1. NEW DRUGS OF ABUSE: BATH SALTS AND SYNTHETIC CANNABINOIDS Bruce D. Anderson, PharmD, DABAT Director of Operations Associate Professor University of Maryland School of Pharmacy

2. Objectives Know what the commonly encountered substances called “bath salts” usually contain Understand the basic pharmacology of bath salts and synthetic cannabinoids Be able to describe the usual acute clinical effects from users of bath salts and from synthetic cannabinoids Be able to describe the potential psychiatric impact of bath salts use

3. WHO AM I AND WHY AM I HERE?

4. Service program of the University of Maryland School of Pharmacy since 1972 First year of operations, received 5,600 calls In 2012, MPC received ~62,000 calls MPC Overview

5. Open 24 hours/day Staffed by pharmacists & nurses Nationally certified Specialists in Poison Information MPC: (continued)

6. Board certified Medical Director Board certified Director Masters in Public Health faculty Additional consultants available MPC: Overview

7. Recognition and prevention of exposures through community education and outreach Professional education to optimize patient care Other Functions

8. Data collection/ reporting nationally Research to optimize patient care * MPC: Overview

9. The mission of the Maryland Poison Center is to decrease the cost and complexity of poisoning and overdose care while maintaining and/or improving patient outcomes. What’s the Mission?

10. Save Lives Save Dollars Bottom Line

11. Save lives by providing emergency triage and treatment information to all callers. Save dollars by managing vast majority of patients (~75%) safely and inexpensively at home. Bottom Line (continued)

12. Last year, ~29,432 poisoning patients were safely managed at home. Usual charge for ED evaluation and treatment: ~$1,000 per patient Estimated cost savings: ~$29,432,000 per year Fiscal Impact:

13. WHAT THE HECK ARE “BATH SALTS???

14. The “Natural” Amphetamine Cathinone; “Khat” Catha edulis Native to Africa Amphetamine like alkaloid Chewed for the effects Ann Pharmacother 2012;46:436-441.

15. In the Market http://www.whitehouse.gov/ondcp/ondcp-fact-sheets/synthetic-drugs-k2-spice-bath-salts. Accessed 7 Dec 2012.

16. Former Fox TV Chair Beaten by Police http://www.nj.com/business/index.ssf/2012/10/bath_salts_used_by_deutsche_ba.html

17. Man Tries to Bite Police http://www.huffingtonpost.com/2012/06/05/brandon-deleon-high-on-cloud-9_n_1570560.html

18. Man Attacks Elderly Woman with a Shovel http://www.huffingtonpost.com/2012/06/25/robert-william-white-la-bath- salts_n_1624688.html

19. Woman Has Baby, Goes on Rampage http://www.huffingtonpost.com/2012/07/06/carla-murphy-had-baby-smoked-bath-salts_n_1653979.html

20. So… what is in “bath salts”? Methylenedioxypyrovalerone (MDPV) Mephedrone Methylone Methcathinone Alpha-pyrillidonopropiophenone (α- PPP) Others

21. Synthetic Cathinones Cathinone Beta ketonated amphetamines N-alkylated cathinones Ring substituted methylenedioxy- phenethylamines Clin Toxicol 2011;49:705-719.

22. Structures and Similarities Gerona RR, Wu AHB. Bath salts. Clin Lab Medicine 2012;32(3):415-27.

23. Audience Question: What synthetic cathinone derivative carries a legal medical indication for use the U.S. and Europe?

24. Answer: Bupropion Substituted cathinone Indications: Depression Smoking cessation Cathinone Clin Toxicol 2011;49:705-719.

25. Bath Salts: Pharmacology Structurally similar to amphetamines and hallucinogenic amphetamines (e.g., MDMA) as well as cathinones Functionally closer in effect to cocaine

26. Clinical Effects See typical stimulant effects Hallucinogenic activity Behavioral changes are common; may be persistent

27. Clinical Effect# Patients (%) Agitation 194 (82%) Combative/violent behavior 134 (57%) Tachycardia 132 (56%) Hallucinations 94 (40%) Paranoia 86 (36%) Confusion 83 (34%) Myoclonus 45 (19%) Hypertension 41 (17%) Chest pain 40 (17%) Mydriasis 31 (13%) Spiller HA et al. Clinical experience with and analytical confirmation of bath salts and legal highs in the United States. Clin Toxicol 2011;49:499-505.

28. Management: Bath Salts Exposures Airway, Breathing, Circulation Charcoal: only for substantial, recent ingestions Calm environment Benzodiazepines Symptomatic care

29. Typical Case: Bath Salts 38 year old presents to ED with altered mental status Hyperverbal, talking out of his head and making no sense BP 160s/100s; HR 120s; unable to get EKG Hallucinating, sweating, agitated Given 10 mg haloperidol, 2 mg lorazepam, 20 mg ziprazidone, 10 mg olanzepine without response; in 4 point restraints Admitted to ICU, placed on dexmedetomidine; remains confused, agitated, diaphoretic, hypertensive 3 hours later, the patient is A&O * 3, VSS, just observing.

30. Bath Salts in Maryland 68.5% Male Age: Range: 9- 60 Mean: 29 Med: 27 79.5 % Abuse 75% Male Age: Range: 16- 48 Mean: 26 Med: 25 84.1% Abuse 2011 2012 Maryland Poison Center 2011: 73 cases 5 major effect 2 deaths 2012: 44 cases 0 major effects 0 deaths

31. Where to Buy? http://ivory-wave.com /

32. Where to Buy? http://legalhighs.net63.net/product.php?id_product=19

33. Regulation Status February 24, 2010: First report of bath salt exposure. October 21, 2011: DEA emergency scheduling December 8 th, 2011: Synthetic Drug Control Act (HR 1254) July 9, 2012: Synthetic Drug Abuse Prevention Act http://www.justice.gov/dea/druginfo/drug_data_sheets/Bath_Salts.pdf. Accessed 7 Dec 2012. http://www.deadiversion.usdoj.gov/drugs_concern/mdpv.pdf. Accessed 7 Dec 2012. http://www.govtrack.us/congress/bills/112/s3189. Accessed 7 Dec 2012. Clin Toxicol 2012;50:911-1164.

34. Banned But Replaced http://www.fridayflyer.com/2012/10/05/banned-bath-salts-replaced-with-new-products

35. Replaced by…What??? http://www.ncbi.nlm.nih.gov/pubmed/22528592

37. Synthetic Cannabinoids What are they? What are the effects on people?

38. Synthetic Cannabinoids http://sfgyc.com/k2-and-spice-now-illegal-tools-for-parents/2012/07/03/ http://www.noozhawk.com/article/053112_police_wary_florida_face_eating_incident/ http://www.mystoresupplier.com/L-A-SPICE-HERBAL-INCENSE-1-5-GRAM-32-COUNT-p/af079.htm

39. Synthetic Cannabinoids: MPC YearTotal Cases Deaths 2010160 20111500 20122221*

40. Synthetic Cannabinoids: Effects Altered mental status Paranoia Psychosis Seizures Tachycardia Hypertension Nausea and vomiting Loss of consciousness Acute pain Hypokalemia Acute kidney injury Bhanushali GK, Jain G, Fatima H, et al. AKI associated with synthetic cannabinoids: a case series. Clin J Am Sco Nephrol 2012;ePud ahead of print Dec 14.

41. Typical Case: Synthetic Cannabinoids Call from ED regarding a 15 year old who presents after smoking synthetic cannabinoids On presentation, patient was combative, screaming, and hallucinating Treated with haloperidol and alprazolam After 4 hours of observation, patients symptoms subsided and he was discharged home.

42. Synthetic Cannabinoids Why use? avoid urine drug screen tests Thought to be “safe” alternative to marijuana Avoid going to a drug dealer

43. Synthetic Cannabinoids Synthetic Drug Abuse Prevention Act of 2012 Specified “cannabinimimetic agents” as Schedule I substances Producers have changed formulations to avoid the law and are still selling online, convenience stores and in head shops

44. Cases of intentional abuse or misuse of synthetic cannabinoids reported to the Maryland Poison Center over time. Time Number of cases

45. Synthetic Cannabinoids Management: Supportive care (ABC’s) NOTE: Symptoms may persist