10/22/2018 Emerging Drugs of Abuse: The New Kids on the Block Jared O’Connor MS, MPH Raman Nagra Health Education and Outreach Specialist EWU Intern Washington Poison Center Eastern Washington University [email protected] [email protected] Emerging Drugs of Abuse • Overview • Nicotine • Cannabinoids • Opiates • Other Drugs of Abuse Always here to help, 24/7/365. Modes of Administration • 1. Inhalation (7‐10 sec) • 2. Injection • ▪ IV “slamming” (15‐30 sec) • ▪ SC “skin popping” (3‐5 min) • ▪ IM “muscling” (5‐7 min) • 3. Mucosal Absorption (?) • ▪ snorting • ▪ buccal • ▪ vaginal/rectal “bumping” • 4. Oral (20‐30 min) • 5. Contact Absorption (?) • ▪intraocular • ▪ lingual • ▪ transdermal Always here to help, 24/7/365. 1 10/22/2018 Synthetics • Drugs like Molly, MDMA, 2CE, bath salts, synthetic marijuana small segment of drug use • Synthetic opiates are an increasing problem • Present a problem because they rapidly change and can be deadly • Synthetics tend to have more profound effects then their natural counterparts • Greater receptor affinity • More addictive Always here to help, 24/7/365. Origin • Per DEA, many synthetic drugs coming from China • Bath salts • Spice/K2 • Methamphetamine in the state produced locally • Krokodil coming from Russia or produced locally • Lack of quality control and standardization Always here to help, 24/7/365. Nicotine Always here to help, 24/7/365. 2 10/22/2018 What is in the e‐juice/e‐liquid? • Liquids or “Juices” typically have 4 ingredients: • Liquid nicotine • Propylene glycol • Vegetable glycerin • “Flavoring” • LD 50 in mice is 1mg per lb • Can have 36mg ML • 15ml a bottle Always here to help, 24/7/365. What is in the e‐juice/e‐liquid? • High doses of Nicotine • Nausea • Lethargy • Central nervous depression • Respiratory depression • Death Always here to help, 24/7/365. Always here to help, 24/7/365. 3 10/22/2018 Always here to help, 24/7/365. Cannabis Always here to help, 24/7/365. Cannabis • In general... • Toxicity is mild • Effects not prolonged and usually not life threatening • Potentially problematic in children who ingested edibles or abuse of hash oil • Psychiatric effects predominate • Usually a sense of well being and relaxation, euphoria, “dream‐like”state • Use of marijuana in naïve users or using large amounts can produce more significant symptoms • Anxiety, paranoia, acute psychosis or obsessional thinking • Impairment of speech and fine motor skills • Increased risk for MVA Always here to help, 24/7/365. 4 10/22/2018 Cannabis • Various different cannabinoids out there • THC most common and used to achieve the characteristic high • CBD popular in medical marijuana due to its anti‐inflammatory/analgesic effects • Smoking marijuana produces a high within 8‐10 minutes and last around 4‐6 hours • Impairment, including fine motor skill impairment, can last up to 24 hours • Ingesting marijuana produces high from 1 hour to 3 hours • Potential for “Overdose” if patient redoses multiple times Always here to help, 24/7/365. Cannabis and Health • Extremely addictive • 1/10 users of marijuana will become addicted • Under 18, 1/6 will become addicted • Health Effect • Problems with memory, attention, and learning • Anxiety, paranoia, and sometimes extreme psychotic reactions • Can impact the development of the brain until age 25 • Harmful to lung tissue • Many of the same carcinogens as in tobacco smoke • Small blood vessel damage • Second hand smoking Always here to help, 24/7/365. Cannabis “Waxes” • Butane Hash Oil (BHO) is a wax‐like or pollen‐like residue • Placed directly onto coil that is then turned on • Need temperatures to reach 350‐450 ˚F to release cannabinoids Homemade BHO Wikimedia commons G Pen Coil http://www.npr.org/sections/health-shots/2014/04/18/302992602/pot-smoke-and-mirrors-vaporizer- pens-hide-marijuana-use Always here to help,Micro G Pen & Container 24/7/365. 5 10/22/2018 Cannabis • Butane Hash Oil (BHO) or dab • Dangerous manufacturing which can be explosive • Highly concentrated form of THC • Up to 95% THC • Plant typically up to 20% (8‐12% more common) Always here to help, 24/7/365. Vaping & Dabbing: Not quite the same http://googleweed.com/ Always here to help, 24/7/365. Cannabis edibles • Homemade edibles • Unknown concentration or if other drugs present • Many edibles easily confused with commercial products intended for children • Recent Crackdown might outlaw commercial Edibles Always here to help, 24/7/365. 6 10/22/2018 WAPC Trends ‐ Marijuana Always here to help, 24/7/365. Common Symptoms For Cannabis Exposure Top 5 symptoms for marijuana exposure include: 1. Drowsiness/Lethargy 2. Increased heartrate 3. Agitated/Irritable 4. Vomiting 5. Nausea Always here to help, 24/7/365. Synthetic Cannabinoids • Illegal as of May 2013 • DEA classified as Class 1 Drug • Several drugs • Spice/K2 • Up to 800x more powerful then marijuana • B‐FUBINACA/ AK‐47 24 Karat Gold • 50 x more powerful then K2 • Per DEA, Synthetics are coming from China, same with synthetic opiates • Patents are published and use by foreign nations Always here to help, 24/7/365. 7 10/22/2018 Synthetic Cannabinoids • Extremely addictive • Compared to Heroin or Cocaine • Health effects • Severe agitation and anxiety. • Fast, racing heartbeat and higher blood pressure. • Nausea and vomiting. • Muscle spasms, seizures, and tremors. • Intense hallucinations and psychotic episodes. • Suicidal and other harmful thoughts and/or actions. • Can cause Death • Hyperthermia, Seizures, Heart attack, Coma, Kidney damage, & Brain Edema among others • Jan 1,2016 to Jun 30th, Poison Centers received 4,270 calls regarding exposures • Few cases in Washington Always here to help, 24/7/365. Opioids Always here to help, 24/7/365. What is An Opiate/Opioid? • Opiate is a drug derived from Opium • Morphine • Codeine • Heroin • Opioids refer to synthetic or semi‐synthetic drugs that attach to the Opioid receptors to produce morphine like effects • Semi‐synthetic Opioids are derived from an opiate: oxycodone, hydrocodone, hydromorphone • Synthetic Opioids are completely lab made: methadone, fentanyl, tramadol, naloxone • Synthetics tend to have more profound effects than their natural counterparts • Greater receptor affinity • More addictive 24 "Opiate Abuse." DrugAbuse.com. N.p., 13 Aug. 2016. Web. 26 Jan. 2017. Available Alwaysat: http://drugabuse.com/library/opiate-abuse/#signs-and-symptoms here to help, 24/7/365. 8 10/22/2018 Opioids Swallowed Snorted Smoked Injected Injection especially risky • Spread of HIV/AIDS and Hepatitis C • Damage veins and cause abscesses • Can lead to bacterial infection of the blood and heart problems Always here to25 help, 24/7/365. Opioids • Depending on type, there are different side effects • Analgesia (inability to feel pain) • Euphoria • Respiratory depression • Body less sensitive to hypercapnia (Feed back that causes you to breath) • Can be fatal • Cardiac arrhythmias • Methadone and propoxyphene • Seizures– • tramadol, meperidine, and propoxyphene • Muscle rigidity following rapid IV injection of fentanyl (chest wall rigidity) • Effects and be magnified with use of benzodiazepines (e.g.Xanax) or alcohol Always here to help, 24/7/365. OpioidsDid you know… • Drug overdoses are the leading cause of accidental death • Drug overdoses have surpassed car crashes and firearm related deaths. • 2 Washingtonians die from the opioid cause every day Always here to help, 24/7/365. 9 10/22/2018 Opioids Always here to help, 24/7/365. WAPC – in 2016 by age Always here to help, 24/7/365. Naloxone (Narcan) Used to reverse an opiate overdoes • Is an opiate that has competitive affinity for the same receptors • Limitations • Utility decrease with Synthetic's, due to their greater affinity • Halflife is often shorter then competing opiate • Various ways to administer • Spray • Injection • IV drip Always here to help, 24/7/365. 10 10/22/2018 Naloxone (Narcan®) Half life in hours 9 • Limitations 8 • Efficacy may decrease with synthetics, due to their 7 greater affinity for the receptor • Synthetics such as Fentanyl and Carfentanil 6 • Half‐life is often shorter then competing opiate 5 4 7.7 7 • Various ways to administer 3 • Spray 2 4 • Injection (IM or IV) 1 1 0 0.5 Heroin Naloxone Hydrocodone Fentanyl Carfentanil Always here to help, 24/7/365. Fentanyl 100x more potent than morphine Used medically as a painkiller • Lollipop • Patch • Used patches present risks Often adulterated into heroin or counterfeit oral painkillers Overdose and death likely underreported • Clinical presentation similar to other opioid overdoses • May not show up on urine drug screen Standard therapy and doses of naloxone may not be of benefit due to drugs affinity to receptors • Airway support • IV naloxone Always here to help, 24/7/365. Carfentanil Analog of synthetic opioid fentanyl • 10,000x more potent than morphine • 100x more potent than fentanyl Often adulterated into heroin or counterfeit oral painkillers 2mg of carfentanil, enough to Standard therapy and doses of naloxone unlikely to incapacitate a 2,000lb elephant, next to a be of benefit penny. Source: DEA Always here to help, 24/7/365. 11 10/22/2018 W‐Series Compounds Class of opioids identified at Univ. of Alberta in 1982 • W-18, 100x more potent than fentanyl, • sold as street drugs in North America • Not regulated • Recent death in Calgary Narcan is ineffective Always here to help, 24/7/365. Krokodil Contains desomorphine • Derivative of morphine Highly adulterated and dirty drug • Codeine from cough syrup • Gasoline fuel • Lighter fluid • Red phosphorus •