Download DESIGNER & CLUB DRUGS IN OUR COMMUNITY Patricia Junquera, MD

DESIGNER & CLUB DRUGS
IN OUR COMMUNITY
Patricia Junquera, MD
Daniel Castellanos, MD
Assistant Professor, Department of Psychiatry & Behavioral Health
Herbert Wertheim College of Medicine, Florida International University
Founding Residency Program Director
Department of Psychiatry, Citrus Health Network
in affiliation with FIU Herbert Wertheim College of Medicine
Professor and Founding Chair, Department of Psychiatry &
Behavioral Health
Herbert Wertheim College of Medicine, Florida
International University
Student Services Mini-Conference
Miami Dade County Public Schools
February 7, 2014
Designer & Club Drugs
Objectives:
 Participants will identify the names of the most
commonly used designer and club drugs
 Participants will recognize the psychoactive and
physical effects of the most commonly used designer
and club drugs
 Participants will identify the signs and symptoms of
persons using designer and club drugs
Junquera & Castellanos, 2014
Overview of the Problem
 Designer and club drug use has increased in popularity
over the past few years
 Serious medical consequences can result
 We have seen an increase in ED visits associated with use
of these drugs
Junquera & Castellanos, 2014
High School Students Who Reported Current
Alcohol Use, 2011
* Had at least one drink of alcohol on at least 1 day during the 30 days before the survey.
Source: National Youth Risk Behavior Survey, 2011
Junquera & Castellanos, 2014
High School Students Who Reported
Current Marijuana Use, 2011
* Used marijuana one or more times during the 30 days before the survey.
Source: National Youth Risk Behavior Survey, 2011
Junquera & Castellanos, 2014
Nonmedical use of prescription drugs
 The 2011 National Youth Risk Behavior Survey
(YRBS) (www.cdc.gov/yrbss) found that 1 in 5 high school
students in the US have ever taken a prescription
drug, such as OxyContin, Percocet, Vicodin,
Adderall, Ritalin, or Xanax, without a doctor’s
prescription.
Junquera & Castellanos, 2014
Percentage of High School Students Who Ever Took Prescription
Drugs Without a Doctor's Prescription,* by Type of Grades
Earned , 2009
Source: United States, Youth Risk Behavior Survey, 2009
Junquera & Castellanos, 2014
Percentage of High School Students
Who Ever Used Ecstasy, 2011
* Used ecstasy/MDMA one or more times during their life.
Source: National Youth Risk Behavior Survey, 2011
Junquera & Castellanos, 2014
Annual Prevalence of Designer Drug Use by
US 8th, 10th & 12th Graders, 2013
8
7.9
7.4
7
6
5
8th
10th
%
4
4
12th
4
3.6
3
2
1.4
1.1
1
1
0
Synthetic
Marijuana
MDMA
GHB
Ketamine
Source: Johnson LD et al, Monitoring the Future National Survey on Drug Use, 2014
Junquera & Castellanos, 2014
% of Florida High School Students
who used Club Drugs* & Synthetic Marijuana, 2013
16
14.8
14
12
10
8th
10th
8
%
12th
6
5.3
4.6
4
2
2.1
1.1
1.8
0.3
0
Lifetime
Past 30 Days
Club Drugs*
1.8
unk
unk
Lifetime
unk
unk
Past 30 Days
Synthetic Marijuana
*Ecstasy, Rohypnol, GHB, Ketamine
Source: 2013 Florida Youth Substance Abuse Survey
Junquera & Castellanos, 2014
Emergency Room Visits,
Miami-Dade County
Source: DAWN Report, 2012; http://www.samhsa.gov/data/2k12/DAWN096/SR096EDHighlights2010.htm
Junquera & Castellanos, 2014
Emergency Room Visits,
Miami-Dade County
 398 MDMA -involved ED visits for Miami-Dade County
during 2011
 Represents 2 percent of all ED visits among 6 categories of
substances (cocaine, cannabinoids, illicit stimulants,
MDMA, nonmedical use of prescription opioids & BZs
 The 2011 total represented a 91 percent increase over the
209 MDMA reports in 2004
Junquera & Castellanos, 2014
Designer & Club Drugs

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Synthetic Marijuana
GHB
MDMA
Ketamine
N-Bomb
Bath Salts
Kratom
Dextromethorphan
DMT
Sizzurp
Junquera & Castellanos, 2014
Synthetic Cannabinoids
Junquera & Castellanos, 2014
Introduction
 Product line marketed as incense, herbal or aromatic
incense or potpourri
 “Not for human consumption”
 All ingredients don’t have to be listed
 Not “intended” for smoking but most of the products are
smoked in hand-held pipes, water pipes or rolled in
cigarette paper
 Synthetic cannabinoid is sprayed on the product
 Manufacturers are substituting more potent synthetic
cannabinoid products every day
Junquera & Castellanos, 2014
Source for syn cann chart: Data extracted from NMS Labs Laboratory Information Management System. Synthetic Cannabinoid confirmed positive
blood samples. Oct 2010-Jan 2013. (n=155)http://www.nmslabs.com/uploads/PDF/Designer%20Drug%20Testing%20March%202013.pdf
Introduction II
 After marijuana, synthetic canniboids are the
most frequently used illicit drugs by 12th
graders
 One of 9 US high school students reported
having used an SCP in 2012.
 Sold in Europe since 2006, possibly as early as
2004
 Can be purchased:
 Online
 Head shops
 Convenience stores
 Gas stations
Junquera & Castellanos, 2014
2/11/2014
Draft
Synthetic Cannabinoids
Physical Effects
 Gastrointestinal: Nausea, vomiting
 Appetite changes
 Conjunctival injection / Red eyes
 Tremors
 Numbness
 Dry mouth
 Paleness of skin
 Listlessness / Lack of interest
 Sweating
 Tachycardia
 Increased blood pressure
Junquera & Castellanos, 2014
Synthetic Cannabinoids
Psychoactive Effects
 Mood changes:
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
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Euphoria
Anxiety
Irritability
Depression
 Cognitive changes:
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Impaired short term memory
Confusion
Cognitive dulling
Impairment of linear thinking
Junquera & Castellanos, 2014
Synthetic Cannabinoids
Psychoactive Effects II
 Changes in activity:
 Sedation
 Excitability
 Agitation
 Sleep Changes
 Psychosis:
 Disorganized thinking
 Paranoid delusions
 Auditory and visual hallucinations
Junquera & Castellanos, 2014
Dangers of Synthetic Cannabinoids
 Psychosis
 New onset
 Exacerbation of previously stable psychotic disorders
 Extreme mood changes
 Effects persist beyond acute intoxication
 Tolerance, withdrawal & dependence may be
associated with long term use.
Junquera & Castellanos, 2014
GHB
Junquera & Castellanos, 2014
Overview of GHB
 Hypnotic (non analgesic) anesthetic
 Epileptogenic agent in animals
 Increases growth hormone
 Promotes slow wave sleep
 Trials for the treatment of opiate and alcohol
withdrawal
 Treatment of narcolepsy/cataplexy
Junquera & Castellanos, 2014
History of GHB
 1960: induce a sleeplike state with cardiovascular





stability
1960’s anesthetic was abandoned because of poor
analgesic effects
1970’s: first studied for treatment of
narcolepsy/cataplexy
1980’s: marketed as a “fat burner and muscle
developer”
1990: FDA ordered it to be removed from store’s
shelves
2000: Federally classified as a 'Schedule I' drug
Source: am, PC, & Yoong, FF. (1998). Gamm a-hydroxybutyric acid: an emerging recreational drug. Anaesthesia, 53(12), 1195-8
Junquera & Castellanos, 2014
Reasons for use
 Sense of improved sleep
 Sense of improved dancing
 Antidepressant (mood lifting)
 Anxiolytic
 Socialization increases (disinhibiting)
Junquera & Castellanos, 2014
GHB Street Names
 Blue Nitro
 Revivarant
 Blue Nitro Vitality
 Serenity
 G3
 Solar Water
 Gamma G
 SomatoPro
 GHRE
 Thunder Nectar
 Invigorate
 Verve
 Jolt
 Weight Belt Cleaner
 Remforce
 ZEN
 Renewtrient
 Revitalize Plus
 www.ashesonthesea.com/
 GHB/analogs.htm#trinka2
Junquera & Castellanos, 2014
GHB
 Often sold as clear salty liquid, taken in capsules
or in drinks (Often carried in Visine containers)
 Capsule concentration varies 500mg-5g
 Rapidly absorbed, peak concentration 20-60 min
 Half life is 20 min.
 Almost completely oxidized to carbon dioxide
 Readily crosses the blood brain barrier and
placenta
Junquera & Castellanos, 2014
Psychoactive and Physical effects of GHB
 Euphoria
 Optimism
 Increased sexuality
 Increased energy
 Wellbeing
 Giddiness
 Relaxation
 Talkative
 Increased sensitivity
to sound
 Tranquility
 Silliness
 Drowsy
 Sweaty
 Loss of consciousness
Junquera & Castellanos, 2014
Dangers of GHB
GHB has an incredibly
small therapeutic index:
 Difficult for
enforcement officials to
detect as it may be
smuggled in vessels like
Visine containers
 Overdose may result in:
 Decreased respiration
 Death due to carbon
dioxide poisoning
Junquera & Castellanos, 2014
Ecstasy - MDMA
Junquera & Castellanos, 2014
Overview of Ecstasy
 MDMA 3,4 methylenedioxymethamphetamine
 Hallucinogenic amphetamine
 Historical use in research and psychotherapy
 DEA ban on MDMA in 1985
Junquera & Castellanos, 2014
History of MDMA/Ecstasy
 1914: E. Merck Pharmaceutical company developed MDMA
in Germany
 1950's: briefly evaluated as an adjunct to psychotherapy based
on a reported ability to produce a state of consciousness that
promotes willingness towards emotional self-disclosure
 1970's: and early 1980's: again investigated as an adjunct to
psychotherapy
 1985: Drug Enforcement Agency in US placed MDMA on
Schedule I of controlled substances, citing increasing
recreational use and concern over potential neurological
damage
Junquera & Castellanos, 2014
Psychoactive and physical effects of MDMA
 Altered time perception
 Increased ability to interact with others
 Decreased defensiveness
 Changes in visual perceptions
 Increased awareness of emotions
 Decreased aggression
 Decreased restlessness
 Less impulsive
Leister M et al, J of Nerv Ment Dis, 1992; 180 345-352 and
McDowell & Kleber, Psychiatric Annals 1994; 24 127-130
Junquera & Castellanos, 2014
Adverse Effects of the Use of MDMA
 Decreased desire to




perform mental or
physical task
Bruxism
Decreased libido
Increased restlessness
Increased anxiety
 Depressed mood
 Nystagmus
 Motor tics
 Headaches
 Anhedonia
 Lethargy
 Anorexia
 Decreased motivation
Leister M et al, J of Nerv Ment Dis, 1992;
180 345-352 and McDowell & Kleber,
Psychiatric Annals 1994; 24 127-130
Junquera & Castellanos, 2014
Ecstasy- MDMA
 Dose concentration 50 to 300 mg
 Cost $25 per tablet
 Onset 20 to 40 minutes
 Effects less than 24 hours
 Street names: e, Adam, X, XTC, purest form
MOLLY( Usually white pill or powder)
Junquera & Castellanos, 2014
Dangers of MDMA / Ecstasy
 Memory problems for at least 2 weeks after use
 Functional consequences
 Reduction in number of serotonin transporters - PET Studies
(can leads to depression)
 Damage of serotonin nerve endings
 Hyperthermic Syndrome:
 elevated temperature
 tachyarrhythmia's
 hypertension
 muscle rigidity, rhabdomyolysis
 Hepatotoxicity
 Neurotoxicity
Bolla, McCann & Ricaurte Neurology 51, 1998
Junquera & Castellanos, 2014
“Molly”
 Hundreds of “Molly” capsules tested in two
South Florida crime labs in 2012, for
example, contained:
 methylone, a dangerous stimulant commonly
found in “bath salts”
News reports elsewhere have reported “Molly”
capsules containing:
 cocaine
 Heroin
 and other substances.
Junquera & Castellanos, 2014
Ketamine
Take a little ‘K’ and
Meet the “K-Monster”
Junquera & Castellanos, 2014
Overview of Ketamine
 Central nervous system depressant
 Usually snorted or insufflated
 Rapid acting-acting dissociative anesthetic
 Sedative-hypnotic, analgesic and
hallucinogenic properties
 Structurally similar to PCP
 N-methyl-D-Aspartate (NMDA) antagonist
Junquera & Castellanos, 2014
History of Ketamine
 1962: developed and initially promoted as a fast acting
general anesthetic
 1970’s: approved for human use by federal
government, and as a result became
 late 1970’s and early 1980’s: abuse began to increase
across the country
 1999: classified as a Schedule III controlled substance
in August 1999, creating more stringent controls of the
drug
 2012: Being studied for adjunct treatment in patients
with Major depressive disorder
University of Maryland, http://www.cesar.umd.edu/cesar/drugs/ketamine.asp
Junquera & Castellanos, 2014
Subjective Psychoactive and physical effects of
Ketamine
 Muscle spasm
 Blurred vision
 Dizziness
 Slurred speech
 Visual “flashbacks”
 Psychological effects
 Tolerance
 Agitation
 Increased temperature
Junquera & Castellanos, 2014
Ketamine – “Special K”
 Snorted or insufflated
 Dissociative effects called a “K-hole” – your
brain is active but your body isn’t, “like you’re
in a tunnel, your hear echoes, you’re in a semiconscious state”
 Used at rave/dance club scene, not as popular
as in past “like living inside a big cotton ball,”
“everything is in slow motion”
Junquera & Castellanos, 2014
Ketamine
 Administration: injected, intranasal, oral
 10 ml vials provide 5 illicit doses
 Sell for $20 a dosage unit
 Rapid onset of effects
 Duration of effects 4-6 hours
 Street names: Special K, Vitamin K, KitKat,
Blind squid, Super acid
Junquera & Castellanos, 2014
Dangers of Ketamine
 Paralyzing agent
 Flammable
 Confusion
 Loss of Consciousness
 With Chronic use:
 Brain damage in the form of vacuoles
 Personality changes
Junquera & Castellanos, 2014
N-Bomb
Junquera & Castellanos, 2014
Overview of N-Bomb
 It affects the serotonin receptors in the
brain
 It is considered a powerful synthetic
hallucinogen
 They are being sold as LEGAL substitutes
for LSD and mescaline.
Junquera & Castellanos, 2014
History of N-Bomb
 Discovered in 2003 by a chemist in Berlin
 It was further investigated by a team of
researchers in 2007 by a research team in
Perdue University
 The compound was labeled as 25I-NBOMEe
 It was classified as a radiotracer used in PET
scans
 2013 this compound is being sold in the
internet as a designer drug.
Junquera & Castellanos, 2014
Psychoactive and Physiological effect
of N-Bomb
 Agitation
 Visual & Auditory hallucinations
 Seizures
 Increased body temperature
 Muscle breakdown
 Aggression
 Acute kidney injury
Junquera & Castellanos, 2014
N-Bomb
 25I-NBOMe usually taken sublingually or
by mouth
 The effects usually last 4-6 hours could be
up to 12 hours
 Liquid more potent faster acting
 Stamps with caricatures usually laced with
the substance
Junquera & Castellanos, 2014
N-Bomb Street names
 25I
 Smiles
 Legal acid
Junquera & Castellanos, 2014
Dangers of N-Bomb
 Confusion
 Seizure
 Cardiac arrest
 Respiratory arrest
 Death
 At least 19 young people are reported to have
died after taking 25I- 25C- or 25B-NBOMe
between March 2012 and August 2013.
Junquera & Castellanos, 2014
Bath Salts
Junquera & Castellanos, 2014
Overview of Bath Salt Abuse
 Patients report: “It’s like a poor man’s cocaine
that’s legal”
 Poison Control Center has received over 4,000
call last year
 MDPV (methylenedioxypyrovalerone)
 Mephedrone
 Increased Blood Pressure, Heart Rate,
 Agitation, Hallucinations, Paranoia,
 Delusions
Junquera & Castellanos, 2014
History of Bath Salts
 First synthesized in the 1920s
 In 2009-2010: they became popular in the
underground market
 2010: started to be marketed as “ not for
human consumption”
 2011:New York was one of the first states to
ban the sale of Bath salts
 2012: President Obama signed a bill that
amended the Federal drug policy of the United
States to ban “bath salts”
Junquera & Castellanos, 2014
Psychoactive and Physiological effects of
Bath Salts
 Agitation
 Hypertension
 Increased temperature
 Muscle breakdown
 Impulsivity
 Lack of Judgment and Insight
 Bruxism
 Muscle spasm
 Increased body strength
Junquera & Castellanos, 2014
Bath Salts
 Powder packets of 50 mg
 $20-$40 Latest Designer Drug
 Used as synthetic stimulant; snort/insufflate,
smoke, inject
 Illegal in 41 states and pending legislation in
the others
 Deaths reported
 Some call it a Mini Crack
Junquera & Castellanos, 2014
Bath Salts Street Names
 Ivory Wave
 Bliss
 White Lightning
 Vanilla Sky
 Cloud 9
 Hurricane Charlie (most popular)
 Zoom
 Purple wave
Junquera & Castellanos, 2014
Dangers of Bath Salts
 Overstimulation of the central nervous
system
 Body temperature dysregulation
 Seizures due to temperature
 Supernatural aggression
 Death
Junquera & Castellanos, 2014
Kratom
Junquera & Castellanos, 2014
Overview of Kratom
 Opiate like sedation
 Coca like stimulation
 Stimulating at low dose levels
 Higher doses more opiate like
Junquera & Castellanos, 2014
Psychoactive and Physiological effects of
Kratom
 Sedation at higher doses
 Stimulation at low doses
 Low acting anesthetic
 Depression after use or in withdrawal
 Nausea, vomiting
Junquera & Castellanos, 2014
Kratom
 Effects noticeable in 20-30 minutes
 Effects can last 2-6 hours.
 Physical dependency can occur
 Withdrawal symptoms: irritability, yawning,
diarrhea, pain
 Street names: Kakaum, Ithang, Thom
Junquera & Castellanos, 2014
Dangers of Kratom
 Same as those of Heroin and Cocaine
 Low doses much like Cocaine (upper)
 Higher doses much like Heroin (downer)
Junquera & Castellanos, 2014
Dextromethorphan
Junquera & Castellanos, 2014
Dextromethorphan
 Over the counter cough and cold remedies
 Street names:
 “DXM”
 “Triple-C” “Skittles”
 “Robo-tripping”
 PCP or ketamine-like
Junquera & Castellanos, 2014
Psychoactive and Physiological effects of
Dextromethorphan
 Hallucinations
 Delirium
 Hypertension
 Tachycardia
 Ataxia
 Agitation
 Seizures
Junquera & Castellanos, 2014
DMT
(Dimethyltryptamine)
Junquera & Castellanos, 2014
Overview of DMT
 A psychoactive chemical in the tryptamine family
 Present in thousands of species of plants
 Used traditionally in South America
 Intense visuals and strong psychedelic
 Mental effects when smoked, injected, snorted or
when swallowed orally (usually with an MAOI)
 Standard Dose (15-60mg) Hit ($10-30)
Junquera & Castellanos, 2014
Psychoactive and physiological effects of
DMT
 Hallucinations
 Delirium
 Agitation
 Confusion
 Palpitations
Junquera & Castellanos, 2014
Sizzurp
Junquera & Castellanos, 2014
Overview of Sizzurp
 It’s a concoction which includes:
 Cough syrup with codeine
 Promethazine
 Jolly Rancher candy or Skittles
 Soda pop
 Usually served in Styrofoam cup but also drank
out of the soda bottle
Junquera & Castellanos, 2014
History of Sizzurp
 Originated in Houston, Texas
 1960: It was first used by Blues singers in the in order to perform
and continue to work.
 They used Robitussin with beer and then when wine coolers
became popular they replaced it.
 1980-1990: The recipe was changed to use it with codeine
promethazine cough syrup with a lemon lime soda and Jolly
Ranchers
 1990s: Made popular by a DJ in Houston and his music being
played in a slow tempo as if they were on codeine and
promethazine
 This concoction caused his early death and it was then that is
caught the attention of law enforcement
 2012: It became popular in the hip hop community
Junquera & Castellanos, 2014
Psychoactive and physiological effects of
Sizzurp
 Slow reaction time
 Sedation
 Relaxation
 Decreased respiratory rate
 Weight gain
 Tooth decay
 Dizziness
 Lethargy
 Dissociative feeling
 Motor skill impairment
Junquera & Castellanos, 2014
Sizzurp Street Names
 Purple drank
 Purple lean
 Purple jelly
 Texas Tea
 Syrup
Junquera & Castellanos, 2014
Dangers of Sizzurp
 Seizures when mixed with alcohol or if person
prone to seizures
 Shut-off of the respiratory center in the brain
Junquera & Castellanos, 2014
What can we do?
 Education to:
 Young Adults
 Parents
 Educators
 Community at large
 Decrease stigma about substance used
disorders in order to increase the users from
seeking help.
 Arm ourselves with a “First Aid Kit” to
recognize intoxication with these substances
and get them help.
Junquera & Castellanos, 2014
Edible Cannabis
Junquera & Castellanos, 2014
Closing Remarks
Designer drug use will not go away
 New drugs will continue to emerge

No matter how designer drugs evolve,
we need to be ready
Junquera & Castellanos, 2014
References
 Galloway, GP, Frederick Osborne, SL, Seymour, R, et al. (2000).
Abuse and therapeutic potential of gammahydroxybutyric acid.
Alcohol, 20(3), 263-9.
 Kam, PC, & Yoong, FF. (1998). Gamma-hydroxybutyric acid: an
emerging recreational drug. Anaesthesia, 53(12), 1195-8.
 Koesters, SC, Rogers, PD, & Rajasingham, CR. (2002). MDMA
('ecstasy') and other 'club drugs'. The new epidemic. The Pediatric
clinics of North America, 49(2), 415-33.
 Rochester, JA, & Kirchner, JT. (1999). Ecstasy (3,4-
methylenedioxymethamphetamine): history, Neurochemistry, and
toxicology. The journal of the American Board of Family Practice,
12(2), 137-42.
 www.clubdrugs.org
 NIDA’s “Initiative to Combat Club Drugs
Junquera & Castellanos, 2014