Drug Abuse and Overdose Trends: What’s Still Out There and What’s New?
Ernest Stremski, MD, MBA Children’s Hospital of WI – ED Trauma Medical College of WI – Pediatrics
Concordia University School of Pharmacy and Physician Assistant Program
No Financial Disclosures Today, Fond du Lac EMS will be responding to:
Smoking “spice”
Bath salts Seizure from MDMA
Skittles
Apnea Arymo
1-800-222-1222 Some easy Neuropharmacology: How drugs affect the brain Cerebral Cortex
MESOLIMBIC & VTA
Limbic System
Multi-divergent pathways of the CNS are projections from the Brainstem & Midbrain, into the Cerebral Cortex and Limbic System
Series of stimulating and inhibiting messages via chemical neurotransmitters
These chemical neurotransmitters mediate:
Mood , Appetite, Sleep – Wake Cycles, Motivation, Pain Perception, Cognition, Sex drive, Behavioral, Reward, Pleasure
Drugs (be it prescription or illicit) affect the actions of these neurotransmitters:
Xanax – Gamma amino butyric acid Cocaine – Dopamine Adderall – Norepinephrine MDMA – Serotonin Euphoria NOREPINEPHRINE
Stimulant DOPAMINE
Dissociative Sedation & Anxiolytic
SEROTONIN
ANANDAMIDE Psylocibin
Myristicin LSD Heroin & Opioids
So many ways to get “High” Synthetic Cannabinoid Many are provided by Mother Nature
Many neurotransmitters & Cathoniones receptors can mediate dissociative effects
THC
Muscimol GHB Lysergol Peyote Dextromethorphan
PCP MDMA MME Salvinorin A 2C-B Ketamine Scopolamine Our first group of drugs, stimulants
(AKA: Psychostimulants)
Naturally occurring & synthetic forms Enhance effects of catecholamines
AMPHETAMNES, PHENYLETHYL AMINES, CATHINONES, METHYL XANTINES, TROPANE ALKALOIDS
Used to: Keep Partying (stay up and going), Performance enhancing (sports & sex)
Tachycardia (SVT), Hypertension / Vasoconstriction (MI, CVA, Ischemia) Agitation & Violence, Seizures, Diaphoresis & Dehydration Military Weight Loss
Historical use of Amphetamines in the USA
Increase work & productivity Treat Depression Weight loss / Appetite suppressant
5mg Methamphetamine
Recreational Pharmaceutical
Mood Elevator ADD / ADHD Arousal / Energy Narcolepsy Sexual stamina Weight loss Sport enhance Decongestant
Should NOT be prescribing amphetamines for Depression, Chronic Fatigue, Asthma
Depression Normally, we have a baseline amount of catecholamine stimulation of the brain
Example: Water going into the sink (Epi releasing into the brain)
Keeps EPI in the brain Enhances amount of EPI Enhances and prolongs for longer duration released to the brain EPI in the brain The “bath salts” (again, nothing to do with a relaxing spa)
Typically are synthetic cathinone products (Khat – natural source of Cathus edulis)
Mephedrone, Methylone, Methylenedioxypyrovalerone (MDPV)
Approach with Caution:
CV & Neuro Support
Benzodiazepines
Cool Hydrate Not detected in standard drug screens Another groups of synthetic psychostimulants – Phenethylamines MDMA, MME, 2C-B – names include XTC, E, Molly, Hug Drug, Foxy, Dragonfly, …)
Dissociative effects are based on enhancement of Serotonin
B-DFLY XTC 2C-B
Methylene dioxymethylmethamphetamine Bromo dimethoxyphenethylamine Bromo aminopropylbenzodifuran
Manage as per other stimulant drugs, special focus on cooling & hydration Weed versus Synthetic Pot
Each are a form of a Cannabinoid We have 2 cannabinoid neurotransmitters They both act like THC (active component of marijuana)
Anandamide and Arachadonyl glycerol
There action is mediated at a receptor known as CB1
Marijuana (Sacred grass) – effects written B.C.
Marijuana widely available OTC – pre 1910
Marijuana warnings – Refer Madness 1930s
Marijuana Hippies – 1960s
Marijuana – isolated THC as component 1964
Marijuana – discovered site of action at CB1 1992
Marijuana – medical & dispensaries begin 1998
New targets for CB1 – JWH compounds 2000s
Marijuana – legalized recreational use ____ & ____ 2014
Where is the legitimate medicinal use of THC?
Reduce intra-ocular pressure in certain forms of glaucoma
Effective anti-emetic during chemotherapy
Reduce pain of Multiple Sclerosis & peripheral neuropathy
Minimize seizures in certain forms of refractory Epilepsy
Appetite enhancing effects in HIV wasting
Roles in: Cancer? Auto Immune Suppression? PTSD? …..
Is marijuana a “stepping stone” to drug abuse and Heroin?
Would you rather have your kid doing marijuana versus ______?
Are the motor & long term effects of THC less problematic than ETOH? Medical marijuana legislation
In February 2017, Sen. John Erpenbach and Rep. Chris Taylor introduced S 38/A 75, which would create a state-regulated program allowing access to medical cannabis for patients with serious medical conditions and their doctors’ recommendations. Meanwhile, two other proposals — SJR 10/ AJR 7 — would call for an advisory referendum on whether Wisconsin should create a medical marijuana program. Unfortunately, no action has been taken since the bills were referred to committee.
However, there has been modest progress on improving Wisconsin’s CBD- focused medical cannabis law. On April 17, 2017, Gov. Scott Walker signed Act 4, which expands the state’s existing limited medical cannabis law, Lydia’s law, enacted in 2014. The original law allowed patients with documentation of a seizure disorder to possess CBD treatments, but it did not legalize the production of CBD products in the state. Act 4 expands the program to protect all patients who possess CBD and have a letter from their physician. Unfortunately, it remains illegal to produce or distribute CBD products. Sen. Chris Larson and Rep. Jimmy P. Anderson introduced legislation (S 104/A 158) that would allow state-licensed businesses to produce and dispense CBD treatment products. POT and SYNTHETIC POT are both activators of CB1
The synthetic forms are more profound in their ability to act on CB1 and other sites
Leads to exaggerated effects (CV)
JWH 018 - 1-pentyl-3-(1-naphthoyl)indole
“pure THC” user
delta 9, tetrahydrocannabinol (THC)
“synthetic pot” user Tachycardic & Hypertensive Agitated Unresponsive Seizures Endogenous: Botanical: Synthetic:
Anandamide & 2, AG Tetrahydrocannabinol Many, JWH compounds
Careful, today there are many hybrids of While synthetic pot activates CB1, the cannabis plant with varying growing it is also more potent & dirty, no and extraction techniques standardization practices
THC concentrations vary Experience more profound neuro & cardiovascular effects What did they take?
Unresponsive, minimal to zero respiratory effort, pinpoint pupils, hypotonia
Ingested oral tablets Crushed and insufflated tablets Injected a powder The Journal of the Pharmacy Society of Wisconsin, 2014: Volume 17
Prescription drug abuse affects > 6,000,000 US Citizens As many as 50 deaths / day due to Opioid Analgesic Overdose 80 % of heroin abusers have previously used Opioid analgesic medications Opioid Analgesic Drugs Natural source is the opium poppy (Papaver somniferum)
Up to 10 % dry weight is Morphine
Actions of Opioid Drugs (Stimulate Mu, Kappa, Delta receptors of CNS)
Stimulation of these 3 receptors blocks neural processing Primary effect on spinal cord / brain is to stop pain processing
Problems: Slows and can fully inhibit respiratory processing
Enhances Dopamine release in the Mesolimbic system
Relaxes smooth muscle (drops BP, stops labor, slows peristalsis)
Release histamine (warm flushed, pruritic, red skin)
Heroin
0.01 0.01
Katzung, Basic and Clinical Pharmacology, 2012, 13th Ed. Are we only dying due to heroin and fentanyl products?
It’s ALL the Opioid Analgesic drugs: Morphine, Hydromorphone, Oxycodone, Hydrocodone, Codeine
Long acting opioid analgesic drugs, some of these are “newer”
? Hydromorphone
Arymo
Exalgo Palladone
Avinza
Embeda
Oxymorphone Tapentadol Hydrocodone Oxycodone Kadian Old OxyContin New OxyContin
ABUSE – DETERRANT TABLET TECHNOLOGY Agonist Antagonist
Remember the duration of Narcan is almost always shorter than that of the opioid DXM looks like an opioid but has almost zero opioid effect.
A metabolite (DXO) has Dissociative effects via Serotonin and NMDA
SKITTLES – not going to be Narcan-reversible, let it wear off Today, Fond du Lac EMS rescued:
Smoking “JWH Compounds” BENZO
Cathinone stimulants BENZO BENZO Phenethylamine
Dextromethorphan NO NARCAN
Morphine NARCAN
1-800-222-1222
Questions? Comments ?