Synthetic Drugs

Synthetic Cannabinoids

• Contain dried, shredded plant material.

• “Spice” is sprayed onto the plant material.

• Also known as “K2”, “Yucatan Fire”, “sence”, amongst others.

• Cheap, easy to purchase, and legal.

https://www.pinterest.com/klconlee/drugs-synthetic-cannabinoids/

Epidemiology

• Referrals to emergency services have increased from 11, 406 in 2010 to 28, 531 in 2015

• Adverse effects include neurological symptoms (62%), cardiovascular (44%), GI (21%, and respiratory (8%)

• 60% of the cases presented with “extreme” toxicity

http://www.journalagent.com/nci/pdfs/NCI-44153-INVITED_REVIEW-BILICI.pdf

Synthetic Cannabinoids

• Usually smoked, but can be prepared as tea.

• Labeled “not safe for human consumption.”

• Many of the chemicals found in K2 are schedule I controlled substances

http://spiceaddictionsupport.org/wp-content/uploads/2014/12/scooby-snax.jpeg

Synthetic Cannabinoid Biochemistry

• Synthetic cannabinoid receptor agonists are functionally similar THC, the active principle of cannabis.

• Like THC, they bind to the same cannabinoid receptors in the brain as the endogenous ligand anandamide

• Anandamide is a molecule that acts as a neurotransmitter, with a structure very similar to THC– The molecule plays a role in appetite, memory, pain,

depression, and fertility • Increased potential for toxicity and OD that doesn’t exist with

cannabis• Spice inhibits GABA transmission more than marijuana,

resulting in the seizures often seen with spice use

Abusing the Drug

• When smoked, the high can last 2-3 hours• Often mixed with other drugs such as

ketamine or kratom• Also mixed with vitamin E and clenbuterol, a

sympathomimetic– This mixture worsens the adrenergic effects

including hypertension, tachycardia, and potential for MI.

Side Effects of Synthetic Cannabinoids

• Mild– Nausea, vomiting,

paranoia, hyperactivity, ABD pain/cramps, and hallucinations

• Severe– seizures, hypertermia

especially when used with alcohol

EMS Considerations

• Most users transported via EMS

• Complaints include paranoia, hallucinations and violence

• Increased physical activity may lead to rhabdomyolysis and renal failure

• Seizures can lead to anoxia, hyperthermia, and acidosis

• Seizures carry a 2% mortality when associated with synthetic cannabinoids use.

Prehospital Treatment

• Patients showing signs and symptoms of excited delirium should be treated with – Benzodiazepines (lorazepam, midazolam)– Antipsychotics (Haldol)– Active cooling– Sodium bicarbonate as needed rhabdomyolysis

and acidosis

Synthetic Canthinones

• Also called “bath salts”• Amphtetamine

analogues found in the leaf of the khat plant

• Illegal in the U.S. because canthinones are schedule I drugs

Epidemiology

• Gender: female-16, male-19• Age (yrs): 20–29 (22), 30–39

(5), 40–49 (6), ≥50 (2) • Route: Injected-22, Snorted-

9, Ingested-4, • Signs and symptoms:

agitation, tachycardia, delusions/hallucinations, seizure/tremor, hypertension , drowsiness, paranoia, mydriasis

• Disposition: Treated in ED and released 15, Admitted 17, Dead upon arrival 1, Left AMA 2

• 5 patients reported multiple exposure routes.

Michigan, November 13, 2010–March 31, 2011

Demographic and clinical characteristics for 35 patients evaluated in an ED after exposure to drugs sold as “bath salts”

Synthetic Canthinones

• Advertised as a “legal high”, or legal meth, legal cocaine or ectasy

• May be ingested or inhaled as a powder, pill or capsule– Injection and per rectum

use are also common

• Note that often products sold as bath salts do not contain canthinones

Synthetic Canthinones

• Highly addictive, similar to cocaine

• 33% of users develop an increased tolerance with strong cravings and binges lasting greater than 48 hrs.

• Withdrawal symptoms are confined to psychological complaints

Synthetic Canthinone Biochemistry

• Acts like an amphetamine

• Stimulates dopamine, norepinephrine, and serotonin release

• Highs generally last 1-2 hours

Symptoms

• May see hypertension, tachycardia, pupil dilation, bruxism, and tremors

• More severe reactions follow the sympathomimetic toxidrome including excited delirium, renal/hepatic failure, cerebral edema, and psychosis

• Hyponatremia may result due to overhydration from vasopressin secretion

Clinical Symptoms of Synthetic Cathinone Use in Patients Admitted to the Emergency Department

• 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%SOURCE: Spiller et al. (2011). Clinical Toxicology, 49, 499-505.

Prehospital Treatment

• Treatment follows that of the sympathomimetic toxidrome.

• Benzodiazepines may be used when agitation, seizures, and excited delirium are present

• Hyperthermic patients require active cooling• If hyponatermia is suspected:– Restrict PO intake and use hypertonic saline if

available

Kratom

• A naturally occuring drug that is abused recreationally

• Also known as “biak-biak” or “Thom”

• Frequent cannabinoid substitute in “spice”

Kratom Use

• Used by chewing, smoking , or drinking as tea

• Effects are dose dependent– Small doses act as a

stimulant– Larger does create opioid

like sedation

• Effects begin in minutes and can last 90 minutes or more

Kratom Abuse

• “4x100” acts like an alcohol substitute

• Mixture of kratom, caffeine, cough syrup w/ codeine, benadryl, and either an anxiolytics, analgesics, or antidepressants

• Deaths have been attributed when mixed with a benzodiazepines and propylhexadrine (nasal decongestant)

Kratom Abuse

• Dependence may result after 6 months

• Users are generally unsuccessful at quitting

• Immediate effects: – Xerostomia (dry mouth),

oliguria/polyuria, anorexia, nausea/vomiting

• Withdrawal symptoms include cravings, irritability, insomnia, diaphoresis, and dissociation from reality

Kratom cont’d

• Few studies on the long term effects of kratom have been done

• Thus far, no known deaths have been attributed to kratom use alone

• Kratom becomes dangerous when mixed or used in conjunction with other drugs

Salvia

• Member of the mint family of plants

• Traditionally used for its psychadelic effects and to treat headaches, diarrhea, and anemia.

• Chewing the leaves can lead to instant results lasting approx. 30 minutes

• Hallucinations can last up to 2 hours

Pharmacodynamics

• The drug is absorbed via the GI tract– the amount taken in the

mouth and lungs dictates the effects

• Selective full agonist of opioid receptors

• Inhibits the release of dopamine while stimulating the release of noradrenaline

Pre-hospital Treatment

• Negative symptoms include panic, confusion, difficulty communicating, flushed skin, dissociation from reality

• Polysubstance abuse with salvia can lead to seizures

• Benzodiazepines are used to treat behavioral emergencies associated with salvia abuse– Charcoal may be effective if given within an hour of

salvia ingestion• Addiction potential is low

References• Ballici, R Synthetic Cannabinoids. North Clin Istanbul 2014:1(2):121-126• Will They Turn You into a Zombie? What Clinicians Need to Know about Synthetic Drugs (2nd

Edition)-PPT• http://www.dea.gov/docs/drugs_of_abuse_2011.pdf