Jay Lance Kovar, MD, FACEP

Tomball Regional Medical Center

EMS WEEK

2012

• Review new synthetic substances of abuse

• Discuss pharmacology and clinical

presentations

• Identify emergency treatment options for care

Just when you were

getting used to

drunks and junkies…

• 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.

• 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.

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

• 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.

• i.e. perfect for high school promotion

• 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 (50-100 packets) for a discount rate.

Bath salts have increased in “club scene” use as ecstasy availability and use have declined

• Poison Control calls 2009 0

• Poison Control calls 2010 303

• Poison Control calls 2011 4,100

Samples seized from different regions

reveal a great deal of variance despite

the same labels and producers

• Multiple manufactures sources

• Vary in purity, concentration, and fillers

• Sold in

• packages 50mg to 200mg

• vials 500mg

• Consumed

• orally, rectal, insufflated, injected, or smoked

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

• 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.

• 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

• muscular pain/spasms

• emotional fragility

• acute paranoid psychosis

• sore jaw

• kidney failure

• loss of bowel control

• intense high followed by painful hangover

• suppressed appetite

• West Virginia woman scratched herself “to pieces”

over several days because she thought there was

something under her skin.

• August 2010 - UK man died after he experienced

severe hallucinations and jumped off a cliff top.

November 2010 - Louisiana man sliced his throat

and said, "I can't handle what this drug has done to

me. I'm never going to touch anything again."

Hours later he shot and killed himself when he had

visions of army men swarming his house.

December 2010 - Mississippi man shot and killed

Tippah County Deputy Sheriff DeWayne Crenshaw

at a disturbance call. It took six men more than

half an hour to wrestle the man into an ambulance.

He ripped through gurney straps and heavy

medical tape.

• January 2011 - Florida woman attacked and

attempted to behead her 71 year-old mother with a

machete.

• March 2011 - Pennsylvania man broke into a

monastery and stabbed a priest.

• March 2011 - Pennsylvania couple almost slashed

their 5 year-old daughter with knives as they

attacked “voices in the walls”.

• May 2011 - West Virginia man killed his neighbor's goat. Man was found semi-dressed in women's clothing in his bedroom with blood everywhere. The goat was dead on the floor next to a pornographic photo.

• June 2011 - Indiana man climbed a roadside flagpole and jumped into traffic.

• July 2011 - Arizona man seriously burned his child’s hands because the child had touched his Bible. The man stated that voices told him the child was possessed.

• 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

• 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

•Paranoia amplified 4-10x

• 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”

• Internet source from China

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:• 14-27 yr. olds

• Prisoners/probationers

• Military (use now banned by all military branches)

• 50% of 2010 users were from mid-west US

• 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.

• Majority of the compounds were identified as JWH related varieties

• JWH-018 (63%)

• JWH-250 (14%)

• JWH-073 (9%)

• JWH-081 (5%)

• JWH-200 (2%)

• JWH-019, JWH-210, JWH-251, RCS-4, AM-2201, AM-694, CP-47, CP-497, AM-356

• 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

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

“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 cannabinoidreceptors that regulate body’s immune system.

• 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.

• The NEW Pot

• Ancient drug (natural product)

• Psychoactive, dissociative, hallucinogenic

• Non alkaloyd drug with similar effects to LSD

• Most potent natural hallucinogen, low toxicity

• 2006-2007 saw use grow from 750,000 to > 1,000,000

US persons

• Chewed, tinctured, or smoked

• Uncontrollable laughter

• Past memories, such as revisiting places from childhood memory

• Sensations of motion, or being pulled or twisted by forces

• Visions of membranes, films and various two-dimensional surfaces

• Merging with or becoming objects

• Overlapping realities, such as the perception of being in several locations at once

• Youtube effect has mobilized

• Communities to ban.

• Controlled Substances Act amendment for Schedule I

status in 2002 did not pass

• Texas banned 2011, Class A misdemeanor $4,000 fine

• Banned by various branches of the U.S. military and

some military bases

42

• An imminently life threatening medical emergency…

• Massive release of epinephrine, norepinephrine,

dopamine, serotonin in the body and brain.

• Severe delirium and agitation

43

• 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

44

• 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)

45

• 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

46

• Alcohol intoxication or withdrawal

• Other drug use problems

• Example: Cocaine psychosis

• Pure psychiatric disease

• Head injury

• Dementia (Alzheimer’s Disease)

• Hypoglycemia

• Hyperthyroidism

• Combative

• Self destructive

• Homicidal/suicidal

• Agitation followed by severe depression

• Differential

• PCP

• LSD

• Cocaine

• Methamphetamines

• Alcohol

• Hypoglycemia

• Hypoxia

• Head trauma

• CNS infection

• 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

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

No Antidote

Supportive therapies

• Psychosis

• Benzodiazepines

• Versed, Valium, Ativan

• Antipsychotics

• Haldol, Inapsine

• Geodon

• Ketamine

• Unpredictable dose and duration

• Psychiatric evaluation when clear

• Home

• Jail

• Psychiatric facility

• 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

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

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.

JWH-004;

JWH-007;

JWH-009;

JWH-015;

JWH-016;

JWH-018;

JWH-019;

JWH-020;

JWH-046;

JWH-047;

JWH-048;

JWH-049;

JWH-050;

JWH-070;

JWH-071;

JWH-072;

JWH-073;

JWH-076;

JWH-079;

JWH-080;

JWH-081;

JWH-082;

JWH-094;

JWH-096;

JWH-098;

JWH-116;

JWH-120;

JWH-122;

JWH-148;

JWH-149;

JWH-180;

JWH-181;

JWH-182;

JWH-189;

JWH-193;

JWH-198;

JWH-200;

JWH-210;

JWH-211;

JWH-212;

JWH-213;

JWH-234;

JWH-235;

JWH-236;

JWH-239;

JWH-240;

JWH-241;

JWH-242;

JWH-262;

JWH-386;

JWH-387;

JWH-394;

JWH-395;

JWH-397;

JWH-398;

JWH-399;

JWH-400;

JWH-412;

JWH-413;

JWH-414;

JWH-415;

JWH-175;

JWH-184;

JWH-185;

JWH-192;

JWH-194;

JWH-195;

JWH-196;

JWH-197;

JWH-199;

JWH-030;

JWH-145;

JWH-146;

JWH-147;

JWH-150;

JWH-156;

JWH-243;

JWH-244;

JWH-245;

JWH-246;

JWH-292;

JWH-293;

JWH-307;

JWH-308;

JWH-346;

JWH-348;

JWH-363;

JWH-364;

JWH-365;

JWH-367;

JWH-368;

JWH-369;

JWH-370;

JWH-371;

JWH-373;

JWH-392;

JWH-176;

JWH-167;

JWH-201;

JWH-202;

JWH-203;

JWH-204;

JWH-205;

JWH-206;

JWH-207;

JWH-208;

JWH-209;

JWH-237;

JWH-248;

JWH-249;

JWH-250;

JWH-251;

JWH-252;

JWH-253;

JWH-302;

JWH-303;

JWH-304;

JWH-305;

JWH-306;

JWH-311;

JWH-312;

JWH-313;

JWH-314;

JWH-315;

JWH-316;

CP-55,940;

CP-47,497;

and

analogues

of CP-

47,497,

including

VII, V, VIII,

I, II, III, IV,

IX, X, XI,

XII, XIII,

XV, and

XVI;

delta-9-

THC;

delta-8-

THC;

Nabilone;

HU-210;

HU-211;

and

WIN-

55,212-2.

• If the patient has illegal substances, is using substances

illegally, or is under the influence of these substances,

are we required to report that to the police?

• No

• Are we violating patient rights (HIPAA) if we report it?

• No, commission of a

crime invalidates HIPAA

in Texas

1. They are harmless

2. They are neither food or drug

3. They have been marked “not for human consumption”

4. There is a popular demand

1. Cocaine

2. Ecstasy

3. Methamphetamine

4. Mr. Bubble

6/21/2012

1. Alcohol intoxication or withdrawal or Cocaine

psychosis

2. Pure psychiatric disease

3. Head injury or Dementia (Alzheimer’s Disease)

4. Hypoglycemia or Hyperthyroidism

5. All of the above

1. Developing a differential of causes and addressing

appropriately

2. Administering the Bath Salt antidote

3. Incomplete without 5 large policemen to restrain the

patient

4. A contraindicated condition for Ketamine use.

1. Bath salts are legal for purchase

2. Bath salts are legal to sell

3. Bath salts are legal to possess

4. Bath salts sale, purchase, and possession

are a felony

1. 3

2. 4

3. 5

4. 1

5. 4