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Street Drugs the ones we know and don't - what to
look out for
Denis O’Driscoll
BSc Pharm., MPSI, PhD
Addiction Services, Cherry Orchard Hospital, Dublin 10
[email protected]
0872904852
SSSTDI Spring Meeting 9th April 2016
This is what Say Quah Wants
 ‘So we would love to know what u do, risk reduction stuff,
non sharing needles, extent of BBV, risk taking behaviour you
see, chemsex, G’s, crystal, meph, what is the best thing to do
in your mind, when we see those that use adhoc steroid,
melanotan, chemsex but denies addiction, and those that do
have addiction, etc’
SSSTDI Spring Meeting 9th April 2016
SSSTDI Spring Meeting 9th April 2016
Drug Classes of Drugs of Misuse
 CNS depressants
 Opioids
 Benzodiazepines
 Alcohol
 Ketamine
 NPS
 CNS Stimulants
 Cocaine
 Amphetamines
 NPS
 Others
 Hallucinogenic
 Cannabis
 NPS
SSSTDI Spring Meeting 9th April 2016
Harm Reduction is….
 A policy or programme directed towards decreasing adverse
health, social and economic consequences of drug use even
though the drug user continues to use at the time
SSSTDI Spring Meeting 9th April 2016
Harm Reduction and Addiction
 Conceptualises drug users as normal service users, with
strengths and competencies rather than primarily in
pathological terms
 Traditionally seen as in the grip of addiction/pathology
 Harm reduction views drug users as making rational
choices about whether and how to use drugs
 And, as having the capacity to help others whilst still
using
SSSTDI Spring Meeting 9th April 2016
Risks, Aetiology, Interventions
Individual level
Aetiology
 HIV, hepatitis B and C
 Sexually transmitted diseases
 Unsafe sex
(STIs)
 Mortality
 Overdose
Community level
 Public nuisance and criminal
activity
 Infection of injection sites
 Unsafe injecting practices
Interventions
 Needle and syringe programmes
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(NSPs)
Opioid substitution treatment
(OST)
Drug consumption rooms (DCRs)
Peer naloxone distribution
Information, education and
communication
Voluntary counselling and testing
Overdose HRB Statistics (2004-2013)
 Total of 6,002. Of these deaths, 3,519 were due to poisoning
In 2013 there were 387 DRD, 69% were male, average age 38
 Over half (57%) of all poisoning deaths involved more than one
substance (polysubstance use).
 Alcohol was involved in 137
 Benzodiazepines/Z-Compounds were implicated in 202
 Heroin implicated in 86 and methadone in 93
 NPS in 15
http://www.hrb.ie/uploads/tx_hrbpublications/NDRDI_web_update_2
004-2013.pdf
SSSTDI Spring Meeting 9th April 2016
HPSC - Weekly HIV & STI Report
http://www.hpsc.ie/A-Z/HIVSTIs/SexuallyTransmittedInfections/Publications/STIReports/STIWeeklyReports/File,15641,en.pdf
Disease
Week Ending
2016
2015
02/04/2016
Week 1 - 13
Week 1 - 13
Chlamydia trachomatis infection
156
1810
1797
Gonorrhoea
33
403
313
Herpes simplex (genital)
24
324
342
Human immunodeficiency virus
infection*
15
142
88
Syphilis**
12
164
75
SSSTDI Spring Meeting 9th April 2016
Potential
 Allows effective interventions to take place in local generic
service settings, rather than solely in specialist, centralised
service settings
 Normalisation, interventions that reinforce commonalties
rather than differences
 Normalising other aspects of drug users’ lives, e.g. school,
training, jobs, etc.
 Drug users peer education
SSSTDI Spring Meeting 9th April 2016
Approach
 Users decision to use is accepted as a fact
 User treated with dignity and as a ‘normal’ service
user with the expectation that they will behave
‘normally’
 Recognises drug users are not reckless – will have
 HR is neutral on the long-term goals of intervention,
rather it involves a prioritization of goals
 The focus is on the immediate needs, realistic
outcomes, & realizable goals
SSSTDI Spring Meeting 9th April 2016
Notifications from EMCDDA
www.emcdda.europa.eu
08/03/2016 1-(1,3-benzodioxol-5-yl)-2-(propylamino)propan-1-one
02/03/2016 N-phenyl-N-[1-(2-phenylethyl)-4-piperidyl]pentanamide
02/03/2016 ethyl 2-(4-fluorophenyl)-2-(2-piperidyl)acetate
02/03/2016 4-[[7-bromo-5-(2-chlorophenyl)-2-oxo-1,3-dihydro-1,4-benzodiazepin-3-yl]oxy]-4-oxo-butanoic
acid
25/02/2016 2-(pyrrolidin-1-yl)-1-(5,6,7,8-tetrahydronaphthalen-2-yl)hexan-1-one
25/02/2016 1-(4-cyanobutyl)-N-(1-methyl-1-phenyl-ethyl)indazole-3-carboxamide
22/02/2016 1-(4-chlorophenyl)-2-(isopropylamino)propan-1-one
29 other notifications
27/11/2015 5-methyl-2-phenyl-morpholine Other names: isophenmetrazine
16/11/2015 3-ethyl-2-phenyl-morpholine (Phenetrazine) Other names: 3-ethyl-2-phenylmorpholine, 2-phenyl3-ethylmorpholine
09/11/2015 4-fluoro-α-pyrrolidinohexanophenone (4-F-α-PHP) IUPAC name: 1-(4-fluorophenyl)-2(pyrrolidin-1-yl)hexan-1-one
05/11/2015 4-chloro-α-pyrrolidinovalerophenone (4-Cl-α-PVP) IUPAC name: 1-(4-chlorophenyl)-2pyrrolidin-1-yl-pentan-1-one
04/11/2015 N-phenyl-N-[1-(2-phenylethyl)piperidin-4-yl]-furan-2-carboxamide (Furanylfentanyl) Other names
SSSTDI
Spring Meeting
9th April 2016
and
abbreviations:
FU-F, 2-furanoylfentanyl
 https://www.youtube.com/watch?feature=player_detailpag
e&v=E5lLOTa3EYI
 https://www.youtube.com/watch?feature=player_detailpag
e&v=7jF6S6YNC3U
 http://www.emcdda.europa.eu/publications/eu-drugmarkets/2016/online/new-psychoactive-substances Chapter
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SSSTDI Spring Meeting 9th April 2016
CNS Depressants
physiological depression of the CNS that can result in decreased rate
of breathing, decreased heart rate, and loss of consciousness
possibly leading to coma or death. CNS depression is specifically
the result of inhibited brain activity
generally caused by the use of depressant drugs such as alcohol,
opioids, barbiturates, benzodiazepines, general anesthetics, and
anticonvulsants such as pregabalin used to treat epilepsy.
be caused by the accidental or intentional inhalation or ingestion of
certain volatile chemicals such as Butanone or isopropyl alcohol.
Other causes of CNS depression are metabolic disturbances such as
hypoglycaemia
SSSTDI Spring Meeting 9th April 2016
Alcohol
Types
 Distilled alcohol i.e. ethanol
 Wood alcohol i.e. methanol  blindness, metabolic
acidosis
 Anti-freeze i.e. ethylene glycol  metabolic acidosis
 Mode of action  Unsure, may affect GABA
SSSTDI Spring Meeting 9th April 2016
Benzodiazepines
 A large family of drugs used for their anxiolytic, tranquillizer,
anticonvulsant, pre-medication and hypnotic action.
Different duration of action.
 Affect the GABA receptor.
 1960 Chlordiazepoxide (Librium©).
 Newer compounds affect serotonin e.g. Buspirone.
SSSTDI Spring Meeting 9th April 2016
What are Benzodiazepines & Z-drugs?
Benzodiazepines
 Group of medicines used to treat anxiety, sleep disturbance & insomnia
 Have potential to cause dependence so usually recommended for short-term
use
 Other uses: muscle spasms, certain forms of epilepsy (status epilepticus),
cancer treatment – more long-term treatment
 Some common brands: Valium, Anxicalm, Xanax, Noctamid
Z-drugs
 Group of medicines also used to treat anxiety, sleep disturbance and insomnia
 Also recommended for short-term use due to increasing evidence of potential
for dependence
 Common brands: Zimovane, Stilnoct, Sonata
SSSTDI Spring Meeting 9th April 2016
Side effects
 CNS depression: sedation, muscle weakness
 Effect on mental function: no evidence of impairment in
global measure of intellectual functioning ie memory,
flexibility and rxn time (Psychol Med, 18, 1988)
 Vertigo, Headache, confusion, slurred speech, GI
disturbance
 Respiratory depression
 Paradoxical reaction (<1%) Pharmacotherapy, 24(9), 2004
SSSTDI Spring Meeting 9th April 2016
Opioids
 binding to receptors on the cell membranes of neurones
and other cells
 Similar effects
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Subjective effects
Analgesia
Gastrointestinal
Respiration
Miosis
Urinary effects
Histamine release-related effects
SSSTDI Spring Meeting 9th April 2016
Opioids
 Heroin
 Buprenorphine
 Methadone
 Fentanyl
 Codeine
 MST
 Tapentadol
SSSTDI Spring Meeting 9th April 2016
Observable Signs of Opioid Overdose
 Heavy intoxication, lethargy
 Pale skin, lips/fingernails ‘bluish’ tinge
 Pinpoint pupils (not with everyone)
 No response to noise or touch – ‘unrousable’
 Loss of consciousness
 Breathing problems e.g. slow/shallow breathing, heavy
snoring/rasping breaths or not breathing at all
 www.drugs.ie or Drugs & Alcohol Helpline
1800459459
SSSTDI Spring Meeting 9th April 2016
Ketamine and emerging substances
 Reduce sensations in the body, giving you a floating or detached feeling
as if the mind and body have been separated, with some people feeling
incapable of moving. This has been linked to having a near-death
experience and is sometimes called "entering the k-hole".
 Change how you see and hear things and can cause hallucinations.You
can 'trip' for between half and hour to several hours, and after-effects
may be felt for some hours afterwards.
 Cause confusion, agitation, panic attacks, and impairment in short and
long term memory. Frequent use is sometimes associated with mental
health issues.
 Cause very serious bladder problems
SSSTDI Spring Meeting 9th April 2016
Response
 Responsive care
 CPR
 Naloxone
 Flumazenil
 Mixed intoxication
SSSTDI Spring Meeting 9th April 2016
Stimulants CNS
Amphetamines: MDMA, PMMA
Nootropics: ‘cognitive enhancing drugs’, e.g Modafinil
Cocaine Hydrochloride
o Freebase
o Crack
o Base
SSSTDI Spring Meeting 9th April 2016
Effects and intoxication
 Withdrawal symptoms associated with discontinuing
stimulant use include fatigue, depression, and disturbance of
sleep patterns.
 Repeated abuse of some stimulants (sometimes within a
short period) can lead to feelings of hostility or paranoia,
even psychosis.
 Further, taking high doses of a stimulant may result in
dangerously high body temperature and an irregular
heartbeat. There is also the potential for cardiovascular
failure or seizures
SSSTDI Spring Meeting 9th April 2016
Stimulant overdose
 It is possible to overdose on cocaine, amphetamines such as speed and
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ice. Amphetamine overdose increases the risk of heart attack, stroke,
seizure or drug-induced psychotic episodes.
Amphetamine overdoses look different from an opioid OD, and signs and
symptoms include:
chest pain
disorientation/confusion
severe headache
seizures
high temperature (overheating, but not sweating)
difficulty breathing
agitation and paranoia
hallucinations
unconsciousness
SSSTDI Spring Meeting 9th April 2016
Cannabinoids
 PhytoCannabinoids –in plant only
 Endocannabinoids- anandamide
 Synthetic cannabinoids-’Spice’ products
SSSTDI Spring Meeting 9th April 2016
Complexity of cannabis
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500 different types of chemicals in plant
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70 Cannabinoids
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THC –euphoric/psychotogenic/anxiogenic
CBD- anxiolytic/anti-psychotic
3 chemovars are visually same
1. Fibre (Hemp): Rich in CBD/ Low THC
2. Drug type: Low CBD/High THC
3. Intermediate: Equal THC/CBD
SSSTDI Spring Meeting 9th April 2016
Cannabis….
 THC, delta-9-tetrahydrocannibol
 Marijuana (dried and crushed flower-heads and small
leaves which contains 0.5- 2.5% THC)
 Hashish (cannabis resin after removal from the plant,
and THC content can vary from 2-10%)
 Hash oil (concentrated resin extract containing 60%
or more THC)
 ‘Skunk’- can contain up to 30% THC
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2016
Mechanism of action
 Receptor sites on cerebullum
 Cannabinoid-like
neurotransmitter in the body:
anandamide
SSSTDI Spring Meeting 9th April
2016
Short term Effects
 Memory and Learning
 Reaction and co-ordination
 Chronic effects
 Criteria for dependence and withdrawal
 Mental health
 Possible carcinogen: Nitrosamines/benzantracenes/benzopyrene
 Hormone modulator effect
 Respiratory
SSSTDI Spring Meeting 9th April 2016
SKUNK/ POLLEN
 High strength and potency
 Evidence
 Weed Higher levels of schizoid symptoms and delusions vs Hash
group
 Hash less anhedonia
 Higher THC greater depressions/anxiety
 Higher THC poorer memory in daily use
 CBD seemed to have a ‘protecting effect’
SSSTDI Spring Meeting 9th April 2016
Skunk and Psychosis
 Use for 5 years double the risk
 Daily use six times the risk
When compared to usual hash smokers evidence suggests that
skunk users atre seven times greater risk and this increase to
12 fold increase if daily users
SSSTDI Spring Meeting 9th April 2016
Is there a risk to mental health
 The evidence is sufficient to warn most particularly young
people that using cannabis could increase their risk of
developing psychotic illness
 Risk groups:
 Young people with mental illness
 Daily or near daily use
 Reporting unpleasant psychotic like symptoms (1 in 7)
SSSTDI Spring Meeting 9th April 2016
SSSTDI Spring Meeting 9th April 2016
Prevalence and Trends
 Limited Irish data :
 PNEX have been picking up trends
 recommendation in evaluation has advised expanding service to
incorporate steroid users
 19/31 service reported that clients attending their service
injected steroids.
 Glasgow accurate needle exchange data: 1588 individual clients
responsible for 2897 PIEDs transactions (mid 2011-mid 2012)
SSSTDI Spring Meeting 9th April 2016
Steroid use in Ireland
 2008 National report EMCDDA National Focal Point Ireland
New Developments, trends and in – depth information on
selected issues
 Drug Prevalence Survey 2010/11: Regional Drug Task Force
(Ireland) and Health & Social Care Trust (Northern Ireland)
However reports suggest otherwise
 “Everybody who competes in bodybuilding is using steroids” JS (Client of NEX
Limerick)
 “There is no drug testing at Mr Cork. So has everyone dabbled in something
from beneath the counter” “You have to take something to get you where you
want.” (Irish Examiner 6/4/2013)
SSSTDI Spring Meeting 9th April 2016
Warning
 From recent data we know
 Increasing use newer drugs, such as crystal meth, mephedrone, GHB/GBL,
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steroids and tanning agents
Often sharing needles and using drugs in the context of risky sexual
behaviour.
HIV rates are increasing www.hpsc.ie
This poses a significant HIV risk as these newer injectors may not
understand safe injecting practices. There is evidence of elevated HIV and
hepatitis rates amongst steroid injectors.
IN 2010 survey 45% of the general public knew HIV can be transmitted
through sharing injecting equipment.
If newer communities are starting to inject drugs, there is an urgent task
to ensure health promotion and harm reduction messages reach these
groups. Otherwise there will be new transmissions of HIV and hepatitis B
and C.
SSSTDI Spring Meeting 9th April 2016
Hope et al, JAIDS Journal of Acquired Immune Deficiency Syndromes
Risk of HIV and hepatitis B and C over time among men who inject image and
performance enhancing drugs in England and Wales: results from cross sectional
prevalence survey 1992-2013
BBV prevalence among IPEDs injectors have increased, and for HIV is now
similar to that among psychoactive drug injectors.
Uptake of diagnostic testing for HIV and HCV, and HBV vaccination
increased (to 43%, 32% and 44%)
Condom use was consistently poor; needle/syringe sharing
occurred
Targeted interventions to reduce risks are indicated.
SSSTDI Spring Meeting 9th April 2016
Party and Play:ChemSEX
 Stimulants e.g methamphetamine, mephedrone,
GHB, and GBL.
 Associated with less inhibitions
 Euphoric intoxicant: increase sexual arousal,
reduce ejaculation
 ‘Crystal Dick’
 Reduced boundaries: ‘bareback’, toys
 Transmission party: ‘bugchasers’
https://www.lambeth.gov.uk/sites/default/files/sshchemsex-study-final-main-report.pdf
SSSTDI Spring Meeting 9th April 2016
 Many thanks
SSSTDI Spring Meeting 9th April 2016