Tales of Bath Salts and Legal Marijuana: TheRapidExpansion OfNewDesignerStreetDrugs

Tales of Bath Salts and Legal Marijuana: TheRapidExpansion OfNewDesignerStreetDrugsjay lance kovar, md, faceptcep 2012ObjectivesReview new synthetic substances of abuseDiscuss pharmacology and clinical presentationsIdentify 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 Salts Sold 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 SkyFlySnowIvoryChargeIvory CoastPurple WaveCristaliusMagicOcean BlueColumbian Salts Bolivian Salts Ocean BurstLunar WaveLady BubblesArctic BlastSextacyDiscoSnow LeopardNatural NRGTranquility

Whats in it?MDPV (methylene-dioxy-pyro-valerone) usually referred to as pyro-valerone, (Super Coke) powerful psychoactive chemical similar to Ritalinacts as a stimulant that inhibits re-uptake of dopamine & norepinephrineminimal 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:CocaineCrack Ecstasy

Most often used by snorting.

Where can I find it?It is sold most frequently on-linetobacco/smoke shops as a novelty item not for human consumption $30 for a small packagein bulk (50-100 packets) for a discount rate.

Bath salts have increased in club scene use as ecstasy availability and use have declined Whats the prevalence?Poison Control calls 20090Poison Control calls 2010 303Poison Control calls 20114,100

Whats the purity?Samples seized from different regions reveal a great deal of variance despite the same labels and producers

PharmacologyMultiple manufactures sourcesVary in purity, concentration, and fillersSold inpackages 50mg to 200mgvials 500mgConsumed orally, rectal, insufflated, injected, or smokedPhamacologyEffectsOnset, peak, and duration depends upon route

Major source seems to be China, routed through New Orleans and out I-10 corridorHouston #1Montgomery County Top 10

Why is it popular?Effects of amphetamines, cocaine, and ecstacy without hangover, comedown, or depression commonly following the use of those drugsElevates 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.

DownsideAcute psychosisSevere anxiety, paranoia, agitation, bizzarre behavior, tremors, persecutory hallucinationsSympathetic overdrivePalpitations, shortness of breath, diaphoresis, hot flashes, headaches, hyperthermia, overwhelming thirstBruxism

Side effectsmuscular pain/spasmsemotional fragilityacute paranoid psychosissore jawkidney failureloss of bowel controlintense high followed by painful hangoversuppressed appetite

Its legalK2

K2/Spice products are a mixture of herbal/spice plant products sprayed with potent psychotropic drugsoften contaminated with unidentified toxic substances which contribute to various adverse health effectscause hallucinogenic effects similar to effects of PCP. Marketed under variety of names 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 RisksSymptoms/Side-Effects may include:mimics marijuana high (often induced more quickly/more intense than real marijuana)hallucinationsseizures/tremorscoma/unconsciousnessvomitingnumbness/tingling

K2/Spice Health RisksSymptoms/Side-Effects may include:increased respiration rateelevated 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 drinkMost likely users:14-27 yr. oldsPrisoners/probationersMilitary (use now banned by all military branches)

Creation of K2/SpiceDeveloped 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 FDAIt is like Russian roulette to use these drugs. We dont know a darn thing about them for real. It shouldnt 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 drugssome may be toxic pharmacologically active-differing from batch to batch in kind/amount appliedhigher 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 bannedIncreasing 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 presenceone 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 bodys immune system.

On the riseSource primarily Mid-West USRecent 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 incidentssuicide 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 emergencyMassive release of epinephrine, norepinephrine, dopamine, serotonin in the body and brain. Severe delirium and agitation2929Recognizing Excited DeliriumAgitation or Excitement = Increased activity and intensityAggressive, threatening or combative gets worse when challenged or injuredAmazing feats of strengthPressured loud incoherent speechSweating (or loss of sweating late)Dilated pupils/less reactive to lightRapid breathing3030Recognizing Excited DeliriumDelirium = ConfusionDisorientedPerson, place, time, purposeRapid onset over a short period of recent timeHe just started acting strangeEasily distracted/lack of focusDecreased awareness and perceptionRapid changes in emotions (laughter, anger, sadness)3131Recognizing Excited DeliriumPsychotic = bizarre behaviorThought content inappropriate for circumstancesHallucinations (visual or auditory)Delusions (grandeur, paranoia or reference)Flight of ideas/tangential thinkingMakes you feel uncomfortable3232Bad Behavior: Other ReasonsAlcohol intoxication or withdrawalOther drug use problemsExample: Cocaine psychosisPure psychiatric diseaseHead injuryDementia (Alzheimers Disease)HypoglycemiaHyperthyroidism3333ED presentationsCombativeSelf destructiveHomicidal/suicidalAgitation followed by severe depressionED presentationsDifferentialPCPLSDCocaineMethamphetaminesAlcoholHypoglycemiaHypoxiaHead traumaCNS infectionThe Work UpUrine Toxr/o routine street drugs + polypharmacyBMPHypoglycemia, metabolic acidosisCBCInfection and anemiaCT Head Intracranial hemorrhage, hydrocephalus12 lead EKGBiomarkers, myoglobin, lactic acidTemperature monitoringTreatment OptionsNo AntidoteSupportive therapiesSympathetic OverdriveAlpha and beta receptor stimulationSustained endogenous norepinephrine releaseBeta blocker caution?Metabolic dysfunctionHepatic metabolism of bath saltsHyperthermiaTreatment OptionsNo AntidoteSupportive therapiesPsychosisBenzodiazepinesVersed, Valium, AtivanAntipsychoticsHaldol, InapsineGeodonKetamineDispositionUnpredictable dose and durationPsychiatric evaluation when clearHomeJailPsychiatric facility

Status of K2/SpiceMany European countries ban sale and useKansas was first state to ban use15 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 themBath Salts are a Schedule 1 substance

Texas May 2011The Texas House passed a bill banning K2 or spice, a synthetic marijuanaThe 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 331Certain 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. ANY QUESTIONS???43