legal (and not so legal) highs tom heaps consultant acute physician
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Legal (and not so legal) Highs
Tom HeapsConsultant Acute Physician
Legal Highs Research Chemicals
Novel Psychoactive Substances (NPS)
Designer Drugs
Herbal Highs
BubbleLuvPlant Foods
Incense
Bath Salts
Party Pills‘Psychoactive drugs, newly
available in the UK, which are not
prohibited by the United Nations
Drug Conventions but which may
pose a public health threat
comparable to that posed by
substances listed in these
conventions.’
-NPS Expert Review Panel Report, 2014
Legal Highs: the basics Often manufactured in laboratories in China Readily available on the internet or in ‘headshops’ Often marketed as ‘research chemicals / powders’, ‘bath
salts’, ‘herbal incense’ or ‘plant foods’ Disclaimers ‘for research purposes only’ or ‘strictly not for
human consumption’ No quality control or guarantee of purity Often adulterated with illegal substances and / or cut with
other (toxic) substances e.g. caffeine, benzocaine, detergents
Actual constituents often differ markedly to ingredients listed on packet
‘Same’ product / brand name may contain completely different chemicals
Black Mamba
2011
- AM-2201
2014
- 5F-PB-22- 5F-AKB48
Green Rolex ‘legal’ ecstasy tablets
caffeineMDMAcaffeine
5-MeO-DALTPMAPMMA
Legal Highs: a growing problem?
INCB Annual Report 2013
UK has 5th largest market for legal highs in the world
56% increase in UK hospital admissions from 2009-2012
20% of all websites selling legal highs are hosted on servers in the UK
EMCDDA European Drugs Report 2015
10% of 15-24 year-olds in the UK have used legal highs
ROI has highest prevalence (22% of 15-24 yo) of legal high use in Europe
Toxbase Statistics
Novel NPS detected by EMCDDA
2010 2011 2012 2013 20140
20
40
60
80
100
120
Deaths from NPS in the UK
2007 2008 2009 2010 2011 2012 2013 20140
20
40
60
80
100
120
Gogaine (ethylphenidate)
Geeb (GBL, gamma butyrolactone)
Green Beans (AMT)
Benzo Fury (5-APB)
Blue Cheese (SCRA)
Mexxie (MXE, methoxetamine)
Krokodil (desomorphine)
Salvia divinorum
Drugs and their ‘families’Stimulant
Depressant
Hallucinogen
Empathogen
Synthetic Cannabinoid (SCRA)
Dissociative
Opioid
Ethnobotanical
Stimulants Bath salts, research powders / pills, plant foods
Cathinones, MPA, PMA/PMMA, MDPV, ethylphenidate, 2-AI, BZP, khat
Gogaine, Ching, Chang, Charly Sheen, Charles, China White
Insufflated (powders), swallowed (tablets or ‘bombs’) or injected
Elevate levels of adrenaline, noradrenaline and dopamine
PMA/PMMA have strong serotonergic properties
Similar chemical structure and toxicity to amphetamines
Chemical Structures
Mephedrone 4-methylmethcathinone, 4-MMC, MCAT Bubbles, Meow Meow, Drone Cathinone which occurs naturally in ‘khat’ (Catha Edulis) First synthesized in 1929 (from pseudoephedrine) but
recreational use prominent since 2007 Usually taken by nasal insufflation (‘snorting’) or swallowed
(‘bombing’) Increasingly injected (high rates of soft tissue and vascular
complications) Stimulant and entactogenic/empathogenic properties Anxiety/agitation, seizures, cardiovascular and serotonergic
toxicity Heavy use associated with significant ‘comedowns’, psychosis
and dependency Class B under MDA in April 2010 (responsible for 29 deaths)
Synthetic Cannabinoid Receptor Agonists (SCRAs)
incense, pot pourri, herbal blend, spice
AKB48, 5F-AKB48, PB-22, 5F-PB22, JWH-018 etc.
Spice, K2, Black Mamba, Blue Cheese, Psyclone, Exodus Damnation, Clockwork Orange, Pandora’s Box
Usually smoked (sprayed onto herbal blends or put into e-liquids)
Many times more potent than THC (higher affinity for CB-1 receptor)
Do not give a positive urine test result for cannabis
Anxiety, hallucinations, delirium, seizures, agitation / aggression, hypokalaemia and AKI
Clinical Case 24-year-old male with no relevant past medical history
Admitted to AMU with severe anxiety / agitation, vomiting and sweating
ED clerking states that he had been given a ‘legal high’ at a party the previous night
BP 162/97, HR 121 (sinus tachycardia on ECG)
No obvious confusion / delirium
Pupils symmetrically dilated
Mild metabolic acidosis on VBG
HOW SHOULD YOU PROCEED?
Difficulties in Management Multiple drugs may be co-ingested (often with alcohol)
Patients often do not know exactly what they have taken
Even if they can provide you with the name / packaging of the legal high….
- Impossible to ascertain dosing
- Ingredients listed on packet may not be representative of actual contents
- Same ‘brand’ may contain completely different chemicals in differing quantities
- Unknown toxins often present
Toxicological databases and clinical experience of managing toxicity cannot keep pace with the development of novel compounds
DOES THIS MATTER?
So What Can You Do? Attempt to identify chemical compound / group
responsible for toxicity
- Collateral history / packaging
- Formulation / route of administration
- Toxbase
- WEDINOS
- Google and other websites
Determine the predominant toxidrome and manage accordingly
Toxidromes associated with legal highs
Stimulant
tachycardia, hypertension, dilated pupils, sweating, seizures, agitation +/- signs of serotonin syndrome
history of smoking a ‘herbal’ product, mild stimulant / hallucinogenic features, seizures
reduced conscious level and hypoventilation +/- bradycardia and constricted pupils
visual, auditory or tactile hallucinations, agitation, confusion. +/- mild-moderate stimulant features
primarily neuropsychiatric features including ‘out of body’ experiences, agitation, analgesia, drowsiness, nystagmus, ataxia, coma, seizures
Hallucinogen
Dissociative
Depressant
SCRA
Stimulant
Hallucinogen
Dissociative
Depressant
SCRA
General Management Principles
ABCDE approach ECG, bloods (including clotting and CK) and VBG Monitoring (observations, GCS, CBG, cardiac monitoring)
Agitation / anxiety / delirium: benzodiazepines
Hyperthermia: benzodiazepines, active cooling, dantrolene, paralysis
Hypotension: IV fluids, vasopressors
Hypertension: benzodiazepines, IV GTN, labetalol
Metabolic acidosis: oxygen, IV fluids, IV sodium bicarbonate
Seizures: benzodiazepines, (phenytoin), thiopental
QRS / QTc prolongation: IV bicarbonate / IV magnesium
Respiratory depression: naloxone, (flumazenil), airway and respiratory support
Refer to www.toxbase.org for more specific management
Legal Highs: summary
Rapidly growing public health problem in the UK
Legal highs are not necessarily legal and may not give you a high!
Legal does not mean safe (legislation just hasn’t caught up yet)
Systems of classification (e.g. the drug wheel) can be informative
Often very difficult to know exactly what compounds have been taken….
…..manage according to toxidrome
Psychoactive Substances Bill 2015 currently going through House of Commons but refer to experience in ROI…..