female Anxious & Agitated Agitated, responding to loud verbal Agitated, responding to loud verbal A – Open with intact gag reflex A – Open with intact gag reflex B - RR / minute, clear lungs B - RR / minute, clear lungs C - Tachycardic (Sinus - 130’s) C - Tachycardic (Sinus - 130’s) Hypertensive (180/110) Hypertensive (180/110) D - No Seizure, Glucose 108 D - No Seizure, Glucose 108 Decontamination? Decontamination? E – Elimination? E – Elimination? Designer Drugs

12 Poisoning Management ABCDE ABCDE Safety Net Safety Net –IV, Monitors (ECG & O2) Focused History Focused History –What, when, why, what has been done? –What else is available? Focused Physical Examination Focused Physical Examination –Toxicologic Syndrome? Designer Drugs

13 Toxicologic Syndromes Asphyxiant Asphyxiant Cholinergic Cholinergic Anticholinergic Anticholinergic Cyclic Antidepressant Cyclic Antidepressant Opiod Opiod Sedative Sedative Stimulant Stimulant Hallucinogenic Hallucinogenic Serotonergic Serotonergic Hepatotoxic Hepatotoxic Heavy Metal Heavy Metal Irritant gas Irritant gas Caustic Caustic Salicylates Salicylates Toxic Alcohols Toxic Alcohols Hydrocarbons Hydrocarbons Calcium antagonists Calcium antagonists Designer Drugs

14 Poisoning Management Physical Examination – Toxicologic Syndrome Physical Examination – Toxicologic Syndrome Designer Drugs

15 Poisoning Management Physical Examination – Toxicologic Syndrome Physical Examination – Toxicologic Syndrome –Vital Signs –Mental Status confused, stimulated, depressed confused, stimulated, depressed –Pupils; small or large, reactive or not –Mucus membranes; color, moisture –Respiratory rate & depth, bronchospasm, pulmonary edema rate & depth, bronchospasm, pulmonary edema –Gastrointestinal Tract; hyper- or hypoactive –Skin; color, temperature, moisture Designer Drugs

16 Poisoning Case A 20 year-old female “crazy” A 20 year-old female “crazy” Tachycardic, hypertensive, warm, & wet Tachycardic, hypertensive, warm, & wet –(P 130, BP 185/110) Synthetic marijuana? Synthetic marijuana? Designer Drugs

17 Poisoning Case A 20 year-old female “crazy” A 20 year-old female “crazy” Tachycardic, hypertensive, warm, & wet Tachycardic, hypertensive, warm, & wet –(P 130, BP 185/110) Synthetic marijuana? Synthetic marijuana? Toxicologic Syndrome? Toxicologic Syndrome? Designer Drugs

18 Physical Examination Stimulant Syndrome Vital Signs Vital Signs Mental Status Mental Status Pupils Pupils Mucus membranes Mucus membranes Respiratory Respiratory Gastrointestinal Gastrointestinal Skin Skin T, P, R, BP T, P, R, BP Seizures Seizures Dilated & reactive Dilated & reactive Moist Moist Rate, depth Rate, depth Motility Motility Pink, warm, moist Pink, warm, moist Designer Drugs

19 Spice Case Roomate produces packets of incense purchased at a local “head shop.” Roomate produces packets of incense purchased at a local “head shop.” Designer Drugs

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21 Spice Case A 20 year-old female “crazy” A 20 year-old female “crazy” Begins screaming & struggling Begins screaming & struggling –Attempting IV –Has 3 minute seizure Management? Management? Designer Drugs

22 Stimulant Agents - ? Designer Drugs

23 Stimulant Agents Cocaine Cocaine Amphetamines Amphetamines –Methamphetamine, Ecstasy, methylphenidate, phentermine Decongestants Decongestants –Ephedrine, Pseudo-ephedrine Beta Stimulators Beta Stimulators –Albuterol, caffeine, theophylline Withdrawal States Withdrawal States –EtOH, benzodizepine, GHB Designer Drugs

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25 Cannabinoids

26 Cannabinoids Spice products - Europe in 2004 Spice products - Europe in 2004 “Herbal smoking blend” “Herbal smoking blend” “Not for Human Consumption” “Not for Human Consumption” Synthetic agents, created to simulate effects of cannabis Synthetic agents, created to simulate effects of cannabis CNS cannabinoid receptors CNS cannabinoid receptors Derived from cathinones (“Khat”) Derived from cathinones (“Khat”) Designer Drugs

27 Cannabinoids Sold in small packets Sold in small packets Variety of names Variety of names –K2, Spice Gold, Spice Diamond, Spice Silver, Spice of Life Retail U. S. $25-$40 Retail U. S. $25-$40 Designer Drugs

28 Plant & Herbal Blends Marketed as incense Marketed as incense Desire for ‘legal high’ Desire for ‘legal high’ Ability to avoid detection on drugs- of-abuse testing (THC) Ability to avoid detection on drugs- of-abuse testing (THC) Designer Drugs

29 What’s up with the Eye? Designer Drugs

30 What’s up with the Eye? Wide-open-eye imprint Wide-open-eye imprint Allusion to ‘‘Dune’’ Allusion to ‘‘Dune’’ Fictional drug ‘‘Melange’’ Fictional drug ‘‘Melange’’ Called ‘‘the spice” Called ‘‘the spice” Excessive use caused blue sclera Excessive use caused blue sclera Designer Drugs

31 Cannabinoids Heterogeneous structured compounds Heterogeneous structured compounds –Agonize endogenous cannabinoid receptors –Include phytocannabinoids derived from Cannabis sativa (delta 9-THC) –Endogenous cannabinoids –Synthetics Designer Drugs

32 Synthetic Cannabinoids Synthesized 1960s at Hebrew University (HU) Synthesized 1960s at Hebrew University (HU) –HU-210 Pfizer 1970s; Cyclohexylphenol series Pfizer 1970s; Cyclohexylphenol series J W Huffman (JWH) 80s J W Huffman (JWH) 80s –JWH-018, JWH-073, JWH-200 Designer Drugs

33 Cannabinoids Signs & Symptoms Tachycardia Tachycardia Hypertension Hypertension Hyperthermia Hyperthermia Anxiety Anxiety Seizures Seizures Paranoia & hallucinations Paranoia & hallucinations Designer Drugs

34 European Experience Within weeks of regulatory control Within weeks of regulatory control Non-prohibited cannabinoids found in products Non-prohibited cannabinoids found in products Structures heterogeneous Structures heterogeneous –No THC rxn Designer Drugs

35 Synthetic Cannabinoids 2010 U.S. DEA, Office of Diversion Control JWH – 73 11% JWH – %

36 U.S. DEA Activity March, 2011 March, 2011 Temporary Schedule I Temporary Schedule I –unsafe, highly abused, no medical usage Five synthetic cannabinoids Five synthetic cannabinoids –JWH-018, JWH-073, JWH-200 –CP-47,497 & Cannabicyclohexanol –HU-210 all ready Schedule I Designer Drugs

37 Synthetic Cannabinoids 2011 U.S. DEA, Office of Diversion Control JWH – % JWH – 210 9% JWH % JWH-18 14% AM %

38 Synthetic Drug Abuse Prevention Act of 2012 Signed into law July 9, 2012 Signed into law July 9, 2012 Adds certain classes of synthetic cannabinoids & two substituted cathinones­—mephedrone and MDPV— to the federal controlled substances act. Adds certain classes of synthetic cannabinoids & two substituted cathinones­—mephedrone and MDPV— to the federal controlled substances act. Designer Drugs

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40 Stimulant Agents Cocaine Cocaine Amphetamines Amphetamines Decongestants Decongestants Beta Stimulators Beta Stimulators Withdrawal States Withdrawal States Cannabinoids Cannabinoids –JWH-018, JWH-073, JWH-200 –CP-47,497, Cannabicyclohexanol –HU-210 Designer Drugs

41 Stimulant Agents Mechanisms of Action - ? Designer Drugs

42 Stimulant Agents Mechanisms of Action

43 Central inhibition of catecholamine reuptake Central inhibition of catecholamine reuptake –Epinephrine, norepinephrine Peripheral stimulation of alpha & beta receptors Peripheral stimulation of alpha & beta receptors Additional effects (nuances) Additional effects (nuances) –Na channel / local anesthetic (cocaine) –Serotonin reuptake inhibition (MDMA) Designer Drugs

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45 Stimulant Toxicity Clinical Management - ? Designer Drugs

46 Stimulant Toxicity Clinical Management Central inhibition of catecholamine reuptake Central inhibition of catecholamine reuptake –Benzodiazepines (GABA receptor agonists) mg/kg Diazepam IV (5-10 mg) mg/kg Diazepam IV (5-10 mg) 0.05 mg/kg Lorazepam or Midazolam IV or IM (2-5 mg) 0.05 mg/kg Lorazepam or Midazolam IV or IM (2-5 mg) Repeat every 5-10 minutes for seizures, every 10 minutes until calm Repeat every 5-10 minutes for seizures, every 10 minutes until calm –Neuroleptics (monitor the QT interval) 2-5 mg IM or slow IV Haloperidol or Droperidol 2-5 mg IM or slow IV Haloperidol or Droperidol Designer Drugs

47 Stimulant Toxicity Management Peripheral stimulation of alpha & beta receptors Peripheral stimulation of alpha & beta receptors –Benzodiazepines (cardiac receptors) –Vasodilators; phentolamine, nitroprusside –Cardiac monitoring Additional effects Additional effects –Benzodiazepines –Hydration, Cooling, Neuromuscular paralysis Designer Drugs

48 Spice Case A 20 year-old female “crazy” A 20 year-old female “crazy” Tachycardic, hypertensive, warm, & wet Tachycardic, hypertensive, warm, & wet –(P 140, BP 185/110) Diazepam 5 mg IV X 2 Diazepam 5 mg IV X 2 Temp o Temp o –Urine reddish brown –IV ½ NS with 2 amps NaHCO 3 Designer Drugs

49 Spice Case CT head negative CT head negative Urine Tox negative Urine Tox negative Admitted ICU Admitted ICU –Continuous EEG monitoring Awakens next morning Awakens next morning –Admits binge of “Spice” –Peak CPK 14,000 –No renal failure –Discharged home intact day #3 Designer Drugs

50 Smoking ‘Bath Salts’ 26 y.o. male – agitated & confused 26 y.o. male – agitated & confused 3 day binge 3 day binge –Smoking ‘Bolivian Bath Salts’ Roomate found him face-down on floor Roomate found him face-down on floor Designer Drugs

51 26 Year Old Male Agitated & Confused Management? Management? Designer Drugs

52 Initial Management WA Poison Center WA Poison Center Airway Airway Breathing Breathing Circulation Circulation –80% of poisonings Disability/Decontamination Disability/Decontamination –90% of poisonings Exposure/Elimination Exposure/Elimination –Antidotes –100% of poisonings Designer Drugs

53 26 Year Old Male Agitated & Confused Agitated, responding to loud verbal Agitated, responding to loud verbal A – Open with intact gag reflex A – Open with intact gag reflex B - RR 28 / minute, clear lungs B - RR 28 / minute, clear lungs C - Tachycardic (Sinus - 130’s) C - Tachycardic (Sinus - 130’s) Hypertensive (160/100) Hypertensive (160/100) D - No Seizure, Glucose 120 D - No Seizure, Glucose 120 Decontamination? Decontamination? E – Elimination? E – Elimination? Designer Drugs

54 ‘Bath Salts’ Case Agitated, responds to loud verbal stimuli Agitated, responds to loud verbal stimuli No trauma No trauma Pupils 6 mm Pupils 6 mm P 130 BP 160/100 P 130 BP 160/100 Diaphoretic & Hot Diaphoretic & Hot Designer Drugs

55 Physical Examination Stimulant Syndrome Vital Signs Vital Signs Mental Status Mental Status Pupils Pupils Mucus membranes Mucus membranes Respiratory Respiratory Gastrointestinal Gastrointestinal Skin Skin T, P, R, BP T, P, R, BP Seizures Seizures Dilated & reactive Dilated & reactive Moist Moist Rate, depth Rate, depth Motility Motility Pink, warm, moist Pink, warm, moist Designer Drugs

56 “Bath Salts” “White Ice, Ocean Snow, Lunar Wave, Purple Wave, Ivory Wave, Ivory Soft, Vanilla Sky, Bliss” “White Ice, Ocean Snow, Lunar Wave, Purple Wave, Ivory Wave, Ivory Soft, Vanilla Sky, Bliss” $20 packets from convenience stores, truck stops & via Internet $20 packets from convenience stores, truck stops & via Internet Designer Drugs

57 “Bath Salts” - Compounds Very similar to amphetamines Very similar to amphetamines Side effects largely the same we see with amphetamines in large dose Side effects largely the same we see with amphetamines in large dose –Jeffrey Baldwin, University of Nebraska Medical Center Typically snorted, smoked, injected Typically snorted, smoked, injected Can be mixed with water as a beverage Can be mixed with water as a beverage Designer Drugs

58 Snorting & Smoking Bath Salts Designer Drugs

59 “Bath Salts” - Contents Mephedrone Mephedrone MDPV (3,4-methylenedioxypyrovalerone) MDPV (3,4-methylenedioxypyrovalerone) Designer Drugs

60 Mephedrone - Europe Cathinone derivative Cathinone derivative Marketed as ‘plant feeder’ ‘not for human consumption’ Marketed as ‘plant feeder’ ‘not for human consumption’ Potentially addictive & Potentially addictive & Increasingly popular legal substitute for cocaine & ecstasy Increasingly popular legal substitute for cocaine & ecstasy Designer Drugs

61 MDPV – 3,4 methylendioxypyrovalerone Epinephrine & Nor- epinephrine re-uptake inhibitor Epinephrine & Nor- epinephrine re-uptake inhibitor Designer Drugs

62 MDPV – 3,4 methylendioxypyrovalerone Epinephrine & Norepinephrine re-uptake inhibitor Epinephrine & Norepinephrine re-uptake inhibitor Beta ketone ‘research chemical’ Beta ketone ‘research chemical’ Intake (Dose 5-15 mg); Intake (Dose 5-15 mg); –Oral (capsule, ‘bombing,’ beverage) –Rectal, Insufflation, Smoking, IV –Onset 1 hr, Peak 1.5 hr, Duration 3-12 hrs Designer Drugs

63 MDPV Toxicity -? Designer Drugs

64 “Bath Salts” Toxicity 35 patients, Michigan ED’s 35 patients, Michigan ED’s Agitation - 23 patients (66%) Agitation - 23 patients (66%) Tachycardia - 22 (63%) Tachycardia - 22 (63%) Delusions/hallucinations - 14 (40%) Delusions/hallucinations - 14 (40%) 17 patients hospitalized, 1 DOA 17 patients hospitalized, 1 DOA –MDPV Identified MMWR / May 20, 2011 / Vol. 60 / No. 19 MMWR / May 20, 2011 / Vol. 60 / No. 19 Designer Drugs

65 ‘Bath Salts’ Case Agitated for 18 hours at hospital Agitated for 18 hours at hospital Tachycardia resolves with IV benzos & fluids Tachycardia resolves with IV benzos & fluids Temp Temp Urine (+) benzos only Urine (+) benzos only CK Peak 6500 CK Peak 6500 Designer Drugs

66 Cannabinoids & Bath Salts Designer Drugs Olives TD, et al. Bath salts: the ivory wave of trouble. West J Emerg Med Feb;13(1):58-62.

67 “Bath Salts” - Banned DEA Temporary Schedule I (Oct 2011) DEA Temporary Schedule I (Oct 2011) –Up to 12 months for permanent Louisiana, Florida, North Dakota, WA Louisiana, Florida, North Dakota, WA –New York, Kentucky, Mississippi - Pending PC calls fell with Louisiana ban PC calls fell with Louisiana ban –Now ordering by Internet –Shipping to Mississippi Executive Health February 04, 2011 Executive Health February 04, 2011 Designer Drugs

68 Stimulant Agents Cocaine Cocaine Amphetamines Amphetamines Decongestants Decongestants Beta Stimulators Beta Stimulators Withdrawal States Withdrawal States Cannabinoids Cannabinoids ‘Bath Salts’ ‘Bath Salts’ –Mephedrone –MDPV Designer Drugs

69 New “Rave” (2 C agents) Minneapolis, MN 17 March 2011 Minneapolis, MN 17 March 2011 –Eleven hospitalized (16-21 y.o.) –2 critical, 1 dead Konawa, OK 7 May 2011 Konawa, OK 7 May 2011 –Seven hospitalized (19-20 y.o.) –2 critical, 1 dead 2,5-dimethoxy-4-ethyl-phenethylamine 2,5-dimethoxy-4-ethyl-phenethylamine Designer Drugs

70 2, 5, I-NBOMe Deaths Erowid.org (Extracts) March 2012 – Adult male South Australia March 2012 – Adult male South Australia –2C-I-NBOMe & 2C-B-NBOMe (MVC) June 2012 – 17 & 18 yo males MN June 2012 – 17 & 18 yo males MN –Mixed 25i with chocolate candy July yo female, NC July yo female, NC –25i pills, died >12 hours after ingestion Designer Drugs 2011

71 2 Ci Blotter Paper Designer Drugs

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73 2 C-I Designer Drugs

74 Phenethylamines Chemical NameStreet Name 3,4,5-trimethoxy- phenethylamine Mescaline 2C-E 2,5-dimethoxy-4-ethyl- phenethylamine Europa 2C-B 2,5-dimethoxy-4-bromo- phenethylamine Bees, Bromo, Bromo mescaline, Nexus, Spectrum, Toonies, Venus 2C-I 2,5-dimethoxy-4-iodo- phenethylamine N-Bomb 2C-T7 2,5-dimethoxy-4- propylthio-phenethylamine Blue Mystic, Vanilla Aroma Designer Drugs

75 Phenethylamines Agonist/antagonist 5-HT receptor Agonist/antagonist 5-HT receptor –Hallucinations –Over-stimulation & agitation (amphetamines) Multiple forms Multiple forms –Tablets, capsules, powder for insufflation Kinetics Kinetics –Onset 20 min, peak 2 hrs, duration 6-12 hrs Designer Drugs

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77 Phenethylamines Clinical Effects –Hallucinations, agitation, seizures –Hyperthermia, tachycardia, hypertension, tachypnea –Extreme/rapid cycling emotions –Mydriasis, flushing, diaphoresis –Nausea, vomiting, –Facial dystonia (teeth grinding, grimacing) –Rhabdomyolysis Designer Drugs

78 Phenethylamines (cont) –Insufflation - immediate pain nasal mucosa –Law enforcement officers Phenethylamine laboratories Phenethylamine laboratories Mucous membrane & respiratory symptoms Mucous membrane & respiratory symptoms Designer Drugs

79 Phenethylamines Legal control Legal control –2C-B & 2C-T7 – Schedule I –2C-E & 2C-I - not scheduled controlled substance analogs controlled substance analogs “Bad trips” ?alleviated by SSRIs? “Bad trips” ?alleviated by SSRIs? –Not studied nor recommended Designer Drugs

80 Stimulant Agents Cocaine Cocaine Amphetamines Amphetamines Decongestants Decongestants Beta Stimulators Beta Stimulators Withdrawal States Withdrawal States Cannabinoids Cannabinoids ‘Bath Salts’ ‘Bath Salts’ Phenethylamines Phenethylamines –2 CE & 2 CI Designer Drugs

81 Stimulant Agents Mechanisms of Action Central inhibition of catecholamine reuptake Central inhibition of catecholamine reuptake –Epinephrine, norepinephrine Peripheral stimulation of alpha & beta receptors Peripheral stimulation of alpha & beta receptors Additional effects (nuances) Additional effects (nuances) –Na channel / local anesthetic (cocaine) –Serotonin reuptake inhibition (MDMA) Designer Drugs

82 Poisoning Management ABCDE – Poison Center ( ) ABCDE – Poison Center ( ) Safety Net Safety Net –IV, Monitors (ECG & O2) Focused History Focused History –What, when, why, what has been done? –What else is available? Focused Physical Examination Focused Physical Examination –Toxicologic Syndrome? Laboratory Studies? Laboratory Studies? Designer Drugs

83 Bath Salts and Stimulants Designer Drugs - Expanded, Urine Test (8756U) –Methamphetamine, Amphetamine, O-Desmethyltramadol –MDMA, MDEA, MDA, DOM –Mephedrone, MDPV, Pyrovalerone,, Ethylone, Flephedrone, Buphedrone, Methedrone, Methylone, Cathinone, Methcathinone –2C-B 2C-C 2C-E 2C-H 2C-I 2C-N 2C-P 2C-T-2 2C-T-7 Synthetic Cannabinoid Metabolites Screen - Expanded, Urine (Forensic) Test (9562U) –AM-2201, JWH-018, JWH-019, JWH-073, JWH-081, JWH-122, JWH-210, JWH-250, & RCS-4 metabolites Tox Update 2012

84 Stimulant Toxicity - Key Points Central & Peripheral catecholamine surge Central & Peripheral catecholamine surge –Characteristic clinical toxicological syndrome Specific agents Specific agents –Cocaine, amphetamines, decongestants, cannabinoids, Mephedrone, MDPV, phenethylamines –Often unavailable for decontamination & detection –Treat the patient, not the agent Importance - reduce severity of poisoning (avoid complications) Importance - reduce severity of poisoning (avoid complications) –Benzodiazepines & Hyperthermia prevention Designer Drugs

85 “Spice” References –Gunderson EW, et al. "Spice" and "K2" herbal highs: a case series and systematic review of the clinical effects and biopsychosocial implications of synthetic cannabinoid use in humans. Am J Addict Jul-Aug;21(4): –Simmons JR, et al. Intoxication from smoking "spice”. Ann Emerg Med Feb;57(2): –Vardakou I, et al. Spice drugs as a new trend: mode of action, identification & legislation. Toxicol Lett 2010 Sep 1;197(3): –Schneir AB, et al. "Spice" Girls: Synthetic Cannabinoid Intoxication. J Emerg Med 2010 Dec 15. Designer Drugs

86 “Bath Salts” - References Designer Drugs o Borek HA, et al. Hyperthermia and multiorgan failure after abuse of "bath salts" containing 3,4-methylenedioxypyrovalerone. Ann Emerg Med Jul;60(1): o Prosser JM, Nelson LS. The toxicology of bath salts: a review of synthetic cathinones. J Med Toxicol Mar;8(1): o Murray BL, et al. Death following recreational use of designer drug "bath salts" containing 3,4-Methylenedioxypyrovalerone (MDPV). J Med Toxicol Mar;8(1): o Kasick DP, et al. "Bath salt" ingestion leading to severe intoxication delirium: two cases and a brief review of the emergence of mephedrone use. Am J Drug Alc Abuse Mar;38(2): o Emergency department visits after use of a drug sold as "bath salts"--Michigan, November 13, 2010-March 31, MMWR 2011 May 20;60(19): o Psychonaut WebMapping Research Group, Mephedrone Report, Institute of Psychiatry, King's College London, London, UK (2009).

87 Update in Toxicology 2013 Goal Goal –Increase knowledge in management of the poisoned patient Objectives Objectives –Describe manifestations & management of the stimulant syndrome –List new designer drugs, their mechanisms, & their sources Designer Drugs

88 Update in Toxicology 2013 K2, Spice, Bath Salts, & the New Designer Drugs K2, Spice, Bath Salts, & the New Designer Drugs William Hurley, MD FACEP William Hurley, MD FACEP Harborview Medical Center Harborview Medical Center Washington Poison Center Washington Poison Center –(800) –(800)


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