Why Lecture on Substance Abuse? · 2016. 9. 15. · N-1 American Osteopathic College of...

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American Osteopathic College of Occupational and Preventive MedicineOMED 2016 Didactic Sessions.

Bath Salt GestaltThe New Drugs of Abuse

Brian T. Kloss, DO, JD, PA-C, FACLM

SUNY Upstate Medical University

Syracuse VA Medical Center

Why Lecture on Substance Abuse?

My Only Request What Going on at College Campuses?

Molly – Coming Soon to a College Near You!

What is Molly?

“We Can’t Stop” = DANCING WITH MOLLY"It depends who's doing what. If you're aged ten [the lyric is]

Miley, if you know what I'm talking about then you know. I justwanted it to be played on the radio and they've already had to

edit it so much," the 20-year-old singer told the Daily Mailrevealing interview. "I don't think people have a hard time

understanding that I've grown up. You can Google me and youknow what I'm up to -- you know what that lyric is saying."

2013

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MDMA Testing Kits MDMA

MDMA Identification Charts

LeMoyne

MDMA Art

Molly in Syracuse

• 22 indictments in August 2011

• Investigations began spring of 2009

• 100 kg of “Molly” distributed between March2010 through April 2011

• 25 kg of “Molly” ($525,000), 24 guns, 4vehicles, a Bayliner boat and $100,000 seized

• “Molly” determined to be 4-MMC and 4-MEC

• Substituted Cathinones = Mephedrone

February 201512 Students Hospitalized, 5 Arrested

September 2014Mass Overdoses, Previously Unreported

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Wesleyan Molly

• Enrollment: 3224 students

• 0.1g = $20, 1g = $200 ($80-$100)

• 5 arrested, 5 suspended, charges dropped in 2cases

• Analysis: AB-Fubinaca and “substance similarto MDMA” which was 6-MAPB

• Main distributer created pamphlets todistribute to students on appropriate doseand “safe” drug use

Wesleyan Molly

AB-Fubinaca

• Invented by Pfizer in 2009

• Hit the synth scene in 2012in Japan

• AB-PINACA, 5F-AB-PINACA,ADBICA, etc., etc.

• “Synthetic Marijuana”

• Associated with severaldeaths

6-APB

• 6-(2-aminoproply)benzofuran

• “Benzofury”

• Phenethylamine

• Triple monoamine reuptakeinhibitor and 5-HT2B Agonist

• “Similar” to MDA

Molly? →Career Over?

Mug Shot Modeling Careers

SUNY Oswego

• Enrollment: 7193 students

• May 2015 – 21 year old arrested with 809tablets of Xanax, some marijuana and$170,000 cash.

• $5,000 cash bail $10,000 bond.

History of Synthetic Drugs / Legal Highs

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Background

• “Research Chemicals” have been available for bulkpurchase over the Internet from Chinese Manufacturersfor years.

• Sold as a powder, in bulk weight, and not packaged in apill → thus “not for human consump�on”.

• Some products were a manufacturing precursors toactive compounds (2-CH → 2-CI or 2-CB).

• Some products were pro-drugs converted in the humanliver/kidney to ac�ve form (GBL → GHB).

• Some products are psychoactive drugs by themselves(JWH-018, MDVP, 4-MMC/4-MEC).

• Some products are non-scheduled drugs by themselves(Khat, Salvia, Kratom)

GHB Home Manufacturing Kit – Available Online in the Early 1990’s

GBL (Gamma-Hydroxybutyrate / GHB) Advertisement in High Himes Magazine“Legal Buds” Have Been Advertised in High Times Magazine Since 1990’s

THC

JWH-018

JWH-018 as a “Research Chemical” The Loophole

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How Many Options Are There?

LOTS!!!!

And LOTS!!!!

Where Do These Chemicals Come From? Where to Purchase?

= $419.51

CybercrimesWith Ben

Hammersley

VICE

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How Are They Manufactured? Internet Search

Hubei Prosperity Galaxy Chemical

Inert Plant MaterialProprietary BlendSecret Ingredient

Article on Wholesale Product The Syracuse Smoke Shop Industry

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Incense High School Use

http://www.monitoringthefuture.org/data/15data/15drfig5.pdf http://www.monitoringthefuture.org/data/15data/15drfig3.pdf

SYNTHETIC MARIJUANA

Synthetic Cannabinoids

• “legal buds” & “herbal smoke” sold since early 2000’s.• K2/Spice first major players late 2000’s.• Synthetic cannabinoids first identified as active ingredients

in these products in 2008.• John W. Huffman at Clemson University first synthesized

THC analogs in late 1990’s.• JWH-018, JWH-073, cannabicyclohexinol, and HU-210 have

been some of the compounds identified.• Sold in “head shops” and “smoke shops”.• Concentrations of psychoactive compounds vary per sachet

(0.2-3%), as well as the binding affinity of the synthetic tothe anandamide receptors in brain (can vary between 5-800x affinity).

Stafford, Ned. Synthetic Cannabis Mimic Found in Herbal Incense. Royal Society of Chemistry: Chemistry World. Jan 15, 2009.

Effective Marketing

What You Get

• Tachycardia• Bloodshot Eyes• Discordination• Dry Mucus Membranes• Paranoia*• Hallucinations*• Delusions*• Altered Time Perception*• Psychosis*• Tremors*• Seizures*• Agitation*• Catatonia **• MI***• CVA***• Death****

Adverse Reactions• June 6, 2010 - David Rozga – 18 year old high school athlete in

Indianola, Iowa smoked a synthetic cannabis product, had nohistory of depression, complained to a friend that he “Felt likewas in Hell”, went home and shot himself in the head with ashotgun.

• 2011 Case series of STEMI with elevated troponins, and cleancaths were identified in 3 teens complaining of chest pain an EDin Utah.1

• 2012 – Four cases of oliguric renal failure (ATN) in Alabama.2

Three in Casper, WY and a dozen others sickened with “backpain, nausea and vomiting” after smoking “blueberry spice”.3

1: Mir, Obafemi, et. al. MI Associated with Use of Synthetic K2, Pediatrics June 28, 2011

2: Bhanushali, ain, et al. AKI Associated with Synthetic Cannabinoids, CJASN, December 20123: Zuckerman, L. Wyoming Kidney Failure Outbreak Linked to “Spice” Drug, Reuters. March 5, 2012

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STEMI CVA

• 25 y/o male – JWH-018 – dysarthria, expressiveaphasia, R face and arm weakness: hyperdense LMCA with clot = t-PA improved and lost to followup.

• 19 y/o female – JWH-018 – syncope, AMS,tremors, global aphasia, right hemiplegia, sensoryloss, elevated troponin: L MCA clot and infarct,punctate infarcts in R cerebral hemisphere =outside t-PA window and persistent Rhemiparesis and expressive aphasia.

Freeman, Rose, et. al. Ischemic Stroke After Use of Synthetic Marijuana, Neurology. 2013 Dec 10; 81(24): 2090-2093

Patient A Patient B

Freeman, Rose, et. al. Ischemic Stroke After Use of Synthetic Marijuana, Neurology. 2013 Dec 10; 81(24): 2090-2093

CVA

• 31 y/o male seizure after “Crazy Monkey” XLR-11= multiple intra-parenchymal hematomas,bilateral frontal SAH, left anterior cerebral andmiddle cerebral artery vasospasm.

• 25 y/o female seizure after unknown “spice” =diffuse SAHs, acute ischemic strokes bilateralcortical hemispheres and cerebellum, severevasospasm.

• Neither had aneurysm or artery malformations.

Rose, Guerrero, et. al. Hemorrhagic Stroke Following Use of Synthetic Marijuana, Neurology. 2015; 85:1177-79

So Why So Popular?

• Profitability – both wholesale and retail

• Currently Legal (or at least not illegal)

• Doesn’t show up on conventional urine testing

• Convenience

• Perceived Safety

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Diagnostic Workup and Treatment

• Supportive Care

• Reassurance and Calming Techniques

• EKG to r/o underlying arrhythmias

• Consider CIP (Cardiac Injury Panel) & BMP

• CXR to r/o barotrauma (pneumomediastinum orpneumothorax)

• Mild Benzodiazepine for Anxiety

• Physical and/or Chemical Restraints if Required(Adulterated Marijuana)

What’s New in Syracuse

• Catatonia/Lethargy – Case Reports x 2

• Agitated Delirium – Easy Dx, but safety risk

Brooklyn, NY

33 Overdoses of Synthetic Marijuana Product July 12, 2016

Bath Salts

How Many Options Are There?

LOTS!!!

MDVP - Methylenedioxypyrovalerone

• Norepinephrine-Dopamine Reuptake Inhibitor*• Developed in 1969• Hit the Radar in 2004• MDPK, MTV, Magic, Maddie, Super Coke, PV• White to yellowish color, fishy odor with age• Stimulant Effects > Empathogeneric Effects• More “speedy”, less “trippy”.• 4-6 hour high with a comedown – total effect 10 hours• Addictive – High Desire to Redose• Causes Agitated Delirium – Florid Psychosis

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MDVP - Effects

• Hypertension

• Tachycardia

• Bruxism

• Diaphoresis

• Mydriasis

• Hyperthermia

• Rhabdomyolysis

• Paranoia

• Psychosis

• Delusions

• Hallucinations

Plant Food Molly, 4-MMC, 4-MEC, Mephedrone

• Sold legally under the guise of “plant food”

• Structurally similar to cathinone, like Khat

• 4-Methylmethcathinone

4-Methyl-N-Ethylcathinone

• Increases both dopamine and serotonin*

• More “trippy” than “speedy” when comparedto bath salts

• Syracuse Drug Bust: 22 Arrested 8/16/2011

The New Kids on the Block

• Molly

• 25B-NBOMe = “25B” 25I-NBOMe – “25I”

• 2ci, 2ce = phenethylamines

• AB-FUBINACA

25B-NBOMe “N-BOMB”

• LSD Alternative

• Synthetized 2004 Germany Ralph Heim

• Can be: 25I, 25C, 25B - NBOMe

• Substituted phenethylamine

• Similar to 2CI, 2CE, 2CB

• STRONG 5-HT2a Receptor Agonist (16x 2C-I)

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25B-NBOMe “N-BOMB”

• Tachycardia, Dilated Pupils, Tremors, ↑ WBC, Seizures, Clonus, Agitation, Hallucinations,HTN, AKI, Metabolic Acidosis

• Potent enough for Blotter Paper Hits

• Sublingual, Buccal, Nasal, Vaporized, IV

• March 2012-August 2013 19 deaths inAmericans between ages 15-29 y/o*

* DEA Press Release November 15, 2015

Times Up?

“Synthetic” Drug Summary

• K2/Spice/Incense = synthetic marijuana

• Bath Salts/Glass Cleaner = amphetamine-like

• Molly/Plant Food = substituted cathinones,

phenethylamines,

MDMA-like

• 25-NBOMe = LSD-like

• Kratom = opiate-like

Conclusions

• Synthetic Drugs Are Not Going Away

• Synthetic Drugs Are Always Evolving

• Synthetics Alternatives Exist in Every Class

• Side Effects and Adverse Reactions areBecoming More Severe

• Talk to Your Patients and Children AboutSynthetics

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Fun Websites

Replaced by: Blue Light

• Website: www.klossandbruce.com

• Twitter: @EM_PEARLS

• Facebook: Kloss and Bruce

• YouTube: Kloss and Bruce (Toxicology Videos)

• E-Mail: [email protected]

If you like my style, Invite me Back!

An Easy Way to Learn Toxicology

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Disclaimer

I included additional slides in this Power Point to act as“filler” to be utilized if I moved quickly through the assignedtopic of: synthetic drugs. The lecture as it stands would takeat least 90-120 minutes to cover all the enclosed material.

Other lectures I do on substance abuse include:• Inhalants• Cocaine & Heroin• OTC Drugs of Abuse in the Adolescent Population• Illustrated Toxicology 101• Various EM Focused Lectures

FILLER

Salvia Divenorum

Salvia

• Unique selective kappa-opiate agonist

• Smoked using water bongs and/or blue flamebutane lighters to maximize vaporization ofsalvinorum A and to make smoking moretolerable.

• Sold in concentrated leaf extracts for about$20-$30 online and in smoke shops.

• “Earthy” trancelike and dissociative high for5-10 minutes

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Happy 18th Miley Or is it Hanna Montana?

Kratom Kratom

• Two principle psychoactive alkaloids:7-hydrooxymitragunine and mitragynine.

• Both alkaloids have an agonistic effect at theopioid receptors, with mitragynine having aneffect at alpha-adrenergic receptors in lowerdoses.

• The drug has limited effect on respiratorydrive, making it relatively safe in pure form.

• Kratom is often used in Southeast Asia tomediate the severity of heroin withdrawal.

• The product is sold in the US primarily via internetwebsites and in “head shops” in a chopped leaf orpulverized form as a “concentrated extract”.

• There have been nine deaths in Sweeden from abrand of Kratom called “Krypton Kratom” that waslaced with O-DT (O-Desmethyltramadol), theactive metabolite of tramadol.

• In the US, there has been one reported instance ofa frequent user reporting to an ED with Kratomwithdrawal, which is very similar to opiatewithdrawal.

• Overall, this drug is still “flying under the radar”.

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Why Lecture on Substance Abuse? · 2016. 9. 15. · N-1 American Osteopathic College of...

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