jay lance kovar, md, facep tcep 2012

Objectives Review new synthetic substances of abuse Discuss pharmacology and clinical presentations Identify EMS and ER treatment options for care

Bath Salts synthetic product contains hallucinogenic, mind-altering chemicals similar in structure to those also found in cocaine and ecstasy depending on which brand or form is purchased.

Bath Salts Sold as: a bath salt, or plant food Labeled: “for novelty use only” “not for human consumption” to by- pass FDA regulations-not being sold as food or drug product. Sold in: either 250 or 500 mg packets depending on brand or form purchased.

Bath Salts Ivory Wave is the most popular brand of this product Vanilla Sky Fly Snow Ivory Charge Ivory Coast Purple Wave Cristalius Magic Ocean Blue Columbian Salts Bolivian Salts Ocean Burst Lunar Wave Lady Bubbles Arctic Blast Sextacy Disco Snow Leopard Natural NRG Tranquility

What’s in it? MDPV (methylene-dioxy-pyro-valerone) usually referred to as pyro-valerone, (Super Coke) powerful psychoactive chemical similar to Ritalin acts as a stimulant that inhibits re-uptake of dopamine & norepinephrine minimal effects on serotonin levels. most versions of these products as containing Lidocaine may also contain similar components to 2-DPMP or MDMA (aka ecstasy).

Purposely designed in a way that will mimic the effects of: Cocaine Crack Ecstasy Most often used by snorting.

Where can I find it? It is sold most frequently on-line tobacco/smoke shops as a novelty item “not for human consumption” $30 for a small package in bulk ( packets) for a discount rate. Bath salts have increased in “club scene” use as ecstasy availability and use have declined

What’s the prevalence? Poison Control calls Poison Control calls Poison Control calls 20114,100

What’s the purity? Samples seized from different regions reveal a great deal of variance despite the same labels and producers

Pharmacology Multiple manufactures sources Vary in purity, concentration, and fillers Sold in packages 50mg to 200mg vials 500mg Consumed orally, rectal, insufflated, injected, or smoked

Phamacology Effects Onset, peak, and duration depends upon route Major source seems to be China, routed through New Orleans and out I-10 corridor Houston #1 Montgomery County Top 10

Why is it popular? Effects of amphetamines, cocaine, and ecstacy without hangover, comedown, or depression commonly following the use of those drugs Elevates mood, decreases hostility, raises energy levels, improves sense of well-being, improves attentions span and attention to detail, euphoria, empathy, and sexual stimulation.

Appears to be extremely addictive with many users reporting an “almost uncontrollable urge for another hit” immediately, stating that its effects are several times stronger than cocaine when snorted.

Downside Acute psychosis Severe anxiety, paranoia, agitation, bizzarre behavior, tremors, persecutory hallucinations Sympathetic overdrive Palpitations, shortness of breath, diaphoresis, hot flashes, headaches, hyperthermia, overwhelming thirst Bruxism

Side effects muscular pain/spasms emotional fragility acute paranoid psychosis sore jaw kidney failure loss of bowel control intense high followed by painful hangover suppressed appetite

“It’s legal” K2

K2/Spice products are a mixture of herbal/spice plant products sprayed with potent psychotropic drugs often contaminated with unidentified toxic substances which contribute to various adverse health effects cause hallucinogenic effects similar to effects of PCP. Marketed under variety of names K2, Spice, Pep Spice, Spice Silver, Spice Gold, Spice Diamond, Smoke, Sence, Skunk, Yucatan Fire, Genie & Zohai sold in variety of colors/flavors- usually sold in foil packaging

K2/Spice Health Risks Symptoms/Side-Effects may include: mimics marijuana “high” (often induced more quickly/more intense than “real” marijuana) hallucinations seizures/tremors coma/unconsciousness vomiting numbness/tingling

K2/Spice Health Risks Symptoms/Side-Effects may include: increased respiration rate elevated blood pressure (reported up to 200/100) elevated heart rate (reported up to rate of 150) increased level of anxiety/agitation leading to panic attacks (possible suicide attempts)

Depending on synthetic compound in specific commercial brand, can be anywhere from 4 times to over 100 times more potent than marijuana (THC) Sold in tobacco shops, head shops, and convenience stores Sold as “incense” marked “not for human consumption”

Price averages $45 for 3 grams (about equal to 3 sugar packets)-higher than good grade marijuana Most often smoked but can be mixed in with food or drink Most likely users: yr. olds Prisoners/probationers Military (use now banned by all military branches)

Creation of K2/Spice Developed by Dr. John W. Huffman, a Clemson University professor, as part of research for National Institute for Drug Abuse (NIDA) on endogenous cannabinoid receptors-but never tested on humans nor approved by FDA “It is like Russian roulette to use these drugs. We don’t know a darn thing about them for real.” “It shouldn’t be out there.” JWH-018 & many of its “cousins” such as HU-210/211, JWH-073 & CP 47/497 found in these drugs have a chemical structure shared with known cancer-causing agents. All effects of K2/Spice drugs may not be known for very long time because of long time period that body stores them.

????????????????????? Nothing is known about metabolism of the chemical compounds in K2/Spice drugs some may be toxic pharmacologically active-differing from batch to batch in kind/amount applied higher risk of accidental overdosing which has already been seen increase numbers of ER incidents reported

?????????????????????  There are hundreds more of these chemical compounds containing strong, active cannabinoid receptors agonists so can be safely assumed that further such substances will appear on market soon if not banned  Increasing challenges for toxicology testing, law enforcement and medical professionals.  Causing difficulties for law enforcement agencies, probation & parole, as well as drug courts due to difficulties in testing for presence  one lab test now known to detect it in system but at cost of $50 & will probably not test positive for all the known variations

National Institute for Drug Abuse “hijacking the part of the brain important for many major functions: temperature control, food intake, perception, memory and problem solving. Many people taking these high-potency drugs are affecting important functions throughout their bodies-hormone functions for example.” Drugs may involve acute toxicity levels, possibly long term, as well as impacting cannabinoid receptors that regulate body’s immune system.

On the rise Source primarily Mid-West US Recent increase in sales from app. $1000 daily up to $10, 000 daily. Rapid and powerful addiction on a level not usually found among smokers of “real” marijuana. Recently linked to over 352 nationwide emergency room incidents suicide attempts, extremely elevated heart rate/blood pressure, comas, seizures, and anxiety attacks.

What about your patient?

Is this Excited Delirium? An imminently life threatening medical emergency… Massive release of epinephrine, norepinephrine, dopamine, serotonin in the body and brain. Severe delirium and agitation 29

Recognizing Excited Delirium Agitation or Excitement = Increased activity and intensity Aggressive, threatening or combative – gets worse when challenged or injured Amazing feats of strength Pressured loud incoherent speech Sweating (or loss of sweating late) Dilated pupils/less reactive to light Rapid breathing 30

Recognizing Excited Delirium Delirium = Confusion Disoriented Person, place, time, purpose Rapid onset over a short period of recent time “He just started acting strange” Easily distracted/lack of focus Decreased awareness and perception Rapid changes in emotions (laughter, anger, sadness) 31

Recognizing Excited Delirium Psychotic = bizarre behavior Thought content inappropriate for circumstances Hallucinations (visual or auditory) Delusions (grandeur, paranoia or reference) Flight of ideas/tangential thinking Makes you feel uncomfortable 32

Bad Behavior: Other Reasons Alcohol intoxication or withdrawal Other drug use problems Example: Cocaine psychosis Pure psychiatric disease Head injury Dementia (Alzheimer’s Disease) Hypoglycemia Hyperthyroidism 33

ED presentations Combative Self destructive Homicidal/suicidal Agitation followed by severe depression

ED presentations Differential PCP LSD Cocaine Methamphetamines Alcohol Hypoglycemia Hypoxia Head trauma CNS infection

The Work Up Urine Tox r/o routine street drugs + “polypharmacy” BMP Hypoglycemia, metabolic acidosis CBC Infection and anemia CT Head Intracranial hemorrhage, hydrocephalus 12 lead EKG Biomarkers, myoglobin, lactic acid Temperature monitoring

Treatment Options No Antidote Supportive therapies Sympathetic Overdrive Alpha and beta receptor stimulation Sustained endogenous norepinephrine release Beta blocker caution? Metabolic dysfunction Hepatic metabolism of bath salts Hyperthermia

Treatment Options No Antidote Supportive therapies Psychosis Benzodiazepines Versed, Valium, Ativan Antipsychotics Haldol, Inapsine Geodon Ketamine

Disposition Unpredictable dose and duration Psychiatric evaluation when clear Home Jail Psychiatric facility

Status of K2/Spice Many European countries ban sale and use Kansas was first state to ban use 15 states so far to officially ban the sale & use of these products statewide. October 2011 DEA made it illeagal to possess or sell the chemicals or products containing the chemicals found in bath salts in the US for 1 year pending a review of permanently banning them Bath Salts are a Schedule 1 substance

Texas May 2011  The Texas House passed a bill banning K2 or spice, a synthetic marijuana  The Texas Department of State Health Services outlawed the fake pot last month after the Drug Enforcement Agency issued an emergency ban for a year.  The possession of K2 a misdemeanor, but manufacturers and sellers would be charged with a felony effective September 2011

HB 2118, SB 331 Certain synthetic compounds deceptively labeled as “bath salts” and synthetic marijuana products (K2 or spice) have been added to Penalty Group 2 of the Texas Controlled Substances Act.