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Continuing Education Course

Bath Salts and Synthetic Marijuana: An Emerging Threat BY Rommie L. Duckworth

TRAINING THE FIRE SERVICE FOR 135 YEARS

To earn continuing education credits, you must successfully complete the course examination. The cost for this CE exam is $25.00. For group rates, call (973) 251-5055. and Synthetic Marijuana: An Emerging Threat

Educational Objectives On completion of this course, students will

1) Define the term “”. 3) Determine what constitutes Bath Salts, and their effects.

2) Learn how regulation is not inhibiting the production of 4) Determine what constitutes Synthetic Marijuana, and its designer drugs. effects

BY ROMMIE L. DUCKWORTH emergency responders, and healthcare providers. Designer drugs are chemical compounds that are newly created, modi- April 5, 2011. Spanaway, Washington: Medic and Army Ser- fied, or repurposed to provide abusers with effects similar to geant Dave Stewart, high on bath salts bought at a local pipe currently illegal recreational drugs. They are often relatively shop, killed himself and his wife during a police pursuit. Their five-year-old son was also found dead in the car. easy to make and, because of their ever-changing ingredient list, are also extremely difficult to regulate. August 21, 2011. Bowling Green, Kentucky: Teenager Ashley The term “designer drugs” originated in the 1980s, but Stillwell became paralyzed while 7H, a form of syn- the idea of marketing legal chemical combinations related thetic marijuana, with her friends. She lay on the floor, helpless, to regulated or banned drugs dates back to the 1920s. Such as her friends discussed what to do, including how to dispose of her body. compounds, similar in structure or the effects produced by an- other chemical, are called “analogs.” When , , June 5, 2012. Austin, Texas: Eighteen-year-old Giovanni Leask and other opiates were regulated by the International was arrested for attacking and kicking a paramedic in the throat Convention of 1925, dealers began to sell acetylpropionylmor- while he was being treated for injuries resulting from his jump- phine—a similar but as yet unregulated drug.2 ing off a bridge. Leask was high on bath salts at the time. Most recently, emergency responders are confronting synthet- round the country and across the news, ic marijuana and bath salts across and Europe. stories like these are playing out with alarming According to the American Association of Poison Control Cen- frequency. Emergency services are confronted by ters, calls regarding synthetic marijuana almost doubled from A 3 horrific events caused by a surge in the use of new types of 2010 to 2011, and calls related to bath salts went up from 304 designer drugs. This article discusses the upsurge in bath salts in 2010 to more than 6,000 in 2011.4 Not only are these drugs and synthetic marijuana: what they are, where they have been cheap and easy to obtain, but many users believe they are legal coming from, and what form they may take in the future; what or, at least, that they are unlikely to get arrested for using or regulators and law enforcement are doing to stop them; and possessing them. what field providers can do to manage the fallout from this new wave of designer drugs. REGULATION In the in 1986, the Controlled Substance Designer Drugs Analog Enforcement Act was passed to control unregulated Although abuse of prescription painkillers like oxycontin substances that mimic controlled substances. The loophole remains the largest drug problem in the United States (over- through which many designer drugs slip is the fact that, un- doses kill more than 15,000 people per year),1 designer drugs less specifically banned, chemical substances labeled as “not present an evolving problem for law enforcement, regulators, for human consumption” are not considered drugs at all. As a www.FireEngineeringUniversity.com emerging threats ● result, as soon as one “active ingredient” for a designer drug levels, bath salts can still be purchased through many convenience is banned, another analog or variant is substituted, continu- stores, gas stations, head shops, tattoo parlors, and the Internet. ing the game of catch-up for regulators, law enforcement, and Routes. Bath salts are typically snorted, but abusers may also other emergency responders. ingest, inject, or smoke them; insert them rectally directly; or mix One explanation for the popularity of these substances is them with water and use them as eye drops. the relative difficulty in testing for them in suspected abus- Mechanism of action. The active ingredients in bath salts ers; synthetic marijuana is not detectable in standard urine impact monamine neurotransmitters acting as -nor- drug screens. Still, determining what drugs were taken is less epinephrine reuptake inhibitors (NDRI).8 This, in turn, leads to important for field providers than managing the signs and an increase in and, to a lesser extent, dopamine.9 symptoms resulting from the abuse. Intended effects. The sensations abusers seek may either On a federal level on March 1, 2011, a ban on five of the be those similar to MDMA (Ecstasy) such as increased arousal, main synthetic (JWH-018, JWH-073, JWH-200, sociability, and euphoria or those similar to and meth- CP 47,497, and CP 47,497 C8) was enacted, making all of them such as increased mental focus, stimulation, and Schedule 1 Controlled Substances.5 On September 7, 2011, the physical energy. Bath salts are often used in combination with United States Drug Enforcement Agency invoked “emergency other recreational substances such as , marijuana, am- scheduling” on the three primary active ingredients in bath salts phetamines, LSD, opiates, , and other designer to restrict sales from October 7, 2011, to October 7, 2012.6 drugs for a combination of effects. Although federal bans help control large distributors and Unintended effects. The results can vary widely depending cross-state trafficking, state and local authorities must also on product strength, active ingredients and fillers, dosing, route act to affect individual users and local distributors. As of this of administration, and individual physiology. Because of this, writing, most states have banned at least some of the active bath salts frequently produce undesired cardiac side effects in- ingredients in these designer drugs, but the degree to which cluding , hypertension, hyperthermia, and peripheral these drugs are manufactured, distributed, sold, possessed, or vasoconstriction and neurological side effects including insomnia, used still varies widely. depression, , anxiety, psychosis, , confu- sion, and excited .10 In addition, bath salts have been BATH SALTS reported to produce a high craving for immediate re-dosing, What are they? Never intended for use as actual bath salts, leading to increases in the frequency and intensity of these unde- these chemicals have virtually nothing in common with the sired side effects. Epsom salts you might use to relax in your tub after a long Duration. The duration of effects varies greatly in the same way shift. These recreational drugs are marketed as products “not for that the effects themselves can. Onset of action (the “come up” human consumption” to avoid state and federal regulation as phase) is typically from 30 minutes to two hours, with the “peak” drugs or food substances. They are instead sold as fertil- at approximately 90 minutes and the “come down” phase some izers; insect repellants; pond cleaners; vacuum fresheners; and, time from two to four hours. of course, most popularly as bath salts, from which the slang for Why you might see them. Some patients, thinking that this category of drug is derived. bath salts are legal products, may readily admit to their use Where did they come from? Bath salts arrived in the and call for assistance if they begin to experience unpleasant United States around 2008, but both demand and availabil- side effects. You might also suspect bath salt abuse in patients ity of the product exploded in 2010. Typically supplied as a found to be suddenly hyperactive, paranoid, aggressive, “fiend- white, brown, or gray powder (depending on the manufactur- ish” (compulsory drug seeking or re-dosing), suicidal, self-mu- ing method), bath salts are packaged in small foil or plastic tilating, or in excited delirium without other explanation. bags. The active ingredients in these formulations are analogs of , a derivative of the plant used as a stimu- SYNTHETIC MARIJUANA lant for hundreds of years throughout the Middle East and What is it? In an effort to circumvent regulation, synthetic .7 Although cathinone itself is a federal Class I Con- marijuana, like bath salts, is labeled “not for human consump- trolled Substance (high potential for abuse, no medical uses), tion.” Most commonly marketed under the names of “Spice” the cathinone analogs (4-MMC), , and and “K2” and labeled as incense, synthetic marijuana is typi- methylenedioxypyrovalerone (MDPV) are the primary active cally sold as loose-leaf herbs in small prepackaged bags or ingredients in most bath salt concoctions and are not yet prerolled cigarettes.11 Other common names for synthetic permanently federally controlled. (5) Not only can a variety of marijuana include “Genie,” “Yucatan Fire,” “Sence,” “Smoke,” these active ingredients be found in bath salt mixtures sepa- “Skunk,” and “Zohai.” Like bath salts, new slang terms and rately or in combinations, but they can also be mixed with a brand names for synthetic marijuana continue to develop. Also variety of “filler” components. like bath salts, various forms of synthetic marijuana can be Common brand names of bath salts include “Vanilla Sky,” “Cloud obtained through local shops and the Internet. Nine,” “Ivory Wave,” “Aura,” “Blizzard,” “Scarface,” and “White Light- Where did it come from? Trafficking of synthetic canna- ning.” The speed at which new products can be produced means binoids was first reported in the United States in December that this list may be outdated by the time you finish reading this 2008, when a shipment was seized by U.S. Customs in Dayton, sentence. Despite ongoing regulatory efforts at the state and federal Ohio.12

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These herbal concoctions list ingredients including Little scientific research has been done on the long-term thought to produce -like effects including Scutellaria effects of these drugs in humans, but it seems that tolerance nana, Nelumbo nucifera, Leonotis leonurus, Nymphaea caerulea, may develop relatively quickly, leading to a great potential Canavalia maritima, Pedicularis densiflora, latifolia, and for dependence.18 Not only are the active ingredients in these Leonurus sibiricus, but it is now understood that the herbal ingre- products much stronger than most users expect, but it appears dients themselves serve primarily as filler. The active ingredients in that unknown interactions are producing effects that are the these products are typically powdered that opposite of what users and healthcare providers would expect contain no actual marijuana and are simply mixed or sprayed onto to see with natural marijuana.19 the herbs.13 Synthetic cannabinoids are a class of man-made sub- Intended effects. The effects that users typically seek to stances that act as receptor agonists. This means that obtain through synthetic marijuana products are the same as they are chemicals that bind with receptors (CB1 in the brain and those with natural marijuana including euphoria, relaxation, CB2 in the spleen), producing a high similar to that of naturally and sociability. occurring cannabinoids (marijuana, THC).14 Unintended effects. As with bath salts, the effects of synthetic A number of active ingredients have been found in these marijuana can vary widely depending on product strength, ac- mixtures, all variations and derivatives of pharmaceutical tive ingredients and fillers, dosing, route of administration, and research going back 50 years. This research has long been in individual physiology. Undesired cardiac side effects of synthetic an effort to isolate the undesired psychoactive effects of can- marijuana include tachycardia, hypertension, and chest or nabinoids from the therapeutically valuable ones, particularly . Neurological side effects including paras- for the treatment of and loss of appetite from cancer thesias, anxiety, psychosis, paranoia, confusion, tremors, seizures, chemotherapies.15 hallucinations, and excited delirium. As a result of the psycho- Cannabinoid agonists fall into four major groups: logical effects of synthetic marijuana, some users present with • Analogs of THC developed in the 1960s including HU-120 suicidal ideation, self-mutilation, and highly aggressive behavior. (HU stands for Hebrew University, where the chemical was 20-23 synthesized). Some users report such little effect from “normal” dosing that • Nonclassical cannabinoids such as the cyclohexylphenol they may use larger quantities in subsequent doses, enhanc- (CP) series developed by Pfizer in the 1970s. ing the undesired effects. Discussion of synthetic marijuana use • Aminoalkylindoles or JWH compounds, developed in the on Internet discussion forums and comment threads illustrate 1990s and named after their inventor, J. W. Huffman. the variety and unpredictability of the effects of these drugs. • Miscellaneous compounds including fatty acid amides such Comments range from “I tried the ‘legal’ K2 last night and was as oleamide. not impressed” to “I smoke and have for many years! My These chemicals are all fairly volatile (vaporize readily) and, heartbeat started to get my attention. It started to beat harder therefore, “smokeable,” and examples from all four groups and faster. I thought I was going to die or at the very least was have been reported to be in synthetic marijuana. having a heart attack. The pain was really bad, but the fear of Although you probably will not know the specific underlying dying was worse. This is just a warning. I am not trying to scare active ingredient affecting your patient, it is important that you you.” (17) recognize that, like bath salts, synthetic marijuana refers to not Duration. As with bath salts, the duration of the effects of one single product but rather to a wide variety of products with synthetic marijuana can vary greatly. Onset of action (the “come varying active ingredients in varying combinations and with up” phase) is typically from 15 to 30 minutes, with the “peak” at different fillers, which may produce drastic and sudden changes approximately 90 minutes and the “come down” phase extremely in patient condition.16 variable, from one to six hours. The primary synthetic cannabinoid currently in use is JWH- Why you might see them. Like users of bath salts, many 018. (14) Although JWH-018 is currently banned, more than users of synthetic marijuana believe that they are using legal 100 other synthetic cannabinoids that may lead to emergency products, may admit to their use, and call 911 when they or services dealing with ever-changing forms of “legal highs” someone else begins experiencing side effects. You may sus- exist. pect synthetic marijuana abuse in patients found to be expe- Routes. Synthetic marijuana is typically smoked or eaten in riencing uncontrollable tremors, seizures, difficulty breathing, the same manner as natural marijuana. chest pain, or suddenly becoming anxious, paranoid, aggres- Mechanism of action. Natural cannabinoids (such as sive, suicidal, self-mutilating, or in excited delirium without THC) and synthetic cannabinoids (of which more than 100 other explanation. compounds already exist) act by binding to CB1 and CB2 receptors. These receptors are linked to proteins that regulate MANAGEMENT OF neurotransmitters. Although, as with bath salts, the variety of EMERGENCIES active ingredients, fillers, doses, and dosing methods will im- Although there is no “antidote” for either bath salt or synthetic pact the effect or “high” of synthetic marijuana, synthetic can- marijuana intoxication, basic life support (BLS) and advanced life nabinoids tend to bind better and longer to the CB receptors support (ALS) emergency responders can apply a number of very than natural THC, generally producing stronger effects.17 good general guidelines to manage suspected emergencies.

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PREPARATION —Toxins/Trauma (CHI) Police, firefighters, emergency medical service (EMS), and in-hos- —Infection pital healthcare providers must work in close coordination to pro- —Psychiatric vide care for these patients, and this coordination must begin well —Shock/Stroke/Seizure before the call to 911. Law enforcement, EMS, and firefighters called • (ALS) Establish an IV, and protect it from removal. If you to the scene must all have the same expectations as to what is going suspect excited delirium, you may consider a fluid bolus and to happen as well as who will play what roles. Likewise in-hospital administration of sodium bicarbonate for shock and rhabdo- and prehospital healthcare providers must have an understanding of myolysis according to local protocol. each other’s protocols and capabilities. • The patient will often be hyperthermic. This may be because of prior agitation, the protesting of physical restraint, or MANAGE THE SCENE metabolic factors related to the drugs. If this is the case, • As always, first ensure safety for yourself, your fellow pro- consider external cooling as you would any other hyperther- viders, and bystanders. Remember, patients abusing bath salt mic patient. Keep in mind that hyperthermia is another key and synthetic marijuana are particularly prone to sudden indicator of excited delirium. and violent behavioral changes. • (ALS) Closely monitor the patient’s mental state, level of • The 911 calls for these patients may not include any informa- sedation, ECG, pulse oximetry, and other vital signs. tion about drug use. Clues and cues to bath salt and synthetic • Continually reassess your patient, as sudden and drastic marijuana use include or litter on scene, behavioral and physiological changes are the hallmarks of sudden onset tremors, seizures, difficulty breathing, chest pain, designer drug-related emergencies. anxiety, paranoid, and aggressive or suicidal behavior without PITFALLS AND PRECAUTIONS other explanation. Keep in mind that drugs might not be the • Preparation for these calls begins with responder education patient’s only issue. and collaboration. • Cofactors to bath salt and synthetic marijuana-related emer- • Always keep safety in mind, as conditions can change rapidly gencies include police use of chemical (pepper spray) or on these calls. electrical (TASER®) restraint prior to your arrival. Additional- • Coordinate physical restraint, and be prepared for a pro- ly, a patient history of mental illness, multiple types of drugs longed struggle. onboard, and patient comorbid factors such as diabetes or • If at all possible, do not attempt physical restraint without history of respiratory or cardiac problems may be obtainable chemical restraint. only through evidence and bystanders on scene. • Do not attempt chemical restraint without physical restraint. • Consider bath salts/synthetic marijuana/other designer drugs MANAGE THE PATIENT as an underlying cause of sudden patient changes, such as • Attempt to establish a patient rapport, but always be pre- those listed above, without other explanation. pared for sudden changes in patient behavior. • Consider other causes of altered mental status (AEIOU- • Coordinate with other emergency responders to physically TIPS). restrain the patient. You can use a variety of methods, but be sure to control all four extremities as well as the patient’s THE FUTURE head. Do not use chemical pepper spray, and do not place Bath Salts the patient in a prone or hog-tied position. Keep in mind More recently termed “research chemicals,” designer drugs that physical restraint may be particularly difficult in these continue to be created, modified, marketed, and abused at an patients because of increased strength, decreased pain sensi- alarming rate. Now that the primary active ingredients in bath tivity, and loss of rational thought. salts, 4-MMC and MDPV, have been regulated, manufacturers • (ALS) If possible, pharmaceutical restraints should quickly fol- are substituting analogs including a-PPP, MPPP, MDPPP, and low or occur simultaneously with physical restraint. Administer other chemical cousins that produce similar intoxicating and benzodiazepines such as midazolam (Versed®) or lorazepam toxic effects. And the ingredients aren’t the only thing evolv- (Ativan®) per protocol preferably IN or IM. ing. In addition to marketing as bath salts, plant fertilizers, and insect repellants, bath salts are most recently being marketed MANAGE THE CARE under the description of electronic screen cleaners and jewelry • As soon as possible, perform a full physical exam, triaging and cleaners with names like “M-Shine,” “Freebase,” and “Blast.” 24 treating signs and symptoms. As always, focus on the ABCs. • Consider other causes of altered mental states including Synthetic Marijuana those listed in the AEIOU tips mnemonic: Likewise, synthetic marijuana is being updated and marketed —Alcohol on Web sites claiming, “There is a new generation of K2 products —Endocrine/Electrolytes/Encephalopathy that are completely legal everywhere” or “Not covered by any —Insulin (hypoglycemia) ban, restriction, or regulation!” Despite state and federal bans, —Oxygen (hypoxia) these new concoctions are likely to continue to progress through —Uremia the more than 100 synthetic cannabinoids differentiated only by

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12. DEA Diversion Control - Controlled Substance Schedules. deadiversion. new names like “K2 Sky,” “K2 Solid Sex,” “K2 Orisha,” “K2 Amazo- usdoj.gov. Springfield, VA: DEA; http://www.gpo.gov/fdsys/pkg/FR-2012- nian Shelter,” and “K2 Thai Dream.” 25 03-01/html/2012-4982.htm. Despite ongoing efforts to control the distribution and use 13. emcdda.europa.eu. (n.d.). emcdda.europa.eu, European Monitoring of these designer drugs, emergency responders must be pre- Centre for Drugs and Drug . Paper PDF can be accessed at http://www.emcdda.europa.eu/publications/thematic-papers/spice. pared to deal with this problem as it evolves. Bath salts and synthetic marijuana aren’t going away any time soon, and the 14. Huffman, JWJ, Mabon, RR, Wu, MJM, et al. (1999). Current Medicinal Chemistry. (Atta-ur-Rahman, ed.) Cannabimimetic Indoles, Pyrroles and optimal way to prepare yourself is to know and understand Indenes (Vol 6, pp705-720). Boca Raton, FL. what these substances are, how they work, and how best to 15. Huffman, J. W., Dai, D., Martin, B. R., & Compton, D. R. (1994). Design, manage patients who are users: Synthesis and of Cannabimimetic Indoles. Bioorganic & • Manage the scene. Medicinal Chemistry L.etters, 4(4), 563–566. • Manage the patient. 16. Auwärter, V., Dresen, S., & Weinmann, W. (2009). “Spice”and other • Manage the care. herbal blends: harmless incense or cannabinoid designer drugs? … Mass Spectrometry. You may encounter abusers of bath salts or synthetic marijuana under a variety of circumstances. You may not know what they 17. Bergen, K. (2010, February 17). Kansas lab looked at synthetic mari- juana’s effect on brain - Columbia Missourian. Missourian, Potent Combina- took, how much of it they took, or even what was in it. You may tions. Retrieved June 14, 2012, from http://www.columbiamissourian.com/ not know if your call is going to be fatal or just frightful. But you stories/2010/02/17/legal-substance-mimic-marijuana-has-harmful-effects/. can know how to manage the scene, the patient, and the prehospi- 18. Zimmermann, U. S., Winkelmann, P. R., Pilhatsch, M., Nees, J. A., tal care that you will need to provide for the best possible patient Spanagel, R., & Schulz, K. (2009). Withdrawal phenomena and dependence syndrome after the consumption of “spice gold”. Deutsches Ärzteblatt outcome. ● international, 106(27), 464–467. 19. AAPCC. (2010, March 24). American Association of Poison Control References Centers Warn About Dangers of Synthetic Marijuana Product. American Association of Poison Control Centers. ndria, VA. Retrieved June 14, 2012, 1. Barker, P, Chapter, JB, Chapter, JG, Chapter, BH, Hedden, SL, Chapter, from http://www.prnewswire.com/news-releases/american-association- AH, Chapter, MJPO, et al. (2011). Results from the 2010 National Survey on of-poison-control-centers-warn-about-dangers-of-synthetic-marijuana- Drug Use and Health: (No. 11-4658). oas.samhsa.gov, Summary of National products-89004037.html. Findings. Rockville, MD: and Mental Health Services Administration. 20. Castellanos, D., Singh, S., Thornton, G., & Avila, M. (2011). Synthetic Cannabinoid Use: A Case Series of Adolescents. Journal of Adolescent 2. Streatfeild, D. (2002). Cocaine. An Unauthorized Biography (p. 532). Health. Random House. 21. DEA DEA Diversion Control - Controlled Substance Schedules, deadi- 3. AAPCC. (2012a, May 23). American Association of Poison Control Cen- version.usdoj.gov. Springfield, VA: ED A. 4/2012, http://www.deadiversion. ters Synthetic Marijuana Data. aapcc.org, Updated May 23, 2012. Retrieved usdoj.gov/schedules/orangebook/orangebook.pdf. June 13, 2012, from http://www.aapcc.org/dnn/Portals/0/Synthetic%20 Marijuana%20Data%20for%20Website%205.23.2012.pdf. 22. Hoyte, C. O., Jacob, J., Monte, A. A., Al-Jumaan, M., Bronstein, A. C., & Heard, K. J. (2012). A Characterization of Synthetic Cannabinoid Exposures 4. AAPCC. (2012b, May 23). American Association of Poison Control Cen- Reported to the National Poison Data System in 2010. Annals of Emergen- ters Bath Salts Data. aapcc.org, Updated May 23, 2012. Retrieved June 13, cy Medicine, –. doi:10.1016/j.annemergmed.2012.03.007. 2012, from http://www.aapcc.org/dnn/Portals/0/Bath%20Salts%20Data%20 for%20Website%205.23.2012.pdf. 23. Mir, A., Obafemi, A., & Young, A. (2011). Myocardial Infarction Associ- ated With Use of the Synthetic Cannabinoid K2. Pediatrics. 5. DEA. (2011a, April 1). Microgram Bulletin. (D. E. Administration, Ed.)jus- tice.gov, REQUEST FOR INFORMATION ON SYNTHETIC . 24. Allen, R., & Owens, W. (2012, May 31). FDNY Fireguard Update: Bath Retrieved June 13, 2012, from http://www.justice.gov/dea/programs/foren- Salts. FDNY Center for Terrorism and Disaster Preparedness (CTDP), Legal, sicsci/microgram/mg2011/mg0411.pdf. Synthetic . New York, NY. Retrieved June 14, 2012, from http://www.nysvara.org/news/2012/june/120603.pdf. 6. DEA. (2011b, September 7). News from DEA, News Releases, 09/07/11. justice.gov. Springfield, VA. Retrieved June 14, 2012, from http://www. 25. Mazzoni, O., Diurno, M. V., di Bosco, A. M., Novellino, E., Grieco, P., justice.gov/dea/pubs/pressrel/pr090711.html. Esposito, G., Bertamino, A., et al. (2009). Synthesis and Pharmacological Evaluation of Analogs of Indole-Based Cannabimimetic Agents. Chemical 7. Nutt, D., King, L., & Saulsbury, W. (2007). Development of a rational scale Biology & Drug Design, –. doi:10.1111/j.1747-0285.2009.00910.x. to assess the harm of drugs of potential misuse. The Lancet. 8. Springer, D. D., Fritschi, G. G., & Maurer, H. H. H. (2003). Metabolism of the new designer drug alpha-pyrrolidinopropiophenone (PPP) and the toxicological detection of PPP and 4’-methyl-alpha-pyrrolidinopropi- ophenone (MPPP) studied in rat urine using gas chromatography-mass spectrometry. Journal of Chromatography B, 796(2), 253–266. doi:10.1016/j. jchromb.2003.07.008. 9. Karila, L. (2011). GHB and synthetic cathinones: clinical effects and poten- tial consequences - Karila - 2010 - Drug Testing and Analysis - Wiley Online Library. Drug testing and analysis. ● ROMMIE L. DUCKWORTH is a career fire lieutenant and EMS coordinator for the Ridgefield (CT) Fire Department. 10. Wood, D., Davies, S., & Puchnarewicz, M. (2009). 153. Recreational Use of 4-Methylmethcathinone (4-MMC) Presenting with Sympathomimetic He has more than 20 years of experience working in career Toxicity and Confirmed by Toxicological Screening. Clinical Toxicology and volunteer fire agencies, public and private emergency 47:7331. services, and hospital-based healthcare systems. He is a 11. Deluca, P., Schifano, F., Davey, Z., Corozza, O., di Furia, L., Farre, M., frequent speaker at national conferences and a regular con- Flesland, L., et al. (2010). Psychonaut WebMapping Research Group. psy- tributor to research programs, magazines, textbooks, and chonautproject.eu, Spice Report. London, UK: Psychonaut WebMapping new media on fire and emergency service topics. Research Group.

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COURSE EXAMINATION 1) Which prescription painkiller remains the largest cause of 8) What act was passed in 1986 to control unregulated substances overdose deaths in the United States? that mimic controlled substances? a. Vicodin a. Controlled Substance Enforcement Act b. Oxycontin b. Designer Drug Analog Enforcement Act c. Tylenol c. Synthetic Drug and Substance Control Act d. Morphine d. Controlled Substance Analog Enforcement Act

2) Designer Drugs are ______that are newly created, 9) The loophole through which many Designer Drugs slip is the fact modified, or repurposed to provide abusers with effects similar to that, unless specifically banned, chemical substances labeled as currently illegal recreational drugs. “not for human consumption” are not considered drugs at all. a. Chemical Compounds a. True b. Store-bought drugs b. False c. combined drugs d. Single chemical drugs 10) Which drug is usually sold as plant fertilizers, insect repellents, pond cleaners, vacuum fresheners? 3) Designer Drugs are harder to make than their real counterparts. a. Bath Salts a. True b. Designer Oxycontin b. False c. Synthetic Marijuana d. None of the above 4) When did Designer Drugs make an appearance in the United States? 11) How are Bath Salts packaged? a. 1960s a. In large bricks b. 1970s b. In large pails for wholesale c. 1980s c. In small foil or plastic bags d. 1990s d. In small landscape bags for long-term storage

5) Chemical compounds used in Designer Drugs are similar in 12) Bath Salts are typically ______when used as Designer Drugs. structure, or their effects produced by another chemical are a. Snorted called, “analogs”. b. Smoked a. True c. Injected b. False d. Eaten

6) According to the American Association of Poison Control Centers, 13) The mechanism of action for Bath Salts is ______. Calls regarding synthetic marijuana almost ______from 2010 to 2011. a. Decrease in b. Increase in Serotonin a. Doubled c. decrease in Serotonin b. Tripled d. Increase in c. Quadrupled d. Quintupled 14) What Designer Drug is commonly marketed under such names as “Spice” and “K2?” 7) Many users of Designer Drugs believe they are legal, and that they are unlikely to get arrested for using or possessing them. a. Bath Salts b. Oxycontin derivatives a. True c. Synthetic Marijuana b. False d. Synthetic Oxycontin

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15) How is Synthetic Marijuana used as a Designer Drug? 18) Due to the state of euphoria that most Designer Drug users seek, they are less prone to be sudden and violent behavioral a. Smoked or injected changes. b. Smoked or eaten c. Eaten or ingested a. True d. Only Smoked b. False

16) Synthetic Marijuana can produce a stronger “high” than natural 19) Also termed “research chemicals,” Designer Drugs are continuing marijuana. to be created, modified, marketed and abused at an alarming rate. a. True b. False a. True b. False 17) What are some signs and symptoms of Synthetic Marijuana use? 20) The optimal way to prepare yourself against abusers of Designer a. Tremors Drugs is to: b. Seizures a. Manage the scene c. Paranoia b. Manage the patient d. All of the above c. Manage the care d. All of the above

Notes

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PROGRAM COMPLETION INFORMATION If you wish to purchase and complete this activity traditionally (mail or fax) rather than Online, you must provide the information requested below. Please be sure to select your answers carefully and complete the evaluation information. To receive credit, you must receive a score of 70% or better. Complete online at: www.FireEngineeringUniversity.com

PERSONAL CERTIFICATION INFORMATION: Answer Form Please check the correct box for each question below. Last Name (PLEASE PRINT CLEARLY OR TYPE) 1. ❑ A ❑ B ❑ C ❑ D 11. ❑ A ❑ B ❑ C ❑ D 2. ❑ A ❑ B ❑ C ❑ D 12. ❑ A ❑ B ❑ C ❑ D First Name 3. ❑ A ❑ B ❑ C ❑ D 13. ❑ A ❑ B ❑ C ❑ D 4. ❑ A ❑ B ❑ C ❑ D 14. ❑ A ❑ B ❑ C ❑ D Profession/Credentials License Number 5. ❑ A ❑ B ❑ C ❑ D 15. ❑ A ❑ B ❑ C ❑ D

Street Address 6. ❑ A ❑ B ❑ C ❑ D 16. ❑ A ❑ B ❑ C ❑ D 7. ❑ A ❑ B ❑ C ❑ D 17. ❑ A ❑ B ❑ C ❑ D Suite or Apartment Number 8. ❑ A ❑ B ❑ C ❑ D 18. ❑ A ❑ B ❑ C ❑ D 9. ❑ A ❑ B ❑ C ❑ D 19. ❑ A ❑ B ❑ C ❑ D City/State Zip Code 10. ❑ A ❑ B ❑ C ❑ D 20. ❑ A ❑ B ❑ C ❑ D

Daytime Telephone Number with Area Code Course Evaluation Fax Number with Area Code Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 1.

E-mail Address 1. To what extent were the course objectives accomplished overall? 5 4 3 2 1

traditional compleTION INFORMATION: 2. Please rate your personal mastery of the course objectives. 5 4 3 2 1 Mail or fax completed answer sheet to 3. How would you rate the objectives and educational methods? 5 4 3 2 1 Fire Engineering University, Attn: Carroll Hull, 1421 S. Sheridan Road, Tulsa OK 74112 4. How do you rate the author’s grasp of the topic? 5 4 3 2 1 Fax: (918) 831-9804 PAYMENT & CREDIT INFORMATION 5. Please rate the instructor’s effectiveness. 5 4 3 2 1 Examination Fee: $25.00 Credit Hours: 4 6. Was the overall administration of the course effective? 5 4 3 2 1 Should you have additional questions, please contact Pete 7. Do you feel that the references were adequate? Yes No Prochilo (973) 251-5053 (Mon-Fri 9:00 am-5:00 pm EST).  ❑ I have enclosed a check or money order. 8. Would you participate in a similar program on a different topic? Yes No  ❑ I am using a credit card. 9. If any of the continuing education questions were unclear or ambiguous, please list them. My Credit Card information is provided below. ______ ❑ American Express  ❑ Visa  ❑ MC  ❑ Discover 10. Was there any subject matter you found confusing? Please describe. Please provide the following (please print clearly): ______Exact Name on Credit Card 11. What additional continuing education topics would you like to see? Credit Card # Expiration Date ______Signature PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

AUTHOR DISCLAIMER INSTRUCTIONS COURSE CREDITS/COST The author(s) of this course has/have no commercial ties with the sponsors or the providers of the unrestricted educational All questions should have only one answer. Grading of this examination is done manually. Participants will receive All participants scoring at least 70% on the examination will receive a verification form verifying 4 CE credits. grant for this course. confirmation of passing by receipt of a verification form. Participants are urged to contact their state or local authority for continuing education requirements. SPONSOR/PROVIDER EDUCATIONAL DISCLAIMER RECORD KEEPING No manufacturer or third party has had any input into the development of course content. All content has been derived The opinions of efficacy or perceived value of any products or companies mentioned in this course and expressed PennWell maintains records of your successful completion of any exam. Please go to www.FireEngineeringUniversity.com to from references listed, and or the opinions of the instructors. Please direct all questions pertaining to PennWell or the herein are those of the author(s) of the course and do not necessarily reflect those of PennWell. see your continuing education credits report. administration of this course to Pete Prochilo, [email protected]. Completing a single continuing education course does not provide enough information to give the participant the COURSE EVALUATION and PARTICIPANT FEEDBACK feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and © 2009 by Fire Engineering University, a division of PennWell. We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. clinical experience that allows the participant to develop skills and expertise. Please e-mail all questions to: Pete Prochilo, [email protected].

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