Download Tales of Bath Salts and Legal Marijuana: TheRapidExpansion

jay lance kovar, md, facep
tcep 2012
Objectives
 Review new synthetic substances of abuse
 Discuss pharmacology and clinical presentations
 Identify EMS and ER treatment options for care
Bath Salts
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Bath Salts
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synthetic product
contains hallucinogenic, mind-altering chemicals
similar in structure to those also found in cocaine and
ecstasy
depending on which brand or form is purchased.
Bath
SoldSalts
as:
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a bath salt,
or plant food
Labeled:
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“for novelty use only”
“not for human consumption”
to by- pass FDA regulations-not being sold as food
or drug product.
Sold in:

either 250 or 500 mg packets depending on brand
or form purchased.
Bath Salts
Ivory Wave is the most popular brand of this product
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Vanilla Sky
Fly
Snow
Ivory
Charge
Ivory Coast
Purple Wave
Cristalius
Magic
Ocean Blue
Columbian Salts
Bolivian Salts
 Ocean Burst
 Lunar Wave
 Lady Bubbles
 Arctic Blast
 Sextacy
 Disco
 Snow Leopard
 Natural NRG
 Tranquility
What’s in it?
 MDPV (methylene-dioxy-pyro-valerone)
usually referred to as pyro-valerone, (Super
Coke)
 powerful psychoactive chemical similar to Ritalin
 acts as a stimulant that inhibits re-uptake of
dopamine & norepinephrine
 minimal effects on serotonin levels.
 most versions of these products as containing
Lidocaine
 may also contain similar components to 2-DPMP
or MDMA (aka ecstasy).
 Purposely designed in a way that will mimic the
effects of:
 Cocaine
 Crack
 Ecstasy
 Most often used by snorting.
Where can I find it?
 It is sold most frequently
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on-line
tobacco/smoke shops
as a novelty item “not for human consumption”
$30 for a small package
in bulk (50-100 packets) for a discount rate.
Bath salts have increased in “club scene” use as
ecstasy availability and use have declined
What’s the prevalence?
 Poison Control calls 2009
 Poison Control calls 2010
 Poison Control calls 2011
0
303
4,100
What’s the purity?
 Samples seized from different regions reveal a great
deal of variance despite the same labels and
producers
Pharmacology
 Multiple manufactures sources
 Vary in purity, concentration, and fillers
 Sold in
 packages 50mg to 200mg
 vials 500mg
 Consumed
 orally, rectal, insufflated, injected, or smoked
Phamacology
Effects
 Onset, peak, and duration depends upon route
Major source seems to be China, routed through New
Orleans and out I-10 corridor
 Houston #1
 Montgomery County Top 10
Why is it popular?
 Effects of amphetamines, cocaine, and ecstacy without
hangover, comedown, or depression commonly
following the use of those drugs
 Elevates mood, decreases hostility, raises energy levels,
improves sense of well-being, improves attentions
span and attention to detail, euphoria, empathy, and
sexual stimulation.
 Appears to be extremely addictive with many users
reporting an “almost uncontrollable urge for
another hit” immediately, stating that its effects
are several times stronger than cocaine when
snorted.
Downside
 Acute psychosis
 Severe anxiety, paranoia, agitation, bizzarre behavior,
tremors, persecutory hallucinations
 Sympathetic overdrive
 Palpitations, shortness of breath, diaphoresis, hot
flashes, headaches, hyperthermia, overwhelming thirst
 Bruxism
Side effects
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muscular pain/spasms
emotional fragility
acute paranoid psychosis
sore jaw
kidney failure
loss of bowel control
intense high followed by painful hangover
suppressed appetite
“It’s legal”
 K2

K2/Spice products are a mixture of herbal/spice plant
products sprayed with potent psychotropic drugs
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Marketed under variety of names
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often contaminated with unidentified toxic substances which
contribute to various adverse health effects
cause hallucinogenic effects similar to effects of PCP.
K2, Spice, Pep Spice, Spice Silver, Spice Gold, Spice Diamond,
Smoke, Sence, Skunk, Yucatan Fire, Genie & Zohai
sold in variety of colors/flavors- usually sold in foil
packaging
K2/Spice Health Risks
 Symptoms/Side-Effects may include:
 mimics marijuana “high” (often induced more
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quickly/more intense than “real” marijuana)
hallucinations
seizures/tremors
coma/unconsciousness
vomiting
numbness/tingling
K2/Spice Health Risks
 Symptoms/Side-Effects may include:
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increased respiration rate
elevated blood pressure (reported up to 200/100)
elevated heart rate (reported up to rate of 150)
increased level of anxiety/agitation leading to panic
attacks (possible suicide attempts)
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Depending on synthetic compound in specific
commercial brand, can be anywhere from 4
times to over 100 times more potent than
marijuana (THC)
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Sold in tobacco shops, head shops, and
convenience stores
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Sold as “incense” marked “not for human
consumption”
Price averages $45 for 3 grams (about equal to 3
sugar packets)-higher than good grade
marijuana
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Most often smoked but can be mixed in with
food or drink
Most likely users:
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14-27 yr. olds
Prisoners/probationers
Military (use now banned by all military branches)
Creation of K2/Spice
 Developed by Dr. John W. Huffman, a Clemson University professor, as
part of research for National Institute for Drug Abuse (NIDA) on
endogenous cannabinoid receptors-but never tested on humans nor
approved by FDA
 “It is like Russian roulette to use these drugs. We don’t know a darn
thing about them for real.” “It shouldn’t be out there.”
 JWH-018 & many of its “cousins” such as HU-210/211, JWH-073 & CP
47/497 found in these drugs have a chemical structure shared with
known cancer-causing agents.
 All effects of K2/Spice drugs may not be known for very long time
because of long time period that body stores them.
?????????????????????
 Nothing is known about metabolism of the
chemical compounds in K2/Spice drugs
 some may be toxic
 pharmacologically active-differing from batch to batch
in kind/amount applied
 higher risk of accidental overdosing which has already
been seen
 increase numbers of ER incidents reported
?????????????????????
 There are hundreds more of these chemical
compounds containing strong, active cannabinoid
receptors agonists so can be safely assumed that
further such substances will appear on market
soon if not banned
 Increasing challenges for toxicology testing, law
enforcement and medical professionals.
 Causing difficulties for law enforcement agencies,
probation & parole, as well as drug courts due to
difficulties in testing for presence
 one lab test now known to detect it in system but at
cost of $50 & will probably not test positive for all the
known variations
National Institute for Drug Abuse
“hijacking the part of the brain important for many
major functions: temperature control, food
intake, perception, memory and problem solving.
Many people taking these high-potency drugs are
affecting important functions throughout their
bodies-hormone functions for example.”
Drugs may involve acute toxicity levels, possibly
long term, as well as impacting cannabinoid
receptors that regulate body’s immune system.
On the rise
 Source primarily Mid-West US
 Recent increase in sales from app. $1000 daily up to
$10, 000 daily.
 Rapid and powerful addiction on a level not
usually found among smokers of “real” marijuana.
 Recently linked to over 352 nationwide emergency
room incidents
 suicide attempts, extremely elevated heart rate/blood
pressure, comas, seizures, and anxiety attacks.
What about your patient?
Is this Excited Delirium?
 An imminently life threatening medical emergency…
 Massive release of epinephrine, norepinephrine,
dopamine, serotonin in the body and brain.
 Severe delirium and agitation
29
Recognizing Excited Delirium
 Agitation or Excitement = Increased activity and
intensity
 Aggressive, threatening or combative – gets worse when
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challenged or injured
Amazing feats of strength
Pressured loud incoherent speech
Sweating (or loss of sweating late)
Dilated pupils/less reactive to light
Rapid breathing
30
Recognizing Excited Delirium
 Delirium = Confusion
 Disoriented
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Person, place, time, purpose
 Rapid onset over a short period of recent time
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“He just started acting strange”
 Easily distracted/lack of focus
 Decreased awareness and perception
 Rapid changes in emotions (laughter, anger,
sadness)
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Recognizing Excited Delirium
 Psychotic = bizarre behavior
 Thought content inappropriate for circumstances
 Hallucinations (visual or auditory)
 Delusions (grandeur, paranoia or reference)
 Flight of ideas/tangential thinking
 Makes you feel uncomfortable
32
Bad Behavior: Other Reasons
 Alcohol intoxication or withdrawal
 Other drug use problems
 Example: Cocaine psychosis
 Pure psychiatric disease
 Head injury
 Dementia (Alzheimer’s Disease)
 Hypoglycemia
 Hyperthyroidism
33
ED presentations
 Combative
 Self destructive
 Homicidal/suicidal
 Agitation followed by severe depression
ED presentations
 Differential
 PCP
 LSD
 Cocaine
 Methamphetamines
 Alcohol
 Hypoglycemia
 Hypoxia
 Head trauma
 CNS infection
The Work
Up
 Urine Tox
 r/o routine street drugs + “polypharmacy”
 BMP
 Hypoglycemia, metabolic acidosis
 CBC
 Infection and anemia
 CT Head
 Intracranial hemorrhage, hydrocephalus
 12 lead EKG
 Biomarkers, myoglobin, lactic acid
 Temperature monitoring
Treatment
Options
No Antidote
Supportive therapies
 Sympathetic Overdrive
 Alpha and beta receptor stimulation
 Sustained endogenous norepinephrine
release
 Beta blocker caution?
 Metabolic dysfunction
 Hepatic metabolism of bath salts
 Hyperthermia
Treatment
Options
No Antidote
Supportive therapies
 Psychosis
 Benzodiazepines
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Versed, Valium, Ativan
 Antipsychotics
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Haldol, Inapsine
Geodon
 Ketamine
Disposition
 Unpredictable dose and duration
 Psychiatric evaluation when clear
 Home
 Jail
 Psychiatric facility
Status of K2/Spice
 Many European countries ban sale and use
 Kansas was first state to ban use
 15 states so far to officially ban the sale & use of
these products statewide.
 October 2011 DEA made it illeagal to possess or sell
the chemicals or products containing the
chemicals found in bath salts in the US for 1 year
pending a review of permanently banning them
 Bath Salts are a Schedule 1 substance
Texas May 2011
 The Texas House passed a bill banning K2 or spice, a
synthetic marijuana
 The Texas Department of State Health Services
outlawed the fake pot last month after the Drug
Enforcement Agency issued an emergency ban for a
year.
 The possession of K2 a misdemeanor, but
manufacturers and sellers would be charged with a
felony effective September 2011
HB 2118, SB 331
Certain synthetic compounds deceptively labeled as
“bath salts” and synthetic marijuana products (K2 or
spice) have been added to Penalty Group 2 of the Texas
Controlled Substances Act.