Summary Report

SUMMARY REPORT MEETING 31

Date: Wednesday, February 26, 2014 Time: 11:00AM – 12:00PM PST Location: Conference Call Hosts: UCLA Integrated Substance Abuse Programs (ISAP) & CA Department of Health Care Services (DHCS) Topic: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs Presenter: Beth Rutkowski, MPH Associate Director of Training/Epidemiologist UCLA Integrated Substance Abuse Programs

Logistics . Summary and materials discussed from the previous ILC meetings are available at http://www.uclaisap.org/Affordable-Care-Act/html/learning-collaborative/index.html. Subsequent meeting materials will continue to be posted on this site. . The next ILC meeting will be held on March 26, 2014 at the County Alcohol and Drug Program Administrators' Association of California (CADPAAC) Quarterly Meeting in Sacramento, CA. Future meetings are planned for 11:00AM (PT) on the 4th Wednesday of every month, unless otherwise noted.

ILC Meeting 31 Topic: Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs Topic Introduction – Brandy Oeser, MPH – UCLA ISAP . For today’s learning collaborative, Beth Rutkowski will present on what clinicians need to know about synthetic drugs. This topic has relevance and practice implications for all types of providers, whether they are working in integrated primary care or in specialty MH and SUD treatment settings. We thank Ms Rutkowski for her time and effort to present this topic to help inform ILC participants. Beth Rutkowski, MPH Associate Director of Training/Epidemiologist UCLA Integrated Substance Abuse Programs

Summary  Key Topics o Characteristics and effects of synthetic drugs, most notably synthetic cannabinoids and synthetic cathinones. o Neurobiology of synthetic drug use, and the differential impact of synthetic drugs vs. “classic” illicit drugs, such as marijuana and cocaine. o Availability and patterns of synthetic drug use in the United States. o Strategies to communicate the dangers involved with synthetic drug use.  Review of Synthetic Drugs o Categories of “Designer” Psychoactive Substances . Psychedelics . Cannabinoids . Stimulants . Dissociatives . Sedatives o From the term “Bath Salts” to… . Synthetic cathinones . 2C- phenethylamines . Tryptamines . Piperazines . Dissociatives (related to ketamine and PCP) . Opioids (related to morphine, fentanyl, and heroin) o Synthetic Drugs . Not really “Spice,” “Bath Salts,” “Incense,” or “Plant Food” . Chemically-based; not plant derived . Complex chemistry . Constantly changing to “stay legal” . Need to prove “intended to use” to convict in some areas o Marijuana (Cannabis) vs. Synthetic Cannabinoids . Synthetic Cannabinoids  Wide variety of herbal mixtures  Marketed as “safe” alternatives to marijuana  Brand names include: “Spice,” “K2,” fake weed, “Yucatan Fire,” “Skunk,” “Moon Rocks,” herbal incense, “Crazy Clown,” “Herbal Madness”  Labeled “not for human consumption”  Mainly abused by smoking (alone or with marijuana); may also be prepared as an herbal infusion for drinking.  Many of the active chemicals most frequently found in synthetic cannabis products have been classified by the DEA as Schedule I controlled substances, making them illegal to buy, sell, or possess.  Multiple “generations” of drugs.  Cases reported of kidney damage linked to synthetic cannabinoids; seizures and psychotic behavior in pregnant woman o Khat vs. Synthetic Cathinones . Synthetic Cathinones  Could be MDPV, 4-MMC, mephedrone, or methylone  Sold on-line with little info on ingredients, dosage, etc.  Advertised as legal highs, legal meth, cocaine, or ecstasy  Taken orally or by inhaling  Serious side effects include tachycardia, hypertension, confusion or psychosis, nausea, convulsions  Labeled “not for human consumption” to get around laws prohibiting sales or possession o Synthetic Drug Testing Protocol – What to Consider . Questions to consider when selecting a toxicology laboratory:  For which synthetic drugs should you test?  How many derivatives/formulations can the laboratory detect with their test?  Are the newest generations (4th and above such as the AM,  XLR, and UR versions) detected?  How much does the test cost?  Effects of Synthetic Drugs o Effects of Synthetic Cannabinoids . Most symptoms are similar to cannabis intoxication: tachycardia, reddened eyes, anxiousness, mild sedation, hallucinations, acute psychosis, memory deficits . Effects not typically seen after cannabis intoxication: seizures, hypokalemia, hypertension, nausea/vomiting, agitation, violent behavior, coma . Unlike cannabis, synthetic cannabinoids have no therapeutic effects o Effects of Mephedrone . Intended effects: euphoria, stimulation, enhanced music appreciation, decreased hostility, improved mental function, mild sexual stimulation . Unintended (adverse) effects: bruxism (teeth grinding), delusions, dilated pupils, hallucinations, poor concentration, poor short-term memory, problems focusing visually o Effects of Methylone . Anorexia, anxiolysis/anxiogenesis, bruxism (teeth grinding), central nervous system stimulation, de-realization/de-personalization, dilated pupils, euphoria or dysphoria, hallucinations, hypertension (high bp), hyperthermia, increase in sociability, insomnia, nausea and vomiting, nystagmus, psychosis, restlessness, sweating, tachycardia (rapid pulse), trismus (inability to open the mouth)  Neurobiology of Synthetic Drug Use o “Classic” Cannabinoids and Synthetic Cannabinoids o “Classic” Stimulants and Synthetic Stimulants o Synthetic Cathinones  Epidemiology of Synthetic Drug Use o Emerging Drug Items Identified in U.S. NFLIS Forensic Labs . Indicates increasing use of synthetic cannabinoids and synthetic cathinones . Increase in number of different chemical formulations which have been seized and identified for synthetic cannabinoids and cathinones by forensic laboratories located throughout the United States. o Calls Received by U.S. Poison Control Centers for Human Exposure to Synthetic Marijuana . According to the American Association of Poison Control Centers, 2,906 calls relating to human exposure to synthetic marijuana were received in 2010. Twice that number (6,968) were received in 2011, and 5,205 received in 2012, and 1,413 had been received as of June 30, 2013 o Use of Synthetic Drugs by U.S. Students . More high school students report using synthetic marijuana than any other substance besides alcohol and marijuana, according to data from a survey of 9th to 12th graders recently released by the Partnership for a Drug-Free America o Emergency Room Visits Related to Synthetic Cannabis and Cathinones: DAWN, 2011 . A higher percentage of synthetic cannabinoid patients were under the age of 21, as compared to synthetic cathinone patients. The synthetic cathinone patients were less likely to be discharged home and 12% were sent to the Intensive Care Unit or to a substance abuse treatment program  Other Notable Synthetic Drugs – “New and Old” o MDMA (Ecstasy) . “Molly” (usually is not a pure form of MDMA, but may be a drug that can be very dangerous since its contents are unknown) o Piperazines o 2C-Phenethylamine o Dextromethorphan (DXM) o Kratom o Krokodil o Benzo Fury o “Syrup” o Dabs, BHO, Honey, Budder  Sample Treatment Protocols and Concluding Thoughts o Synthetic Cannabinoids – Clinical Presentation . Persistent depression . Memory problems (can last for several weeks) . Blunted affect . Difficulty focusing . Difficulty participating in clinical until stabilized . Users also report elevated mood, relaxation, and altered perception . Psychotic effects, such as extreme anxiety, paranoia, and hallucinations o Sample Clinical Treatment Protocol for Synthetic Cannabinoid Users . Direct individual to emergency room via ambulance . Consult a regional Poison Control Center . Acute management consists of:  Supportive care with the use of benzodiazepines, if needed, to control agitation and anxiety  Observe until resolution of abnormal vital signs, vomiting, and psychiatric symptoms o Recognizing Synthetic Cathinone Intoxication . Present with severe sympathetic stimulation: hypertension, hyperthermia, seizures, tachycardia . Present with profoundly altered mental status: agitation, hallucinations, paranoia, severe panic attacks, suicidal behavior o Sample Clinical Treatment Protocol for Synthetic Cathinone Users . Supportive care . Aggressive sedation with benzodiazepines (for agitation, seizures, tachycardia, and hypertension) . Significant hyperthemia may require passive or active cooling . Lab studies including electrolytes, renal and liver function tests, cardiac markers, and creatine kinase should be considered  In Summary: Key Points o Lack of information on the chemical contents, dosage levels, and consistent quality of the products is a major problem since users are taking drugs about which they know little, which makes provision of health care for adverse events more difficult.

o Despite widespread Internet availability and use among certain populations, health care providers remain largely unfamiliar with synthetic drugs and the multiple variations which have appeared recently.

o Research is needed to better understand the side effects and long-term consequences associated with the use of synthetic cannabinoids and synthetic cathinones.

o More toxicological identification of these new drugs, more information on the sources of them, as well as their distribution and patterns of use is needed to curtail future increases in use.

o We do not have human neurobiological data or long-term data, but we can extrapolate a few key points from the existing literature:

. Synthetics vs. Classics: Neurobiological concerns hold up, plus more

. In all cases, neurobiology predicts abuse potential

. In general, synthetic versions are not a simple substitute for “classics” – effects tend to be more intense (including side effects), some unexpected, and some new interactions that were not a concern before APPENDIX 1 – ATTENDEES

COUNTY PARTICIPANTS  Andrew Williams (Solano)  Brett O’Brien (Orange)  Clint Huffman (Tuolumne)  Margot Carabali (Los Angeles)

OTHER PARTICIPANTS  Terri Viana (The Villa Center)

DHCS PARTICIPANTS  Craig Chaffee

UCLA PARTICIPANTS  Beth Rutkowski (presenter)  Brandy Oeser  Cheryl Teruya  Elise Tran  Valerie Pearce Antonini APPENDIX 2 – AGENDA AND RELEVANT MATERIALS

 Topic Discussion – Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs  Q and A

MATERIALS FOR THIS MEETING 1. PPT Presentation – Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs

RELEVANT LINKS 2. ATTC Synthetic Drug Training Package, Full Curriculum http://www.uclaisap.org/slides/synthetic-drug-training-package.html

Copies of materials can be found at UCLA ISAP’s ACA Resources Website: http://www.uclaisap.org/Affordable-Care-Act/html/learning-collaborative/index.html.