Synthetic Drugs of Abuse

4/12/2016
Bath Salt Gestalt
The New Drugs of Abuse
Brian T. Kloss, DO, JD, PA-C, FACLM
SUNY Upstate Medical University
Syracuse VA Medical Center
My Only Request
Molly – Coming Soon to a College Near You!
Why Lecture on Substance Abuse?
“We Can’t Stop” = DANCING WITH MOLLY
"It depends who's doing what. If you're aged ten [the lyric is]
Miley, if you know what I'm talking about then you know. I just
wanted it to be played on the radio and they've already had to
edit it so much," the 20-year-old singer told the Daily Mail
revealing interview. "I don't think people have a hard time
understanding that I've grown up. You can Google me and you
know what I'm up to -- you know what that lyric is saying."
2013
What is Molly?
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MDMA Testing Kits
MDMA
MDMA Identification Charts
MDMA Art
LeMoyne
Molly in Syracuse
• 22 indictments in August 2011
• Investigations began spring of 2009
• 100 kg of “Molly” distributed between March
2010 through April 2011
• 25 kg of “Molly” ($525,000), 24 guns, 4
vehicles, a Bayliner boat and $100,000 seized
• “Molly” determined to be 4-MMC and 4-MEC
February 2015
12 Students Hospitalized, 5 Arrested
September 2014
Mass Overdoses, Previously Unreported
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Wesleyan Molly
• 0.1g = $20, 1g = $200 ($80-$100)
• 5 arrested, 5 suspended, charges dropped in 2
cases
• Analysis: AB-Fubinaca and “substance similar
to MDMA” which was 6-MAPB
• Main distributer created pamphlets to
distribute to students on appropriate dose
and “safe” drug use
Molly? →
Career Over?
Wesleyan Molly
AB-Fubinaca
• Invented by Pfizer in 2009
• Hit the synth scene in 2012
in Japan
• AB-PINACA, 5F-AB-PINACA,
ADBICA, etc., etc.
• “Synthetic Marijuana”
• Associated with several
deaths
6-APB
• 6-(2-aminoproply)benzofuran
• “Benzofury”
• Phenethylamine
• Triple monoamine reuptake
inhibitor and 5-HT2B Agonist
• “Similar” to MDA
College Enrollments
SUNY Oswego
• May 2015 – 21 year old arrested with 809
tablets of Xanax, some marijuana and
$170,000 cash.
• $5,000 cash bail $10,000 bond.
Where to Purchase?
2,848
3,224
7,193
= $419.51
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Cybercrimes
With Ben
Hammersley
The New Kids on the Block
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Molly
25B-NBOMe = “25B” 25I-NBOMe – “25I”
2ci, 2ce = phenethylamines
AB-FUBINACA
25B-NBOMe “N-BOMB”
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LSD Alternative
Synthetized 2004 Germany Ralph Heim
Can be: 25I, 25C, 25B - NBOMe
Substituted phenethylamine
Similar to 2CI, 2CE, 2CB
STRONG 5-HT2a Receptor Agonist (16x 2C-I)
25B-NBOMe “N-BOMB”
• Tachycardia, Dilated Pupils, Tremors, ↑ WBC,
Seizures, Clonus, Agitation, Hallucinations,
HTN, AKI, Metabolic Acidosis
• Potent enough for Blotter Paper Hits
• Sublingual, Buccal, Nasal, Vaporized, IV
• March 2012-August 2013 19 deaths in
Americans between ages 15-29 y/o*
* DEA Press Release November 15, 2015
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“Old School” Outline and Objectives
• K2/Spice – Incense and Synthetic Marijuana
• Bath Salts – The “Speedy” Cocaine/Speed Alternative
• Plant Food – The “Trippy” Ecstasy Alternative
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Salvia Divenorum – The Diviner’s Sage
Kratom – The Opiate Alternative
Levamilsole – The Leukocyte Killer
Strychnine – The Glycine Inhibitor
Huffing Agents – The Unsophisticated Drug of Abuse
Background
• “Research Chemicals” have been available for bulk
purchase over the Internet from Chinese Manufacturers
for years.
• Sold as a powder, in bulk weight, and not packaged in a
pill → thus “not for human consumption”.
• Some products were a manufacturing precursors to
active compounds (2-CH → 2-CI or 2-CB).
• Some products were pro-drugs converted in the human
liver/kidney to active form (GBL → GHB).
• Some products are psychoactive drugs by themselves
(JWH-018, MDVP, 4-MMC/4-MEC).
• Some products are non-scheduled drugs by themselves
(Khat, Salvia, Kratom)
GHB Home Manufacturing Kit – Available Online in the Early 1990’s
GBL (Gamma-Hydroxybutyrate / GHB) Advertisement in High Himes Magazine
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JWH-018 as a “Research Chemical”
JWH-018
“Legal Buds” Have Been Advertised in High Times Magazine Since 1990’s
The Loophole
THC
How Many Options Are There?
LOTS!!!!
And LOTS!!!!
The Syracuse Smoke Shop Industry
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Incense
Synthetic Cannabinoids
• “legal buds” & “herbal smoke” sold since early 2000’s
• K2/Spice first major players late 2000’s
• Synthetic cannabinoids first identified as active ingredients
in these products in 2008.
• John W. Huffman at Clemson University first synthesized
THC analogs in late 1990’s.
• JWH-018, JWH-073, cannabicyclohexinol, and HU-210 have
been some of the compounds identified.
• Sold in “head shops” and “smoke shops”
• Concentrations of psychoactive compounds vary per sachet
(0.2-3%)1, as well as the binding affinity of the synthetic to
the anandamide receptors in brain (can vary between 5800x affinity)
What the User Expects
Effective Marketing
Idiosyncratic Reactions
What You Get
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Tachycardia
Bloodshot Eyes
Discordination
Dry Mucus Membranes
Paranoia*
Hallucinations*
Delusions*
Altered Time
Perception*
Psychosis*
Tremors*
Seizures*
Agitation*
Catatonia **
• June 6, 2010 - David Rozga – 18 year old high school athlete
in Indianola, Iowa smoked a synthetic cannabis product,
had no history of depression, complained to a friend that
he “Felt like was in Hell”, went home and shot himself in
the head with a shotgun.
• Recently reported case series of STEMI with elevated
troponins, and clean caths were identified in 3 teens
complaining of chest pain an ED in Utah.2
• March 5, 2012 – Three cases of renal failure and a dozen
others sickened with “back pain, nausea and vomiting”
after smoking “blueberry spice” in Casper, Wyoming3
“Clusters”
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So Why So Popular?
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Profitability – both wholesale and retail
Currently Legal (or at least not illegal)
Doesn’t show up on conventional urine testing
Convenience
Perceived Safety
What’s New in Syracuse
Diagnostic Workup and Treatment
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Supportive Care
Reassurance and Calming Techniques
EKG to r/o underlying arrhythmias
Consider CIP (Cardiac Injury Panel) & BMP
CXR to r/o barotrauma (pneumomediastinum or
pneumothorax)
• Mild Benzodiazepine for Anxiety
• Physical and/or Chemical Restraints if Required
(Adulterated Marijuana)
Article on Wholesale Product
• Catatonia/Lethargy – Case Reports x 2
• Agitated Delirium – Easy Dx, but safety risk
Hubei Prosperity Galaxy Chemical
Alibaba.com
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Bath Salts
Inert Plant Material
Proprietary Blend
Secret Ingredient
How Many Options Are There?
MDVP - Methylenedioxypyrovalerone
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Norepinephrine-Dopamine Reuptake Inhibitor*
Developed in 1969
Hit the Radar in 2004
MDPK, MTV, Magic, Maddie, Super Coke, PV
White to yellowish color, fishy odor with age
Stimulant Effects > Empathogeneric Effects
More “speedy”, less “trippy”.
4-6 hour high with a comedown – total effect 10 hours
Addictive – High Desire to Redose
Causes Agitated Delirium – Florid Psychosis
LOTS!!!
MDVP - Effects
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Hypertension
Tachycardia
Bruxism
Diaphoresis
Mydriasis
Hyperthermia
Rhabdomyolysis
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Paranoia
Psychosis
Delusions
Hallucinations
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Plant Food
Molly, 4-MMC, 4-MEC, Mephedrone
• Sold legally under the guise of “plant food”
• Structurally similar to cathinone, like Khat
• 4-Methylmethcathinone
4-Methyl-N-Ethylcathinone
• Increases both dopamine and serotonin*
• More “trippy” than “speedy” when compared
to bath salts
• Syracuse Drug Bust: 22 Arrested 8/16/2011
Salvia Divenorum
Salvia
Happy 18th Miley
• Unique selective kappa-opiate agonist
• Smoked using water bongs and/or blue flame
butane lighters to maximize vaporization of
salvinorum A and to make smoking more
tolerable.
• Sold in concentrated leaf extracts for about
$20-$30 online and in smoke shops.
• “Earthy” trancelike and dissociative high for
5-10 minutes
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Or is it Hanna Montana?
Kratom
Kratom
• Two principle psychoactive alkaloids:
7-hydrooxymitragunine and mitragynine.
• Both alkaloids have an agonistic effect at the
opioid receptors, with mitragynine having an
effect at alpha-adrenergic receptors in lower
doses.
• The drug has limited effect on respiratory
drive, making it relatively safe in pure form.
• Kratom is often used in Southeast Asia to
mediate the severity of heroin withdrawal.
• The product is sold in the US primarily via internet
websites and in “head shops” in a chopped leaf or
pulverized form as a “concentrated extract”.
• There have been nine deaths in Sweeden from a
brand of Kratom called “Krypton Kratom” that was
laced with O-DT (O-Desmethyltramadol), the
active metabolite of tramadol.
• In the US, there has been one reported instance of
a frequent user reporting to an ED with Kratom
withdrawal, which is very similar to opiate
withdrawal.
• Overall, this drug is still “flying under the radar”.
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“Synthetic” Drug Summary
• K2/Spice/Incense = synthetic marijuana
• Bath Salts/Glass Cleaner = amphetamine-like
• Molly/Plant Food = substituted cathinones,
phenethylamines,
MDMA-like
• 25-NBOMe = LSD-like
• Kratom = opiate-like
Fun Websites
Replaced by: Blue Light
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Website: www.klossandbruce.com
Twitter: @EM_PEARLS
Facebook: Kloss and Bruce
YouTube: Kloss and Bruce (Toxicology Videos)
E-Mail: [email protected]
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Crazy Cutting Agents
• Strychnine in Heroin !!!
• Levamisole in Coke !!!
Levamisole
Levamisole
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Jannessen Pharmaceuticals 1966
Imidazothiazole drug
Immune Modulator and anti-helminthic
69-82% of US cocaine supply is cut with it
Neutropenia, Agranulocytosis, Vasculitis
Effects are Reversible
Bulking Agent / Stimulant Effect / Purity Test
(Purity Test = Think Melamine and Dog Food)
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Vasculitis
Typical Reticular Patterns Seen in Vasculitis from Levamisole cut Cocaine.
Expect an extremely low WBC count and Neutrophil Count on CBC.
Urine Drug Screen May/May Not Test Positive for Cocaine.
Agranulocytosis - Bone Marrow Slides
• Normal Marrow
• Neutropenic Marrow
Inhalants
• Glue – toluene
• Aromatic Hydrocarbons (ringed) - solvents
• Aliphatic Hydrocarbons (straight, branched or
cyclic chains) – butane, gasoline
• Halogenated Hydrocarbons – “Dust-Off”
• Nitrates – “poppers”
• Nitrous Oxide – “whip its”
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Inhalants
Roll Video 1 – Inhalants
• Sniffing – to inhale from an open bottle or
container, uncapped marker, etc.
• Huffing – to inhale directly from a rag doused
in the volatile substance/solvent
• Bagging – to inhale directly from a bag placed
to the mouth or over the head – most
concentrated and most dangerous
• “Dusting” – abusing canned air, typically
bagged
Inhalants Demographics
• 793,000 adolescents 12 or older used in 2010*
• Use declines with age, highest use 8th grade.
• More prominent in lower socio-economic
classes, history of child abuse, poor grades,
individuals dropping out of school, rural areas.
* National Survey on Drug Use and Health
2013 Monitoring the Future Data
Huffing Paint
2013 Monitoring the Future Data
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Inhalants Desired Effects
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Short, Rapid High
Initial Excitation
Drowsiness
Disinhibition
Lightheadedness
Agitation
• Anesthesia
• Enhanced Sexual
Performance (Nitrites)
• Dizziness
• Flushed Feeling
• Disorientation
Inhalants – Sudden Sniffing Death
• Chronic Use Can Cause
B12 Deficiency.
• Sold in Balloons for $5
at music concerts.
• Can be purchased in
bulk on Amazon.com!
Inhalants Undesired Effects
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Belligerence
Apathy
Impaired Judgment
Impaired Functioning
Ataxia
Addiction
Depression
Tachycardia
• Demyelination
• “Sudden Sniffing
Death Syndrome”
• Asphyxiation
• Suffocation
• Choking/Aspiration
• Brain Atrophy
• Fatal Injuries/Death
Inhalants Nitrites
Dextromethorphan
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Sizzurp
"Sippin' sizzurp in my
ride, like Three 6“
“Getting’ slizzard
like a lizard”
AKA: Lean
Jimson Weed
Triple C’s
Antihistamine: Chlorpheniramine Maleate 4 mg
Cough Suppressant: Dextromethorphan Hydrobromide 30 mg
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Anticholinergic
Temp: Increased
HR: Increased
BP: Increased
RR: Increased
Eyes/Pupils: Dilated
Lungs: Clear
Bowels: ABSENT
Skin: Hot & DRY
References
1. Stafford, Ned. Synthetic Cannabis Mimic Found in Herbal Incense. Royal Society of
Chemistry: Chemistry World. January 15, 2009.
2. Mir, A., Obafemi, A., Young, A., Kane, C. Myocardial Infarction Associated with the Use of
Synthetic Cannabinoid K2: Pediatrics. November 7, 2011.
3. Zuckerman, L. Wyoming Kidney Failure Outbreak Linked to “Spice” Drug, Reuters. March 5,
2012
HOT & DRY
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Gratuitous Self Promotional Insert – July 2013
Disclaimer
I included additional slides in this Power Point to act
as “filler” to be utilized if I moved quickly through the
assigned topic of: synthetic drugs. The lecture as it
stands would take at least 90-120 minutes to cover all
the enclosed material.
Other lectures I do on substance abuse include:
• Inhalants
• Cocaine & Heroin
• OTC Drugs of Abuse in the Adolescent Population
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