Emerging Trends in Drug Abuse

Joshua Pruitt, MD, FAAEMFebruary 6, 2014

What’s New

• E-Cigarettes• “Krokodil”• “N-bomb”• “Syrup,” “Purple Drank,” “Sizzurp,” “Lean”• “Molly”• Salvia Divinorum

What’s ‘Sort-of’ New

• K-2/Synthetic Cannabinoids• Bath Salts, MDPV, Khat• Energy drinks

E-cigarettes

• Battery-operated devices marketed as “safer” than traditional cigarettes

• Produce flavored nicotine aerosol/steam that looks and feels like tobacco smoke

• No tar or other chemicals from burning tobacco leaves

• Still require a chemical diluent that has an unknown safety profile

E-cigarettes

“Krokodil”

• Cheap heroin substitute• Desomorphine (Heroin is diacetylmorphine)• Made by combining codeine tablets with toxic

chemicals (i.e., lighter fluid, industrial cleaners)• More powerful than heroin with a shorter duration• Causes gray/green scaly flesh at site of injection, thus

the name• Injection sites often become gangrenous• Average life-span after beginning use is 2 years

“Krokodil”

“N-bomb,” “Legal Acid,” “Smiles,” “25I,” “25C,” “25B”

• Three closely-related synthetic hallucinogens• Substitute for LSD or mescaline• Serotonin stimulant, more powerful than LSD• Can cause seizure, MI, respiratory

depression/arrest, death• 19 related deaths in US between 3/2012 and

8/2013

“N-bomb,” “Legal Acid,” “Smiles,” “25I,” “25C,” “25B”

“Syrup,” “Purple Drank,” “Sizzurp,” “Lean”

• Phenergan w/codeine plus soda (Actavis)• May include hard candies• Celebrated in rap music• High risk of respiratory

depression and CNSdepression

• Deaths from prescription opioids now outnumber deaths from all other drugs

“Syrup,” “Purple Drank,” “Sizzurp,” “Lean”

• Implicated in the deaths of DJ Screw and Pimp C

“Syrup,” “Purple Drank,” “Sizzurp,” “Lean”

• Overdose symptoms related to promethazine and codeine

• Promethazine – CNS depression, anticholinergic– Tachycardia, altered mental status, delirium

• Codeine – CNS depression, respiratory depression– Miosis, bradypnea/apnea, hypoventilation

• Seizures highly unusual and usually related to hypoxia

“Syrup,” “Purple Drank,” “Sizzurp,” “Lean”

“Molly”

“Molly”

• Slang for “molecular”• Refers to pure crystalline powder form of MDMA

(Ecstasy)• Sold in capsules• Celebrated in rap/hip-hop music• Produces energy and euphoria• May cause hyperthermia, confusion, depression,

sleep problems

“Molly”

• Symptoms often mixed toxidrome due to co-ingestions

CNS effects CV effects GI effects Derm effectsAMS Palpitations Dry mouth DiaphoresisSeizures Chest pain Nausea/vomiting PiloerectionRestlessness CrampingAgitation Dental effects Anorexia GU effectsHyperthermia Bruxism Urinary retentionSyncope Enamel erosion Sexual dysfunctionAtaxia

“Molly”

Salvia

• Highly selective kappa-opioid receptor agonist• Originated with Mexican Mazatec shamanism• Hallucinogen with psychedelic/dissociative effects• Taken by smoking, no real effects from ingestion

Salvia

• Intoxication effects– Uncontrollable laughter– Vivid reliving of past memories– Sensation of motion or being pulled by something– Visions of membranes or other 2-D surfaces– Merging with or becoming objects– Overlapping realities, such as being in two places at

once

Salvia

“K-2,” “Spice,” Synthetic Cannabinoids

• Very diverse class of drugs• Bind to the cannabinoid receptor• Similar effects to marijuana• Often more intense effects• Include hallucinogenic and psychedelic effects

“K-2,” “Spice,” Synthetic Cannabinoids

• Reported effectsImpaired driving incidents Suicide attempts

Increased anxiety Panic attacks

Palpitations Respiratory “complications”

Aggression Mood instability

Altered perception Paranoia

K-2/Synthetic Cannabinoids

Bath Salts, MDPV, Khat

• Synthetic cathinones• Function as dopamine-norepinephrine reuptake

inhibitors• Four times more potent than Ritalin or Concerta• Duration of action 3-4 hours, with after-effects

lasting as long as 6-8 hours

Bath Salts, MDPV, Khat

CNS/Psych effects CV effects Respiratory effects Renal/GI effects

Aggression Hypertension Tachypnea Transaminitis

Agitation Vasoconstriction Respiratory alkalosis Urinary incontinence

Confusion Tachycardia Fecal incontinence

Extreme anxiety Chest pain Nausea/vomiting

Hallucinations Rhabdomyolysis

Hyperthermia AKI

Delusions

Paranoia

Suicidal ideations

Bath Salts, MDPV, Khat

• Amateur chemists change the chemical composition of the “bath salt” and make it nearly impossible for regulation to keep up with production.

• Mortality rate from “excited delirium” estimated at 8-14%, most die while in police custody

• Treatment is supportive– Benzo’s, restraints if necessary, watch for rhabdo

Bath Salts, MDPV, Khat

Elevated temperature

Agitated delirium

Respiratory arrest

DEATH

Bath Salts, MDPV, Khat

Energy Drinks

• Drinks like Red Bull, Rock Star, Monster• Contain caffeine and other legal stimulants

(guarana, ginseng)• Can contain 75 to >200 mg of caffeine per serving

– 34 mg per serving in Coke– 55 mg per serving in Mt. Dew

• If it says “no caffeine,” then it uses guarana, which is the same as caffeine

Energy Drinks

• 5-hour energy advertises “no crash,” but that relates to the sugar crash– Contains artificial sweeteners

• Short term problems– Increased heart rate, palpitations– Hypertension– Dehydration– Sleep problems

Energy Drinks

• Some may have 2 servings per can• When used occasionally, not necessarily dangerous• Think of them as highly caffeinated drinks• Combination with alcohol

– The stimulant effect of the energy drink can mask how intoxicated someone is

– Can give the drinker the impression they are not impaired– Research shows that people drink more and have higher

BALs when they combine alcohol and caffeine

Energy Drinks

• ER visits related to energy drink consumption– 10,068 in 2007; 20,783 in 2011– 60% of patients drank energy drink alone– 27% of patients combined with prescription drugs– 13% combined with alcohol– 10% combined with illegal drugs– 9% combined with prescription stimulants

Questions