1. Synthetic Drug Use Continued: Focus on Clinical Presentation and Intervention Stefanie Shoults RN MSN April 22, 2016 Spice, not everything nice…

2. Provide an overview of synthetic cannabinoid known on the street as K2/Spice Define key terms Discuss potent and dangerous side effects Explain reason Spice may produce a stronger reaction than marijuana Review Scenarios of adolescent Spice users and the devastating health effects and long-term effects of using synthetic cannabinoids Discuss clinical implications of synthetic drug use The purpose of this presentation is to

3. Introductions I am Parent School Nurse Mental Health Nurse An Advocate Where do you work and what you do there? What is one reason you decided to attend this training session? This presentation will be delivered through the eyes of a mother and as an educator.

4. Educational Objective At the end of this presentation, participants will be able to: Identify the key characteristics and effects of synthetic cannabinoids. Identify at least five reported side effects from synthetic drug use. Identify the reason spice may produce a stronger reaction than marijuana.

5. “People high on these drugs can get very agitated and violent, exhibit psychosis, and severe behavior changes…some have been admitted to psychiatric hospitals and have experienced continued neurological and psychological effects.” (Dr. Rick Dart, AAPCC President) SOURCE: Dimond, D. This Spice Can Kill You. Posted 8/8/12 at 2:49 p.m.

6. What we know Unlike the drugs we are more familiar with, such as heroin or cocaine, these synthetic drugs have only appeared in the last few years and because they are constantly changing, our knowledge of them is not as comprehensive as we would like. Unlike other drugs, which have been subjected to years of toxicological and pharmaceutical testing and numerous clinical trials and research on the users, what we know about synthetic drugs is often based on newspaper stories, pro-drug websites, and “street” information from users or from individuals who really do not know the facts.

7. Terminology Throughout the presentation, the terms Spice, synthetic marijuana, and synthetic cannabinoids will be used interchangeably.

8. Marijuana (Cannabis) Delta-9-tetrahydrocannabinol (THC) is the main active ingredient in marijuana THC acts upon specific sites in the brain, called cannabinoid receptors, kicking off a series of cellular reactions that ultimately lead to the "high" that users experience when they smoke marijuana. Some brain areas have many cannabinoid receptors; others have few or none. The highest density of cannabinoid receptors are found in parts of the brain that influence pleasure, memory, thinking, concentrating, sensory and time perception, and coordinated movement. Cannabinoid receptors are found in mammalian brain and spleen tissue.

9. ‘ Zombie’ attack Texas-style: Man tripping on ‘synthetic pot’ goes wild, attacks family and neighbors, then eats family dog ALIVE’ Michael Daniel smoked synthetic marijuana, known as 'spice' or 'K-2, then started his attacks, while running around on all fours and barking and growling like an animal. BY Philip Caulfield NEW YORK DAILY NEWS Published: Tuesday, June 26, 2012, 10:44 AM

10. (a.k.a. Spice) Synthetic Cannabinoids (SCs) (a.k.a. Spice) Synthetic cannabinoids, "Spice“ are marketed as "safe," legal alternatives to marijuana. Synthetic cannabinoids, are a large family of chemically unrelated structures that are designed to be functionally similar to THC, the principal psychoactive constituent of marijuana. These products contain dried, shredded plant material and chemical additives that are responsible for their psychoactive (mind-altering) effects. People who smoke synthetic cannabinoids may experience adverse health effects affecting the psychological, neurological, cardiovascular, metabolic, gastrointestinal, and autonomic systems.

11. (a.k.a. Spice) Synthetic Cannabinoids (SCs) (a.k.a. Spice) Sold under many names, including K2, fake weed, Yucatan Fire, Skunk, Moon Rocks Marketed as natural “herbal incense” or “potpourri.” Labeled Not for human consumption Available convenience stores, smoke shops, Internet, as well as their promotion on discussion boards

12. Spice and K2 Cost: $30-45 per 3gm Route: by smoking (alone or with marijuana) pipes, water pipes or rolled cigarettes; may also be prepared as an herbal infusion for drinking.

13. (a.k.a. Spice) Origin of Synthetic Cannabinoids (SCs) (a.k.a. Spice) Dr. John Huffman, Clemson University, organic chemistry professor was researching effects of cannabinoids on the brain when his work resulted in a 1995 paper that contained the methods and ingredients used to make the compound (JWH-018, his initials) Dubious Honor of Being the Creator of Synthetic Cannibinoids. Was synthesizing analogues and metabolites of THC ∆9tetrahydrocannabinol, the principle active component of marijuana, for research purposes. JWH-018 is one of these analogues, with studies showing an affinity for the cannabinoid (CB 1 ) receptor five times greater than that of THC.

14. (a.k.a. Spice) What is Synthetic Cannabinoids (SCs) (a.k.a. Spice) Structurally diverse class of mostly synthetic substances that bind to cannabinoid receptors in the brain CB1, CB2 receptors primarily affect the central nervous system JWH-018 JWH-073 HU-210 HU-211 CP47,497 There are around 100 known synthetic cannabinoids and 250 chemical compounds found in the substances.

15. Synthetic Cannabinoids: The Major Compounds a) Naphthoylindoles JWH-018 JWH-073 JWH-398 JWH-200 JWH-081JWH-015 JWH-122 JWH-210 JWH-019 JWH-007 5-Fluoropentyl-JWH-122 b) Cyclohexylphenoles CP-47,497-C8 AM-2201 JWH-020 JWH-387 AM-1220 JWH-412 SOURCE: Agudelo et al. (2012). Effects of Synthetic Cannabinoids on the Blood Brain Barrier, Presented at 74 th Annual CPDD.

16. JWH-018/073 arrived early and have come and gone. JWH-250 arrived a little later and has also cycled out. JWH-081 was part of a second wave that has already completed its cycle. JWH-122 was part of the same wave but has persisted in popularity and is part of the current scene. AM-2201 was part of the same second wave and has gained in popularity, probably currently the most prevalent. JWH-022 and JWH-210 are showing signs of increasing popularity. Recent emergent drugs are the adamantoyl (AM-1248) and tetramethylcyclopropyl (XLR-11 and UR-144) indoles which are ahead of the latest attempts to schedule these drug classes. SOURCE: Logan, B.K. (2012). Testing Strategies to Monitor Novel/Emerging/Designer Drug Use in At- Risk Populations, The Emergence of Synthetic Cannabinoids

17. Timeline of Synthetic Cannabinoids and Spice Products SOURCE: Fattore & Fratta. (2011). Frontiers in Behavioral Neuroscience, 5(60), 1-12.

18. Factors Associated with Spice Products’ Popularity They induce psychoactive effects They are readily available in retail stores and online The packaging is highly attractive They are perceived as safe drugs They are not easily detectable in traditional urine and blood samples Users express their experience as a full body high, more intense than marijuana SOURCE: Fattore & Fratta. (2011). Frontiers in Behavioral Neuroscience, 5(60), 1-12.

19. Side Effects of SC Products Anxiety Paranoia Headache Vomiting Psychosis Diaphoresis HR/BP increase Seizures

20. Cannabis vs. Cannabinoids: Effects Seen in Clinical Cases Most symptoms are similar to cannabis intoxication: – Tachycardia – Reddened eyes – Anxiousness – Mild sedation – Hallucinations – Acute psychosis – Memory deficits Symptoms not typically seen after cannabis intoxication: – Seizures – Hypokalemia – Hypertension – Nausea/vomiting – Agitation – Violent behavior – Coma SOURCES: Hermanns-Clausen et al. (In Press), Addiction; Rosenbaum et al. (2012). Journal of Medical Toxicology; Forrester et al. (2011). Journal of Addictive Disease; Schneir et al. (2011). Journal of Emergency Medicine.

21. Federal Efforts to Ban Synthetic Drugs Mar 2011: Five synthetic cannabinoids were temporarily categorized as Schedule I substances under the CSA. Oct 2011: DEA exercised its emergency scheduling authority to control some of the synthetic substances used to manufacture bath salts; these synthetic stimulants are now designated as Schedule I substances. Dec 2011: House of Representatives approves the Synthetic Drug Control Act (HR 1254). July 2012: Congress passed and President Obama signed the Synthetic Drug Abuse Prevention Act. At least 41 states and Puerto Rico have legislatively banned synthetic cannabinoids.

22.  Drug Enforcement Administration (DEA) has designated the five active chemicals most frequently found in Spice as Schedule I controlled substances, making it illegal to sell, buy, or possess them.  Manufacturers of Spice products attempt to evade these legal restrictions by substituting different chemicals in their mixtures.

23. NM SB 134 (2011) SENATE BILL 134 50TH LEGISLATURE - STATE OF NEW MEXICO - FIRST SESSION, 2011 INTRODUCED BY Sue Wilson Beffort AN ACT RELATING TO CONTROLLED SUBSTANCES; AMENDING THE CONTROLLED SUBSTANCES ACT; MAKING IT A CRIME TO POSSESS AND DISTRIBUTE SYNTHETIC CANNABINOIDS; PROVIDING PENALTIES; DECLARING AN EMERGENCY. NEW MEXICO SB 134 (2011) JWH-122; JWH-073; JWH-019; JWH-018; JWH-250; CP 47,497 and homologues; HU-210; JWH-298; JWH-015; and 5-(1,1-dimethylheptyl)-2-(3-hydroxycyclohexyl)- phenol.

24. Lack of availability of the reference standard for new drugs - limited number of banned chemicals on books. Hundreds of potential compounds used in manufacturing process Moving target – Spice industry responds to bans, laboratories must respond in kind Lack of complete understanding of metabolism Variable quality of reference standards Lack of purity and labeled internal standards Chemical similarity of new drugs within a class requires great care with identification Sensitivity (correctly IDs the drug) Challenges with Chromatography Screening SOURCE: Logan et al. (2012). Journal of Forensic Sciences, 57(5), 1168-1180.

25. Detection JWH-018 usage is readily detected in urine using "spice" screening immunoassays from several manufacturers focused on both the parent drug and its omega-hydroxy and carboxyl metabolites. JWH- 018 will not be detected by older methods employed for detecting THC and other cannabis terpenoids. Detection period roughly 24-72 hours in urine. ▫Only metabolites are detected in urine ▫Typically JWH metabolites analyzed due Detection approximately 12-48 hours in blood and oral fluid.

26. Comprehensive epidemiological data regarding the extent of synthetic drug use in the United States remains quite limited. Most of the data available originates from law enforcement reports, poison control calls, toxicology results, case reports., and new questions added to existing survey instruments.

28. Calls Received by U.S. Poison Control Centers for Human Exposure to Synthetic Marijuana, 2010 to Dec. 2012 SOURCE: American Association of Poison Control Centers, Spice Data, updated August 2012. 2,906 6,968 The number of calls in 2011 were more than double that in 2010 5,202 2010 Jan-Dec 20122011

29. Usual “SPICE” Presentation to Health Office Psychotic Vomiting – clear and non odorous Temperature 101 F – 106 F Tachycardia 150-200+ Dilated pupils greater than 7mm Agitated Paranoid/fearful

30. Case Scenarios – Reason I speak to you today

31. High School Senior No history of drugs or alcohol No disciplinary history Top ten percent of academic class Eagle Scout Active with church Engaged in extracurricular activities Presents to school “God is commanding him” Sudden psychotic break after using synthetic marijuana

32. High School Senior “I had a normal child on a Tuesday and a not normal child on a Friday” – mom of student Two years later now 20, has been institutionalized 17 times for psychiatric care and has made 3 suicide attempts Is homeless living in the tent he had for Boy Scout Trips Graduated early with a 504 plan in place Second senior of that graduating class to require support and early graduation due to spice and psychosis

33. A case of Dependence 17 year old patient reported he had smoked “Spice Gold” daily for 8 months. He developed a tolerance and rapidly increased the dose to greater 3g per day. He felt a continuous desire for the drug and kept using it despite the development of persistent cognitive impairment. Urinary drug screens were negative on admission to the local hospital, as they were again on discharge. On hospital day 4-7, he developed inner unrest, drug craving, nocturnal nightmares, profuse sweating, nausea, tremor, and headache. His blood pressure was elevated for two days, with a maximal value of 180/90mm Hg accompanied by a resting heart rate of 125/mm.

34. Anthony 28 Year Old No previous medical- cardiac history Died February 2014 as a result of heart failure secondary to Infective Endocarditis with Vegetation Carried a mental health diagnosis r/t SPICE Addicted to Spice X 3-5 years Initial cardiac admission Oct 2012; next admission Oct 2013 when he was told he was terminal Colin Kane, a pediatric cardiologist at UT Southwestern & Children's Medical Center in Dallas confirms there is something in the K2 that can cause heart attacks and cardiac damage

35. Long term impact: DEATH Anthony was released October 2012 from Lubbock Hospital in less than a week to his biologic father – who could not understand smoking fake weed could cause illness being seen in 25 year old son. At behest of biologic mother, grandparents, … Anthony was transported to Midland Heart Hospital for evaluation =findings of normal cardiac function with a review of initial presentation to Lubbock, unknown sought clarification of any congenital problem, injury, … Taken to inpatient mental health facility near Midland Texas… He discharged AMA within 24 hours. Picked up by his biologic father due to all other family being afraid of him. He begged to stop and purchase SPICE all the way home, 100 miles. Drug seeking behavior, no acknowledgement that he had just been released from CCU.

36. Final months – SPICE takes all Anthony continued to use SPICE from Oct. 2012 – Oct. 2013 growing increasing psychotic, agitated, unmanageable. No compliance with medication or therapy recommendations. He was admitted to various hospitals, treatments centers, rehabs. Oct. 2013 readmitted to Lubbock almost one year to the day of original admission: cardiac damage beyond repair, unless willing to comply with daily medication regime, dietary and water restrictions, being managed with a cardiac port for medication for next 6 months. He was lucid, organized, friendly, funny, and normal once detoxed – hospitalized for two weeks, then he went home without needed treatments. Sporadic spice use until his death

37. Why I speak to you today Anthony’s funeral was Valentine’s Day 2014. At his funeral, I made a promise to my husband of 28 years that I would speak out to make other parents aware of the dangers and educate persons working with adolescents. Anthony was my step son. Even with 30 years of nursing experience, four years of spice recognition, and endless resources in friends who are also in the field, Anthony succumbed to this drug and died a painful death. In honor of ANTHONY REY GOMEZ 11-1-1985 –2- 10-2014

39. Questions I have continued slides for your information on other common synthetic drugs and more detailed information on them. These Slides can be used as to familiarize you and your work site with other substances

41. Synthetic cathinones are structurally and pharmacologically similar to amphetamine, Ecstasy, and other related substances, which stimulate the central nervous system. Synthetic cathinones are related to the parent compound cathinone, one of the psychoactive principals in khat. (“cot”) Synthetic cathinones are sold in retail stores and on the internet as “bath salts,” “plant food,” and “jewelry cleaner.” People who have consumed synthetic cathinones may experience adverse health effects affecting the cardiovascular, psychological, neurological, musculoskeletal, gastrointestinal, pulmonary, and otolaryngological systems. Synthetic Cathinones:“Bath Salts”

42. Khat Pronounced “cot” Stimulant drug derived from a shrub (Catha edulis) native to East Africa and southern Arabia Use is considered illegal, because one of its chemical constituents, cathinone, is a Schedule I drug Khat found in the U.S. often comes in by mail from Africa SOURCE: NIDA. (2011). NIDA DrugFacts: Khat.

43. “Tales of Bath Salts and Zombie Cannibalism” Bath Salts made headlines in summer 2012 when a story of possible cannibalism was reported in Miami, FL The Miami-Dade Medical Examiner found no traces of bath salts, LSD, or synthetic marijuana in the perpetrator's system The sole psychoactive substance detected was cannabis (marijuana)

44. Synthetic Cathinones: “Bath Salts” Could be MDPV, 4-MMC, mephedrone, or methylone Sold on-line with little info on ingredients, dosage, etc. Advertised as legal highs, legal meth, cocaine, or ecstasy Taken orally or by inhaling Serious side effects include tachycardia, hypertension, confusion or psychosis, nausea, convulsions Labeled “not for human consumption” to get around laws prohibiting sales or possession CNS Stimulants SOURCE: Wood & Dargan. (2012). Therapeutic Drug Monitoring, 34, 363-367.

45. Product Marketing Mtv MDPK Magic Super Coke Peevee Energy-1 (NRG1) Charge Plus White Lightning Scarface Cloud 9 Ocean Ivory Wave

46. MDPV – Developed in the 60’s for chronic fatigue and appetite suppression. Similar in structure to MDMA, but more of a stimulant. Route: Intranasal most common Also: oral, smoking, rectal, and IV White to light brown crumbly powder Degrades if exposed to air for significant periods of time MDMA

47. Pharmacology of MDPV CNS stimulant similar to methamphetamine, MDMA, or cocaine Norepinephrine-dopamine reuptake inhibitor (NDRI) Increased alertness, arousal, anxiety, agitation, diminished requirement for food and sleep, sexual arousal Tachycardia, hypertension, vasoconstriction, diaphoresis

48. Effects of MDPV “High” lasts 2-4 hours Physical effects may last 6-8 hours May cause seizures, panic attacks, or psychosis with high doses or increased frequency of use Avg dose: 5 to 20mg

49. Other Sequelae of MDPV Trismus (inability to open mouth) or bruxism Panic attacks Psychosis with sleep deprivation Hallucinations, delusions, suicidal ideation Abstinence syndrome: depression, lethargy, anxiety, postural hypotension Leads to frequent re-dosing

50. Mephedrone – Originally developed 1929 4-methylmethcathinone (4-MMC) Meow MCAT Miaow Drone Plant Feeder Bubbles

51. Routes of Administration Oral ingestion ▫Swallowing capsules ▫Bombing (swallowing powder wrapped in cigarette paper) Inhalation (snorting) Rectally (either plugging or enema) IV (use 1/2 to 1/3 dose)

52. Pharmacology NE-DA reuptake inhibitor Similar to MA/MDMA (Ectasy) ▫Reportedly less potent, shorter duration Oral dose: 20-50mg “Come up”: 10-20 min Peak: 45-60 min “Comedown”: 60-120 min Re-dosing: common, can result in crushing chest pain Mephedrone reduces to 4-methylephedrine – a known Cardiotoxic compound Mephedrone Amphetamine

53. Synthetic Cathinones are  -keto (‘bk’) Analogs of Amphetamine

54. Effects of Mephedrone Euphoria Sociability Stimulation Sexual Arousal Music Appreciation Hallucinations

55. Mephedrone Side Effects Loss of appetite Increase in body temperature, sweating, hot flushes Tense jaw, bruxism, stiff neck, muscle clenching HR/BP elevation, chest pains Dehydration Mydriasis, nystagmus Painful nasal drip/ulcers in mouth (after inhalation) Insomnia, paranoia, anxiety, dysphoria, psychosis

56. Calls Received by U.S. Poison Control Centers for Human Exposure to Bath Salts, 2010 to July 2012 SOURCE: American Association of Poison Control Centers, Bath Salts Data, updated August 30, 2012. 304 6,138 The number of calls in 2011 were over 20 times that in 2010 2,078 20102011Jan-July 2012 6,138 2,078304

57. Agitation82% Combative/Violent behavior57% Tachycardia56% Hallucinations40% Paranoia36% Confusion34% Myoclonus/Movement disorders19% Hypertension17% Chest pain17% CPK elevations9% Clinical Symptoms of Synthetic Cathinone Use in Patients Admitted to the Emergency Department (N=236) SOURCE: Spiller et al. (2011). Clinical Toxicology, 49, 499-505.

58. Emerging Drug Items Identified in U.S. NFLIS Tox Labs: 2010 – 1/2 2012 (1/2 2012 incomplete) SOURCE: U.S. DEA, Office of Diversion Control, NFLIS data, 2012.

59. Current and Future Epidemiology No data on prevalence of use American Association of Poison Control Centers: Bath Salts: ▫2010: 292 calls ▫2011: 469 calls (2/14/11), a projected14-fold increase

60. How Psychoactive Substances Work Because of their chemical structure, alcohol and drugs have dramatic effects on neurotransmitters in CNS. Effects on: – Mental processes – Behavior – Perception – Alertness SOURCE: NIDA. (2010). Drugs, Brains, and Behavior: The Science of Addiction.

61. Commonly Used Psychoactive Substances SOURCE: National Institute on Drug Abuse. SUBSTANCEEFFECTS Alcohol (liquor, beer, wine) euphoria, stimulation, relaxation, lower inhibitions, drowsiness Cannabinoids (marijuana, hashish) euphoria, relaxations, slowed reaction time, distorted perception Opioids (heroin, opium, many pain meds) euphoria, drowsiness, sedation Stimulants (cocaine, methamphetamine) exhilaration, energy Club Drugs (MDMA/Ecstasy, GHB) hallucinations, tactile sensitivity, lowered inhibition Dissociative Drugs (Ketamine, PCP, DXM) feel separated from body, delirium, impaired motor function Hallucinogens (LSD, Mescaline) hallucinations, altered perception

62. “Designer” Psychoactive Substances SOURCE: http://www.drugs-forum.com.http://www.drugs-forum.com 62

63. MDMA (Ecstasy) 3, 4-methylenedioxy-methamphetamine Street terms: Adam, E, X, XTC, love drug, Molly A synthetic, psychoactive drug with both stimulant and hallucinogenic properties similar to methamphetamine and mescaline Adverse effects: enhanced physical activity, sweating, lack of coordination, mental confusion, jaw clenching, hyperthermia, and agitation NIDA. (2010). NIDA InfoFacts: MDMA (Ecstasy).

64. Party Drugs Identified by U.S. Toxicology Labs: 2005-2011 SOURCE: U.S. DEA, Office of Diversion Control, NFLIS data analysis by J.C. Maxwell.

65. 2C-Phenethylamine A broad range of compounds that share a common phenylethan-2-amine structure. Some are naturally occurring neurotransmitters (Dopamine and Epinephrine), while others are psychoactive stimulants (Amphetamine), entactogens (MDMA), or hallucinogens (the 2C-X series of compounds). 2 C-X can be snorted or dissolved into a liquid and placed on blotter paper under the tongue. May last 6-10 hours; onset takes 15 min to 2 hours. Reports of seizures and renal failure. SOURCE: U.S. DEA, Office of Diversion Control. (2012). National Forensic Laboratory Information System Special Report: Emerging 2C-Phenethylamines, Piperazines, and Trypamines in NFLIS, 2006-2011.

66. Spread of 2C-Phenethylamine throughout the United States SOURCE: U.S. DEA, Office of Diversion Control. (2012). National Forensic Laboratory Information System Special Report: Emerging 2C-Phenethylamines, Piperazines, and Trypamines in NFLIS, 2006-2011.

67. Piperazines Frenzy, Bliss, Charge, Herbal ecstasy, A2, Legal Z, Legal E. Mainly available over internet and sold as ecstasy pills that are “safe.” Two classes: (1) benzylpiperazines (BZP) and (2) phenylpiperazines (TFMPP). Mimics effects of ecstasy (MDMA); dangerous with seizure disorders, psychiatric illness, or coronary disease. Adverse events included hypertension, reduced consciousness, psychotic episode, hallucinations, tachycardia, hyperthermia, coma. Could be toxic if combined with MDMA or amphetamines. SOURCE: Arbo, Bastos, & Carmo. (2012). Drug and Alcohol Dependence, 122(3), 165-258.

68. BZP & TFMPP Benzylopiperazine (BZP) and trifluoromethyl- phenylpiperazine (TFMPP) identified in US Toxicology Labs (NFLIS). BZPTFMPP 2007274106 20084,2521,532 20098,9432,825 20105,2161,647 20113,5361,225 ½ 20121,082367 SOURCE: U.S. DEA, Office of Diversion Control, NFLIS data analysis by J.C. Maxwell.

69. DXM ? What is DXM ? Dextromethorphan Dextromethorphan is a psychoactive drug found in common over the counter cough medicines. SOURCE: NIDA. (2001). NIDA Research Report Series: Hallucinogens and Dissociative Drugs.

70. Dextromethorphan (DXM)- Triple C Dextromethorphan’s slang names include Orange Crush, Triple C's, C-C-C, Red Devils, Skittles, DXM or dex (for dextromethorphan), Vitamin D, Robo, Robo-trippin', Candy and Robo-dosing At high doses, produces dissociative hallucinations (distance from reality, visual effects with eyes open and closed; perceptual changes, drug liking, mystical-type experiences similar to use of psilocybin.) Can also produce tachycardia, hypertension, agitation, ataxia, and psychosis at high doses. Users of DXM engage in “dose dependent” behaviors in which they try to gauge the amount of the drug they take to produce the desired effects, which they call “plateaus”. Plateau is the mildest effect and the 5 th plateau will guarantee a trip to the hospital.

71. Past Month Use of Coricidin®: Texas Secondary School Survey 2004-2010 SOURCE: Texas Department of State Health Services (DSHS), data analysis by J.C. Maxwell.

73. A Few Other Psychoactive Substances to Throw in the Mix… Kratom – opioid-like effects Salvia divinorum – hallucinogenic effects Methoxetamine – “legal ketamine” Methcathinone – synthesized 1928, used in Soviet Union in the 1930’s and1940’s as an anti-depressant. SOURCE: Rosenbaum et al. (2012). Journal of Medical Toxicology, 8(1), 15-32.

74. Synthetic Cannabinoid Varieties 2010 SOURCE: U.S. DEA, Office of Diversion Control, NFLIS data, 2010.

75. Synthetic Cannabinoid Varieties 2011 JWH- 250 12% SOURCE: U.S. DEA, Office of Diversion Control, NFLIS data, 2011.

76. Synthetic Cannabinoid Varieties 2012 (through 8/27/12) SOURCE: U.S. DEA, Office of Diversion Control, NFLIS data, 2012.

77. Synthetic Cathinone Varieties 2010 SOURCE: U.S. DEA, Office of Diversion Control, NFLIS data, 2010.

78. Synthetic Cathinone Varieties 2011 SOURCE: U.S. DEA, Office of Diversion Control, NFLIS data, 2011.

79. Synthetic Cathinone Varieties 2012 (through 8/27/12) SOURCE: U.S. DEA, Office of Diversion Control, NFLIS data, 2012.

80. References Brunt, T.; Poortman, A.; Niesink, R.; Van Den Brink, W. (2010). "Instability of the ecstasy market and a new kid on the block: mephedrone". Journal of psychopharmacology. Drug Enforcement Administration: Office of Diversion Control; Drug and Chemical Evaluation Section. Methylenedioxypyrovalerone [(MDPV) (1-(1,3- Benzodioxol-5-yl)-2-(1-pyrrolidinyl)-1-pentanone]. Available at: www.deadiversion.usdoj.gov/drugs_concern/mdpv.pdf. EMCDDA (2009). Action on new drugs briefing paper: Understanding the ‘spice’ phenomenon. A report from an EMCDDA expert meeting, 6 March, 2009, Lisbon. Wehrman J. U.S. Poison Centers Raise Alarm about Toxic Substance Marketed as Bath Salts; States Begin Taking Action. AAPCC. February 14, 2011. Available at: http://www.aapcc.org/dnn/Portals/0/prrel/FEB14BATHSALTSUSE.pdf Winstock, A.; Mitcheson, L.; Deluca, P.; Davey, Z.; Corazza, O.; Schifano, F. (2010). "Mephedrone, new kid for the chop?". Addiction 106 (1).

81. Resources for Continued Learning American Association of Poison Control Centers, www.aapcc.org www.aapcc.org Drug Enforcement Administration, www.dea.usdoj.gov www.dea.usdoj.gov European Monitoring Centre for Drugs and Drug Addiction, www.emcdda.europa.euwww.emcdda.europa.eu National Institute on Drug Abuse, www.nida.nih.gov www.nida.nih.gov Office of National Drug Control Policy, www.ondcp.org www.ondcp.org Refer to the Synthetic Drugs Reference List** 81

82. Contact Information Stefanie Shoults RN MSN Hobbs High School 575-433-0204shoultss@hobbsschools.net Thank you for your time!