1. Synthetic Drugs

2. Synthetic Cannabinoids Contain dried, shredded plant material. “Spice” is sprayed onto the plant material. Also known as “K2”, “Yucatan Fire”, “sence”, amongst others. Cheap, easy to purchase, and legal. https://www.pinterest.com/klconlee/drugs-synthetic-cannabinoids/

3. Epidemiology Referrals to emergency services have increased from 11, 406 in 2010 to 28, 531 in 2015 Adverse effects include neurological symptoms (62%), cardiovascular (44%), GI (21%, and respiratory (8%) 60% of the cases presented with “extreme” toxicity http://www.journalagent.com/nci/pdfs/NCI-44153-INVITED_REVIEW-BILICI.pdf

4. Synthetic Cannabinoids Usually smoked, but can be prepared as tea. Labeled “not safe for human consumption.” Many of the chemicals found in K2 are schedule I controlled substances http://spiceaddictionsupport.org/wp-content/uploads/2014/12/scooby-snax.jpeg

5. Synthetic Cannabinoid Biochemistry Synthetic cannabinoid receptor agonists are functionally similar THC, the active principle of cannabis. Like THC, they bind to the same cannabinoid receptors in the brain as the endogenous ligand anandamide Anandamide is a molecule that acts as a neurotransmitter, with a structure very similar to THC – The molecule plays a role in appetite, memory, pain, depression, and fertility Increased potential for toxicity and OD that doesn’t exist with cannabis Spice inhibits GABA transmission more than marijuana, resulting in the seizures often seen with spice use

6. Abusing the Drug When smoked, the high can last 2-3 hours Often mixed with other drugs such as ketamine or kratom Also mixed with vitamin E and clenbuterol, a sympathomimetic – This mixture worsens the adrenergic effects including hypertension, tachycardia, and potential for MI.

7. Side Effects of Synthetic Cannabinoids Mild – Nausea, vomiting, paranoia, hyperactivity, ABD pain/cramps, and hallucinations Severe – seizures, hypertermia especially when used with alcohol

8. EMS Considerations Most users transported via EMS Complaints include paranoia, hallucinations and violence Increased physical activity may lead to rhabdomyolysis and renal failure Seizures can lead to anoxia, hyperthermia, and acidosis Seizures carry a 2% mortality when associated with synthetic cannabinoids use.

9. Prehospital Treatment Patients showing signs and symptoms of excited delirium should be treated with – Benzodiazepines (lorazepam, midazolam) – Antipsychotics (Haldol) – Active cooling – Sodium bicarbonate as needed rhabdomyolysis and acidosis

10. Synthetic Canthinones Also called “bath salts” Amphtetamine analogues found in the leaf of the khat plant Illegal in the U.S. because canthinones are schedule I drugs

11. Epidemiology Gender: female-16, male- 19 Age (yrs): 20–29 (22), 30– 39 (5), 40–49 (6), ≥50 (2) Route: Injected-22, Snorted- 9, Ingested-4, Signs and symptoms: agitation, tachycardia, delusions/hallucinations, seizure/tremor, hypertension, drowsiness, paranoia, mydriasis Disposition: Treated in ED and released 15, Admitted 17, Dead upon arrival 1, Left AMA 2 5 patients reported multiple exposure routes. Michigan, November 13, 2010–March 31, 2011 Demographic and clinical characteristics for 35 patients evaluated in an ED after exposure to drugs sold as “bath salts”

12. Synthetic Canthinones Advertised as a “legal high”, or legal meth, legal cocaine or ectasy May be ingested or inhaled as a powder, pill or capsule – Injection and per rectum use are also common Note that often products sold as bath salts do not contain canthinones

13. Synthetic Canthinones Highly addictive, similar to cocaine 33% of users develop an increased tolerance with strong cravings and binges lasting greater than 48 hrs. Withdrawal symptoms are confined to psychological complaints

14. Synthetic Canthinone Biochemistry Acts like an amphetamine Stimulates dopamine, norepinephrine, and serotonin release Highs generally last 1-2 hours

15. Symptoms May see hypertension, tachycardia, pupil dilation, bruxism, and tremors More severe reactions follow the sympathomimetic toxidrome including excited delirium, renal/hepatic failure, cerebral edema, and psychosis Hyponatremia may result due to overhydration from vasopressin secretion

16. Clinical Symptoms of Synthetic Cathinone Use in Patients Admitted to the Emergency Department Agitation – 82% Combative/Violent behavior – 57% Tachycardia – 56% Hallucinations – 40% Paranoia – 36% Confusion – 34% Myoclonus/Movement disorders – 19% Hypertension – 17% Chest pain – 17% CPK elevations – 9% SOURCE: Spiller et al. (2011). Clinical Toxicology, 49, 499-505.

17. Prehospital Treatment Treatment follows that of the sympathomimetic toxidrome. Benzodiazepines may be used when agitation, seizures, and excited delirium are present Hyperthermic patients require active cooling If hyponatermia is suspected: – Restrict PO intake and use hypertonic saline if available

18. Kratom A naturally occuring drug that is abused recreationally Also known as “biak- biak” or “Thom” Frequent cannabinoid substitute in “spice”

19. Kratom Use Used by chewing, smoking, or drinking as tea Effects are dose dependent – Small doses act as a stimulant – Larger does create opioid like sedation Effects begin in minutes and can last 90 minutes or more

20. Kratom Abuse “4x100” acts like an alcohol substitute Mixture of kratom, caffeine, cough syrup w/ codeine, benadryl, and either an anxiolytics, analgesics, or antidepressants Deaths have been attributed when mixed with a benzodiazepines and propylhexadrine (nasal decongestant)

21. Kratom Abuse Dependence may result after 6 months Users are generally unsuccessful at quitting Immediate effects: – Xerostomia (dry mouth), oliguria/polyuria, anorexia, nausea/vomiting Withdrawal symptoms include cravings, irritability, insomnia, diaphoresis, and dissociation from reality

22. Kratom cont’d Few studies on the long term effects of kratom have been done Thus far, no known deaths have been attributed to kratom use alone Kratom becomes dangerous when mixed or used in conjunction with other drugs

23. Salvia Member of the mint family of plants Traditionally used for its psychadelic effects and to treat headaches, diarrhea, and anemia. Chewing the leaves can lead to instant results lasting approx. 30 minutes Hallucinations can last up to 2 hours

24. Pharmacodynamics The drug is absorbed via the GI tract – the amount taken in the mouth and lungs dictates the effects Selective full agonist of opioid receptors Inhibits the release of dopamine while stimulating the release of noradrenaline

25. Pre-hospital Treatment Negative symptoms include panic, confusion, difficulty communicating, flushed skin, dissociation from reality Polysubstance abuse with salvia can lead to seizures Benzodiazepines are used to treat behavioral emergencies associated with salvia abuse – Charcoal may be effective if given within an hour of salvia ingestion Addiction potential is low

26. References Ballici, R Synthetic Cannabinoids. North Clin Istanbul 2014:1(2):121-126 Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs (2 nd Edition)-PPT http://www.dea.gov/docs/drugs_of_abuse_2011.pdf