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Erick Limmer, 26, Owned the apartment that the GHB overdose took place in. CONVICTED! Daniel Brayman, a senior, was one of two boys who picked up the freshman girls took them to the Party… CONVICTED! Nicholas Holtschlag, 18, allegedly handed drinks that were poisoned with GHB to Melanie Sindone and Samantha Reid. CONVICTED! Joshua Cole deliberately slipped the GHB into the girls non alcoholic drinks. CONVICTED! Had enough yet?

• Anesthetic • Approved for both human and animal use in medical settings since 1970 • About 90 percent of the ketamine sold legally today is intended for veterinary use. Ketamine- Street Names

• Special K • Vitamin K • K • Jet • Cat Valium • Psychedelic Ketamine

• Route - Oral - Injected - Snorted - Smoked with marijuana • Effects - Onset within seconds if smoked, 1-5 minutes if injected - Lasts up to 24 hours Ketamine- Signs and Symptoms

• Low-dose • Impaired attention, learning ability, and memory. • High-dose - Delirium - Amnesia - Impaired motor function - High blood pressure - Depression - Potentially fatal respiratory problems - Excessive salivation and lacrimation Ketamine- Management

• ABC’s • Risk for aspiration is high due to decrease level of consciousness and excessive salivation • Oxygenate (15L NRB or BVM) • IV access • Monitor DXM- Introduction

• Yes, its in OR COUGH TABS ()”TRIPPLE C” • acts as a cough suppressant via its (activating) activity at mu- receptors. • In Canada: Contac CoughCaps (30 mg DXM) • Related in effects to Ketamine and PCP DXM • Yes, its in cough syrup OR cough tabs (CORICIDIN)”TRIPPLE C” • Dextromethorphan acts as a cough suppressant via its agonist (activating) activity at mu-opioid receptors. • In Canada: Contac CoughCaps (30 mg DXM) • Related in effects to Ketamine and PCP DXM- How is it used?

• “Robo-ing” (Old Term from early 90’s) • DXM is available over-the- counter in tablet form in several countries as a cough med. Robitussin Maximum Strength Cough (not Robitussin DM) syrup • Users often refer to DXM in “plateaus” • Dose of Robitussin Maximum Strength Cough syrup is two to five full "shots" using the shot glass that comes with the bottle.

DXM- Coricidin Toxicity

• Coricidin Cough and Caps, 30 mg DXM and 4 mgs of Chlorphineramine maleate • Chlorphineramine maleate is an anti- like . • Non Specific reports of “Respiratory Failure” at high doses.

DXM- Coricidin Toxicity

• Robo-Walk • Robo- • Robo-Talk • • Dialated Pupils

DXM- Treatment

• VOMIT • Symptomatic TX. • Be alert for and (Cautiously) treat or , and rarely, cardiovascular problems • Restraints (?) • Avoid Chemical Restraint (Haldol, ),Benzo’s are preferred (Be prepared to manage the airway) • may be given for Dystonic reactions, and for s/s of release. DXM- What does this mean to me?

• Be Careful, take the same precautions you would with a PCP patient. • ALS eval is a must ( HTN, , Respiratory Depression, and self harm) • DXM differs from other . Its presentation of s/s extend well beyond simple CNS depression and but into basic cognitive functions as well. • Understanding that DXM effects last well beyond the 4 hours of intoxication , and that side effects may include “Psychotic Breaks” will help determine deposition of patients. LSD-d-lysergic acid diethylamide “For about a week I couldn't walk through the lobby of A-entry at the dorm without getting really scared, because of the goblin I saw there when I was tripping….”

( …User, circa.1971, )

Background LSD

• Lysergic Acid Diethylamide • • Effects are very unpredictable depending on - amount taken - surroundings in which the drug is used - user's personality, mood, and expectations. Background

• Discovered by Dr. Albert Hofmann in 1938 • Extensive study, use, and abuse by the government in the late 40’s. 50’s, and 60’s. (OSS/CIA, US Navy) • Some documented cases of CIA Operatives taking it to “Immunize” them selves to its effects in the 60’s. • Now that’s job satisfaction! LSD- Street Names

• Acid • Blotter • Trips • Yellow sunshine • Boomers • “Candy flipping” refers to mixing LSD and Ecstasy Slang

• Many names refer to the carrier or “brand”(image printed on blotter) • Blotter, Sugar, Sugar Cube, “cid, Acid • Bart Simpsons, Barrels, Tabs, Blotter, Heavenly blue, "L", Liquid, Liquid A, Lucy in the sky with diamonds, Microdots, Mind detergent, Orange cubes, Orange micro, Owsley, Paper acid, Sacrament, Sandoz, Sunshine, Tabs, Ticket, Twenty-five, Wedding bells, Windowpane, etc. Slang

• Hit- Dose • Body Kinks- Unexpected physical side effects I.e. , jitters, etc • - A person on LSD who becomes depressed, agitated, or confused may these feelings in an overwhelming manner that grows on itself. • LSD psychosis: The effects of LSD exacerbate pre-existing psychological problems for several days. Methods

• Usually taken Sublingually or orally on paper (“Blotter”) • The solution may also be injected s.c. or i.v.(RARE) The effect is identical with that of but sets in more rapidly. • Usual dose is 50-200 mcg, with “Transcending doses” as high as 500 mcg

LSD

• Route - Oral - Tablets, on sugar cubes, squares of gelatin, blotter paper • Action- unknown, effects the system of the • Effects - Onset 30-90 minutes - Lasts up to 12 hours How does it work?

• Similar to other drugs that give hallucinations: • It affects the re-uptake of 5-HT similarly to SSRI (serotonin specific reuptake inhibiting) anti- such as (Prozac), , and • Agonist (stimulation rather than blocking) properties at the 5-HT2 receptor have been found to fairly universally be associated with other psychedelic drugs such as and , and somewhat in MDMA LSD- Signs and Symptoms

• Dilated pupils • Hyperglycemia • Hyperthermia • Rambling speech • • Distortion of • Hypertension sensory • Profuse sweating perception • Loss of appetite • Hallucinations • Dry mouth • Seizures • Tremors • Long term: - Psychosis • Nausea - “flash-back”

LSD- Signs and Symptoms

• Bad Trips - feeling of intense fear about being in a scary experience that you can't control - lasts for hours - can have an enjoyable trip one time, and a scary one the next time - some evidence that LSD can trigger a psychotic episode in someone who is already schizophrenic, or it can trigger the first episode in someone who is going in that direction. S/S OF AN OVERDOSE

• Dilated Pupils • Vivid Auditory, tactile, and visual perception • Nausea • Mild drops in B/P • Hyperglycemia • Piloerection (Goosebumps) • Mild Hyperthermia • Bradycardia • May exacerbate pre-existing behavioral tendencies • Mild stimulatory effects

After trip effects

• (common) • “Jitters” • Flashbacks (inconstantly proven and disproven in literature) LSD- Management

• ABC’s • Reassure the patient • “talk down” the high patient • Protect from injury • Provide dark, quiet environment • Seizure precautions BASIC TREATMENT

• Supportive • Protect the patient • Calm low key, low light, environment • Calm low key, low light environment • Calm low key, low light environment • Calm low key, low light environment • Oh yes… • Calm low key, low light environment

Dependence, Detox, and withdrawal • No documented physical or • A rapid tolerance is built up (about 3-5 days) that just as rapidly disappears Take Home Information

• Facilitate a low key trip, and all is well • The patients respond to your actions as much as we respond to them • Very little clinical problems from drug, just actions resulting from altered behavior Newer synthetics K2 or “Spice” Synthetic Marijuana K2 “Spice”

• What is it? • Side Effects? • Mixture of herbal and spice , sold as • Severe agitation and potpourri • Sprayed with potent • rate and blood psychotropic drugs, the pressure raises to most active JWH-018 & JWH-073 dangerous rates • Created for • Hallucinations experimental use in • Tremors or seizures animals and cell cultures- not humans • In extreme cases it • Compare: causes blackouts or - Marijuana in ’70-’80’s = 7-10% catalepsy- a nervous THC - Marijuana recently = 45-65% THC condition causing fix - K2 is equivalent to 100% THC body posture. Synthetic

• Synthetic drug • Chemical compounds similar to THC in Marijuana - Majority of the compounds were identified as JWH related varieties • JWH-018 (63%) • JWH-250 (14%) • JWH-073 (9%) • JWH-081 (5%) • JWH-200 (2%) • JWH-019, JWH-210, JWH-251, RCS-4, AM-2201, AM- 694, CP-47, CP-497, AM-356 • In 2010, 50% of the reports were from the midwest

Synthetic Cannabinoids

• Packaged: - Small, silvery plastic bags - Dried plant material with added - Labeled as or potpourri - “Not for Human Consumption” • Sold in: - Head shops - Gas stations or convenience shops - shops - Over the internet • Several websites selling product are based in Synthetic Cannabinoids- Street Names

• K2 • Moon rocks • Spice • Skunk • Kush • Black mamba • Fake weed • Bombay blue • Bliss • Genie • Yucatan fire • Mad Hatter • Mix

On the Streets

Street Names… What Kids Do… • Bliss • K2 can be • Black Mamba smoked in a • Bombay , , or • Fake Weed pipes • Genie • Spice • It can also be • Zohai brewed as a

Synthetic Cannabinoids

• Route - Smoked in joints or pipes - Brewed into a tea • Effects - Similar to marijuana - Stored in body for long periods of time K2: Affects your Brain

• The chemicals used bind tighter to the body’s cannabinoid receptors better than THC does, allowing the chemicals to fully activate these receptors. • The use of K2 “hijacks” the part of the brain important for temperature control, intake, perception, memory, problem solving and the receptor that regulates your immune system. • K2 effects hormone functions. • K2 smokers exhibit typical drug dependency signs, withdrawal symptoms, and addictive behaviors.

Synthetic Cannabinoids- Signs and Symtpoms

• Paranoia- 4-10x greater than other • Panic attacks • Giddiness • Tachycardia • Hypertension • • Hallucinations • Seizures Synthetic Cannabinoids- Management

• ABC’s • Support and manage • Oxygenate (15L NRB or BVM) • Reassure the patient • Speak in a quiet voice • IV access if needed • Monitor K2 Effects • There was an incident of a youth in Missouri who was hospitalized after using K2. The youth claimed he could see his heart beat out of his chest. • According to Jeremiah Morris, a forensic scientist for the Johnson County Criminalistics Laboratory in Missouri, you do not need to smoke excessively to experience potentially harmful effects of K2. Local Reports

• Juvenile-1, age 16, suffered a seizure after using K2. The combination of his and K2 caused too much stress on his heart. • Juvenile-2 was lost in the neighborhood that she grew up in for 2 hours after K2. • Juvenile-3 suffered elevated heart rate and has been hospitalized due to this reaction. Results of K2 Use

Poison Control Reports Judge Gunn’s Solution Nation Wide

• American Association • One judge makes it of Poison Control a requirement for Centers has said that her juveniles to sign as of Sept 27, 2010 a contract to not more than 1,503 calls use K2 while on her have been made to poison centers for drug programs. If symptoms such as they are caught racing heart beat, using it they are elevated blood kicked out. pressure, and nausea. • Compared to 14 in 2009

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