ANALYTICAL STRATEGIES 1. November 2016

CLINICAL ANALYTICS: TOXICOLOGICAL SCREENING / SCREENING FOR DRUGS OF ABUSE

Katharina Rentsch Laboratory Medicine, University Hospital Basel

The Laboratory Medicine at the University Hospital Basel provides the following services to the hospital and many external costumers: - > 4.0 Mio. results in 2015 - > 500 different analytes in plasma, serum, blood, urine, faeces, meconium, saliva - Working hours: 365 days/year, 24 hours/day - Very fast turn-around times for a selected panel of analytes - Special diagnostics fields of toxicology, drug monitoring, protein and cerebrospinal fluid analytics.

The analytical techniques used comprise immunological, chemical and enzymatic methods as well as electrophoresis, LC-MS and GC-MS. Most of the analyses are performed with highly automated instruments; the chromatographic instruments are all equipped with autosamplers.

Case: At 1:00 a.m. a 23 year old male patient is admitted to the emergency department of the University Hospital in Basel. He was very agitated, had a combative violent behaviour and hallucination. He has been found in his home standing on his bed complaining of mice everywhere. He was given the antidote for opiate intoxications without any effect. The classical drugs of abuse screening tests in the laboratory were negative. The physicians then suspected the intake of legal highs or research chemicals and sent a urine and a blood sample to the laboratory.

Questions: 1. Which compounds are used as legal highs or research chemicals? 2. What is the action of these substances? 3. Which is/are the method(s) of choice for the analysis of these compounds? Which are the advantages or the disadvantages of the different methods? 4. How is the legal situation with these compounds in Switzerland?

Literature: 1. Clinical Toxicology 2011;49:499-505 2. Clinical Toxicology 2012;50:15-24 3. The American Journal of Drug and Alcohol Abuse 2012;38:176-180 4. http://www.sscc.ch/scdat/en/guidelines.html “Guidelines for drugs of abuse testing”

The American Journal of Drug and Alcohol Abuse, 38:176–180, 2012 Copyright © Informa Healthcare USA, Inc. ISSN: 0095-2990 print / 1097-9891 online DOI: 10.3109/00952990.2011.643999

“Bath Salt” Ingestion Leading to Severe Intoxication Delirium: Two Cases and a Brief Review of the Emergence of Mephedrone Use

David P. Kasick, M.D., Curtis A. McKnight, M.D., and Eleonora Klisovic, M.D.

Department of Psychiatry, The Ohio State University College of Medicine, Columbus, OH, USA

“bath salts,” which have been found to contain the stim- Background: Recreational use of designer substances ulant compound mephedrone (4-methylmethcathinone; containing synthetic cathinones such as mephedrone, Table 1) (1,2). Mephedrone is among several synthetic commonly sold as “bath salts,” has recently been derivatives of cathinone, a schedule I stimulant substance increasing in the United States (National Institute on found in the khat (Catha edulis) plant grown in east Drug Abuse. Available at: http://www.nida.nih.gov/ Africa. These synthetic stimulant compounds have been about/welcome/MessageBathSalts211.html. Accessed previously reported in the United Kingdom and elsewhere March 25, 2011; The Washington Post. Available at: in Europe to produce a profound deliriogenic toxidrome, http://www.washingtonpost.com/national/ generating intense agitation and hallucinations. Similar to officials-fear-bath-salts-becoming-the-next-big- other abusable stimulant agents (cocaine, amphetamines, drug-menace/2011/01/22/ABybyRJ_story.html. methylenedioxymethamphetamine (MDMA)), patients Accessed March 25, 2011). “Bath salt” ingestion can who have ingested the stimulants found in “bath salts” generate an intense stimulant toxidrome and has been have had severe, protracted toxidromes that require gen- associated with significant morbidity. Objectives: The eral hospital admission for adequate management of sus- authors seek to alert clinicians to the potential for tained physical and behavioral sequelae. Although US profound delirium, psychosis, and other medical and law enforcement has verified the presence of mephedrone behavioral sequelae of “bath salt” use. Methods: Case

For personal use only. and other synthetic cathinone derivatives found in “bath series. Results: We describe our recent experience salts,” we are unaware of any published confirmed patient with two highly agitated and delirious patients cases outside of Europe, possibly due to hospital toxicol- following “bath salt” ingestion and offer a brief ogy labs not yet routinely testing for the presence of these review of the emergence of this phenomenon. compounds. We anticipate that clinicians will increas- Conclusions: Challenges and strategies surrounding ingly encounter similar delirious toxidromes as the use diagnosis and treatment are described, which may be becomes more prevalent. Maintaining awareness of this useful as “bath salt” use becomes more widespread. phenomenon when evaluating patients with toxic inges- Scientific Significance: As an emerging trend, bath tions will be helpful until confirmatory testing becomes salt intoxication delirium appears to cause intense more widely available in clinical settings. We report our psychosis that can be managed with antipsychotic recent experiences with two patients seen in psychiatric medications. Clinicians should be aware of this

Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of Basel on 09/19/12 consultation on a general hospital medical unit following phenomenon until more precise detection methods the purposeful ingestion of “bath salts.” are available.

Keywords: bath salts, mephedrone, delirium CASE 1 “Mr. A,” a 38-year-old Caucasian male without prior history of psychosis, was taken to an outside hospital INTRODUCTION by Emergency Medical Services (EMS) after his signif- Since late 2010, news media outlets in the United States icant other called to report that Mr. A was seeing snakes have reported a recent surge in the sale, consumption, and acting strangely. The patient was found in his home and abuse of synthetic stimulants packaged and sold as standing on his bed complaining of “snakes everywhere.”

Address correspondence to David P. Kasick, Department of Psychiatry, The Ohio State University College of Medicine, 1670 Upham Drive, Suite 130, Columbus, OH 43210, USA. Tel: (614) 293-3569. E-mail: [email protected]

176 “BATH SALTS” AND THE EMERGENCE OF MEPHEDRONE USE 177

TABLE 1. Various reported “bath salt” trade names (1,2). obtained 9 hours after the initial drug screen, which was Bath salt trade names positive for benzodiazepines, but negative for PCP or any other substances. He became progressively calmer as Ivory Wave the day progressed, but continued to have difficulty with Purple Wave awareness, orientation, cognitive speed, and attention. Red Dove By the following morning, 35 hours after Mr. A’s Blue Silk first contact with EMS, Mr. A remained guarded and Zoom irritable, but his consciousness and awareness were sig- Bloom nificantly improved. Mr. A clearly described purchasing Cloud Nine Ocean Snow “bath salts” from a local “head shop” and twice drank Lunar Wave a mix of roughly half a tablespoon of “bath salts” in Vanilla Sky a carbonated cola beverage over the 2 days prior to White Lightning admission. He continued to stoutly deny ever using phen- Scarface cyclidine, although described more remote history of Hurricane Charlie alcohol and cannabis use. He denied any history of psy- Posh chosis or prior treatment from a psychiatrist. His vital Arctic Blast signs and elevated CK had normalized. His physical and neurological exams were unremarkable. His Mini- Mental State Examination (MMSE) was 28/30 (missed He was given 2 mg of naloxone twice at the scene with the floor of the hospital, one serial 7). His significant no improvement. After 45 minutes of verbal de-escalation other was contacted who agreed with the history he by medics, the patient was restrained to the EMS cot and presented. taken to an outside hospital. Over the next 24 hours, Mr. A showed sustained While in the outside hospital emergency department improvements in attention, awareness, focus, concentra- (ED), he was tachycardic (EKG revealed heart rate tion, and speed of thought. He had no residual psychotic of 144, occasional premature ventricular contractions symptoms and performed normally on further bedside (PVCs), and QTc of 430 ms) and his temperature was cognitive screening. He was discharged the following day 100.8◦F; he was restrained but refused to be covered with with his significant other. He described his ingestion as a blanket due to fears that “scorpions” would bite him. one of the worst experiences of his life and was adamant The patient’s significant other provided further history that he would not engage in a repeat ingestion. that Mr. A had ingested “bath salts” packaged under the

For personal use only. name “Arctic Blast,” twice over the prior 2 days. The ED physician documented that police found “bath salts” in CASE 2 the patient’s personal effects. In the triage area, Mr. A was complaining of “things crawling on him and in his Mr. B, a 26-year-old Caucasian male, presented to the hair.” He remained agitated in the ED and received 3 ED 2 days after nasally insufflating “four lines” of “bath mg of IV lorazepam over the course of 4 hours with 2 salts” (later approximated to be 2 g of “Posh Aromather- L of IV fluids. Laboratory assessment revealed elevated apy Bath Salts” in an 8-hour period) that he purchased hemoglobin and hematocrit, consistent with his history at a local gas station. He reported first consuming “bath of polycythemia. His white blood cell count and platelets salts” 1 month prior to admission and had been snort- were normal. He also had negative acetaminophen and ing smaller amounts on a daily basis since that time. Mr. salicylate levels, glucose of 99, and TSH within normal B reported auditory hallucinations, as well as prominent

Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of Basel on 09/19/12 limits. Chemistry panel and liver function tests were unre- illusions and feelings of detachment and derealization fol- markable. His first urine drug screen had a presumptive lowing his daily use. He reported developing tolerance to positive for phencyclidine (PCP) only, although this was his daily use of smaller amounts (between 0.25 and 0.5 g) not able to be confirmed. Serum ethanol was zero. and decided to use a larger amount prior to being admitted The patient was subsequently transferred to our tertiary to the hospital. academic medical center. He remained highly agitated In addition to its usual effects, following his 2 g and hyperalert and required 4 mg of IV lorazepam due insufflation, Mr. B developed prominent paranoia, suici- to attempts to leave the hospital. He was persistently dal ideation, confusion, delirium, tremors, hyperreflexia, anxious and paranoid, believing that people were steal- myoclonus, and amnestic effects. He had significant dif- ing his belongings. He was also physically combative ficulty remembering details of his behavior in the 2 days with numerous security officers, at one point undressing that elapsed since his overdose, although we verified later while attempting to elope from the hospital. Due to his that he was briefly in the custody of law enforcement, protracted physical aggression, an additional total of 6 having been found after driving his car into a ditch. He mg of IV lorazepam and 5 mg of IM haloperidol were recalled the desire to die at that time, vaguely recalling administered. Creatine kinase (CK) level was elevated the desire to jump in front of a car while standing along at 1468 U/L. He was given IV fluids at a rate of 200 a freeway. He described intense auditory hallucinations mL/hour over 24 hours. An additional drug screen was and paranoid delusions of being followed by “unmarked 178 D. P. KASICK ET AL.

cars” and was picking in the air at apparent visual hallu- Although the synthesis of mephedrone was first cinations. His chemistries at admission included slightly described in 1929, there is a limited amount of elevated creatinine (1.33), mildly elevated transaminases published data surrounding its bioactive properties (9). (ALT 64, AST 50), and CK of 1665. He was afebrile, but Mephedrone, one of the numerous beta-keto analogues had mild hypertension and tachycardia, although his EKG of amphetamine, shares psychoactive properties similar was otherwise unremarkable. His comprehensive urine to cocaine, amphetamines, and MDMA (10). As cathi- toxicology screen was negative for any identifiable sub- nones bind to noradrenaline, dopamine, and serotonin stances. His roommate also later confirmed that Mr. B had transporters, mephedrone is expected to act as a stimulant only ingested “bath salts” and no other substances. by promoting the release of monoamine neurotransmit- While hospitalized, Mr. B continued to remain rest- ters and likely inhibiting their reuptake (9). Experiences less, paranoid, and at times agitated and inattentive. He with patients who have ingested similar white powdery had limited awareness of his surroundings and contin- substances, confirmed to contain mephedrone, have been ued to hallucinate up through 48 hours post-ingestion. reported in the United Kingdom. The most common He began to gradually improve with IV fluids and a total clinical findings in these cases were tachycardia, hyper- of 5 mg of IV lorazepam. Additionally, we administered tension, and agitation, similar to the sympathomimetic two oral doses of risperidone 0.5 mg, which he tolerated toxidromes observed following MDMA or cocaine use without any adverse effects and correlated with a rapid (11). Mydriasis, anxiety, agitation, paranoia, bruxism, improvement in his symptoms over the subsequent 24 aggression, depression, hallucinations, delusions, and hours. By 96 hours post-ingestion, his chemistries, liver manic behavior and seizures have also been reported from function tests, CK, and vital signs all normalized. His mephedrone use (9,12,13). delirium resolved, and his thinking was organized, aware, Serious complications of mephedrone ingestion have and goal directed, with an MMSE of 29/30 (missing one been reported in the UK hospitals, including serotonin recall item). His neuromuscular exam was normal. His syndrome, delirium due to mephedrone-induced hypona- fluids, lorazepam, and risperidone were discontinued, and tremia, as well as acute myocarditis (14–16). Forensic he was discharged home. examiners in the Netherlands recently attributed the death of a 36-year-old man to mephedrone ingestion, following a period of excited, agitated delirium (17). DISCUSSION Limited data exist regarding the most effective treat- Our cases represent the emerging awareness of the poten- ments for mephedrone toxidromes. However, as in the tial for a severe, toxic delirium generated by “bath salts,” management of other sympathomimetic toxidromes, a which are becoming more widely used and consumed case series published in the United Kingdom supports

For personal use only. for recreational intoxication in the United States. Alerts the use of benzodiazepines for treating the agitation asso- from the National Institute on Drug Abuse suggest that ciated with the acute toxidrome (11). Based on these this trend is increasing, reporting that calls to poison con- previously published reports in Europe, poison control trol centers reporting cases of “bath salt” intoxication in protocols, and concerns for exacerbation of hyperther- the first 2 months of 2011 exceeded the total number mia, rigidity, or seizures with antipsychotic use, a mixture of calls for this reason received for the entirety of 2010 of benzodiazepines, intravenous fluids, and other sup- (1). Sold in gas stations, convenience stores, over the portive measures was initiated following arrival to the Internet, and drug paraphernalia “head shops,” numerous ED. Being unaware of other confirmed cases of “bath states have enacted legislation to classify mephedrone and salt” or mephedrone toxicity reporting the use of antipsy- similar synthetic cathinone-derivative compounds as con- chotics for the treatment of post-ingestion delirium, our trolled substances (2). The United States Drug Enforce- patients were closely monitored on the general medical

Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of Basel on 09/19/12 ment Administration has reported that mephedrone is floor (telemetry, seizure precautions, constant observa- present in products promoted as “bath salts,” as well tion) once antipsychotics were initiated for the protracted as in other substances sold on the Internet as “research delirious symptoms that did not show sustained response chemicals” or “plant food” (3). Similar to “bath salts,” to initial treatment. The use of intramuscular haloperi- mephedrone and other mixed synthetic cathinone deriva- dol and oral risperidone in our patients did not lead to tives have been detected in samples purchased and ana- any observable adverse effects and correlated with a rapid lyzed in the United Kingdom sold as “plant food” and reduction of their residual agitation and delirious features. “NRG-1” (4,5). Mephedrone has been detected in simi- Among the potential diagnostic challenges for clini- lar substances seized by European law enforcement with cians in the diagnosis of “bath salt” intoxication delir- increasing frequency since 2008, culminating its desig- ium is the lack of routine toxicology screening for nation as a controlled substance in the United Kingdom mephedrone and other synthetic cathinones. Assays for in April 2010 (6,7). The rapid growth of the popularity these compounds for clinicians seeking same-day results of mephedrone and other cathinone-derivative stimulants have not yet been developed for widespread routine sold as “bath salts” in a short period of time has been par- hospital use in the United States (Michael Bissell, per- tially attributed to aggressive Internet marketing as well sonal communication, August 3, 2011). To our knowl- as social networking sites serving as a forum to spread edge, only one facility nationally provides access to interest among young adults (8). “send-out” testing, which may not be immediately useful “BATH SALTS” AND THE EMERGENCE OF MEPHEDRONE USE 179

for practicing clinicians (18). Novel methods developed more ominous neurologic and cardiac sequelae derived to detect mephedrone in urine have only been recently from “bath salt” ingestion. described (19). Furthermore, we also encountered each of our patients more than 18 hours following their “bath Declaration of Interest salt” ingestions. This could complicate further post- The authors report no conflicts of interest. The authors metabolism detection efforts, as the human toxicokinetics alone are responsible for the content and writing of this of mephedrone have not been clearly established (19). article. However, as government law enforcement bulletins report that “bath salts” found in the United States contain mephedrone and other synthetic cathinones, we believe REFERENCES that a synthetic cathinone ingestion remains highly likely 1. National Institute on Drug Abuse. Available at: http://www. via the “bath salts” consumed by our patients given the nida.nih.gov/about/welcome/MessageBathSalts211.html. history, corroboration of collateral informants, and clin- Last accessed on March 25, 2011. ical similarity to cases confirmed by serum toxicology 2. The Washington Post. Available at: http://www.washington in Europe (11,17). Despite Mr. A’s initial presumptive post.com/national/officials-fear-bath-salts-becoming-the- positive result for PCP at the outside hospital, this was next-big-drug-menace/2011/01/22/ABybyRJ_story.html. Last unable to be verified through further confirmatory test- accessed on March 25, 2011. ing. If his protracted symptoms were solely caused by 3. United States Drug Enforcement Administration. Avai- a substantive PCP ingestion, a confirmable presence on lable at: http://www.deadiversion.usdoj.gov/drugs_concern/ mephedrone.pdf. Last accessed on March 13, 2011. toxicology screening would seem more likely. His clini- 4. Brandt SD, Freeman S, Sumnall HR, Measham F, Cole J. cal presentation also lacked other acute features of PCP Analysis of NRG ‘legal highs’ in the UK: identification intoxication such as nystagmus, intolerance to pain, and and formation of novel cathinones. Drug Test Anal 2011; ataxia. Although contamination with intoxicants other 3(9):569–75. than synthetic cathinones could be possible among the 5. Gibbons S, Zloh M. An analysis of the ‘legal high’ mephe- variety of “bath salts” available for purchase, such impu- drone. Bioorg Med Chem Lett 2010; 20(14):4135–4139. rities have not been described in laboratory analysis of 6. Europol-EMCDDA joint report on a new psychoactive European samples (4,5). The possibility of mephedrone substance: 4-methylmethcathinone (mephedrone). April causing false-positive PCP result also cannot be excluded, 2010. Available at http://www.emcdda.europa.eu/html.cfm/ as mephedrone or other synthetic cathinones were not index116639EN.html. Last accessed on March 20, 2011. among the 30 potential cross-reactive substances tested 7. McElrath K, O’Neill C. Experiences with mephedrone pre- and post-legislative controls: Perceptions of safety and sources by the manufacturer in the outside hospital’s PCP assay of supply. Int J Drug Policy 2011; 22(2):120–7.

For personal use only. (20). We are unaware of other published reports in Europe 8. Vardakou I, Pistos C, Spiliopoulou C. Drugs for youth via raising this question, although our laboratory toxicol- Internet and the example of mephedrone. Toxicol Lett 2011; ogy director has described several other similar recent, 201(3):191–195. unexpected cases of initial presumptive positive PCP 9. Schifano F, Albanese A, Fergus S, Stair JL, Deluca P, screens that were not reproducible through further confir- Corazza O, Davey Z, Corkery J, Siemann H, Scherbaum N, matory testing, suggesting that this possible phenomenon Farre M, Torrens M, Demetrovics Z, Ghodse AH. Psycho- warrants further research (Michael Bissell, personal com- naut Web Mapping; ReDNet Research Groups. Mephedrone munication, August 3, 2011). We suspect that fellow (4-methylmethcathinone; ‘meow meow’): Chemical, pharma- clinicians may encounter similar negative drug screens cological, and clinical issues. Psychopharmacology (Berl) or possible other confounding data until specific tests for 2011; 214(3):593–602 [Epub 2010 Nov 12]. 10. Winstock AR, Mitcheson LR, Deluca P, Davey Z, Corazza mephedrone or other synthetic cathinones are developed O, Schifano F. Mephedrone, new kid for the chop? Addiction

Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of Basel on 09/19/12 for routine use. 2010; 106:154–161. As the use of “bath salts” continues to surge, clinicians 11. Wood DM, Davies S, Greene SL, Button J, Holt DW, Ramsey should be aware of this emerging trend as an explana- J, Dargan PI. Case series of individuals with analytically con- tion for patients presenting with unexplained delirious firmed acute mephedrone toxicity. Clin Toxicol (Phila) 2010; toxidromes or secondary psychoses, especially if rou- 48(9):924–927. tine toxicology screens may not detect the presence of 12. Wood DM, Davies S, Puchnarewicz M, Button J, Archer R, these agents. Following a literature search, we remain Ovaska H, Ramsey J, Lee T, Holt DW, Dargan PI. Recre- unaware of other confirmed cases published in scien- ational use of mephedrone (4-methylmethcathinone, 4-MMC) tific journals of patients presenting in the United States with associated sympathomimetic toxicity. J Med Toxicol with mephedrone intoxication; however, being mindful 2010; 6(3):327–330. 13. Wood DM, Greene SL, Dargan PI. Clinical pattern of toxic- of the possible presence of synthetic cathinones in “bath ity associated with the novel synthetic cathinone mephedrone. salt” ingestions would be reasonable until broader detec- Emerg Med J 2011; 28(4):280–2. tion of these compounds is routinely available. Beyond 14. Garrett G, Sweeney M. The serotonin syndrome as a the supportive management necessary for common recre- result of mephedrone toxicity. BMJ Case Rep 2010. ational drug toxidromes, clinicians should remain vigilant doi:10.1136/bcr.04.2010.2925. for the risk of increasing morbidity and mortality from 15. Sammler EM, Foley PL, Lauder GD, Wilson SJ, Goudie AR, protracted agitated delirium, as well as the possibility of O’Riordan JI. A harmless high? Lancet 2010; 376:742. 180 D. P. KASICK ET AL.

16. Nicholson PJ, Quinn MJ, Dodd JD. Headshop heartache: 19. Meyer M, Wilhelm J, Peters F, Maurer H. Beta-keto Acute mephedrone ‘meow’ myocarditis. Heart 2010; amphetamines: Studies on the metabolism of the designer 96:2051–2052. drug mephedrone and toxicological detection of mephedrone, 17. Lusthof KJ, Oosting R, Maes A, Verschraagen M, Dijkhuizen butylone, and methylone in urine using gas chromatography- A, Sprong AG. A case of extreme agitation and death after the mass spectrometry. Anal Bioanal Chem 2010; 397: use of mephedrone in the Netherlands. Forensic Sci Int 2011; 1225–1233. 206(1–3):e93–e95 [Epub January 11, 2011]. 20. Chemistry Information Sheet. UniCel® DxC800 System 18. NMS Labs. Available at http://www.nmslab.com/tests/ Homogenous Enzyme Immunoassay Method. Fullerton, CA: Mephedrone—MDPV-Stimulants-Designer-Drug-Test–Blood/ Beckman Coulter, Inc. 2010. 2623B. Last accessed on August 10, 2011. For personal use only. Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of Basel on 09/19/12 Clinical Toxicology (2012), 50, 15–24 Copyright © 2012 Informa Healthcare USA, Inc. ISSN: 1556-3650 print / 1556-9519 online DOI: 10.3109/15563650.2011.645952

REVIEW ARTICLE ‘ Legal Highs ’ – novel and emerging psychoactive drugs: a chemical overview for the toxicologist

SIMON GIBBONS

Department of Pharmaceutical and Biological Chemistry, UCL School of Pharmacy, London, UK

Introduction. ‘ Legal highs ’ are psychoactive chemicals which are sold from ‘ head shops ’ , the internet and from street suppliers and may be possessed without legal restriction. An increase in the marketing of these materials has resulted in a corresponding increase in published reports of their adverse effects. However, a lack of primary literature pertaining to their chemistry, pharmacology and toxicology, makes an evaluation of their harm diffi cult. This review covers the basic chemistry of these novel psychoactive compounds and relates them to endogenous neurotransmitters and existing drugs of abuse. Methods. A survey of the internet was used to identify websites that are marketing ‘ legal highs’ in the UK. Trivial and systematic chemical compound names, for example methoxetamine, 4-methoxyphencycline, 4-fl uorotropacocaine and ethyl phenidate were entered into PubMed to retrieve data on these compounds.This search elicited no citations. Other search terms which were more fruitful included desoxypipradrol, diphenylprolinol, methylenedioxy-2-amino-indane and methylenedioxy-2-amino-tetralin, alpha-methyltryptamine and 5-methoxy-N,N -diallyl-tryptamine. Results. ‘ Legal highs ’ from the phenylethylamine, cocaine, tryptamine and phencyclidine classes are increasingly being marketed and, in the majority of cases, little is cited in the literature on their true chemical identity, pharmacology or toxicology. Conclusions. ‘ Legal highs’ are gaining in popularity and present clear challenges to toxicologists and society as a whole. Whilst improved use of existing legislation and development of new legislation can be used to reduce the supply of these materials, investment in better education for young people on the harms associated with ‘ legal highs ’ is needed.

Keywords Amphetamines; Cathinones; Cocaine; Herbal highs; Mephedrone; Neurotransmitters; PCP; Phenylethylamines; Tryptamines For personal use only.

Introduction data relating to the pharmacology and toxicology of these materials. Consequently, it is highly probable that there ‘ Legal highs’ are novel psychoactive substances which are will be considerable harms associated with the inges- either synthetic chemicals, plant or fungal material which tion of some of these compounds. Users of ‘ legal highs ’ are intended to elicit a psychoactive response, being either may be playing ‘ Chemical Russian Roulette’ with these stimulant, hallucinogenic, sedative or a combination of the 1 unstudied novel chemotypes. The probability of harms three phenomena. Europe, and the UK in particular, has associated with new psychoactive substances should not seen an explosion in the numbers of new compounds 2 that Clinical Toxicology Downloaded from informahealthcare.com by University of Basel on 09/19/12 be underestimated; there have been 70 suspected mephed- are appearing on the internet which display high and close rone-related deaths in the United Kingdom and the deci- structural similarity with existing and controlled drugs of sion to ban this compound4 and closely related synthetic abuse, but which are invariably marketed as ‘ not for human compounds by the UK Government in 2010, has been consumption ’ or even as ‘ plant food ’ , ‘ bath salts ’ or even 3 vindicated, particularly given the acute toxicity associated ‘ pond cleaner ’ . with this material. Unfortunately, there is little published data pertaining The risks of taking uncharacterised chemicals with no to their chemical analysis and even a greater paucity of toxicological assessment is highlighted by the case in 1976 where a young graduate student, Barry Kidston, whilst attempting to synthesise synthetic opiates, in particular pethidine analogues, made MPTP (1-methyl-4-phenyl- 1,2,3,6-tetrahydropyridine). After ingesting this compound 5 Received 4 August 2011 ; accepted 29 November 2011 . he developed mild Parkinson’ s disease-like symptoms. It was later found that MPTP is converted in vivo to Address correspondence to Prof. Simon Gibbons, Department of ϩ Pharmaceutical and Biological Chemistry, UCL School of Pharmacy, MPP (1-methyl-4-phenylpyridinium), which is a potent 29-39 Brunswick Square, London WC1HN 1AX, UK. Tel: ϩ44-207-753- neurotoxin to dopamine-producing neurons in the substantia 5913. Fax: ϩ44 (0)207-753-5964. E-mail: [email protected] nigra.6

15 16 S. Gibbons

OCH3 Nature as a source of psychoactive compounds HO OCH3 Nature is an astounding chemist and has the ability to pro- OH duce compounds that have profound effects on the Central O Nervous System (CNS). Examples range in severity and tox- N icity from the Opium poppy ( Papaver somniferum ) which CH O 7 3 N O produces morphine, the precursor of heroin, to Cannabis HO H3C ( Cannabis sativa ), producing tetrahydrocannabinol,8 to Morphine Tetrahydrocannabinol Mesembrine drugs of limited ethnic usage such as the South African plant (THC) Kanna (Sceletium tortuosum ), which produces the phenyl- Fig. 1. Structures of natural product psychoactive compounds. ethylamine alkaloid mesembrine (Fig. 1).9 More exotic sources of psychoactive compounds include the fungal natural products muscimol and ibotenic acid This review will describe the various sources of psycho- from Amanita muscaria 10 (Fly Agaric), which are analogues active compounds in nature and show that many of the ‘ legal of γ -aminobutyric acid (GABA) and show structural and highs’ currently emerging (and our existing controlled drugs electronic similarity with the drugs γ -hydroxybutyric acid of abuse) have a high degree of structural similarity with- (GHB),11 its lactone, γ -butyrolactone (GBL)12 and the related endogenous neurotransmitters. Examples of naturally occur- butane-1,4-diol (1,4-BD) (Fig. 2).13 ring phenylethylamines and their synthetic derivatives will Magic mushrooms of the genera Psilocybe , Conocybe be described and compounds that are related to the natural and Hygrocybe are still marketed as ‘ legal highs’ , notably product cocaine and the dissociative anaesthetics ketamine the spores and mycelia of Psilocybe cubensis, which are and phencyclidine will also be highlighted. Some of the new sold with sand as ‘ specimens for microscopy’ ; the addition synthetic tryptamine analogues will also be mentioned and of water allows fruiting of the mushrooms after a few days. their structural similarity to serotonin and the older psyche- These species contain the phosphate ester psilocybin which delic drugs such as LSD-25 will be demonstrated. Herbal is hydrolysed in vivo to psilocin, which shows marked simi- and fungal ‘ legal highs’ will also be described and their larity with serotonin (Fig. 3).14 structural similarity to neurotransmitters demonstrated. More exotic psychoactive compounds originate in the skins of poison arrow frogs from Central and South Amer- Methods ica. Epibatidine15 (Fig. 4) from Epipedobatides tricolor is a highly potent analgesic compound which binds to the nico- A survey of the internet was used to identify websites that 16 are marketing ‘ legal highs ’ in the United Kingdom. Trivial tinic acetylcholine receptor. and systematic chemical compound names such as methoxet- For personal use only. amine, 4-methoxy-phencyclidine and 3-methoxy-phencycline were also entered into PubMed in an attempt to retrieve data Structural similarity of many ‘ legal highs ’ and endogenous on these compounds. This search elicited no citations. Other neurotransmitters search terms which were more fruitful included desoxypip- Many of the synthetic and natural psychoactive substances radrol, diphenylprolinol, methylenedioxy-2-amino-indane and not only bind to receptors and exert their effects, but also methylenedioxy-2-amino-tetralin, alpha-methyltryptamine are analogues of endogenous neurotransmitters and have the and 5-methoxy-N,N -diallyl-tryptamine. ability to bind to the dedicated transport systems for these

CO2H O O N N O O Clinical Toxicology Downloaded from informahealthcare.com by University of Basel on 09/19/12 NH2 NH2 NH2 OH OH HO HO HO HO HO Muscimol Ibotenic acid GABA GHB 1,4-BD Fig. 2. Natural and synthetic GABA-mimetics.

O HO P O OH O HO NH HN N 2

N N N H H H Serotonin Psilocybin Psilocin

Fig. 3. Psilocybe psychoactive alkaloids have similarity to serotonin.

Clinical Toxicology vol. 50 no. 1 2012 Legal Highs – Novel Psychoactive Drugs 17

H NH2 Cl N N

Phenylethylamine O Epibatidine NH NH H3CO 2 2 Fig. 4. Epibatidine, an analgesic pyridine alkaloid from Epipedobatides tricolor . H3CO

OCH3 neurotransmitters and inhibit their reuptake. The similarity Mescaline Cathinone CH OH that exists between the psychoactive substance phenyleth- 3 H ylamine, amphetamine (amfetamine) and tryptamine and N N CH3 CH3 dopamine, norepinephrine (noradrenaline) and serotonin can be seen readily (Fig. 5). The simple structural motif of HO HO phenylethylamine exists in dopamine and norepinephrine, as Hordenine Synephrine it does in amphetamine ( α -methyl phenylethylamine). The Fig. 6. Certain plant-derived stimulants are based on the phenylethy- methyl group of amphetamine is in the alpha position next to lamine nucleus. the nitrogen atom. One can also see how similar tryptamine is to serotonin, differing only in the absence of a hydroxyl group on the aromatic ring. These similarities undoubtedly synephrine,21 a phenylethylamine related to ephedrine (Fig. contribute to the ability of phenylethylamine, amphetamine 6). Weight-loss preparations are being marketed globally and tryptamine-related compounds to elicit psychoactivity. through the internet and contain extracts of bitter orange Further examples include the hallucinogen, mescaline, peel, presumably because of the stimulant properties of syn- 17 from the psychoactive cactus Peyote ( Lophophora wil- ephrine, but there are the same risks of tachycardia, hyper- 18 liamsii) and cathinone from Khat ( Catha edulis ). Peyote is tension and palpitations associated with this compound as widely available in the United Kingdom as a house plant and there are with phenylethylamines in general.22 Khat is fl own in daily from East Africa, and the leaves are chewed by members of the Somali and Yemeni communities in the United Kingdom in a social setting. 19 Both of these Mephedrone and the cathinones psychoactive natural products have the structural motif that In 2009 there was an ‘ explosion ’ in the marketing of resembles phenylethylamine (Fig. 6), possessing an aromatic mephedrone23 and very similar compounds broadly termed For personal use only. ring, a two-carbon chain with a nitrogen atom attached to the cathinones due to their similarity to cathinone itself (Fig. 7). end of the chain. This nitrogen atom may be further substi- Mephedrone is the 4' -methyl-N -methyl analogue of cathi- tuted with many other alkyl groups to give the wide range of none and was marketed as Miaow-Miaow and MCAT and phenylethylamine psychoactive compounds seen. sold through many internet websites as ‘ plant food’ , ‘ pond Common horticultural plants and trees, particularly cleaner ’ and even ‘ bath salts ’ . This compound has clear simi- those of the pea family (Fabaceae) also contain psychoac- larity to the amphetamines, but having a ketone group beta tive phenylethylamines such as hordenine20 and surprisingly to the nitrogen atom and directly next to the aromatic ring even food plants such as the peel of bitter orange (Citrus (Fig. 7). Other cathinone analogues that were appearing at the aurantium) have small amounts of compounds such as same time included methylone,24 which is similar to Ecstasy Clinical Toxicology Downloaded from informahealthcare.com by University of Basel on 09/19/12 OH NH2 HO HO NH2 NH2 HO

HO HO N H Norepinephrine (NE) Dopamine (DA) (Noradrenaline) Serotonin (SER)

NH2 NH2 NH2

N H Amphetamine Phenylethylamine Alpha-methyl phenylethylamine Tryptamine

Fig. 5. Many drugs of abuse share structural similarity with our endogenous neurotransmitters.

Copyright © Informa Healthcare USA, Inc. 2012 18 S. Gibbons

O O H N NH2 NH2

Mephedrone, Cathinone Phenylethylamine MCAT, 'Miaow Miaow'

O H H H O N O N N

O O

Methylone MDMA Methamphetamine 'Bubbles' 'Ecstasy' 'Crystal meth' Fig. 7. Natural and synthetic cathinones show striking similarity with amphetamines.

(methylenedioxy-methylamfetamine; MDMA), having only mephedrone was (and still is) highly popular.25 Recent data a carbonyl group in place of a methylene moiety. As these has shown that mephedrone increases dopamine and sero- compounds are similar chemically to MDMA and metham- tonin concentrations in the nucleus accumbens of rats.26 phetamine, the concern was that they might not only exhibit The widespread appearance of mephedrone and related the same psychoactivity but also the same neurotoxicity as compounds was also possibly due to the ease of synthesis these compounds. Mephedrone was either insuffl ated or taken of this compound (Fig. 8). Starting with the solvent toluene, orally in capsules, whereas users of methylone preferred the Friedel – Crafts acylation with propanoyl chloride in the pres- oral route due to the high nasal irritancy of this compound. ence of aluminium chloride as a catalyst, yielded a mixture Users reported stimulation and cocaine-like effects and of isomers but predominantly the para isomer due to steric hindrance at the ortho position. Simple addition of bromine in a solvent to the product would yield the alpha-bromo adduct O which with the addition of an excess of methylamine would O yield mephedrone in high yield and purity. The beauty of this Cl synthesis is that the volatile methylamine can be removed

AlCl3 very easily and the steps provide high purity and yield. For personal use only. Coupled with the ability to start with many different aromatic Br2/DCM substrates, acylating groups (butanoyl, pentanoyl, hexanoyl) and even the fi nal amines (ethylamine, pyrrolidine, piperi- O O H dine), hundreds of cathinone analogues could potentially be N MeNH2 produced. Br The ease of production of many analogues was cause for concern and, coupled with the similarity of these com- Fig. 8. Synthesis of mephedrone. pounds with existing phenylethylamines, the cathinones Clinical Toxicology Downloaded from informahealthcare.com by University of Basel on 09/19/12

Fig. 9. A sample of mephedrone purchased from the internet (See colour version of this fi gure online).

Clinical Toxicology vol. 50 no. 1 2012 Legal Highs – Novel Psychoactive Drugs 19

8.0 7.5 7.0 6.5 6.0 5.5 5.0 4.5 4.0 3.5 3.0 2.5 2.0 ppm 2.00 1.06 3.01 3.00 3.04 2.01

Fig. 10. 1 H NMR spectrum of mephedrone (See colour version of this fi gure online).

were controlled by the UK Misuse of Drugs Act27 in April low as a few milligrams, the ability to titrate this low dose 2010. Before the ban, we acquired samples of mephedrone could have led to many cases of poisoning. Naphyrone was (Fig. 9) that were labelled specifi cally ‘ not for human con- fi nally controlled by an amendment of the classifi cation in sumption ’ but had the structure (correctly drawn). Anyone July 2010,30 but it is possible that users avoided naphyrone with a rudimentary chemical knowledge would realise due to concerns over its potency which was discussed on how similar and close this compound is to the existing and various internet drugs fora, and thankfully this material was controlled amphetamines. Our analysis showed that this never as popular as mephedrone was and is currently.25 material was of high-purity and, in this particular case, the For personal use only. hydrochloride salt (Fig. 10). New synthetic phenylethylamines Following the control of these cathinones, another ana- Other ‘ legal highs ’ of the phenylethylamine class have also logue appeared which was outside of the generic classifi ca- appeared on the internet and notably these are of the indane tion and possessed a naphthylene ring system rather than a and tetralin groups (Fig. 12).31 – 33 Some of these compounds, benzene ring (Fig. 11). This compound, naphthylpyrovale- such as methylenedioxy-2-amino-indane (MDAI), are selec- rone (naphyrone; NRG-1), is related to the previously used tive serotonin releasers and are said to be ‘ entactogens ’ or 28 fatigue medicine pyrovalerone. However, naphthylpy- ‘ empathogens ’ , which are terms used to show that a com- rovalerone is a highly potent triple reuptake inhibitor of pound causes social cohesion and empathy amongst users. nanomolar potency releasing dopamine, norepinephrine and This drug lacks the neurotoxicity31 seen with MDMA and is serotonin at very low concentrations.29 Websites were offer-

Clinical Toxicology Downloaded from informahealthcare.com by University of Basel on 09/19/12 being marketed as a substitute for MDMA and the cathinone ing to sell kilograms of this material packaged up in bags methylone. ready for distribution and given that an effective dose was as Related compounds include the 5-iodo derivative being sold as NRG-2 and methoxyl-methyl-2-amino-indane (MMAI) (Fig. 12). Amino-tetralin stimulants have an addi- tional methylene group making a six-membered ring rather O O than the fi ve-membered ring seen in the amino-indanes. 31,32 N N These include methylenedioxy-2-amino-tetralin (MDAT) and methylenedioxy-2-methylamino-tetralin (MDMAT). Both the indane and tetralin classes are still phenylethylam- ines but are in effect, ‘ masked amphetamines ’ . MDAT and Naphthylpyrovalerone Pyrovalerone MDMAT are commonly available and like the indanes are Naphyrone,'NRG-1', 'O-2482' IC50 = 16 (DA), 'Energy-1' 1070 (SER),11 (NE) seen as substitutes for MDMA, though are purported to lack 31 IC50 (nM) 40 (DA), 46 (SER), 11.7 (NE) serotonin neurotoxicity. It should be noted, however, that Fig. 11. Structures of naphyrone and pyrovalerone showing re-uptake whilst these early data suggest a lack of neurotoxicity of both these groups of compound, an in-depth evaluation of inhibition IC 50 values in nM for dopamine (DA), serotonin (SER) and norepinephrine (NE)29 . the general toxicity has yet to be conducted.

Copyright © Informa Healthcare USA, Inc. 2012 20 S. Gibbons

I H3CO O NH NH2 NH2 2 O H3C MMAI MDAI 5-IAI 'NRG-2' H NH O 2 O N NH2 CH3 O O

MDAT MDMAT Phenylethylamine Fig. 12. Chemical structures of 2-amino-indanes and 2-amino-tetralins and similarity to phenylethylamine.

Other cyclic derivatives are typifi ed by diphenylprolinol be revoked 42 at the end of 2010. Both of these classes of (D2PM)34 and diphenylmethyl-pyrrolidine, which possess compound are structurally related to methylphendiate a fi ve-membered pyrrolidine ring system and are dopamine (Ritalin® ; Fig. 13).43 Other methylphendiate derivatives and norepinephrine reuptake inhibitors. Diphenylprolinol include the ethyl analogue currently marketed as ‘ nopaine ’ is used as a catalyst in organic synthesis (Fig. 13).35 Six- (ethylphendiate). In the body, this compound can be formed membered analogues include pipradrol, a previously licensed by ingestion of methylphendiate and ethanol, presumably medicine used for obesity,36 that is no longer used widely by trans -esterifi cation. 44 It is a dopamine and norepineph- due to its potential for abuse. Pipradrol is classifi ed under rine reuptake inhibitor.45 the UK Misuse of Drugs Act as a Class C substance being a dopamine and norepinephrine reuptake inhibitor.37,38 The desoxy form, desoxypipradrol39,40 (Fig. 13), was Cocaine derivatives developed by Ciba Geigy in the 1950s as a preparation Synthetic derivatives of cocaine also have their represen- to wake patients from anaesthesia and hence its German tatives on the ‘ legal high’ scene. These include the anaes- name ‘ Weckamine ’ . Several reports of patients presenting thetic dimethocaine (larocaine)46 (Fig. 14), which has in a highly agitated state with hallucinations, paranoia and been shown to substitute for cocaine in trained rats,47 and classical amphetamine-like overdose symptoms, such as 4-fl uorotropacocaine. To date there are no published data ‘ formication ’ , after consuming ‘ Ivory Wave’ , which was on 4-fl uorotropacocaine, whereas dimethocaine is a mild later shown to contain desoxypipradrol, have been pub- dopamine releasing agent compared to cocaine.48 Both of For personal use only. lished.41 The long half-life of this compound, coupled with these compounds show structural similarity in terms of the its low dose, show that it has signifi cant potential toxicity, number of bonds between the ester group and the nitrogen and the Advisory Council on Misuse of Drugs advised that atom and 4-fl uorotropacocaine possesses a tropane ring an Open General Important Licence (OGIL) for this material system like cocaine.

CH3 O O H H H

Clinical Toxicology Downloaded from informahealthcare.com by University of Basel on 09/19/12 N N N OH OH

Diphenylprolinol Pipradrol Ritalin Methyl Phenidate

CH2CH3 O O H H H N N N

'Nopaine' Diphenylmethylpyrrolidine Desoxypipradrol 'Ivory Wave' Ethyl Phenidate

Fig. 13. Diphenylprolinol, pipradrol and methylphenidate derivatives.

Clinical Toxicology vol. 50 no. 1 2012 Legal Highs – Novel Psychoactive Drugs 21

Me Me CO Me NH2 F N 2 N N O O O

O O O Cocaine Dimethocaine 4-fluorotropacocaine Fig. 14. Cocaine-derived legal highs.

Ketamine and phencyclidine derivatives Phencyclidine (PCP; Phenyl-Cyclohexyl-Piperidine), also Other marketed ‘ legal highs’ include derivatives of the dis- known as ‘ Angel Dust ’ is controlled globally and is Class sociative anaesthetics ketamine49 and phencyclidine.50 These A in the United Kingdom. Analogues of phencyclidine are compounds are antagonists of the NMDA receptor and are appearing, notably the 3- and 4-methoxy derivatives, which members of the phenyl cyclohexylamine class. Ketamine is possess an additional methoxy group on the phenyl ring (Fig. used as a veterinary anaesthetic and in the military where 15). As with methoxetamine, there is a dearth of data on these rapid anaesthesia is required. Ketamine use is on the increase, close structural analogues of phencyclidine. We conducted particularly in Hong Kong, where it is currently the drug of one test purchase of the 4-methoxy analogue, which was a choice, despite the risks of urinary and bladder dysfunction pure sample and of the correct chemical identity. inherent in its use.51 A close analogue, methoxetamine (Fig. 15), has different substitution of the phenyl ring and amine Synthetic and natural tryptamines functionality compared to ketamine. Very little is known The ‘ legal high ’ scene is also seeing examples of tryptamine- about the chemistry, pharmacology and toxicology of this derived drugs of abuse. Tryptamine (Fig. 16) bears close material. Given the close structural similarity of this com- structural similarity with serotonin as do a number of pound with ketamine, it is highly likely that similar effects ‘ classical ’ controlled drugs of abuse including psilocin, the would be seen in humans. alcoholic hydrolysis product of psilocybin from the ‘ magic mushrooms ’ of the genus Psilocybe and other closely related genera. Other examples include bufotenin, (a positional isomer of psilocin), which occurs in the skins of various spe- Cl OMe cies of toad of the genus Bufo .52 Tryptamines in general have a history of being associ- NH NH ated with the psychedelic movement, and these compounds

For personal use only. O O are hallucinogenic and inhibit the reuptake and increase the Ketamine Methoxetamine release of serotonin. Other examples include more complex chemicals such as the well known LSD-25, with very strong OMe MeO effects onawareness and perception of the environment when doses of 20 μg are used. Two synthetic tryptamines related to these compounds are alpha-methyltryptamine α N N N ( -MT, AMT) and 5-methoxy-N,N -diallyl-tryptamine (5-MeO-DALT) (Fig. 16). There is more primary literature on these materials which release serotonin and dopamine PCP-phencyclidine 3-MeO-PCP 4-MeO-PCP and have structural similarity to serotonin which partially 53,54

Clinical Toxicology Downloaded from informahealthcare.com by University of Basel on 09/19/12 Fig. 15. Phenyl-cyclohexylamine derivatives. explains their effects. We conducted a test purchase of

OH HO NH2 NH2 N

N N N H H H Serotonin Tryptamine Psilocin

N NH HO N H3CO 2

N N N H H H Bufotenin 5-MeO-DALT a - methyl-tryptamine (AMT)

Fig. 16. Natural and synthetic hallucinogenic tryptamines.

Copyright © Informa Healthcare USA, Inc. 2012 22 S. Gibbons

O NH HO 2 N NH2

O N N H N H H H Serotonin Mitragynine O Tryptamine O

Fig. 17. The serotonin nucleus within mitragynine.

both materials, and structure elucidation has shown that they materials. The seeds from species of this family include were of high-purity and correct identity. Compounds of this Hawaiian Baby Woodrose (Argyreia nervosa ), Ipomoea sp. class can greatly alter perception, and this is highlighted by and Convolvulus sp which are marketed through the internet the tragic case of a 26-year-old man, who was killed after as ‘ ethnobotanicals ’ to enhance memory. These seeds con- walking on to a motorway in Cambridgeshire in 2010. The tain alkaloids of the ergot type such as ergine58 (Fig. 18), Coroner recorded a ‘ narrative verdict of death from injuries also known as lysergamide or lysergic acid amide, which sustained when he was in collision with a lorry while under has a close chemical structure to LSD-25, but lacking just the infl uence of 5-MeO-DALT’ (http://www.cambridge- two ethyl groups on the nitrogen atom. A whole range of news.co.uk/Home/Familys-vow-over-legal-high-drugs- these natural products are present in the seeds from this fam- danger.htm). ily, and their ability to cause psychosis are demonstrated by Many analogues of tryptamine can be made by substitution two cases of human consumption of the seeds of Hawaiian on the nitrogen atom or the aromatic ring, and the chemistry Baby Woodrose resulting in one fatality from jumping from to reach these compounds is relatively simple, unfortunately a building; ergine was present in the blood and urine of this giving ease of access to many potential ‘ legal highs ’ . There individual.59 has also been an increase in the marketing of plant extract It is the ability of these ‘ reality-distorting ’ materials to that contain psychoactive compounds of the tryptamine cause such accidents that makes these materials potential class. These include leaf material itself or extracts of the SE dangerous as ‘ legal highs ’ . They are, however, not as popu- Asian tree, Mitragyna speciosa ,55 which is sold in various lar as stimulants such as the now controlled mephedrone,60 concentrated strengths according to the extraction method and it is possible that the majority of ‘ legal high’ users used. This material is known as Kratom in Thailand or avoid them because of the possibility of accidents following

For personal use only. Biak-Biak in Malaysia and is a controlled substance in both ingestion. countries. In Europe, samples bought from the internet can arrive as ‘ buttons ’ of dried extract, which is ingested orally Salvia divinorum and made up as a tea which has a bitter taste. Extracts have been confi rmed to contain the alkaloid, mitragynine 56 (Fig. As with Kratom, herbal material and extracts of the psyche- 17) and its analogues, and this compound is a mu-opioid delic sage ( Salvia divinorum, Lamiaceae), which is a mem- receptor agonist,57 which was investigated for its potential ber of the mint family, can be readily purchased through as an analgesic. Extracts are typically sold as ‘ not for human the internet and is still legal in many countries, including consumption’ and as incense for burning (not to be inhaled!) the United Kingdom. Live plants and leaf cuttings can be and are often labelled as Mitragyna speciosa Thai resin ϫ 20, obtained; the plant is very easy to cultivate as is the closely related culinary sage, Salvia offi cinalis. The extracts and

Clinical Toxicology Downloaded from informahealthcare.com by University of Basel on 09/19/12 clearly indicating the correct botanical nomenclature, origin and strength. plants contain a series of clerodane diterpenes, typifi ed by 61 Obviously, the strength of ϫ 20 is unimportant for incense salvinorin A (Fig. 19), which is a potent kappa-opioid 62 μ but would give users the false impression of the concen- receptor agonist with activity at doses as low as 200 g. tration of the material in the packaging for ingestion. This is fraught with danger, as little is known on the effects of

Kratom resin and only full analytical chemistry would give O NH2 O N rise to the concentration of psychoactive compounds pres- ent or even the presence of adulterant psychoactives. This OH highlights the problems associated with herbal and natural NH2 N N product ‘ legal highs ’ in general as their chemical analysis is highly complex, and there is, of course, the possibility that suppliers could add other psychoactive compounds to these HN HN HN materials which can cause even further problems in terms of polypharmacology and toxicology. Serotonin Ergine LSD Seeds from members of the morning glory family, Con- Fig. 18. Ergine and LSD are highly similar and both have the serotonin volvulaceae, have a long history of usage as psychoactive moiety.

Clinical Toxicology vol. 50 no. 1 2012 Legal Highs – Novel Psychoactive Drugs 23

O 4. http://www.homeoffice.gov.uk/publications/alcohol-drugs/drugs/ acmd1/acmd-cathinodes-report-2010. H 5. Langston JW, Ballard P, Tetrud JW, Irwin I. Chronic Parkinsonism O O in humans due to a product of meperidine-analog synthesis. Science H H 1983; 219:979 – 980. O 6. Langston JW, Irwin I, Langston EB, Forno LS. 1-Methyl-4- O phenylpyridinium ion (MPP ϩ ): identifi cation of a metabolite of O MPTP, a toxin selective to the substantia nigra. Neurosci Lett 1984; 48:87 – 92. O O 7. Benyhe S. Morphine: new aspects in the study of an ancient compound. Life Sci 1994; 55:969 – 979. Salvinorin A 8. Appendino G, Chianese G, Taglialatela-Scafati O. Cannabinoids: occurrence and medicinal chemistry. Curr Med Chem 2011; 18: Fig. 19. Salvinorin A, a potent kappa-opioid receptor agonist from 1085 – 1099. the psychedelic sage Salvia divinorum. 9. Harvey AL, Young LC, Viljoen AM, Gericke NP. Pharmacological actions of the South African medicinal and functional food plant Sceletium tortuosum and its principal alkaloids. J Ethnopharmacol 2011; 137:1124 – 1129. Extracts and leaves are typically smoked, although the tra- 10. Michelot D, Melendez-Howell LM. Amanita muscaria : chemistry, ditional ethnomedical usage of this plant involved the chew- biology, toxicology, and ethnomycology. Mycol Res 2003; 107: ing of the leaves as a ‘ quid ’ to elicit an effect. A variety of 131 – 146. extract strengths are available through internet suppliers, for 11. Brown SD, Melton TC. Trends in bioanalytical methods for the de- ϫ termination and quantifi cation of club drugs: 2000– 2010. Biomed example, 10 extract, although as with the case of Kratom, Chromatogr 2011; 25:300 – 321. no realistic interpretation of the true concentration of salvi- 12. Palmer RB. Gamma-butyrolactone and 1,4-butanediol: abused ana- norinA can be made without proper analysis. Users report logues of gamma-hydroxybutyrate. Toxicol Rev 2004; 23:21 – 31. that they have tried the material once, and have no desire to 13. Wood DM, Brailsford AD, Dargan PI. Acute toxicity and withdrawal re-dose as the experience was not particularly pleasant. syndromes related to gamma-hydroxybutyrate (GHB) and its ana- logues gamma-butyrolactone (GBL) and 1,4-butanediol (1,4-BD). Drug Test Anal 2011; 3:417 – 425. Conclusion 14. Halpern JH. Hallucinogens and dissociative agents naturally grow- ing in the United States. Pharmacol Ther 2004; 102:131 – 138. There are many chemical similarities between ‘ legal highs ’ 15. Daly JW, Spande TF, Garraffo HM. Alkaloids from amphibian skin: and endogenous neurotransmitters, specifi cally serotonin, a tabulation of over eight-hundred compounds. J Nat Prod 2005; 68:1556 – 1575. norepinephrine and dopamine. Several classes of ‘ legal 16. Daly JW. Nicotinic agonists, antagonists, and modulators from natu- highs ’ have been modelled on existing and controlled drugs ral sources. Cell Mol Neurobiol 2005; 25:513 – 552.

For personal use only. of abuse, particularly from the phenylethylamine (amphet- 17. McLaughlin JL. Peyote: an introduction. Lloydia 1973; 36:1 – 8. amine), cocaine, phencyclidine and tryptamine classes. 18. Kalix P. The pharmacology of psychoactive alkaloids from Ephedra The reason for this is the ease in synthesising these com- and Catha . J Ethnopharmacol 1991; 32:201 – 208. 19. Klein A, Metaal P. A good chew or good riddance – how to move for- pounds; chemists can readily identify those compounds ward in the regulation of khat consumption. J Ethnopharmacol 2010; that fall outside of legislation and are therefore legal, and 132:584 – 589. the routes to these compounds are easily accessible from 20. Pemberton IJ, Smith GR, Forbes TD, Hensarling CM. Techni- the literature. The amino-indanes and amino-tetralins cal note: an improved method for extraction and quantifi cation of (MDAI, MDAT), psychedelic drugs (tryptamines) and toxic phenethylamines from Acacia berlandieri . J Anim Sci 1993; 71:467 – 470. anaesthetics (4-MeO-PCP/methoxetamine) are examples 21. Gjessing L, Armstrong MD. Occurrence of (-)-sympatol in oranges. that fall outside of existing legislation. There are consid- Proc Soc Exp Biol Med 1963; 114:226 – 229.

Clinical Toxicology Downloaded from informahealthcare.com by University of Basel on 09/19/12 erable potential harms associated with taking these ‘ legal 22. Rossato LG, Costa VM, Limberger RP, Bastos Mde L, Remi ã o F. highs ’ as they often have insuffi cient supporting biological Synephrine: from trace concentrations to massive consumption in and toxicological data. weight-loss. Food Chem Toxicol 2011; 49:8 – 16. 23. Brunt TM, Poortman A, Niesink RJ, van den Brink W. Instability of the ecstasy market and a new kid on the block: mephedrone. Declaration of interest J Psychopharmacol 2011; 25:1543 – 1547. 24. Cozzi NV, Sievert MK, Shulgin AT, Jacob P 3rd, Ruoho AE. The author reports no confl icts of interest. The author alone Inhibition of plasma membrane monoamine transporters by beta- is responsible for the content and writing of the paper. ketoamphetamines. Eur J Pharmacol 1999; 381:63 – 69. 25. Schifano F, Albanese A, Fergus S, Stair JL, Deluca P, Corazza O, et al. Psychonaut Web Mapping; ReDNet Research Groups. References Mephedrone (4-methylmethcathinone; ‘ meow meow ’ ): chemical, pharmacological and clinical issues. Psychopharmacology (Berl). 1. McNabb CB, Russell BR, Caprioli D, Nutt DJ, Gibbons S, Dalley 2011; 214:593 – 602. JW. Single chemical entity legal highs: assessing the risk for long 26. Kehr J, Ichinose F, Yoshitake S, Goiny M, Sievertsson T, Nyberg F, term harm. Curr Drug Abuse Rev 2011; (Submitted). Yoshitake T. Mephedrone, compared to MDMA (ecstasy) and amphet- 2. Winstock AR, Ramsey JD. Legal highs and the challenges for policy amine, rapidly increases both dopamine and serotonin levels in nucleus makers. Addiction 2010; 105:1685 – 1687. accumbens of awake rats. Br J Pharmacol 2011; 164:1949 – 1958. 3. Gibbons S, Zloh M. An analysis of the legal high mephedrone. 27. http://www.homeoffice.gov.uk/publications/alcohol-drugs/drugs/ Bioorg Med Chem Lett 2010; 20:4135 – 4139. acmd1/acmd-cathinodes-report-2010.

Copyright © Informa Healthcare USA, Inc. 2012 24 S. Gibbons

28. Gorceix A, Jacquemin C. Value of pyrovalerone in the ambulatory treat- enantiomers: the human transesterifi cation metabolite of meth- ment of fatigue states. Ann Med Psychol (Paris) 1970; 2:624– 632. ylphenidate and ethanol. J Med Chem 2005; 48:2876 – 2881. 29. Meltzer PC, Butler D, Deschamps JR, Madras BK. 1-(4- 46. Woolverton WL, Balster RL. Effects of local anesthetics on fi xed- Methylphenyl)-2-pyrrolidin-1-yl-pentan-1-one (Pyrovalerone) ana- interval responding in rhesus monkeys. Pharmacol Biochem Behav logues: a promising class of monoamine uptake inhibitors. J Med 1983; 18:383 – 387. Chem 2006; 49:1420 – 1432. 47. Graham JH, Balster RL. Cocaine-like discriminative stimulus effects 30. http://www.homeoffi ce.gov.uk/drugs/drug-law/naphyrone/ of procaine, dimethocaine and lidocaine in rats. Psychopharmacol- 31. Nichols DE, Brewster WK, Johnson MP, Oberlender R, Riggs RM. ogy 1993; 110:287 – 294. Nonneurotoxic tetralin and indan analogues of 3,4-(methylenedioxy) 48. Wilcox KM, Kimmel HL, Lindsey KP, Votaw JR, Goodman MM, amphetamine (MDA). J Med Chem 1990; 33:703 – 710. Howell LL. In vivo comparison of the reinforcing and dopamine 32. Monte AP, Marona-Lewicka D, Cozzi NV, Nichols DE. Synthesis transporter effects of local anesthetics in rhesus monkeys. Synapse and pharmacological examination of benzofuran, indan, and tetra- 2005; 58:220 – 228. lin analogues of 3,4-(methylenedioxy)amphetamine. J Med Chem 49. Morgan CJ, Curran HV; the Independent Scientifi c Committee on 1993; 36:3700 – 3706. Drugs (ISCD). Ketamine use: a review. Addiction 2011; 107:27 – 38. 33. Marona-Lewicka D, Nichols DE. Behavioral effects of the highly 50. McCarron MM, Schulze BW, Thompson GA, Conder MC, Goetz selective serotonin releasing agent 5-methoxy-6-methyl-2-amino WA. Acute phencyclidine intoxication: incidence of clinical fi ndings indan. Eur J Pharmacol 1994; 258:1 – 13. in 1,000 cases. Ann Emerg Med 1981; 10:237 – 242. 34. Wood DM, Button J, Lidder S, Ovaska H, Ramsey J, Holt DW, 51. Wood D, Cottrell A, Baker SC, Southgate J, Harris M, Fulford S, Dargan PI. Detection of the novel recreational drug Diphenyl-2- et al. Recreational ketamine: from pleasure to pain. Brit J Urol 2011; pyrrolidinemethanol (D2PM) sold legally in combination with 107:1881 – 1884. 1-Benzylpiperzaine (BZP). Clin Toxicol 2008; 46:393. 52. Lyttle T, Goldstein D, Gartz J. Bufo toads and bufotenine: fact and 35. Corey EJ, Bakshi RK, Shibata S. Highly enantioselective borane re- fi ction surrounding an alleged psychedelic. J Psychoactive Drugs duction of ketones catalyzed by chiral oxazaborolidines Mechanism 1996; 28:267 – 290. and synthetic implications. J Am Chem Soc 1987; 109:5551 – 5553. 53. Nonaka R, Nagai F, Ogata A, Satoh K. In vitro screening of psy- 36. Perlstein IB. The use of pipradrol in the problems of obesity. Int Rec choactive drugs by [(35)S]GTPgammaS binding in rat brain mem- Med Gen Pract Clin 1957; 170:55 – 58. branes. Biol Pharm Bull 2007; 30:2328 – 2333. 37. Ross SB, Kelder D. Inhibition of 3 H-dopamine accumulation in 54. Nagai F, Nonaka R, Satoh Hisashi Kamimura K. The effects of non- reserpinized and normal rat striatum. Acta Pharmacol Toxicol medically used psychoactive drugs on monoamine neurotransmis- (Copenh) 1979; 44:329 – 335. sion in rat brain. Eur J Pharmacol 2007; 559:132 – 137. 38. Ursillo RC, Jacobsen JJ. Potentiation of norepinephrine in the iso- 55. Beckett AH, Shellard EJ, Phillipson JD, Lee CM. Alkaloids from lated vas deferens of the rat by some CNS stimulants and antidepres- Mitragyna speciosa (Korth.). J Pharm Pharmacol 1965; 17:753 – 755. sants. J Pharmacol Exp Ther 1965; 148:247 – 251. 56. Lee CM, Trager WF, Beckett AH. Corynantheidine-type alkaloids. 39. Tripod J, Sury E, Hoffmann K. Analeptic effect of a new piperidine II. Absolute confi guration of mitragynine, speciociliatine, mitracili- derivative. Experientia 1954; 10:261 –262. atine and speciogynine. Tetrahedron 1967; 23:375 – 385. 40. Ferris, RM, Tang FL. Comparison of the effects of the isomers of 57. Thongpradichote S, Matsumoto K, Tohda M, Takayama H, Aimi N, amphetamine, methylphenidate and deoxypipradrol on the uptake Sakai S, Watanabe H. Identifi cation of opioid receptor subtypes in of l-3 H-norepinephrine and 3 H-dopamine by synaptic vesicles from antinociceptive actions of supraspinally-administered mitragynine rat whole brain, striatum and hypothalamus. J Pharmacol Exp Ther in mice. Life Sci 1998; 62:1371 – 1378. For personal use only. 1979; 210:422 – 428. 58. Hylin JW, Watson DP. Ergoline alkaloids in tropical wood roses. 41. James DA, Potts S, Thomas SHL, Chincholkar VM, Clarke S, Dear Science 1965; 148:499 – 500. J, Ramsey J. Clinical features associated with recreational use of 59. Van Hout MC, Brennan R. ‘ Heads held high ’ : an exploratory study ‘ Ivory Wave ’ preparations containing desoxypipradrol. Clin Toxicol of legal highs in pre-legislation Ireland. J Ethn Subst Abuse 2011; 2011; 49:201. 10:256 – 72. 42. http://www.homeoffi ce.gov.uk/media-centre/news/drug-import-ban. 60. Klinke HB, M ü ller IB, Steffenrud S, Dahl-S ø rensen R. Two cases of 43. Iversen SD, Iversen LL. Dopamine: 50 years in perspective. Trends lysergamide intoxication by ingestion of seeds from Hawaiian Baby Neurosci 2007; 30:188 – 193. Woodrose. Forensic Sci Int 2010; 197:e1 – e5. 44. Markowitz JS, Devane CL, Boulton DW, Nahas Z, Risch SC, 61. Siebert DJ. Salvia divinorum and salvinorin A: new pharmacologic Diamond F, et al. Ethylphenidate formation in human subjects after fi ndings. J Ethnopharmacol 1994; 43:53 – 56. the administration of a single dose of methylphenidate and ethanol. 62. Roth BL, Baner K, Westkaemper R, Siebert D, Rice KC, Steinberg Drug Metab Dispos 2000; 28:620 – 624. S, Ernsberger P, Rothman RB. Salvinorin A: a potent naturally oc- Clinical Toxicology Downloaded from informahealthcare.com by University of Basel on 09/19/12 45. Patrick KS, Williard RL, VanWert AL, Dowd JJ, Oatis JE Jr, curring nonnitrogenous kappa opioid selective agonist. Proc Natl Middaugh LD. Synthesis and pharmacology of ethylphenidate Acad Sci U S A 2002; 99:11934 – 11939.

Clinical Toxicology vol. 50 no. 1 2012 Clinical Toxicology (2011), 49, 499–505 Copyright © 2011 Informa Healthcare USA, Inc. ISSN: 1556-3650 print / 1556-9519 online DOI: 10.3109/15563650.2011.590812

POISONS CENTRE

Clinical experience with and analytical confi rmation of “ bath salts ” and “ legal highs ” (synthetic cathinones) in the United States

HENRY A. SPILLER 1 , MARK L. RYAN2 , ROBERT G. WESTON3 , and JOANNE JANSEN4

1 Kentucky Regional Poison Center, Louisville, KY, USA 2 Louisiana Poison Center, Shreveport, LA, USA 3 Oklahoma State Bureau of Investigation, Edmond, OK, USA 4 Sullivan University, College of Pharmacy, Louisville, KY, USA

Recently, there has been a worldwide rise in the popularity and abuse of synthetic cathinones. In 2009 and 2010, a signifi cant rise in the abuse of a new group of synthetic cathinones was reported in Western Europe. In 2010, the rapid emergence of a new drug of abuse, referred to as bath salts or “ legal high,” occurred in the USA. The growing number of cases along with the alarming severity of the effects caused by the abuse of these substances prompted signifi cant concern from both healthcare providers and legal authorities. We report the experience of the fi rst 8 months of two regional poison centers after the emergence of a new group of substances of abuse. Method . This was a retrospective case series of patients reported to two poison centers with exposures to bath salts. Additionally, 15 “ product samples ” were obtained and analyzed for drug content using GC/MS. Results . There were 236 patients of which 184 (78%) were male. Age range was 16– 64 years (mean 29 years, SD 9.4). All cases were intentional abuse. There were 37 separate “ brand ” names identifi ed. Clinical effects were primarily neurological and cardiovascular and included: agitation (n 194), combative behavior (n 134), tachycardia (n 132), hallucinations (n 94), paranoia (n 86), confusion (n 83), chest pain (n 40), myoclonus (n 45), hypertension (n 41), mydriasis (n 31), CPK elevations (n 22), hypokalemia (n 10), and blurred vision (n 7). Severe medical outcomes included death (n 1), major (n 8), and moderate (n 130). Therapies included benzodiazepines (n 125), antipsychotics (n 47), and propofol (n 10).

For personal use only. Primary dispositions of patients were: 116 (49%) treated and released from ED, 50 (21%) admitted to critical care, 29 (12%) admitted to psych, and 28 (12%) lost to follow up. Nineteen patients had blood and/or urine analyzed using GC/MS. MDPV was detected in 13 of 17 live patients (range 24– 241 ng/mL, mean 58 ng/mL). The four samples with no drug detected, reported last use of bath salts 20 h prior to presentation. Three of fi ve patients had MDPV detected in urine (range 34 – 1386 ng/mL, mean 856 ng/mL). No mephedrone or methylone was detected in any sample. Quantitative analysis performed on postmortem samples detected MDPV in blood at 170 ng/mL and in urine at 1400 ng/mL. No other synthetic cathinones were detected. Discussion . This is the fi rst report of MDPV exposures with quantitative blood level confi rmation. Clinical effects displayed a sympathomimetic syndrome, including psychotic episodes often requiring sedation, movement disorders, and tachycardia. Within 8 months of their appearance, 16 states had added synthetic cathinones to the controlled substances list as a Schedule I drug. Conclusion . We report the emergence of a new group of substances of abuse in the USA, known as bath salts, with quantitative results in 18 patients. State and federal authorities used timely information from poison centers on the bath salt outbreak during investigations to help track the extent of use and the effects occurring from these new drugs. Close collaboration between

Clinical Toxicology Downloaded from informahealthcare.com by University of Basel on 09/19/12 state authorities and poison centers enhanced a rapid response, including legislation.

Keywords Synthetic cathinone; Designer drugs; Stimulants; Sympathomimetic syndrome; Drugs of abuse

Introduction edly had been developed in the former Soviet Union as an antidepressant in the 1930s and separately developed in Recently, there has been a worldwide rise in the popularity the West in the 1950s as an appetite suppressant, but was and abuse of synthetic cathinones. Abuse of one synthetic never marketed due to its strong addictive potential. In 2009 cathinone – methcathinone – occurred for several decades and 2010, a signifi cant rise in the abuse of a new group of in the former Soviet Union, Russia, and Eastern Europe and synthetic cathinones was reported in Western Europe. 4 – 11 spread to the West in the 1990s. 1 – 3 Methcathinone report- In 2010, the fi rst cases of exposure to products marketed as “ legal highs” and bath salts were reported to US poison Received 27 April 2011 ; accepted 19 May 2011. centers. Based on the increased use in Europe and availabil- Address correspondence to Henry A. Spiller, MS, DABAT, FAACT, ity on the Internet for similar “ legal highs, ” these products Kentucky Regional Poison Center, PO Box 35070, Louisville, KY were believed to contain various synthetic cathinones, 40232-5070, USA. E-mail: [email protected] including mephedrone (4-methylenemethcathinone), MDPV

499 500 H. A. Spiller et al.

(methylenedioxypyrovalerone), methylone (3,4-methelendioxy- their sealed original containers were obtained from separate n-methylcathinone), methedrone (4-methoxymethcathinone), commercial locations (stores) in the two states for analysis and fl uorormethcathinone.12,13 The product packages were of content. labeled as bath salts, insect repellants, stain removers, and Blood/serum and/or urine waste samples were obtained plant food. However, the users of these products openly from 18 patients for analysis as an initial effort to dis- spoke of using them as “ legal methamphetamine” or “ legal cover what substances might be involved in the toxidrome cocaine. ” The product labels did not provide any indication displayed by the patients. This was part of a public health of the true active ingredients. Unlike the European experi- response to what was considered as an outbreak of a newly ence, where many of the products were being purchased emergent substance of abuse. All samples were obtained from a “ dealer ” or over the Internet, in the USA the majority during initial patient presentation and examination in the of the new “ bath salt” products were being purchased locally emergency department and were obtained after initial clini- in small independent stores, such as gas stations, smoke cal use (if any) had been performed. shops, and “ head shops. ” The growing number of cases along with the alarming severity of the effects caused by the Chemicals and reagents abuse of these substances prompted signifi cant concern from both healthcare providers and legal authorities. During this Analytical reference standards for MDPV, mephedrone, meth- period in 2010, there was limited information about what cathinone, and phencyclidine (the latter two used for internal these “ products ” actually contained or the clinical effects standards) were obtained from Cerilliant. MDPV was received that would be expected from abuse of these substances. as the powdered HCl salt. A 1 mg/mL (calculated as the free We report the experience of the fi rst 8 months of two regional base) stock solution was prepared from this solution by dis- poison centers after the emergence of a new group of solving 11.3 mg MDPV HCl in 10 mL DI water. Mephedrone, substances of abuse. methcathinone, and phencyclidine were received as 1 mg/mL solutions. Blank blood was donated by a local blood bank and determined to be drug free by GC/MS analysis. Methods A retrospective search was performed at two poison centers Analysis of purchased products for all records involving what came to be known as bath salts, After dissolution in methanol, the products were each ana- for the period January 2010 through February 2011. An initial lyzed using an Agilent 7890A gas chromatograph coupled search was performed to locate any case with a substance name to an Agilent 5975C mass spectrometer. The column was an listed as bath salts, insect repellant, stain remover, plant food, Agilent DB-1 (100% dimethylpolysiloxane) (12 m 0.2 MDPV, mephedrone, methylone, cathinones, white lightening, mm 0.33 μm). Ultra-pure helium was used as the mobile For personal use only. zoom, blue silk, red dove, ivory wave, white cloud, cloud 9, phase using a constant fl ow of 0.80 mL/min. Other instru- cloud 10, dynamite, or unknown drug. Poison center case notes mental parameters included: 1 μ L injection, split ratio were then reviewed to verify if there was documentation that 300:1, injection port 290 ° C, oven program 100 ° C for 15 sec, the substances involved an illicit “ bath salt ” case. In November ramped at 65 ° C/min to 220 ° C, then at 40 ° C to 290 with a 2010, both poison centers had agreed to code all these expo- fi nal hold time of 6.15 min. The total analysis time was 10 sures under the term “bath salts”. Product names and descrip- min. The mass spectrometer was programmed with a trans- tions were obtained from the documentation in the case notes. fer line temperature of 290 ° C, source temperature of 230 ° C, Both centers utilize the electronic medical record system Toxi- quadrupole temperature of 150 ° C, solvent delay of 0.85 min, call, which allows review of the record stripped of personal and was operated in scan mode from 50 to 550 m/z for the identifi ers. All charts were then reviewed by the investigators duration of data collection. Identifi cation of the substances

Clinical Toxicology Downloaded from informahealthcare.com by University of Basel on 09/19/12 to verify the substance from the case notes. Calls were received present in the bath salts was determined by retention time from both the general public and hospitals/healthcare facili- and mass spectral comparison of the GC/MS data to known ties. Toxicall allows storage of all calls and consultations on standards. a specifi c patient in a single medical record, so that each case involved in this study was included only once, despite multiple calls and consultations of many of these patients. Data obtained Quantitation of biological specimens included age, gender, substance involved, reason for exposure, For the quantitation of the bath salt drugs in biological history of use if obtained, clinical effects, pertinent laboratory specimens, methcathinone and phencyclidine were used as values, therapies administered, and medical outcome. Medical internal standards. The internal standard solution was made outcome designation was the standard American Association by combining 25 μ L aliquots of the 1 mg/mL methcathinone of Poison Control Center categories utilized by poison cen- and phencyclidine standards and diluting to 25 mL with DI ters.14 In a number of cases, because of the confused, agitated, water, resulting in a 1 μg/mL solution for each drug. Simi- or delusional mental state of the patient, the history of use and larly, a 1 μ g/mL solution containing both mephedrone and any previous abuse history were obtained from signifi cant oth- MDPV was prepared by diluting 25 μL of each of the 1 mg/ ers of the patient. mL solutions to 25 mL DI water. During December 2010, because of the lack of informa- Mephedrone and MDPV calibrators with concentrations of tion on the contents of these new “ products, ” 15 products in 25, 50, 75, 100, and 150 ng/mL were prepared by pipetting

Clinical Toxicology vol. 49 no. 6 2011 Bath salt (synthetic cathinone) abuse 501

appropriate volumes of 1 μ g/mL solution into 1 mL aliquots Month of occurance of bath salt cases of blank blood obtained from a local blood bank and deter- 120 mined to be drug free by GC/MS analysis. Kentucky 100 Sample preparation Louisiana

The calibrators, 1 mL aliquots of biological specimens, and a 80 1 mL aliquot of blank blood were pipetted into culture tubes and then extracted using the following procedure. Internal 60 standard (50 μ L) was added to each sample, followed by 1 mL of borate buffer. After briefl y mixing the samples by vortex, 4 mL of n-butyl chloride was added to each sample. 40 Each tube was capped and shaken for 2 min, followed by centrifugation at 3000 rpm for 3 min. After transferring the 20 resulting organic layer to a 5-mL conical centrifuge tube, 2 mL of 1.0 N HCl was added. The conical tubes were 0 capped and placed on a rotary extractor for 15 min, followed

by another 3 min centrifugation at 3000 rpm. The organic August October Janauary February layer was discarded. Seven drops (approximately 350 μ L) of September November December conc. NH OH was added to each to basify the aqueous solu- 4 μ Fig. 1. Month of occurrence of synthetic cathinone cases by state (see tion. Chloroform (75 L) was added, and the samples were colour version of this fi gure online). capped, shaken for 2 min, and centrifuged again at 3000 rpm for 3 min. The resultant chloroform layer was transferred into autosampler vials and then analyzed by GC/MS. call was from the hospital, with 6% originating from EMS/ ambulance service and 22% from the public. Analysis Clinical effects were primarily neurological and Determination of blood concentration and/or urine concen- cardiovascular and are reported in Table 2. Severe medical tration was performed using another Agilent 7890A/5975C outcomes included: death (n 1), major (n 8), and mod- GC/MS. This instrument was equipped with a DB-1 column erate (n 130). The single fatality occurred in a 21-year-old having dimensions of 30 m 0.320 mm 0.25 μ m. For male from a self-infl icted gunshot after an active delusional biological samples, 2 μ L of extract was injected in splitless episode witnessed by family members. A number of alarm- mode. Other instrumental parameters: injection port 250° C, ing and dangerous behaviors (to either self or others) were

For personal use only. ultra-pure helium column fl ow 1.788 mL/min, oven initial reported in these patients in temporal association with acute temperature 60 ° C for 1 min, then 15 ° C/min ramp to 300 ° C use of large amounts or prolonged use of “ bath salts ” over with a hold time of 3 min, total run time 20 min. The mass several days to several weeks. Examples of these new onset spectrometer transfer line, source, and quadrupole tem- behaviors in separate patients included: jumping out of a peratures were 280, 230, and 150 ° C, respectively. The mass window to fl ee from non-existent pursuers; requiring electri- spectrometer scanned from 40 to 400 m/z after a solvent cal shock (Taser) and eight responders to initially subdue delay of 3 min. the patient; repeatedly fi ring guns out of the house windows at “ strangers ” who were not there; walking into a river in January to look for a friend who was not there; leaving a Results 2-year-old daughter in the middle of a highway because she

Clinical Toxicology Downloaded from informahealthcare.com by University of Basel on 09/19/12 The fi rst case was reported in August 2010 in Kentucky and had demons; climbing into the attic of the home with a gun the fi rst case in Louisiana occurred in September 2010. From to kill demons that were hiding there, and breaking all the August 2010 through February 2011, there were 236 patients windows in a house and wandering barefoot through the with a rapid escalation in the number patients reported broken glass. after November 2010 (see Fig. 1). The majority of patients Therapies were primarily sedation and treatment for per- (n 184, 78%) were male. The age range was from 16 to sistent myoclonus and included the benzodiazepines diaz- 64 years (mean 29 years, SD 9.4). All cases reported the epam, lorazepam, and/or midazolam (n 125, 53%), the reason for exposure as intentional abuse. Where history was antipsychotics haloperidol and ziprasidone (n 47, 20%), available, a large number of cases reported previous abuse of propofol (n 10, 4%), and diphenhydramine (n 2, 1%). methamphetamine and/or cocaine and the use of bath salts The dispositions of patients were: 116 (49%) treated and as a “ legal ” replacement for these substances. Results from released from the emergency department, 50 (21%) admit- qualitative urine drug screens were recorded in 44 patients ted to a critical care unit, 29 (12%) admitted to behavioral and detected positive results for amphetamines, barbiturates, health/psychiatry, 28 (12%) were lost to follow up, and 13 benzodiazepines, caffeine, cannabinoids, cocaine, MDMA, (6%) were managed at a non-healthcare facility. methadone, opiates, oxycodone, and oxymorphone. There Eighteen live patients had blood and/or urine analyzed were 39 separate “ brand ” names identifi ed from patient using GC/MS. MDPV was detected in the blood/serum of histories (Table 1). In 72% of cases, the originating contact 13 of 17 patients (range 24 – 241 ng/mL, mean 58 ng/mL).

Copyright © Informa Healthcare USA, Inc. 2011 502 H. A. Spiller et al.

Table 1. Names of products reported by users. (methylone). Additional substances found included caffeine and an unidentifi ed substance (see Table 3). Product name Frequency of reports Artic blasting station 1 Atomic 1 Discussion Bayou revitalisant 1 Blaze 1 We report the largest series of synthetic cathinone exposures Blitz 2 with a number of important features, including a high inci- Blue moon 1 dence of new onset severe neurological/psychiatric changes; Blue silk 5 qualitative results of the contents of “ bath salts ” ; and quan- Bohemian bath salts 2 titative results of blood and urine in synthetic cathinone Bolivian bath salts 2 Dr. booga shooga 3 users. Cloud 9 73 Previous reports of synthetic cathinone use/abuse have Cloud 10 2 focused primarily on mephedrone and have reported clinical Columbian odorizer 1 effects consistent with a sympathomimetic syndrome, includ- Cotton cloud 4 ing tachycardia, agitation, hypertension, palpitations, chest Dream 1 pain, confusion, paranoia, hallucinations, violent behavior, Dynamite 1 4 – 6,8 Euphoria 1 and seizure. Our results are consistent with these previ- Hurricane charlie 1 ous reports. However, in our case series, we found aggres- Ivory wave 9 sive violent behavior, hallucinations, and paranoia in higher Ivory wave ultra 1 percentages than previously reported. It is interesting to note Kush blitz 1 that the high incidence of neurological/psychiatric changes Lady bubbles 2 Legal 2 occurred in a population that had pre-existing experience Love potion 69 2 in illicit stimulant abuse, such as cocaine and methamphet- Moon dust 4 amine, who had not previously reported episodes of neuro- Night cap 1 logical/psychiatric changes of such severity. The increased NRG-1 1 incidence may have occurred for a number of reasons. Expe- Q concentrated 1 rience with misuse/abuse of this drug is limited. While the Red dove 1 Resin 1 reported incidence pattern is different from previous reports Scar face 1 of synthetic cathinone abuse, the clinical effects reported are Serenity 1 similar, and this may simply be a refl ection of a difference in Super clean stain remover 1 dosing patterns or patient populations (e.g. “ club ” drug use White cloud 1 For personal use only. vs. street drug abuse). Another possibility is that this may White diamonds 2 White dove 1 represent a difference in clinical patterns from the individual White girls bath salts 1 synthetic cathinones, perhaps based on subtle differences in White lightening 24 the effects on neurotransmitters. 15 – 17 The previous reports Zoom 6 from the European experience primarily involved mephed- rone. However, in our case series, all verifi ed serum or urine samples contained MDPV, with no detected mephedrone or methylone. This second possibility should be viewed with The four samples with no synthetic cathinone detected, caution as only 6% of patients in our series had laboratory reported last use of bath salts 20 h prior to presentation. verifi cation of their exposure. Movement disorders may also

Clinical Toxicology Downloaded from informahealthcare.com by University of Basel on 09/19/12 Additional drugs detected in the blood/serum included cit- be a differentiating factor. A previously unreported fi nding in alopram, diazepam, diphenhydramine, hydrocodone, and our series was myoclonus in 19% of the patients and elevated zolpidem. Three of fi ve patients had MDPV detected in CPK in 9% of the patients. One report of “ ivory wave ” expo- urine (range 34 – 1386 ng/mL, mean 856 ng/mL). Additional sure, which may have involved MDPV, reported involuntary drugs detected in the urine were alprazolam, citalopram, facial contortions, supporting a possible movement disorder diphenhydramine, hydrocodone, and methamphetamine. as a clinical effect with MDPV abuse.18 Previous reports of a No mephedrone or methylone was detected in any sample. parkinsonian syndrome associated with methcathinone have Ethanol detection was not included in analysis. Quantita- been attributed to a manganese contamination during illicit tive analysis was performed on postmortem samples in the preparation of the drug.1,2 single fatality. MDPV was detected in blood at 170 ng/mL Analysis of the “ legal high ” or “ bath salt ” products and in urine at 1400 ng/mL. No other synthetic cathinones revealed a combination of three synthetic cathinones: were detected. mephedrone, methylone, and MDPV. This is similar to the Fifteen products in their sealed original containers were European experience, with some differences.12,19 In the USA, obtained from separate locations in the two states. The products the primary synthetic cathinone available was not mephed- contained one or more of three of the known synthetic cathino- rone, and the main distribution point was through small nes: 4-methylmethcathinone (mephedrone), methylenedioxypy- local stores. We believe that the wide availability, coupled rovalerone (MDPV), or 4-methylenedioxy-N-methylcathinone with the ease of anonymous local purchase and inexpensive

Clinical Toxicology vol. 49 no. 6 2011 Bath salt (synthetic cathinone) abuse 503

Table 2. Reported clinical effects.

No. of patients with reported Clinical effect effect (% of total patient group) Comments Agitation 194 (82%) Combative violent behavior 134 (57%) Tachycardia 132 (56%) Mean heart rate for those with reported tachycardia was 124 (SD 15.5) with a range of 100–178 beats per minute Hallucinations 94 (40%) Paranoia 86 (36%) Confusion 83 (34%) Myoclonus 45 (19%) Hypertension 41 (17%) Chest pain 40 (17%) Mydriasis 31 (13%) CPK elevations 22 (9%) Mean reported CPK elevation was 1825 U/L with a range of 301–4400 U/L Hypokalemia 10 (4%) Mean reported potassium for those with hypokalemia was 2.9 mEq/L with a range of 2.1–3.4 mEq/L Blurred vision 7 (3%) Catatonia 1 (1%) Defi nitions: Tachycardia was a heart rate 99 bpm; hypertension was systolic pressure 170 mmHg or diastolic pressure 90 mmHg; hypokalemia K 3.5 mEq/L, CK elevation CPK 250 U/L.

products, allowed a rapid expansion of these drugs into the Quantitative analysis showed serum levels of 24 – 241 ng/mL market. In many cases, they were easier to obtain than beer of MPV. Previous serum MDPV concentrations in live patients or cigarettes. Additionally, no ingredients were listed on the have not been reported, but these concentrations are in the range packaging. Unlike web sites that may allude to ingredients of the mephedrone level (0.15 mg/L) reported by Wood et al.20 that the knowledgeable prospective customer might recog- A limitation of interpreting these blood/serum levels of MDPV nize and/or desire, the bath salt products were primarily sold is that the time from use of the drug to the time of obtaining in small stores by clerks with little or no knowledge of what the sample is not known. We believe this is the fi rst report of the product might contain. Analysis of two “ brand names” postmortem quantitative MDPV concentrations. Postmortem (white lightening and dynamite), which were obtained at dif- concentrations in fi ve fatalities associated with another synthetic For personal use only. ferent locations, revealed different synthetic cathinones as cathinone, mephedrone, ranged from 0.13 to 5.1 mg/L.4,5 Urine the primary ingredient, despite similar appearing packaging. concentrations after abuse of MDPV have recently been reported The 15 products analyzed and reported here were purchased in Finland in a group of opioid-dependent patients undergoing in December 2010 and may not represent the psychoactive opioid substitution therapy.21 The similarities between our substances in future “ bath salt ” or “ legal high ” products. A patient group and the report by Ojanpera et al. were the reported wide variety of novel psychoactive substances are available use of MDPV as a substitute for illicit amphetamine and similar and may replace the substances detected in the present group urine concentrations. This suggests that urine may be a useful of products.12,24 medium to detect previous MDPV abuse.

Clinical Toxicology Downloaded from informahealthcare.com by University of Basel on 09/19/12 Table 3. Ingredients detected in “bath salt” samples.

Product name Drug found Labeled “use” Physical appearance

White lightening Mephedrone Insect repellent White dry powder White lightening MDPV Natural stain remover White dry powder Zoom MDPV Bath salt Beige powder Energizing aromatherapy powder MDPV and caffeine Potpouri Beige powder Euphoria Methylone and caffeine Bath salt Beige powder Cotton cloud Mephedrone, methylone, and MDPV Bath salt White crystalline powder Cloud 9 Methylone and MDPV Bath salt Beige powder Bayou ivory fl ower Mephedrone Bath salt Beige powder Cloud 10 MDPV Not on product Beige powder White dove Methylone Bath salt Beige powder Dynamite Methylone Bath salt White dry powder Dynamite “plus” MDPV Bath salt Beige powder White china MDPV and unknown compound Bath salt Beige powder Snow day Methylone and MDPV Bath salt Beige powder Bolivian bath salts (scarface) MDPV Bath salt White dry powder

Copyright © Informa Healthcare USA, Inc. 2011 504 H. A. Spiller et al.

Little is known of the mechanism of action of syn- of these substances prompted signifi cant concern from thetic cathinones, but a clinical picture of a sympathomi- both healthcare providers and legal authorities. Since the metic syndrome has become evident. Methcathinone and emergence of these bath salts, a growing number of states methylone appear to inhibit membrane catecholamine have designated six synthetic cathinones as Schedule I transporters, suggesting a reuptake inhibition. Comparison controlled substances. However, there are a large number of methcathinone and methylone to methamphetamine of potential novel psychoactive “ designer ” drugs that may and methylenedioxymethamphetamine (MDMA) showed possibly be distributed in the future. 24 Changes to specifi c similar effects on dopamine and norepinephrine reuptake moieties may not be addressed in the current legislation, inhibition, but methylone with its 3,4-methylenedioxy leaving clinical toxicologists, poison centers, and emer- group showed increased serotonin reuptake inhibition.15 gency physicians to face an on-going pattern of chasing Animal studies with methylone showed potent monoam- the next ivory wave. ine release effects for dopamine and serotonin and less so for norepinephrine, and refl ected reuptake inhibition of dopamine, norepinephrine, and serotonin. 16 In a mouse Declaration of interest model, MDPV increased dopamine concentrations but did The authors report no confl icts of interest. The authors alone 17 not appear to affect serotonin concentrations. While the are responsible for the content and writing of the paper. mechanism is not yet fully elucidated, it appears that the behavioral toxicity (including self-injurious behavior and schizophrenic-like psychoses) and movement disorders of References synthetic cathinones may have a dopaminergic mechanism 22,23 1. Stephens A, Logina I, Liguts V, Aldins P, Eksteina I, Platkajis A, similar to amphetamines. et al. A parkinsonian syndrome in methcathinone users and the role Within 8 months of their appearance on the US mar- of manganese. N Engl J Med 2008; 358:1009 – 1017. ket, more than 1400 cases of misuse and abuse of “ bath 2. de Bie RM, Gladstone RM, Strafella AP, Ko JH, Lang AE. salts ” had been reported to US poison centers in 47 of Manganese-induced parkinsonian associated with methcathinone 50 states. On 6 January 2011, Louisiana passed an emer- (ephedrine) abuse. Arch Neurol 2007; 64:886 – 889. 3. Emerson TS, Cisek JE. Methcathinone: a Russian designer gency rule placing six synthetic cathinones in Schedule I. The amphetamine infi ltrates the rural Midwest. Ann Emerg Med 1993; substances banned were 3,4-methylenedioxymeth cathinone 22:1897 – 1903. (methylone), 3,4-methylenedioxypyrovalerone (MDPV), 4. Lusthof KJ, Oosting R, Maes A, Verschraagen M, Dijjhuizen A, Sprong 4-methyl methcathinone (mephedrone), 4-methoxymeth- AGA. A case of extreme agitation and death after the use of mephedrone cathinone (methedrone), 3-fl uromethcathinone, and 4- in the Netherlands. Forensic Sci Intern 2011; 206:e93 – e95. 5. Maskell PD, Paoli GD, Seneviratne C, Pounder DJ. Mephedrone fl uoromethcathinone (fl ephedrone). The number of cases (4-methylmethcathinone)-related deaths. J Analyt Toxicol 2011;

For personal use only. reported in Louisiana decreased dramatically after the ban 35:188 – 191. was put in place on 6 January 2011 (Fig. 1). Within 3 months 6. Regan L, Mitchelson M, Macdonald C. Mephedrone toxicity in a of this, 15 more states added synthetic cathinones to the con- Scottish emergency department. Emerg Med J 2010 Dec 23. [Epub trolled substances list as Schedule I drugs, either through ahead of print] doi 10.1136/emj.2010.103093. 7. Durham M. Ivory Wave: the next mephedrone? Emerg Med J 2011 temporary emergency rule or direct legislation (Kentucky, Mar 15. [Epub ahead of print] doi: 10.1136/emj.2011.112920. Alabama, Arkansas, Florida, Hawaii, Illinois, Idaho, Mis- 8. Wood DM, Davies S, Greene SL, Button J, Holt DW, Ramsey J, sissippi, North Dakota, Oregon, Utah, Virginia, Washing- Dargan PI. Case series of individuals with analytically confi rmed ton, Wisconsin, and Wyoming). Legislation is pending in a acute mephedrone toxicity. Clin Toxicol 2010; 40:924 – 927. number of additional states. Timely information from poison 9. Vardakou I, Pistos C, Spiliopoulou C. Drugs for youth via internet and the example of mephedrone. Toxicol Lett (2011) doi: 10.1016/ centers on the bath salt outbreak was used by state and fed- jtoxlet.2010.12.014.

Clinical Toxicology Downloaded from informahealthcare.com by University of Basel on 09/19/12 eral authorities during investigations to help track the extent 10. Dargan PI, Albert S, Wood DW. Mephedrone use and associated ad- of use and effects occurring from these new drugs. Close verse effects in school and college/university students before the UK collaboration between state authorities and poison centers legislation change. QJ Med 2010; 30 July [Epub ahead of print] doi: enhanced a rapid response, including legislation. 10.1039/qjmed/hcq134. 11. McElrath K, O’ Neill C. Experiences with mephedrone pre- and post-legislative control: perceptions of safety and sources of supply. Conclusion Int J Drug Policy 2011; 22:120 – 127. 12. Brandt SD, Sumnall HR, Measham F, Cole J. Analyses of second We report the emergence of a new group of substances of generation “ legal highs” in the UK: initial fi ndings. Drug Test Anal abuse in the USA, known as bath salts, with quantitative 2010; 2:377 – 382. 13. Karlia L, Reynaud M. GHB and synthetic cathinones: clinical effects results of MDPV use in 19 patients. Calls to US poison and potential consequences. Drug Test Anal (2010) doi: 10.1002/ centers as a result of the use and abuse of these drugs were dta.210. fi rst noted in 2010. Rapid analysis and identifi cation of 14. Bronstein AC, Spyker DA, Cantilena LR Jr., Green JL, Rumack BH, the synthetic cathinones involved in these substances as Giffi n SL. 2009 Annual Report of the American Association of Poi- well as the coordinated response by two poison control son Control Centers ’ National Poison Data System (NPDS): 27th Annual Report. Clin Toxicol 2010; 48:979 – 1178. centers have permitted a picture of this new epidemic to 15. Cozzi NV, Sievert MK, Shulgin AT, Jacob III P, Ruoho AE. Inhibi- be presented. The growing number of cases together with tion of plasma membrane monoamine transporters by beta-ketoam- the alarming severity of the effects caused by the abuse phetamines. Eur J Pharmacol 1999; 381:63 – 69.

Clinical Toxicology vol. 49 no. 6 2011 Bath salt (synthetic cathinone) abuse 505

16. Nagai F, Nonaka R, Satoh K, Kamimura H. The effects of non-med- 4-MMC) with associated sympatomimetic toxicity. J Med Toxicol ically used psychoactive drugs on monoamine neurotransmission in 2010; 6:327 – 330. rat brain. Eur J Pharmacol 2007; 559:132 – 137. 21. Ojanpera IA, Heikman PK, Rasanen IJ. Urine analysis of 3,4-methyl- 17. Fuma T, Kodama T, Honda Y, Tanaka T, Kubo Y, Ohashi N, et al. enedioxypyrovalerone in opioid-dependent patients by gas chroma- Infl uence of methylenedioxypyrovalerone on central nervous sys- tography-mass spectrometry. Ther Drug Monit 2011; 33:257 – 263. tem using micro dialysis method. ChemBio Integrated Management 22. Kita T, Miyazaki I, Asanuma M, Takeshima M, Wagner GC. 2009; 5:62 – 72. Dopamine-induced behavioral changes and oxidative stress in 18. Durham M. Ivory wave: the next mephedrone? Emerg Med J 2011: methamphetamine-induced neurotoxicity. Int Rev Neurobiol 2009; doi 10.1136/emj.2011.112920. 88:43 – 64. 19. Archer RP. Fluoromethcathinone, a new substance of abuse. Forens 23. Greene SL, Kerr F, Braitberg G. Review article: amphetamines and Sci Int 2009; 185:10 – 20. related drugs of abuse. Emerg Med Australas 2008; 20:391 – 402. 20. Wood DM, Davies S, Puchnarewicz M, Button J, Archer R, Ovaska H, 24. Wohlfarth A, Weinmann W. Bioanalysis of new designer drugs. Bio- et al. Recreational use of mephedrone (4-methylenemethcathinone, analysis 2010; 2:965 – 979. For personal use only. Clinical Toxicology Downloaded from informahealthcare.com by University of Basel on 09/19/12

Copyright © Informa Healthcare USA, Inc. 2011