Transcript - UAW-GM Center For Human Resources

Will They Turn You into a
Zombie?
What You Need to Know
about Synthetic Drugs
Presented by: Gary
Seech
Educational Objectives
At the end of this presentation,
participants will be able to:
1. Identify the key characteristics and
effects of synthetic drugs, most notably
synthetic cannabinoids and synthetic
cathinones.
2. Describe the current information available
on the availability and patterns of
synthetic drug use in the United States.
3
“Tales of Bath Salts and
Zombie Cannibalism”

Bath Salts made headlines in summer
2012 when a story of possible cannibalism
was reported in Miami, FL

The Miami-Dade Medical Examiner found
no traces of bath salts, LSD, or synthetic
marijuana in the perpetrator's system

The sole psychoactive substance detected
was cannabis (marijuana)
4
Substance Use Continuum
Dependence with Addiction
Substance Abuse
At Risk Use
Non-problem Use
Abstinence
“At Risk” Substance Use
Definition:

Planned use to intoxication/disinhibition

Generally rare adverse consequences

Use remains within peer group norms
Substance Abuse
Definition:

ABUSE is a maladaptive pattern of substance
use, leading to clinically significant impairment
or distress as manifested by one or more
behavioral based criteria:

failure to carry out obligations at home or work

use even when physically dangerous

legal problems resulting from use

use despite the development of social and
interpersonal problems
Physical Dependence
Definition:

PHYSICAL DEPENDENCE is a state of
adaptation that is manifested by a drug
class specific withdrawal syndrome that
can be produced by abrupt cessation,
rapid dose reduction, decreasing blood
level of the drug, and/or administration of
an antagonist.
Some Additional Important
Terminology

Psychological craving

Tolerance

Withdrawal symptoms
9
Psychological Craving

Psychological craving is a strong desire or
urge to use drugs. Cravings are most
apparent during drug withdrawal.
10
Tolerance

Tolerance is a state in which a person no
longer responds to a drug as they did
before, and a higher dose is required to
achieve the same effect.
11
Withdrawal

The following symptoms may occur when
drug use is reduced or discontinued:

Tremors, chills

Cramps

Emotional problems

Cognitive and attention deficits

Hallucinations

Convulsions

Death
12
Addiction is simply:
compulsive use
despite adverse
consequences
Addiction: A Vicious Cycle
What drives this never ending cycle?
Addiction: A Vicious Cycle
The Drivers:
Addiction: A Vicious Cycle
The Drivers:
Neurotransmitters and
Addictive Drugs of Abuse
Neurotransmitter
is mimicked by….
Drug of Abuse
Acetylcholine
Nicotine
Serotonin
LSD
Dopamine
Amphetamine
Endorphin
Morphine
GABA
Alcohol
Natural Rewards Elevate Dopamine Levels
200
% of Basal DA Output
NAc shell
150
100
Empty
50
Box Feeding
SEX
200
150
100
15
10
5
0
0
0
60
120
180
Time (min)
ScrScr
BasFemale 1 Present
Sample1 2 3 4 5 6 7 8
Number
Scr
Scr
Female 2 Present
9 10 11 12 13 14 15 16 17
Mounts
Intromissions
Ejaculations
Source: Di Chiara et al.
Source: Fiorino and Phillips
Copulation Frequency
DA Concentration (% Baseline)
FOOD
Accumbens
1100
1000
900
800
700
600
500
400
300
200
100
0
AMPHETAMINE
Much greater
Activity than any
DA
Other drug ofDOPAC
abuse
HVA
-causes neurotoxicity
250
NICOTINE
200
Accumbens
Caudate
150
100
Accumbens
COCAINE
DA
DOPAC
HVA
300
200
100
0
5 hr
250
% of Basal Release
1
2
3
4
Time After Amphetamine
% of Basal Release
400
0
% of Basal Release
% of Basal Release
Effects of Drugs on Dopamine Release
0
1
2
3
4
Time After Cocaine
Accumbens
5 hr
ETHANOL
Dose (g/kg ip)
200
0.25
0.5
1
2.5
150
100
0
0
1
2
3 hr
Time After Nicotine
0
0
Source: Di Chiara and Imperato
1
2
3
Time After Ethanol
4hr
Dopamine and The Brain’s
Reward Circuit
Neuroanatomic Substrates of
Drug Action
How Psychoactive
Substances Work

Because of their
chemical structure,
alcohol and drugs
have dramatic effects
on neurotransmitters
in CNS.

Effects on:




Mental processes
Behavior
Perception
Alertness
22
Commonly Used Psychoactive Substances
SUBSTANCE
EFFECTS
Alcohol
(liquor, beer, wine)
euphoria, stimulation, relaxation,
lower inhibitions, drowsiness
Cannabinoids
(marijuana, hashish)
euphoria, relaxations, slowed
reaction time, distorted perception
Opioids
(heroin, opium, many pain meds)
euphoria, drowsiness, sedation
Stimulants
(cocaine, methamphetamine)
exhilaration, energy
Club Drugs
(MDMA/Ecstasy, GHB)
hallucinations, tactile sensitivity,
lowered inhibition
Dissociative Drugs
(Ketamine, PCP, DXM)
feel separated from body, delirium,
impaired motor function
Hallucinogens
(LSD, Mescaline)
hallucinations, altered perception
SOURCE: National Institute on Drug Abuse.
23
“Designer” Psychoactive Substances
24
A Review of Synthetic
Cannabinoids and Synthetic
Cathinones
25
Synthetic
Drugs

Not really “Spice,” “Bath Salts,” or “Incense”

Chemically-based; not plant derived

Complex chemistry

Constantly changing to “stay legal”

Need to prove “intended to use” to convict in
some areas
26
Marijuana (Cannabis)

Often called pot, grass, reefer, MJ, weed,

A mixture of the dried, shredded leaves,
stems, seeds, and flowers of Cannabis sativa—
the hemp plant

Most commonly used drug in the U.S.

Delta-9-tetrahydrocannabinol (THC) is the main active
ingredient in marijuana

Common effects include: euphoria, relaxation, heightened
sensory perception, laughter, altered perception of time,
and increased appetite

May also produce anxiety, fear, distrust, or panic, and can
lead to severe mental health problems for some users.
27
herb
Synthetic Cannabinoids
(a.k.a. Spice)

Wide variety of herbal mixtures

Marketed as “safe” alternatives to marijuana

Brand names include: K2, fake weed, Yucatan
Fire, Skunk, Moon Rocks

Labeled “not for human consumption”

Contain dried, shredded plant
material and chemical additives
that are responsible for their
psychoactive effects.
28
Synthetic Cannabinoids
(Spice)

Mainly abused by smoking (alone or with
marijuana); may also be prepared as an
herbal infusion for drinking.

The five active chemicals most frequently
found in “Spice” products have been
classified by the DEA as Schedule I
controlled substances, making them illegal
to buy, sell, or possess.
29
Timeline of Synthetic Cannabinoids and
Spice Products
SOURCE: Fattore & Fratta. (2011). Frontiers in Behavioral Neuroscience, 5(60), 1-12.
30
Factors Associated with
Spice Products’ Popularity

They induce psychoactive effects

They are readily available in retail stores
and online

The packaging is highly attractive

They are perceived as safe drugs

They are not easily detectable in urine and
blood samples
SOURCE: Fattore & Fratta. (2011). Frontiers in Behavioral Neuroscience, 5(60), 1-12.
31
Synthetic Cathinones:
“Bath Salts”

Could be MDPV, 4-MMC,
mephedrone, or methylone

Sold on-line with little info on
ingredients, dosage, etc.

Advertised as legal highs,
legal meth, cocaine, or ecstasy

Taken orally or by inhaling

Serious side effects include tachycardia, hypertension,
confusion or psychosis, nausea, convulsions

Labeled “not for human consumption” to get around
laws prohibiting sales or possession
32
Actual Product Names

“Ivory Wave”

“Purple Wave”

“Vanilla Sky”

“Bliss”

“White Lightening”

“Blizzard”

“Hurricane Charlie”

Also known as “PLANT FOOD”
33
What Is The Experience Like?

Agitation

Paranoia

Hallucinations

Chect Pains

Suicidal Thoughts

Muscle Spasms

Increased blood pressure/pulse
34
Treating M.D.’s Comment

“If you take the very worst of some of the
other drugs – LSD and Ecstasy with their
hallucinations/delusional type properties,
PCP with the extreme agitation,
superhuman strength and competiveness,
as well as the stimulant properties of
cocaine and meth and take them all
together, this is what you get. It is
absolutely ugly.”
35
Sources and Continuing
Availability

A number of synthetic marijuana and bath salt
products appear to originate overseas and are
manufactured in the absence of quality
controls and devoid of governmental
regulatory oversight.

The large profits from sales, plus the fact that
these chemicals can be easily synthesized to
stay one step ahead of control, indicate there is
no incentive to discontinue retail distribution
of synthetic cannabinoid products under the
current statutory and regulatory scheme.
36
Federal Efforts to
Ban Synthetic Drugs

Mar 2011: Five synthetic cannabinoids were temporarily
categorized as Schedule I substances under the CSA.

Oct 2011: DEA exercised its emergency scheduling
authority to control some of the synthetic substances
used to manufacture bath salts; these synthetic
stimulants are now designated as Schedule I
substances.

Dec 2011: House of Representatives approves the
Synthetic Drug Control Act (HR 1254).

July 2012: Congress passed and President Obama
signed the Synthetic Drug Abuse Prevention Act.
37
Texas Poison Control Exposures and
Effect of Controls
Synthetic Cannabis
Synthetic Cathinones
38
39
“People high on these drugs can get very
agitated and violent, exhibit psychosis, and
severe behavior changes…some have
been admitted to psychiatric hospitals and
have experienced continued neurological
and psychological effects.”
(Dr. Rick Dart, AAPCC President)
40
Cannabis vs. Cannabinoids:
Effects Seen in Clinical Cases

Most symptoms are
similar to cannabis
intoxication:

Symptoms not
typically seen after
cannabis intoxication:

Tachycardia

Seizures

Reddened eyes

Hypokalemia

Anxiousness

Hypertension

Mild sedation

Nausea/vomiting

Hallucinations

Agitation

Acute psychosis

Violent behavior

Memory deficits

Coma
41
Clinical Symptoms of Synthetic Cathinone Use in
Patients Admitted to the Emergency Department
(N=236)
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%
42
The Epidemiology
of Synthetic
Drug Use
43
Calls Received by U.S. Poison Control Centers
for Human Exposure to Synthetic Marijuana
The number of calls in 2011 were more than
double that in 2010
6,959
3,821
2,906
2010
2011
Jan-July 2012
44
45
Calls Received by U.S. Poison Control Centers for
Human Exposure to Bath Salts, 2010 to July 2012
The number of calls in 2011 were
over 20 times that in 2010
6,138
2,078
304
2010
2011
Jan-July 2012
46
Challenges with
Chromatography Screening

Lack of availability of the reference standard for
new drugs

Variable quality of reference standards

Lack of purity and labeled internal standards

Chemical similarity of new
drugs within a class requires
great care with identification

Sensitivity (correctly IDs
the drug)
47
Other Notable Synthetic
Drugs – “New And Old”
48
MDMA (Ecstasy)

3, 4-methylenedioxy-methamphetamine

Street terms: Adam, E, X, XTC, love drug, Molly

A synthetic, psychoactive drug with both
stimulant and hallucinogenic properties similar to
methamphetamine and mescaline

Adverse effects: enhanced physical activity,
sweating, lack of coordination, mental confusion,
jaw clenching, hyperthermia, and agitation
49
2C-Phenethylamine

A broad range of compounds that share a common
phenylethan-2-amine structure.

Some are naturally occurring neurotransmitters
(Dopamine and Epinephrine), while others are
psychoactive stimulants (Amphetamine), entactogens
(MDMA), or hallucinogens (the 2C-X series of
compounds).

2 C-X can be snorted or dissolved into a
liquid and placed on blotter paper under
the tongue.

May last 6-10 hours; onset takes 15 min-120
to 2 hours.

Reports of seizures and renal failure.
50
Piperazines

Frenzy, Bliss, Charge, Herbal ecstasy, A2, Legal Z,
Legal E.

Mainly available over internet and sold as ecstasy pills
that are “safe.”

Two classes: (1) benzylpiperazines (BZP) and (2)
phenylpiperazines (TFMPP).

Mimics effects of ecstasy (MDMA); dangerous with
seizure disorders, psychiatric illness, or coronary
disease.

Adverse events included hypertension, reduced
consciousness, psychotic episode, hallucinations,
tachycardia, hyperthermia, coma. Could be toxic if
combined with MDMA or amphetamines.
51
A Few Other Psychoactive
Substances to
Throw in the Mix…

Kratom – opioid-like effects

Salvia divinorum – hallucinogenic effects

Methoxetamine – “legal ketamine”
52
Phencyclidine

PCP, Angel Dust, Killer Weed

Dissolved in embalming fluid (“Fry,” “Amp,”
“Water, Water”)

Swallowed, sniffed, smoked on joints
dipped in “Fry”

Users report out-of-body strength
53
DXM
What is
? Dextromethorphan is a
psychoactive drug found in common over the
counter cough medicines.
54
Dextromethorphan (DXM)

Dextromethorphan’s slang names include “Robo”.

At high doses, may produce dissociative hallucinations
(distance from reality, visual effects with eyes open and
closed; perceptual changes, drug liking, mystical-type
experiences similar to use of psilocybin.

Can also produce tachycardia, hypertension, agitation,
ataxia, and psychosis at high doses.

Users of DXM engage in “dose dependent” behaviors in
which they try to gauge the amount of the drug they take
to produce the desired effects, which they call “plateaus”.
Plateau is the mildest effect and the 5th plateau will
guarantee a trip to the hospital.
55
56
Sample Clinical Treatment Protocol
for Synthetic Cannabinoid Users

Direct individual to emergency room via
ambulance

Consult a regional Poison Control Center

Acute management consists of:

Supportive care with the use of benzodiazepines, if
needed, to control agitation and anxiety

Observe until resolution of abnormal vital signs,
vomiting, and psychiatric symptoms
57
Sample Clinical Treatment Protocol
for Synthetic Cathinone Users

Supportive care

Aggressive sedation with benzodiazepines (for
agitation, seizures, tachycardia, and
hypertension)

Significant hyperthemia may require passive or
active cooling.

Lab studies including electrolytes, renal and liver
function tests, cardiac markers, and creatine
kinase should be considered.
58
What do you do if someone has
taken a Spice Product or Bath Salts?


Call your local poison center at 1-800-222-1222

57 poison centers around the country have experts
waiting to answer your call.

Experts can help you decide whether someone can
be treated at home, or whether he or she must go to a
hospital.
Dial 9-1-1 immediately if they:

Stop breathing

Collapse

Have a seizure
…or if they have taken
one of these and are
having physical symptoms
or behaving in a way that is
concerning to you
59
In Summary: Key Points

Despite widespread Internet availability and use
among certain populations, health care providers
remain largely unfamiliar with Spice products and
Bath Salts.

Research is needed to better understand the side
effects and long-term consequences associated
with the use of synthetic cannabinoids and
synthetic cathinones

More toxicological identification of these new
drugs, more information on the sources of them,
as well as their distribution and patterns of use is
needed to curtail future increases in use.
60
In Summary: Key Points

Despite widespread Internet availability and use
among certain populations, health care providers
remain largely unfamiliar with Spice products and
Bath Salts.

Research is needed to better understand the side
effects and long-term consequences associated
with the use of synthetic cannabinoids and
synthetic cathinones

More toxicological identification of these new
drugs, more information on the sources of them,
as well as their distribution and patterns of use is
needed to curtail future increases in use.
61
Resources for Continued
Learning

American Association of Poison Control Centers,
www.aapcc.org

Drug Enforcement Administration,
www.dea.usdoj.gov

European Monitoring Centre for Drugs and Drug
Addiction, www.emcdda.europa.eu

National Institute on Drug Abuse, www.nida.nih.gov

Office of National Drug Control Policy,
www.ondcp.org

Refer to the Synthetic Drugs Reference List**
62