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Designer Drugs, Substance Use Disorders (SUD) & Treatment Reinhard Straub, LICSW, LCDCS Cell (401) 741-5109 [email protected] 1 Today’s Agenda Substance Use Disorders (SUD) Clinical treatment Designer drugs Cannabinoids 2 In My Experience SUD require chronic disease management e.g. diabetes, asthma & hypertension Communication between medical & behavioral health treatment et al Leverage – “Nudge from the judge” Family involvement 3 Experience (cont.) Unless the psychiatric presentation is historically primary Traditional psychotherapy, insight oriented counseling & psychiatry can be ineffective & even contraindicated SUD primary = SUD TX is effective Psych primary = Psych TX with SUD component is effective 4 Do No Harm Hippocrates The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants and externals cooperate. 5 “What is your rehab’s success rate?” • Indicates a lack of understanding of SUD • Same rate of relapse as diabetes, asthma & hypertension. 6 National Institute of Alcoholism and Alcohol Abuse $27 million study • • • • • • • After 6 months 45% were abstinent After 18 mos. 38% were abstinent After 36 mos. 27% were abstinent Same rate as diabetes & asthma 7 What Works 5 year monitoring programs for physicians, nurses, pilots, etc. 48 physician health programs (PHP) National PHP rate of recovery = 78% NYS Medical Society = 88% for 5000 MD’s FAA rate of recovery = 90% of pilots were abstinent in 5 year program 8 3-5 years Coordination All prescribers including PCP need to aware of and/or approve all prescribed and OTC medications Psychiatric care with experienced prescriber re Dual Diagnosis & Substance-Induced Disorders Coordination of efforts with everyone involved in participant’s recovery: TX, family, work/education & all stakeholders 9 3 to 5 Year Plan Individual SUD/dual diagnosis therapy Group therapy Toxicology testing – urine, hair, PETH etc. Documented self-help meeting attendance Sponsor/mentor Home Group 10 Recovery Activities Ongoing assessment re need for other modalities of care e.g. marital, family, trauma, neuro-psych testing, ED, gambling, etc. Holistic activity e.g. exercise, meditation, yoga, volunteering 11 Facts • • • • • • RX painkillers =$57 Billion Global sales USA = 4.6% of the world’s population Consumes 75% of the world’s RX meds Consumes 99% hydrocodone Consumes 81% oxycodone Recent SAMHSA study - 80% of heroin addicts started with RX opioids • Heroin use has doubled in last decade for young adults 18-25 12 Denial • Primary symptom of SUD • Unconscious narcissistic defense to avoid pain • Normal & Pathological Denial • Minimization, rationalization & justification • Unwilling to go to any lengths 13 Denial • Shame & guilt are the key motivating factors • Family denial is greater than the addict’s denial • Family & stakeholder denial must be addressed • Without external involvement, chances of success are greatly diminished 14 Mindset of the Patient Immediate short-term objective “I want what I want when I want it” Psychotherapy on the way into the OR Acceptance of the need for chronic disease management requires stabilization, TX and more importantly, a lot of time & effort 15 Have everything ready to go – backfill first • • • • • Insurance Admissions Finances Employment issues Travel logistics • Child care, pet care • Remove the barriers • Packed bag – cigarettes, etc. • Enabling? 16 Who uses Designer Drugs? • Average age is 26 & younger • “To be ignorant of one's ignorance is the malady of ignorance.” ~A. Bronson Alcott • Progressed Substance Use Disorder • Primary Psychiatric Disorder 17 Drug of choice DOC • DOC is the focus during stabilization & initial treatment • DOC becomes increasingly irrelevant over time • Recovery activities become the focus • Thinking or Behavior? 18 What are designer drugs? • A structural or functional equivalent of a controlled substance that mimics the pharmacological effects of the original drug • Profit • Avoid being classified as illegal • Avoid detection in standard drug tests 19 Synthesis & Manufacture Synthesized for academic or industrial research, then “borrowed” for illicit use Clandestine laboratories Efficacy and safety unknown Easy to obtain 20 “Chinese labs modify deadly fentanyl to circumvent ban on (Acetyl fentanyl)…” AUGUST 26, 2016 “I know a young person who recently died from furanylfentanyl. he had no idea what he had gotten himself into. He had lied to a website from China and said he was using it for his lab he did not have a lab but just wanted a quick buzz it only took him one time and he had a seizure and died …” https://www.statnews.com/2016/04/26/chinese-sellmodified-fentanyl 21 Online Fentanyl Analogue • “ Furanyl fentanyl online from Ching Labs • Furanyl fentanyl (Fu-F) is an opioid analgesic that is an analog of fentanyl and is offered from our company as a research chemical for use in the lab” 22 Very Easy to Obtain Contact Person: Sara Zhang Email: [email protected] Website: http://chinglabs.com Skype: ching.labs Company: Hebina Higer Chemical Technology Address: Qibin district,Xinghe street,Xinhua building, Hebi, Henan, 458030, China 23 24 “For Research Only” Baofoo Korea,604-7 Digitalro 33 gil 48 Guro-gu Seoul, South Korea 642-87-00085 25 www.best-feel.com • New Chemicals Adrafinil Discontinued French stimulant MDBP Discontinued due to liver damage MDPH phenethylamine psychodelic PCP, DXM • Dissociatives • Empathogens Entactogens 2-A1MP 6-EAPB coming 6-MAPB bk-epdp(crystal) bk-MAPB Dibutylone(crystal) Dibutylone(powderl) • 26 www.best-feel.com JWH-018 • Naphthoylindo EAM-2201 MAM-2201 • Pyrrolidin and Pyrrolidinophena 4F-PVP(crystal) 4F-PVP(powder) a-PBP a-PVP (powder) a-PVP(crystal) a-PVT PV-8(powder) • Quinolinylindolee 5F-PB-22 FDU-pb-22 FUB-pb-22 PB-22F Flakka Cannabinoid 27 www.best-feel.com • Methiopropamine(MPA) • Tropanee and Piperidinee Ethylphenidate(EPH) Stimulant petroleum derivative dopamine & norepinephrine reuptake inhibitor • psychodelics natural in magic mushrooms Tryptamin 5-meo-dalt 5-meo-dipt 5-MEO-DMT 5-meo-Mipt aMt • Psychedelics 4-Ho-met ZDCM-04 28 www.best-feel.com • Cannabinoids 5F-MN-18 coming 5F-MN-21(5F-PCN) 5F-MN-24(5F-NNE1) ADB-CHMINACA BB-22 EG-018 EG-2201 FAB-144 FU-PX-2 Fub-AKB-48 FUB-AMB FUB-APINACA MMB-2201 MMB-CHMINACA NM-2201 PX-1 THJ-018 THJ-2201 29 www.best-feel.com • Stimulants 23b-PVP 2nmc(crystal) 4-C-PVP(crystal) 4-CDC 4-CEC 4-Cl-PVP(crystal) 4-CMM 4-CPrC 4-MEO-PV8 coming 4-MEO-PV9 coming 4-MPD 4-MPD(white) 4F-Pentedrone coming 4F-PHP 4F-PHP(crystal) 30 • Sedatives Alprazolam Etizolam U-47700 www.best-feel.com XANAX PCP • Arylcyclohexylamin Methoxetamine (MXE) Methoxphenidine(MXP) • Benzofurans 5-MAPB • Cathinon 3-CMC 4-CMC(crystal) 4-CMC(powder) 4-EMC Pentedrone MDA Ectasy Bath Salts 31 www.best-feel.com • Cannabinoids Indazole based 5-fur-144 5F-AKB-48 AB-chminaca AB-FUBINACA AB-FUPINACA AB-PINACA ADB-FUBINACA ADB-PINACA AKB-48 AMB MDMB-CHMINACA PX-2 XLR-11 • Etc. Etc. Etc. 32 Psychedelics/Hallucinogens • LSD, psilocybin (magic mushrooms), mescaline, peyote • Potent hallucinogens • Dangerous for people genetically predisposed for psychiatric illness • But these drugs are not directly toxic, even at high doses. • They do not interact with receptors that control functions that cause death i.e. heart rate, temp 33 Toxicity of New Drugs • LSD and psilocybin have specific effects on serotonin in the brain. • Designer drugs are not nearly as specific. Besides serotonin, they variously affect other vital chemical signals i.e. dopamine and norepinephrine. • Because these chemical messengers affect cells throughout the body, they can have drastic, unexpected effects on vital functions such as heart rate and body temperature. 34 Lack of Analysis • DEA research lab In the last five or six years almost 400 new drugs have emerged. • Jenny Wiley, a behavioral pharmacologist at RTI International • “These drugs haven’t even been tested in animals, much less in humans” • “People are basically the guinea pigs.” 35 “Every new drug is somewhat different” • Michael Baumann, National Institute on Drug Abuse in Baltimore • “When a new drug appears, it’s up to chemists, pharmacologists and researchers to quickly develop tests that will detect the drug in a person’s system and figure out how it works.” http://cen.acs.org/articles/94/i28/Designer-drug-detectivework.html • Impossible to stay ahead of secret labs in China, India, Pakistan etc. 36 Bath Salts • • • • • Not traditional bath salts Central nervous system stimulant drug Marketed to avoid regulation Popular among teens & young adults Contains manmade chemicals such as: • Methylenedioxypyrovalerone (MDPV) • Mephedrone (4-MEC) • Methylone 37 Route of Admission Intranasal Intravenous Smoked Mixed with food Mixed with drink Airborne mist 38 39 40 Effects • Similar to cocaine, methamphetamines, MDMA (Ecstasy) or LSD • Initial euphoria lasts longer • Long terms effects unknown • Users UTI – threat to public safety 41 Signs & Symptoms • • • • • Extreme paranoia • Psychotic features• Violent behavior • • Tachycardia Chest pain Confusion High blood pressure Sweating Hyper-alertness 42 Product Names Cosmic Blast, Red Dove, Aura, Zeus 2, Zoom, White Dove, Wave, Scarface, Hurricane Charlie, Pure Ivory, Ivory Purple Wave, Vanilla Sky, Bliss, White, Rush, Blow, Blue Silk, White Lightening, Ocean, etc, etc. 43 Testing Stimulants – Bath Salts Alpha PVP, Butylone, 4-Bromo-2,5 dimethoxyphenethylamine, Cathinone, 3,4 Dimethylcathinone Norephedrine, DOB, 3,4 DMMC, Ethylone, N-Ethylcathinone Ephedrine, 4Ethylmethcathinone, 3-Fluoromethcathinone, 4Fluoroephedrine,4-Fluoromethcathinone (Flephedrone), MDPV, Mephedrone Norpseudoephedrine, 4-Methylethcathinone (4MEC), 4- MEC Metabolite, Methcathinone, Mephedrone, Methylone, Pentedrone, Pentedrone Norephedrine, Pentylone, 2C-B-Fly, 2C-C, 2C-E, 2C-I, 2C-N, 2C-P, 2C-T-7, 2C-T-2, 2C-T-4, 25B-NBOMe, 25CNBOMe, 25I-NBOH, 25I-NBOMe, 25I-NBF,25I-NBMD 44 Molly Ecstasy Initially popular at “raves”, but now used by a broader range of social groups. Taken orally, usually as a capsule or tablet. Usually combined with other drugs – cannabis, alcohol 45 MDMA • • • • • • • • Faintness Panic attacks Loss of consciousness Seizures High Blood Pressure Heart failure Kidney failure Arrythmia 46 47 Blogosphere "Does anyone know if Ethylphenidate (research chemical) and alcohol are good together I can't find any information on it. All i can find is methylphenidate (Ritalin & Concerta) + alcohol as when taken together they apparently form Ethylphenidate. So i guess alcohol won't hurt?... lol. confusing... a quick response would be brilliant. 48 Dark Sites “The Lycæum is committed to supplying honest and unbiased information about all aspects of visionary plants, fungi, and chemicals; as well as providing a virtual meeting place for members of the online psychedelic community. We consider psychedelic drugs to be potentially valuable teachers and allies.” “The Lycæum is presently run by a team of volunteers, and supported entirely by generous donations of time, money, and bandwidth.” http://www.lycaeum.org 49 Blogs • “Dr. D.M.T.: or How I Learned to Stop Reality and Love Psychedelics” • (MOA Inhibitor) "Sick as Dogs: Harmaline problems” • (Psychedelics) “A Wonderful Synergy: the combined wisdom of Salvia and Ayahuasca” • “Ayahuasca Dreams: Synergy with Nitrous? Of course!” • (DMT) “Botched Huasca: Nausea without any pesky psychedelic effect? Learn how!” 50 Blog Sites with Reviews “SIMON’S ENDORSED LEGAL HIGH SHOPS” “Simon’s Wall of Shame: Legal high shop blacklist I collect all my online headshop reviews and legal high scams I know of and review them, so you will not fall victim to them.” HTTPS://SIMONSBLOGPARK.COM 51 52 Flakka • Illicit drug laboratories altered bath salts' chemical composition slightly to get around laws and, in the process, made it 30 times more potent. • Prevents the brain's neurons from metabolizing the excitement hormones • With hours of sustained hormone escalation, the body temperature spikes as much as 10 degrees 53 The next LSD? “Smiles” 54 NBOMes – “En-Bombs” • Chemically resemble mescaline • Overdose can prompt paranoia, seizures, a racing heart or high blood pressure. • “…prone to stab themselves.” • J. Suzuki et al. “My friend said it was good LSD”: A suicide attempt following analytically confirmed 25I-NBOMe ingestion.Journal of Psychoactive Drugs. Vol. 46, November 2014 55 Plant Food 56 57 Cannabis 58 NYC K2 Spice AK-47 Geeked up Smacked Green Giant Scooby Snax Red Giant Mr. Bad Guy iBlown Trippy “Since 2015, there have been more than 6,000 synthetic cannabinoid-related emergency department visits in NYC.” http://www1.nyc.gov/site/doh/health/healthtopics/k2.page 59 AAC Testing - Synthetic Cannabinoids A-796260, AB-CHMINACA – 2-Indole Isomer, ABFUBINACA Metabolite, ADBICA,ADBICA NPentanoic Acid Metabolite, ADBICA N-4,5 Hydroxypentyl) metabolite, ADBPINACA, 5FluoroADB-PINACA Isomer, AKB48 N-(4,5 Hydroxypentyl) metabolite, AKB48 5 fluoro Nhydroxypentyl metabolite, APP-FUBINACA, AM 694, AM 694 N-Pentanoic Acid Metabolite, AM 694 N-5 hydroxypentyl metabolite, AM-1248, AM 2201, AM-2201 4 Hydroxypentyl metabolite, AM 2233, BB-22, BB-22 3 carboxyindole metabolite, 5 – Fluoro PB-22, Homologue, JWH-015, JWH -018, JWH-018 4,5 Hydroxypentyl metabolite 60 AAC Testing - Synthetic Cannabinoids • JWH-018 5 Pentanoic Acid Metabolite, JWH019, JWH-019 5-Hydroxyhexyl metabolite, JWH-073, JWH-073 3-Hydroxybutyl Metabolite, JWH-073 4-Butanoic acid Metabolite, JWH-081, JWH-122, JWH-122 4,5 Hydroxypentyl metabolite, JWH-200, JWH-203, JWH-210, JWH 210 4,5 Hydroxypentyl metabolite, JWH-250, JWH 250 4,5 Hydroxypentyl metabolite, MAM 2201 N-(3,4 fluoropentyl Isomer), MAM 2201 NPentanoic Acid Metabolite, MAM 2201 N-4 Hydroxypentyl Metabolite, RCS-4, RCS-8, UR144, XRL-11 4-Hydroxypentyl metabolite 61 What are Cannabinoids? • Natural cannabinoids – only in plant • Endogenous cannabinoids – in the body • Synthetic cannabinoids – in the lab • Half life of natural cannabis? • Daily use = no detox • New potency • Half life of synthetic cannabinoids ? 62 Chemicals in a hemp plant • Delta-9-tetrahydrocannabinol (THC) • THC is fat soluble • THC storage in the body 63 63 Does Pot Kill Brain Cells? • Evidence • Accumulation of THC in the body & brain • Communication effects • A-motivational Syndrome 64 JWH • John W. Huffman an organic chemist at Clemson University synthesized analogues and metabolites of THC, the principal active component of cannabis. • JWH-018 is one of these analogues, with studies showing an affinity for the cannabinoid (CB1) receptor five times greater than that of THC. 65 K2 Incense 66 “NEW LEGAL Supplements” Herbal Blends K2 Stash Spices Gold NOW Legal in 50 States We are shipping all orders for only $2.95 within USA, Shipping takes 5-10 days.. SEND MONEY ORDERS OR CHECKS TO Natural Herbs and Supplies Po box 71 Pingree Id. 83262 Store owners can order from our wholesale website 67 New Items 68 68 68 Scooby Doo where are you? Scooby Snax 8 Grams legal medically sealed Incense. If you try this one you will want another and another and another. Very potent with a strong scent. Good product strongly recommended and ships to every state in the US. This is a k2 alternative that is very effective. 100% Satisfaction Guaranteed! 69 Disclaimer Package says this is not intended for human consumption. Any unlawful consumption of this product is the sole responsibility of the consumer. 70 Some Potent Stuff! I absolutely love this product. I am in the military so I can't smoke the real thing... but this is better then the real thing! Strongly recommend it.. Spice Time is great at shipping it fast as well! 71 “Spice” Analysis • Analysis by the German government • Mislabeled “harmless herbs” sprayed with • JWH-018, JWH-073, JWH-200, AM-2201 UR144, XLR-11, AKB4, cannabicyclohexanol, etc. • Prescription drug phenazapam 72 More Cannabinoids 73 “Legal Herbal Bud” 74 75 Hand Sanitizer Drunken Gummies 76 Meth Lab 77 Red Dawn Party Enhancer 78 Designer Drugs, Substance Use Disorders (SUD) & Treatment Reinhard Straub, LICSW, LCDCS Cell (401) 741-5109 [email protected] 80 References “Marijuana and Medicine: Assessing the Science Base.” Janet E. Joy, Stanley J. Watson, Jr., and John A. Benson, Jr., Editors Division of Neuroscience and Behavioral Health INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1999 http://spiceaddictionsupport.org/ https://en.wikipedia.org/wiki/Designer_drug http://www.drugabuse.gov/publications/drugfacts/mdma-ecstasy-or-molly https://www.erowid.org/chemicals/ghb/ghb.shtml http://www.rxlist.com/suboxone-drug/medication-guide.htm http://www.cbsnews.com/news/methadone-to-blame-for-one-third-of-us-prescriptionpainkiller-deaths-cdc-says/ http://www.drugs.com/suboxone.html 81 References (cont.) • • • J. Suzuki et al. “My friend said it was good LSD”: A suicide attempt following analytically confirmed 25I-NBOMe ingestion. Journal of Psychoactive Drugs. Vol. 46, November 2014. doi: 10.1080/02791072.2014.960111 J. Suzuki et al. Toxicities Associated With NBOMe Ingestion—A Novel Class of Potent Hallucinogens: A Review of the Literaturee.Psychosomatics.Vol. 56, March 2015. doi: 10.10166 M. Baumann et al. Powerful cocaine-like actions of 3,4methylenedioxypyrovalerone (MDPV), a principal constituent of psychoactive 'bath salts' products. Neuropsychopharmacology. Vol. 38, March 2013. doi: 10.1038/npp.2012.204 82