Tales of Bath Salts and Legal Marijuana: TheRapidExpansion
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Transcript Tales of Bath Salts and Legal Marijuana: TheRapidExpansion
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
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
SoldSalts
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 (50-100 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 2009
Poison Control calls 2010
Poison Control calls 2011
0
303
4,100
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
Marketed under variety of names
often contaminated with unidentified toxic substances which
contribute to various adverse health effects
cause hallucinogenic effects similar to effects of PCP.
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:
14-27 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.