“New(er) Street Drugs of Abuse.”
Sean Patrick Nordt, M.D., Pharm.D., DABAT, FAACT, FAAEM, FACMT
CME Disclaimers & Disclosures
• HIPAA Disclaimer – All patient information and identifiers have been altered or removed
• Financial Disclosures – none
• For educational purposes only
• No part of this lecture can be presented, reproduced or distributed or presented without permission
Objectives
• At the end of this lecture
• Describe the clinical effects of newer drugs of abuse • List the various street names of these agents • Develop a focused treatment plan of each of these agents
K2/Spice Synthetic Cannabinoids
• “Spice” products typically list various plant and herbal blends as ingredients • Impregnated onto herbal material then smoked • Marketed as incense or potpourri with statement, “not for human consumption”
Synthetic Cannabinoids
• Called “Herbal Marijuana Alternatives” (e.g., JWH-018, JWH-073, JWH-00, CP47-497, HU- 210) • Agonists at endogenous cannabinoid receptors • Herbal components may contribute to high • Head shops initially now Internet • Cost $25 to $50
Clinical Presentation
• Anxiety • Paranoia • Agitation • Psychosis • Tachycardia • Diaphoresis • Seizures Diagnosis
• Generally by history • Clinical suspicion • Does not show up on routine urine toxicology screen • GC-MS can detect some but not all as new compounds being formulated
Treatment
• Supportive care • Benzodiazepines • IVF hydration • Butyrophenones
Hallucinogenic Amphetamines
• Substituted amphetamine structure with serotoninergic properties • Became popular in late 1960s • Once used in psychotherapy adjunct to “expand consciousness” • Became Schedule I substance under Controlled Substance Act in 1988 • Primarily imported from Europe as tablets MDMA 3,4-Methylenedioxymethamphetamine Street Names
• Molly • Clarity • Ecstasy • X • XTC • Happy pill • Scooby snacks • Rave Energy • Adam • E
Other Designer Amphetamines – MDEA “Eve” • 3,4-METHYLENEDIOXY-N-ETHYLAMPHETAMINE – MDA “Love Drug” • METHYLENEDIOXY-AMPHETAMINE – DOB • 2,5-Dimethoxy-4-bromoamphetamine – Bromo dragonfly • 2R)-1-(4-bromofuro[2,3-f][1]benzofuran-8-yl)propan-2-amine – DOM or STP • Dimethoxyamphetamine – MMDA • 3-METHOXY-4,5-METHYLENEDIOXYAMPHETAMINE Ecstasy
• Usually taken orally but also snorted, smoked, injected, rectal • 1/10th amphetamine’s sympathomimetic activity – Therefore sympathomimetic effects are mild at low doses • However at large doses similar to other amphetamines • Due to chemical structure serotonin release
Effects- Desirable
• Sense of physical closeness, empathy, and euphoria, desire to socialize – “Enactogens” meaning “touching within” • Onset within 1 hour • Duration of 4 to 6 hours • Increases sensitivity to auditory and visual stimulation • Mild sympathomimetic Effects- Undesirable
• Bruxism, dehydration, anxiety, depression, insomnia, paranoia, • Hypertension, tachycardia, cardiac dysrhythmias • Seizures, hyperthermia, rhabdomyolysis • Hyponatremia • Serotonin increases ADH release causing an SIADH-like state • Ingestion of large amounts of free water • Chronic use • Damage to serotonergic and possibly dopaminergic nerve terminals • Possible permanent alteration in mood, sleep, cognition, memory, and impulse control Hallucinogenic Amphetamines
Treatment • Supportive care – Benzodiazepines for agitation – IVF hydration – Cooling measure if hyperthermic – Possible intubation and paralysis – No acidification of urine • Does not reverse toxicity • May worsen rhabdomyloysis
Newer Hallucinogens
Potent serotonergic agents Piperazines
• 1940s benzylpiperazine (BZP) as antiparasitic • 1970s studied as antidepressant • BZP acts similar to dexamphetamine (NE, DA, 5HT) • BZP 250-500 mg combined with TFMPP 5-100 mg as MDMA “substitute” – Orally powder or tablets or smoked or snorted • TFMPP causes MDMA-like serotonin effects
Piperazines • Clinically – Agitation, tachycardia, hypertension, – Hyperthermia, seizures, psychosis, – Hyponatremia less than MDMA, rhabdomyolysis – Serotonin syndrome • Street names “party pills” BZP, A2, Legal E, Legal X • Treat with BZDs, haloperidol, IVF NS, aggressive cooling
2C Agents • 2Cs – Two carbons between amino and benzene ring –Not new 2C-B, 2C-T-7, 2C-E, 2C-D, 2C-C, 2C-I, 2C- T2, 2C-T4, 2C-H, 2C-N, 2C-P • Newer 2C-I and 2C-I-NBOMe – 25I-NBOMe, 25I • 2-MethoxyBenzyl Nitrogen of phenethylamine “NBOMe”
25I-NBOMe
• 5-HT2 and α-adrenergic receptor effects • Submilligram doses snorted or placed on blotter paper “new LSD” • Clinically sympathomimetic toxidrome, hallucinations, agitated delirium, hyperthermia, seizures, death • Street names Solaris, Smiles, N-Bomb, Pandora, Dime, C-Boom • Treat with BZDs, haloperidol, IVF NS, aggressive cooling
Bromo Dragon Fly
• Synthetic hallucinogen • Sold as “research chemical” on Internet • Used on blotter or solution similar to “LSD” • Long duration of action 12–24 hours • Strong serotonergic effects • Hallucinations, seizures, death • Treatment BZD, haloperidol, IVF NS, cooling
Ketamine
• Dissociative anesthetic • Developed 1963 • Used in humans and veterinary medicine for short diagnostic and surgical procedures • Liquid injected or smoked or powder which is snorted or ingested • Much sold on street diverted from veterinarian sources Ketamine Street Names • Special K • Cat Valium • K • Kit Kat • Ket • Super Acid • Vitamin K • Purple Ketamine
• Structurally similar to phencyclidine (PCP) but less potent and shorter action • No effect on pharyngeal or laryngeal reflexes airway remains intact • Non-competitive antagonist of NMDA receptors • Alters perception, memory, and cognition • NMDA blockade causes increased dopamine concentrations in the prefrontal cortex and midbrain • May also stimulate 5HT receptors and inhibit reuptake of 5HT, DA, and NE Ketamine Effects-Desirable • Onset 10-20 minutes • Duration 1-4 hours • Pleasant feeling of floating and relaxation • Mild euphoria • Feeling of physical detachment • Causes visual, auditory and tactile hallucinations • “K-Land”
Ketamine Effects-Undesirable
• Tachycardia, mild hypertension, anxiety, loss of muscle control, inability to communicate • ? Seizures…does not make pharmacologic sense • Terrifying feeling of sensory detachment likened to near-death experience • “K-hole” • Recurrent Flashbacks • Treatment – Supportive Methoxetamine
• MXE, M ket, Mexxy • Similar to ketamine and PCP • Snorting, IV, IM, sublingual • Onset 10 to 20 minutes • Duration 2 to 3 hours • Sold on Internet as “GI friendly” although nausea and vomiting seen • Treatment supportive Butane Hash Oil
Known as “Wax” Very concentrated THC content Made by packing PVC tubing with marijuana and then butane under pressure Solubilized oil with THC collected Cooled and evaporated into “wax” Smoke by “dabbing” Risk of explosions
Butane Hash Oil
• Known as “Wax” • Very concentrated THC content • Made by packing PVC tubing with marijuana and then butane under pressure • Solubilized oil with THC collected • Cooled and evaporated into “wax” • Smoke by “dabbing” • Risk of explosions Summary • There are a wide variety of illicit drugs being used and always new ones • Clinicians should have a fundamental knowledge of the pharmacologic agents of abuse • Internet provides information of current drugs of abuse – e.g., Erowid, NIDA, DEA