Download Rickett Benkiser - American Osteopathic Association

Presented by:
William Morrone DO

CMU College of Medicine
Abridged from: Jeffrey Bargeon DO, Wayne State University
Dr. Morrone has been a paid teaching advocate for
Rickett Benkiser (Suboxone, Frank’s “Red Hot”
(Louisiana) cayenne pepper sauce & French’s
Mustard
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1. Understand and list the epidemiological
risk factors and current offending agents in
recognized circles of risk evaluation.
2. Provide a historical time line and origin of
the new substances of abuse.
3. Recognize sentinel red flags in risk and
proper selection of treatment for recovery.
Adapted by CESAR from Paulozzi, L.J., Budnitz, D.S., and Xi, Y. “Increasing Deaths
from Opioid Analgesics in the United States,” Pharmacoepidemiology and Drug
Safety15(9):613-617, 2006. For more information, contact Dr. Paulozzi at
[email protected]
1,345,645 Misuse or Abuse of
Pharmaceuticals
1,400,000
1,200,000
991,640
1,171,024
1,000,000
800,000
626,472
600,000
400,000
200,000
0
2004
2005
2006
2007
2008
2009
2010
Misuse or Abuse of
Illicit Drugs
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parents, siblings and peers who smoke
exposed to tobacco/cannabis advertising or
literature.
poor academic record
one-parent family
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White Lightening
Super Coke
Magic
Hurricane Charlie
Ivory Wave
Raving Dragon
Ivory Snow
Bliss
Vanilla Sky
White Rush
Blue Silk
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Modes of Use
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Insufflation (snort)
Injection
Oral Ingestion
Rectal (Mucosal)
Ingestion
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“Ideal Bath” (Dose
dependent)
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5-20 mg
Subjective effects 3-4 hours
Side effects last up to 8 hours
Increased panic attacks with
increased doses and
frequencies
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Oral
Total Duration 2.0 - 7.0
hrs
 Onset 15 - 30 mins
 Coming Up 30 - 60
mins
 Plateau 30 - 180 mins
 Coming Down 30 - 120
mins
 After Effects 2 - 48
hours
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Insuffate
Total Duration 2.0 - 3.5
hrs
 Onset 5 - 20 mins
 Coming Up15 - 30 mins
 Plateau 30 - 120 mins
 Coming Down 30 - 60
mins
 After Effects 2 - 48
hours
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Good
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Euphoria
Anorexia
Increased Energy
Increased Alertness
Increased Sex Drive
Bad
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Tachycardia
Hypertension
Headache
Sweating
Nausea/Vomiting
Anxiety
Agitation
Psychosis
Insomnia
Anorgasmia
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In chronic pain – did demonstrate analgesia
oral cannabinoid (THC) with cancer pain
 Noyes et al (Clin Pharm Therap) dbpc*
 5mg-20mg with results at 15mg & 20mg
 ZERO nausea and vomiting
 14 % experienced significant ANXIETY
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chronic pain thresholds by cannabinoid, THC,
10-20mg translate to 60-120 mg codeine.
 Noyes et al (Clin Pharm Therap) single dose study
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Agitation
Combative behavior
Tachycardia
Hallucinations
Paranoia
Confusion
Blurred Vision
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Chest Pain
Myoclonus
Hypertension
Mydriasis
Elevated CPK
Seizure
Death
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“I don’t believe in the hype so I ordered some
offline and received in roughly a week and a half.
It came in a 250mg package that ran me roughly 18
dollars with tax and shipping included. I tried
roughly 10mg and absolutely loved it.
Immediately after ingestion of the bath salts I felt a
rush of energy and even a slight euphoria to go
along with it. My mind felt like it was working in
overdrive and I wanted to talk to anyone about
anything I possibly could…”
“At about 1 hour and 10 minutes in I got the
strongest urge to redose I have ever felt from a
drug, including cocaine.”
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White to Light Brown
Hydrophilic
Crumbly powder
Slight odor
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First call December 18, 2010
February 3, 2011 first death
February 2-7 10 cases
One Death
Primarily in Marquette
Reported in Bay City, Iron Wood, Mt. Clemons
Ended as quickly as it started
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35 patients
Majority in upper peninsula
17 required ICU care
One death
Male 46% Female 54%
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Age
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20-29
30-39
40-49
>50
63%
14%
17%
6%
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Exposure route
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Injected
Snorted
Ingested
Unknown
63%
26%
4%
14%
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Additional drug use
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Marijuana
Opiates
Benzodiazepines
Cocaine
Amphetamines
29%
23%
14%
11%
6%
* Five patients reported two exposure routes
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Sings and symptoms
Agitation
 Tachycardia
 Delusions/hallucinations
 Seizure/tremor
 Hypertension
23%
 Drowsiness
 Paranoia
 Mydriasis
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66%
63%
40%
29%
23%
20%
20%
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Disposition
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D/C from ED
Admitted
Dead upon arrival
AMA
43%
49%
3%
6%
Cases are in bold and cases per 100,000 are in parenthesis.
Cleveland Poison Center did not provide cases.
Date Banned
ND March11
IL April-11
IN
June-11
MI
July-11
MN July-11
OH July-11
WI
July-11
KY
None
SD
None
USA Sept-11
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Inhalation
Ingestion
Unknown
Injection
45%
27%
13%
10%
Product
Cases
White Rush
42
White Lightning
Ivory Wave
Zoom
White Horse
MDPV
Mephedrone
Other
Unknown
33
13
12
11
5
6
585
255
Compounds Found
Methylone
Butylone
a-PVP
bk-MBDP
MDPV
Lidocaine
p-MMA
4-MEC
4-MPPP
MPA
MDPBP
2-BPMP
2-DPMP
Clinical Effect
Agitation
Tachycardia
Hallucinations
Hypertension
Confusion
CPK elevation
Drowsy
Tremor
Chest Pain
Mydriasis
Electrolyte Abnormality
Fever
Percent
54.6
44.9
25.8
20.3
15.3
12.0
9.0
7.8
6.9
5.8
5.9
5.1
Phenethylamines
I Have Known And Loved
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Similar mechanism for dopamine and serotonin
NH2
Dopamine
effects
Norepi
Serotonin
effects
OH
N
H
HO
Epinephrine
HO
NH2
N
H
Methamphetamine
(crystal meth)
Amphetamine
(Speed)
OH
N
H
O
N
H
O
Ecstasy
Pseudoephedrine
Methylenedioxypyrovalerone-MDPV
3,4-Methylenedioxymethamphetamine
MDMA or Ecstasy
Pyrovalerone
Then I could feel angels throughout the
room, there were at least 2 or 3 of
them. I shut my eyes again and
travelled. I envisioned myself travelling
in a spiral pattern out of the house I
was in, into the sky, out from the earth,
and then out of the universe.
---User experience
www.erowid.org3
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Serotonin effects
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Amphetamine like
Water intoxication
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Tooth grinding
Visual Hallucinations
Seizures
Death
Long term neuro
effects?
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Often mixed with other drugs
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Antidepressants
Sildenafil (Viagra)
 Sexstasy
 Hammerhead
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THC
Sedative-hypnotics
LSD?
 “Candy flipping”
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Ketamine
 “Kittie Flipping”
Drug
MAO
5HT
NE
Pyrovlerone
52
>10,000
56
Ecstacy
1572
238
46
Amphetamine
34
3830
39
Cocaine
461
494
378
Meltzer et al (2006) and Rothman & Baumann (2003). Values are the drug
concentrations (in nanomolar ) for 50% inhibition of monoamine uptake in test
tube model in vitro. Lower numbers are increased drug potency.
Soothing Bath Salts - Relax and soak away in
RECHARGE EXTRA Concentrated Bath Salts. Add the
contents to a hot bath to naturally soften the water
which will leave you feeling very soothed and relaxed.
PLEASE NOTE:
The RECHARGE Extra line of Bath products provide
a immediate and intense experience that is always
enjoyable. Once you have experienced RECHARGE
EXTRA Bath Salts, you will know which method of
application provides the most exhilarating experience
for you.
**This Powerful and Immediate rush of
heightened sensation lasts from 1-3 hours.
NOT FOR HUMAN CONSUMPTION
http://www.legalsalts.com/

“I love Alexander
Shulgin. I’ve loved
him from the first
moment I read about
him. He is my idol,
my hero, my sun, my
O2.”
-Hamilton Morris
http://www.viceland.com/int/v17n5/htdocs/the-last-interview-with-alexander-shulgin423.php?page=1
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Published in 1991
179 chemicals
150 others discussed
Most are legal
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Psychedelic
Phenethylamines and
Related Compounds
by: Alexander Shulgin
Tania Manning
and Paul Daley
Available the first week of
March
(Hardcover)
ISBN: 978-0-9630096-3-0
list price: $85.00 (US Dollar)
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>1000 chemicals
749 Phenethylamines
dimethocaine
3-(p-fluorobenzoyloxy)tropane
(pFBT)
cocaine
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Glaxo-Wellcome
synthesized in 1944 as a
potential anti-parasitic
agent
1970s tested as an
antidepressant
1990s reported as
adulterant
Frequently found in
“Ecstasy”
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Peripheral α2-antagonist
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(Central a2?)
Reuptake inhibitor of NE and DA
Amphetamine-like inhibition of reuptake and
stimulation-independent release of 5-HT
High rate of seizures
Schedule I in 2002 in the US
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Befuraline*-antidepressant
Bifeprunox-antipsychotic
Buclizine-antihemetic
Chlorbenzoxamine-GI
agent
Fipexide*-Nootropic
Imatinib-antineoplastic
Piberaline*-antidepresent
Piribedil-antiparkinsonian
Trimetazidine-antianginal
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Vesnarinone-cardiotonic
Meclizine-antihistamine
4-methyl-1-benzylpiperazine
(MBZP)
4-Bromo-2,5-dimethoxy-1benzyliperazine (2C-B-BZP
1,4-Dibenzyliperazine
(DBZP)
3,4-Methylenedioxy-1benzyliperazine (MDBZP)
Trifluoromethylphenylp
iperazine
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Near infinite compounds
Important medical compounds
Easy to make
Need to get ahead of dealers
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Goal to prevent new legislation monthly
Problems
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Analogue is defined as substantially similar
Substantially similar to or greater than schedule I
and II drug
Does not cover products not met for human
consumption
Limit production of drugs with medicinal purpose
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Legal Uses
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ADHD
Weight Loss
Narcolepsy
Military
 Modafanil
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Diversion
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Medical, Law students
Clandestine production
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Chocolate
Caffeine
ICU
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Epi
Norepi
Dopamine
Dobuamine
Parkinson Drugs
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Anti-depresants
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SSRI
Bupropion
TCA
MAI
Decongestants
Asthma/COPD
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albuterol
theophylline
Selegiline
Dopamine
Buproprion
MDMA
THC
Percentage of U.S. 12th Grade Students Reporting
Use of Cigarettes and Marijuana, 1975 to 2008
40%
30%
Cigarettes
20%
10%
Marijuana
0%
1978 1982
1986 1990 1994 1998
2002 2006
1976 1980
1984 1988 1992 1996
2000 2004
2008
CESAR FAX January 19, 2009, Vol. 18, Issue 2. Adapted by CESAR from University of Michigan,
“Trends in 30-Day Prevalence of Use of Various Drugs in Grades 8, 10, and 12,”Monitoring the Future study, 2008.
THC
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Dr. John W. Hoffman-Clemson Chemist
Chemically different than THC
Hundreds of analogs synthesized
Urine does not test positive for TCA
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Agonists
THC (Banner, Roxane, Solvay, Unimed, Watson)
WIN 55212-2
CP 55940
HU-210
Anandamide (natural ligand) aka AEA
2-arachidonylglycerol (natural ligand) aka 2AG
Antagonists
SR 141716A (Sanofi-Aventis, Rimonabant)
SR 144528
Sources: Felder and Glass, 1998, Mechoulam et al., 1998
“As I said they are so chemically distinct, what
possible enzymatic process could result in a
common chemical product?”
JWH-073
http://www.drugsforum.com/forum/showthread.php?t=91939&pag
e=2#ixzz1RkzUDjoG
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Each synthetic cannabinoid is between 5-200 X
more potent than THC
What is the plant material?
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Some believed to have psychoactive plants
Varying concentrations of active ingredient
Bottom Line: You don’t know what your getting
•
Cannabis use can worsen symptoms associated with
psychotic illnesses:
delusions
hallucinations
http://hnb.dhs.vic.gov.au/dsonline/dsarticles.nsf/page
s/Cannabis_and_psychosis?OpenDocument
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Delusions
Hallucinations
Confusion
Agitation
Tachycardia
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Psychosis (persistent)
Paranoia
Seizure
Elevated troponin
Elevated CPK
Individuals with one or two
copies of the "Val" variant
have higher risk of
developing psychosis
and schizophrenic-type
disorders if they used
cannabis in adolescence.
adapted from Caspi et al., Biol. Psych May 2005
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213 cases in the past 2 months
154 cases with significant CNS effect
11 seizures
Benzodiazepines
Dose: Enough
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IV benzodiazepines
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Repeated frequent dose until achieve control of
symptoms
Avoid physical restraints
IV fluids
Activated Charcoal for oral ingestion
Monitor for seizure
Useful Studies: Chem 7, CPK, EKG, trop
External cooling as necessary
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We will leave that up to the drug companies
We should be asking
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Next incense, plant food, bath salt, pond water
cleaner, collector's item, or …..
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Images from Google Images
www.Erowid.com
M. Badioun K2/Spice Lecture to Poison Control Center
T. Kuschel K2/Pyrovalorne and Spice Lecture to Poison Control Center
D. Rhodes Bath-salts May Be Not Lecture to Poison Control Center
B. Dolcourt Phenethamines Toxicology Grand Round presentation
Wikipedia.com
http://www.emcdda.europa.eu/index.cfm
N. Uchiyama et. al. Chemical analysis of synthetic cannabinoids as designer
drugs in herbal products. Forensic Science International 1988 (2010) pg 31-32
H. Spiller et al Clinical experience with and analytical confirmation of “bath
salts” and “legal highs” (synthetic cathinones in the United States. Clinical
Toxicology (2011) 49 pg 499-505

Jeffrey Bargeon DO, Wayne
State UniversityI share his hard
work and what he taught me.
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www.ResearchChemz.com
http://www.mdairesearch.com/
www.BuyBestRC.com
www.ResearchChemicalsOnline.com
www.Buzz-Wholesale.com