“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) • at endogenous cannabinoid receptors • Herbal components may contribute to high • Head shops initially now Internet • Cost $25 to $50

Clinical Presentation

• Anxiety • • Agitation • Psychosis • • 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

• Substituted 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- – DOM or STP • – 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 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, , insomnia, paranoia, • Hypertension, tachycardia, cardiac dysrhythmias • Seizures, , rhabdomyolysis • Hyponatremia • Serotonin increases ADH release causing an SIADH-like state • Ingestion of large amounts of free water • Chronic use • Damage to and possibly 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

Potent serotonergic agents

• 1940s (BZP) as antiparasitic • 1970s studied as • 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 – • Street names “party pills” BZP, A2, Legal E, Legal X • Treat with BZDs, , IVF NS, aggressive cooling

2C Agents • 2Cs – Two carbons between amino and benzene ring –Not new -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 “NBOMe”

25I-NBOMe

• 5-HT2 and α-adrenergic receptor effects • Submilligram doses snorted or placed on blotter paper “new LSD” • Clinically sympathomimetic , 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 • 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 Street Names • Special K • Cat Valium • K • Kit Kat • Ket • Super Acid • Vitamin K • Purple Ketamine

• Structurally similar to (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 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

• 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