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2. 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

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

4. 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

5. US Drug Enforcement Administration (DEA)
US National Institute on Drug Abuse (NIDA)

6. 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) 

7. 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

8. 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):
Weaver, M. F., J. A. Hopper, et al. (2015). "Designer drugs 2015: assessment and management." Addict Sci Clin Pract 10: 8.

9. 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):
Weaver, M. F., J. A. Hopper, et al. (2015). "Designer drugs 2015: assessment and management." Addict Sci Clin Pract 10: 8.

10. 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):
Weaver, M. F., J. A. Hopper, et al. (2015). "Designer drugs 2015: assessment and management." Addict Sci Clin Pract 10: 8.

11. 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):
Weaver, M. F., J. A. Hopper, et al. (2015). "Designer drugs 2015: assessment and management." Addict Sci Clin Pract 10: 8.

12. 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):
Weaver, M. F., J. A. Hopper, et al. (2015). "Designer drugs 2015: assessment and management." Addict Sci Clin Pract 10: 8.

13. 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.