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Transcript
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 1 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 04/07/14 2 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 3 “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 4 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 5 “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 6