Download Poison Control Centers Synthetic Drugs of Abuse

Keeping Up with New
Synthetic Drugs:
A Perpetual Game of
Whack-a-Mole
Linda B. Kalin, RN, BS, CSPI
Director
[email protected]
Hotline: 800-222-1222
Office: 712-279-3710
www.iowapoison.org
National 800 Phone Number
Works just like 911
Program your
cell phone!
24 hours a day- 7 days a week
Federally funded by HRSA
Poison Control Centers
Synthetic Drugs of Abuse
• Network of 56 PCCs in U.S.
• Synthetic Cannabinoids
• Provide free, confidential, expert medical advice
• National near real-time data collection
 Data is automatically uploaded to national database
 Ability to detect new public health threats and quickly
notify appropriate authorities at the local, state and
federal levels
 Partnerships with DEA, HRSA, FDA, CDC and private
industry
iPhone app
is available
 AKA “K2”, “Spice” (brand names)
 Marketed as “fake pot/weed” or “legal marijuana”
 Scores of different agents have been identified in “K2”
• Synthetic Stimulants/Hallucinogens
 AKA “Bath Salts” (marketing name)
 May contain synthetic cathinones/cathinone analogues
but may also contain synthetic cannabinoids,
hallucinogenic-like drugs, or many other compounds
 Marketed as meth, cocaine, or ecstasy substitute
Synthetic Drugs of Abuse
• Contain man-made powerful chemicals designed
specifically to be abused and to mimic the effects
of various illegal drugs particularly marijuana,
amphetamines and hallucinogens
• To disguise their intended use and circumvent the
law, drugs are sold and advertised as:
 Bath salts, herbal incense, potpourri, plant fertilizer,
novelty powder, pipe cleaner
 “Not intended for human consumption”
 “Not to be sold to minors”
04/07/14
Contents Often Unknown
• Advertising/packaging is often misleading
• No regulatory oversight or quality control
 Combination of synthetic cannabinoids and synthetic
stimulants have been detected in same sample
 No consistency in purity or potency
 Not tested in humans for safety
 Websites promise to protect customers by shipping
products in discreet or unmarked packages
Users don’t know what chemicals they’re taking
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Synthetic Cannabinoids
John W. Huffman (JWH)
• Created for scientific research
• The materials to make JWH018 are available from lab
chemical suppliers.
 Dr. John W. Huffman, professor of organic chemistry
at Clemson University, was researching the effects of
cannabinoids on the brain (for NIDA in 1990’s)
• Developed chemical compounds to mimic effects of
marijuana; published research in 1998
• Synthetic cannabinoids (CBs) bind to the same
receptors in the brain as tetrahydrocannabinol
(THC)
“I'm concerned that it could
hurt people…We made this as
a research compound and
published it and did what we
were supposed to do. You
can’t be responsible for what
idiots are going to do.”
JWH Trends
Pharmacology
• First generation synthetic CBs: JWH-018, JWH-073
• JWH-018, JWH-073, JWH-200
 Hundreds of JWH compounds
 Part of a “second wave”
• JWH-022, JWH-210
THC is a partial
agonist of CB1;
Synthetic CBs are
full agonists
 Showing signs of increasing popularity
• Both THC & synthetic cannabinoids
bind to the cannabinoid receptors
(CB1 and CB2) to activate them
• Synthetic CBs bind more strongly
than THC (up to 100X)
 Much more potent effects than THC
• 2012 Synthetic Drug Ban includes analogue

• JWH compounds are now far less encountered
Lock-and-key mechanism
Lock= cannabinoid receptor sites of the brain
Key= THC (partial agonist) and JWH (full agonist)
“Key”
“Lock”
• JWH-018 was made by a
summer undergrad research
student, with supervision
• Agonist: A drug that binds to and
activates a receptor of a cell
 Banned by DEA in 2011 (also HU-210, CP47,497)
• JWH-250, JWH-081, JWH-122, AM-2201
• A good college chemistry
major could make them with
supervision and decent lab
equipment.
potential for OD and severe effects
• This is not synthetic THC
Appearance
• Typically found in a powder form, dissolved
in solvents (ex. acetone) and sprayed onto
herbal mixture
• Varying amounts/potencies in different products
• “Hot spots”
• Plant material may be potpourri, plants, herbs
(oregano, parsley, damiana) and even grass
cuttings sprayed with Syn CBs then smoked
• Smoking mixtures are usually sold in metal-foil
sachets
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David Mitchell Rozga
Iowa Law
• K2 implicated in Iowa teen suicide
2011: Iowa Legislature bans 6 Syn-Cans & 2 Syn-Caths
– Purchased K2 at local head shop
2012: Iowa Legislature expands ban to 43 Syn Drugs
– Smokes with friends, develops severe paranoia
• 26 Syn-Caths & 17 Syn-Cans + 5 “classes” of Syn-Cans
– Dies of a self-inflicted gunshot
• DEA/Congress Takes Action
David M. Rozga
Died 06/06/10
 2011: S 605 David Mitchell Rozga Act (Grassley-IA)
DEA bans 5 Syn Drugs (JWH-018, JWH-073,
JWH-200, CP-47,497, and cannabicyclohexanol)
 2012: Congress Adds 26 Syn Drugs to CSA
 2013: 3 Syn Drugs Added in May: UR-144, XLR11, AKB48;
Nov 2013: 25I-NBOMe, 25C-NBOMe, 25B-NBOMe
 2014: 4 Syn CBs: PB-22, 5F-PB-22, AB-FUBINACA, ADB-PINACA
Why Aren’t These Drugs Illegal?
• House approved 96-0; Senate 45-0
2013: Iowa Pharmacy Board follows Feds and
emergency bans +3 Syn-Cans
2014: SSB 3008 Bill before Iowa Legislature to ban +8
syn drugs (DEA in process of emergency
scheduling +4 Syn-Cans & +10 Syn-Caths
Synthetic drugs classified as Schedule I; misdemeanor in Iowa, federal felony
Dangerous Street Chemistry
• States ban specific formulas but
drug makers can easily sidestep
these regulations
• Manufacturers adapt by replacing
the chemical compound of a banned
substance with a newer formulation
that is not yet known to authorities
• Poses increasing risk as users are
unaware of the reactions the new
chemicals may cause
• Usually smoked to provide marijuana-like high
 Often smoked in bongs
 Rolled in papers and smoked
 Packed into a blunt
 Inhaled after burning as incense
Looks like marijuana
or potpourri
• May be ingested or snorted, rare IV use
• Some users make it into a tea
AM-2201
(part of a “2nd wave”)
Fluorinated version
of JWH-018
Effects1
Routes of Administration
 Hookah pipes
JWH-018
(prototypical JWH
compound)
•  heart rate
•  blood pressure
• Nausea/Vomiting
• Chest pain
• Disorientation
• Nystagmus
• Severe agitation
• Paranoia
• Hallucinations
• Suicidal thoughts
• Seizures
• Withdrawal syndrome2
Scientific research into long-term effects in humans has been limited.
1National
Poison Data System 2010-2011
2Nacca
N, Vatti D, Sullivan R, Sud P, Su M, Marraffa J. The synthetic cannabinoid withdrawal
syndrome. Addict Med. 2013 Jul-Aug;7(4):296-8.
04/07/14
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“Bath Salts”
“Bath Salt” Appearance
• Contain one or more synthetic chemicals
related to cathinone (amphetamine-like
stimulant found naturally in the Khat plant)
• “Bath salts” has become an umbrella term
 May contain cathinone/cathinone analogues
 May contain synthetic cannabinoids
• Usually a highly pure white or brown powder
• May be compressed into crystal to resemble
actual bath salts
 May be mistaken for Ecstasy or crushed meth crystals
• Can be purchased in pill or capsule form
 May contain hallucinogenic-like drugs (“N-bomb”)
• Injected, smoked, snorted or ingested
 May contain many other compounds
• Little or no odor
• Without analytical testing, it’s impossible to
determine active compounds of these drugs!
Synthetic Cathinones
Methylone
“bath salt”
“Gravel”
• α-PVP
• Methcathinone (MCAT)
• New, potent form of “bath salts”
• Butylone
• Methylone
• Rock-like substance containing
alpha-Pyrrolidinopentiophenone
(Alpha-PVP or α-PVP)
• Flephedrone (4-FMC) • Methedrone
• MDPV
• Naphyrone
• MDPBP
• Pentedrone
• Smoked or injected
• Synthetic cathinone
• Mephedrone (4-MMC) • Pentylone
• 4-MEC
 Potent CV and CNS stimulant
• Pyrovalerone
 Known to cause extreme paranoia
• May be mixed with other drugs
“Molly”
“Molly”
• Refer to pure MDMA or ecstasy
• Typically swallowed or snorted
• Short for “molecule”
• Reputation as “speed with a psychedelic and
empathetic twist”
• Available in crystals, powder,
powder-filled capsules and tablets
• Has become drug of choice for
young adults ages 18-25 yo
 Popular among club-and party-goers
 Music references: Madonna, Miley
Cyrus, Kanye West and Lady Gaga
04/07/14
• Classified as Schedule I drug
• Often mixed with other drugs (alcohol + THC)
• A wide variety of other amphetamine-like drugs
have been substituted
 Mephedrone, Methylone (“bath salts”) sold as Molly
 Could be cut with anything
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Recent Deaths Attributed to Molly
How These Drugs Work
• 19 y/o F dies Aug 28, 2013 in a
Boston club after taking Molly
• 2 students in their early twenties
died Aug 31, 2013 after taking what
they believed to be Molly during the
Electric Zoo Festival in NYC
The Electric Zoo 2013 in NYC,
linked to fatal Molly overdoses.
(Photo by Daniel Zuchnik/Getty Images)
• Univ of Virginia student dies Aug 31,
2013 at a rave in DC after taking
what her friends said was Molly
The Art of “Rolling”
•  appreciation of music,
vision, touch and taste
Sense of peace and joy
•  awareness of senses
Strong stimulant effect
• Life-changing spiritual
 fear, anxiety and
experiences
insecurities
• Feelings of love &
 pleasure from being
empathy
touched
• Urge to hug and kiss
Closeness to others
people
• Euphoria
•
•
•
•
•
Mephedrone
“Triple reuptake inhibitor”- inhibits reuptake of serotonin,
norepinephrine, and dopamine increasing brain levels of
these stimulatory neurotransmitters
Broad Range of Negative Effects
•  Heart rate
• Nausea and Vomiting
•  Blood pressure
• Hangover
•  Temp
• Insomnia
• Mild depression and
fatigue
• Bruxism
• Dizziness
• Agitation
• Dehydration
• Short-term memory loss
• Profound Hyponatremia
• Delirium
• Erectile dysfunction and
difficulty reaching
orgasm
• Headaches
“2C” Drugs
• Chemical name: 4-methylcathinone
• Hallucinogenic drugs that act as
CNS stimulants
• Synthetic cathinone (aka “bath salt”)
• Found in powder, pill or liquid form
 Schedule I (2012)
 Effects similar to Molly
= substitution site
 Users snort, ingest or use IV
• Originally marketed as a plant fertilizer
• Undetectable in drug tests
• Available as powder, crystals or capsules
• Most common 2C-E, 2C-I and 2C-P
• Sniffed/snorted, ingested or injected
• 2012 law bans 9 2C drugs
• Street names: 4-MMC, meow meow, m-CAT,
bounce, bubbles, drone and mad cow
Maurer, Hans. Chemistry, Pharmacology, and Metabolism of Emerging Drugs of Abuse. Ther Drug Monit 2010.
04/07/14
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“N-bomb” (NBOMe drugs)
• AKA “legal acid,” “smiles,” “25I,” “25C”
• Refers to closely related synthetic hallucinogens:
 25I-NBOMe, 25C-NBOMe, 25B-NBOMe
• Sold as legal substitutes for LSD or mescaline
 Highly potent full agonist for the 5-HT2A receptor
• Found as powder, tabs or on blotter paper
• Active at very low sub-milligram doses
• New chemical variations unregulated
Management of Toxicity
• No antidotes
• Benzodiazepines (BZDs)
 May need large doses
 No real ceiling to BZD doses
 Treats agitation, HTN, hyperthermia, seizures
 DPH likely won’t be effective
 Haloperidol could be problematic
• Hypertension unresponsive to BZDs  vasodilator
 Avoid beta blockers
Messages You Can Deliver
Management of Toxicity
• Protect yourself, staff and patient from harm
 Difficult to manage patients; unpredictable behavior
• Never tested on humans
 Without provocation, may lash out
 Minimize stimulation
• Good supportive care! ABC’s!
• Treat the patient, not the poison!
• Rule out other substances/medical conditions
Drug Testing
• These don’t show up on routine UDT
 DCI labs and private labs have limited capability
• Lack of validated field tests
 Very limited on compounds detected
 False negatives likely
• A moving target
 New compounds being developed all the time
 No test can detect all the different compounds
 Generally need lab analysis before charges filed
Looking Ahead…
• It is impossible to know what these drugs contain,
or who made them, or what you are going to get
• Chemicals change to reflect legislation?
• Getting high – no matter how – carries risks of
making unsafe or unhealthy decisions
• Long term effects?
• Just because a drug is legal – or is labeled as
legal – does not mean that it is safe
• Refer to drug courts
• We don’t know the long term effects of synthetic
drugs because the drugs are so new
• Prevent, Intervene, Get Treatment, Recover
Source: The Partnership at DrugFree.org
04/07/14
 Discouraging & reducing consumption most important
• Care for the chronic user?
 How to monitor?
• Develop better drug screens
 Worth investing in?
• Prevention
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