Flakka’: a Low-Cost, Dangerous High

Pearlsearls

‘Flakka’: A low-cost, dangerous high

Allen Dsouza, MD, Lionel Pereira, MD, and Petros Levounis, MD, MA

Dr. Dsouza is a third-year psychiatry resident, and Dr. Pereira is a se of α-pyrrolidinovalerophenone arrhythmia, myocardial infarction (MI), psychiatrist, Lowell Community (α-PVP), a psychostimulant related and myocarditis.5 Alpha-PVP also may Health Center, Lowell, Massachusetts. to cathinone derivatives (“bath result in neurologic symptoms, includ- Dr. Levounis is Chair, Department U of Psychiatry, Rutgers New Jersey salts”), has been reported in the United ing headache, mydriasis, lightheadedness, Medical School, Newark, New Jersey. States, especially in Florida.1 Known by the paresthesia, seizures, dystonic movements, Disclosures The authors report no financial street names “flakka” or “gravel,” α-PVP is tremor, amnesia, dysgeusia, cerebral edema, relationship with any company inexpensive, with a single dose (typically motor automatisms, muscle spasm, nys- whose products are mentioned in 100 mg) costing as little as $5.2 Alpha-PVP tagmus, parkinsonism, and stroke.5 Death this article or with manufacturers of competing products. can be consumed via ingestion, injection, may occur by cardiac arrest, renal damage, insufflation, or inhalation in vaporized or suicide. forms, such as E-cigarettes, which deliver the drug quickly into the bloodstream and Case reports. The effects of α-PVP have can make it easy to overdose.1 The low cost been documented in the literature: of this drug makes it likely to be abused. • A 17-year-old girl was brought to an Here we review the mechanism of action emergency department in Florida with and effects of α-PVP and summarize treat- acute onset of bizarre behavior, agitation, ment options. and altered mental status. It took 6 days and repeated administrations of olanzapine and Mechanism of action lorazepam for the patient to become calm, Alpha-PVP is a structural parent of 3,4- alert, and oriented.2 methylenedioxypyrovalerone (MDPV)— • ST-elevated MI with several intra- the first widely abused synthetic cathi- cardiac thrombi was reported in a 41-year- none.3 Much like cocaine, α-PVP stimulates old woman who used α-PVP.4 the CNS by acting as a potent dopamine • In 2015, 18 deaths related to α-PVP use and norepinephrine reuptake inhibitor. were reported in South Florida.5 However, unlike cocaine, it lacks any action • Deaths related to α-PVP use also have on serotonin transporters. The pyrrolidine been reported in Japan and Australia.5 ring in MDPV and α-PVP is responsible for the highly potent dopamine reuptake inhibitor action of these agents.3 Every issue of Current Psychiatry A wide range of adverse effects has its ‘Pearls’ Discuss this article at Use of α-PVP results in a state of “excited Yours could be found here. www.facebook.com/ delirium,” with symptoms such as hyper- CurrentPsychiatry Read the ‘Pearls’ guidelines thermia, hallucinations, paranoia, violent for manuscript submission at aggression, and self-harm.1 Alpha-PVP CurrentPsychiatry.com, or request a is known to cause rhabdomyolysis.4 copy from Assistant Editor Jason Orszt at [email protected]. Some studies have reported cardiovascu- Then, share with your peers a ‘Pearl’ lar effects, such as arterial hypertension, Current Psychiatry of wisdom from your years of practice. e4 September 2017 palpitations, dyspnea, vasoconstriction, Pearls

Treatment options that may elude drug screens are continually There are no treatment guidelines for emerging. The lack of evidence-based guide- α-PVP-related psychiatric symptoms. lines on recognizing and managing intoxica- Case reports describe remission of symp- tion, withdrawal, and long-term effects of toms following aggressive treatment with α-PVP and other “designer drugs” calls for antipsychotics and benzodiazepines.2 greater research in this emerging area of sub- Guidelines for treatment of stimulant- stance use disorders. induced behavioral and psychotic symp- toms6 may be considered for patients who References 1. National Institute on Drug Abuse. “Flakka” (alpha-PVP). have used α-PVP. https://www.drugabuse.gov/emerging-trends/flakka- Reassurance and supportive care are alpha-pvp. Accessed July 26, 2017. 2. Crespi C. Flakka-induced prolonged psychosis. Case Rep the basic principles of such interven- Psychiatry. 2016;2016:3460849. doi: 10.1155/2016/3460849. tions. A quiet environment and benzo 3. Glennon RA, Young R. Neurobiology of 3,4-methylenedioxypyrovalerone (MDPV) and diazepines may provide relief of agitation. α-pyrrolidinovalerophenone (α-PVP). Brain Res Bull. Consider Antipsychotics may be helpful if a patient 2016;126(pt 1):111-126. 4. Cherry SV, Rodriguez YF. Synthetic stimulant reaching benzodiazepines exhibits psychotic symptoms. epidemic proportions: flakka-induced ST-elevation myocardial infarction with intracardiac thrombi. J and antipsychotics Cardiothorac Vasc Anesth. 2017;31(1):e13-e14. Similar drugs may emerge 5. Katselou M, Papoutsis I, Nikolaou P, et al. α-PVP (“flakka”): to manage In 2014, the DEA classified α-PVP as a a new synthetic cathinone invades the drug arena. Forensic Toxicol. 2016;34(1):41-50. α-PVP–related Schedule I substance. Laws against the import 6. Sadock BJ, Sadock VA, Ruiz P. Hallucinogen-related agitation and of such substances via the Internet or other disorders. In: Sadock BJ, Sadock VA, Ruiz P. Kaplan and Sadock’s synopsis of psychiatry: behavioral sciences/ psychosis means also may help control the spread of clinical psychiatry. 11th ed. Philadelphia, PA: Wolters this drug. However, chemically similar drugs Kluwer; 2015:648-655.

Current Psychiatry Vol. 16, No. 9 e5