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Novel Synthetic Mixed Hallucinogen/Stimulants: Diagnosis and Treatment David A. Gorelick, M.D., Ph.D., DLFAPA Professor of Psychiatry University of Maryland School of Medicine

Intoxication syndrome The Diagnosis of Novel Synthetic Mixed Hallucinogen/Stimulants Collateral informants Intoxication syndrome History Drug samples Packaging Not as helpful

Substituted piperazines Forms NBOMes Substituted piperazines Powder N-bomb Bliss Bolt Solaris Liquid Charge Smiles Blotter paper Euphoria CIMBI-5 Tablets and capsules Herbal Ecstasy Frenzy Legal X Party Pill

US Drug Enforcement Administration (DEA) www.dea.gov US National Institute on Drug Abuse (NIDA) www.drugabuse.gov

Medical Evaluation Clinical laboratory testing Review of systems CBC Electrolytes Blood chemistry Medical Evaluation 12-lead electrocardiogram Physical and neurological examination Imaging (e.g., brain imaging) 

Diagnosis is often made by exclusion. Confirmed by sophisticated and expensive assay methods Results delayed several days  False negative results due to novel chemical structures

Clinical Manifestations Warranting a High Index of Suspicion (1) Sudden onset of otherwise unexplained psychosis or delirium (2) Sudden onset of otherwise unexplained mixed signs and symptoms suggestive of hallucinogen, stimulant, and serotonin toxicity (3) Sudden onset of otherwise unexplained neurological signs (e.g., muscle clonus or seizures), cardiovascular problems (e.g., chest pain, tachycardia, arrhythmia, or hypertension), or hyperthermia Kersten, B. P. and M. E. McLaughlin (2015). "Toxicology and management of novel psychoactive drugs." J Pharm Pract 28(1): 50-65.   Weaver, M. F., J. A. Hopper, et al. (2015). "Designer drugs 2015: assessment and management." Addict Sci Clin Pract 10: 8.

Treatment: No Specific Antidote Hospitalization: observation and monitoring Supportive and symptomatic measures Antipsychotics to be avoided Short-acting benzodiazepines for anxiety, agitation, or muscle clonus Kersten, B. P. and M. E. McLaughlin (2015). "Toxicology and management of novel psychoactive drugs." J Pharm Pract 28(1): 50-65.   Weaver, M. F., J. A. Hopper, et al. (2015). "Designer drugs 2015: assessment and management." Addict Sci Clin Pract 10: 8.

Observation and monitoring Supportive and symptomatic measures Transient suicidal ideation rarely requires treatment unless: Psychiatric symptoms > 1 week: Close evaluation for a comorbid psychiatric disorder It persists. It reflects a comorbid mood disorder. Kersten, B. P. and M. E. McLaughlin (2015). "Toxicology and management of novel psychoactive drugs." J Pharm Pract 28(1): 50-65.   Weaver, M. F., J. A. Hopper, et al. (2015). "Designer drugs 2015: assessment and management." Addict Sci Clin Pract 10: 8.

Specific Treatment for Serotonin Toxicity Cyproheptadine 5HT2 Oral loading dose: 12 mg 2 mg repeated every 2 hours Kersten, B. P. and M. E. McLaughlin (2015). "Toxicology and management of novel psychoactive drugs." J Pharm Pract 28(1): 50-65.   Weaver, M. F., J. A. Hopper, et al. (2015). "Designer drugs 2015: assessment and management." Addict Sci Clin Pract 10: 8.

No published treatment studies Users Withdrawal syndrome No published treatment studies Users Substance use disorder Kersten, B. P. and M. E. McLaughlin (2015). "Toxicology and management of novel psychoactive drugs." J Pharm Pract 28(1): 50-65.   Weaver, M. F., J. A. Hopper, et al. (2015). "Designer drugs 2015: assessment and management." Addict Sci Clin Pract 10: 8.

Key Points Synthetic mixed hallucinogen/stimulants combine the clinical manifestations of a conventional hallucinogen with those of a conventional stimulant. Intoxication may produce severe neuropsychiatric complications, including psychosis, delirium, and seizures. Clinical effects can last for much longer than with conventional hallucinogens or stimulants. Treatment is supportive and symptomatic, as there is no specific antidote.