Stimulants

STIMULANTS
AND
NEW PSYCHOACTIVE SUBSTANCES (NPS)
dr.Adhi Wibowo Nurhidayat,SpKJ(K),MPH
Institute of Mental Health, Addiction,and Neuroscience (IMAN)
Soeharto Heerdjan Psychiatric Hospital - Jakarta
Disclosure
No Financial Support
from Pharmaceutical Companies
Outline
Stimulants
Definition of New Psychoactive Substances
(NPS)
Bath Salts, Party Pills, Synthetic Cannabinoids
Krokodil
Summary
Stimulants
 Cocaine
 Methamphetamine
 Dextroamphetamine
 Methylphenidate
 MDMA (Ecstasy)
Prescription stimulants
 Dextroamphetamine (Adderall)
 Methylphenidate (Ritalin, Concerta)
Stimulants
Increase alertness and energy
Increase blood pressure and heart rate
Constricts blood vessels
A sense of euphoria
Stimulants
Sel serotonin
Neuron serotonin
(kuning)
serotonin (titik-titik merah)
Methamphetamine
Methamphetamin tablets (‘yaba’) –
small pills typically of low purity, available
in many different shapes and colours.
Crystalline (‘crystal meth’, ‘ice’ or ‘shabu’),
usually of much higher purity
Methamphetamine
Methamphetamine tablets (5-20% purity)
Crystalline methamphetamine (40-90% purity)
Overdose
 Retensi cairan/ gagal ginjal
 Agitasi, konfusi, gangguan bicara, psikosis, halusinasi,
konvulsi, sakit kepala berat
 Takikardia (debar jantung istirahat >120 per menit)
 Hipertensi / hipotensi
 Hiperthermia (temp >38.6o C )
 Nausea atau muntah
 Konsumsi air berlebihan
 Otot kaku
 Kematian
Long term effects
Increase tolerance
Potential neurotoxicity
ekstasi & Party drug
New Psychoactive Substances (NPS)
A new narcotic drug or a new psychotropic
drug in pure form or in a preparation
(European Monitoring Centre for Drugs
and Drug Addiction-EMCDDA)
New
Does not necessarily refer to new
inventions, but to substances that have
recently become available
New Psychoactive Substances
"Emerging substances that are used for
psychotropic effects that are not subject
to control under the United Nations
Conventions“
e.g mephedrone Class B drug in UK,
subject to EU order 16523/10, but not
included in UN Conventions
'legal highs' in professional discussion
New Psychoactive Substances
A substance in pure form or in a preparation,
that has not been scheduled under the 1961
UN Single Convention on Psychotropic
Substances, and that may pose a threat to
public health comparable to the substances
listed
in Schedule I,II, III or IV
“Legal
Highs”
Piperazines
Phenylethylamines
2000’s
2005
BZP
TFMPP
MCPP
2C-B
derivatives
Synthetic
Cannabinoids
2008
Spice
Cathinones
Mephedrone
MPDV
15
UNODC World Drug Report
 Legal highs, herbal highs, bath salts,
research chemicals
 The number of NPS:
166 (2009)  >600 (early 2016)
NPS >total number of substances
under international control
Controlled drugs and NPS
600
541
500
Number of substances
193
400
348
300
243
234
206
200
115
166
37
251
8
NPS identified for the first time in
current year
97
NPS identified in previous years
40
Psychotropic substances (1971
Convention)
102
100
119
Narcotic drugs (1961 Convention)
0
2014
Internationally
controlled
2009
2010
2011
2012
2013
2014
New Psychoactive Substances (NPS)
NPS
Some NPS contain molecules that might share
similar effects and profiles of MDMA that they
are designed to mimic
Synthetic cathinones can evoke stimulant and
empathogenic effects similar to ATS, including
MDMA
 Reports of seized “ecstasy” tablets that have
been found to contain little or no MDMA
NPS
Share similar effects and profiles of
substances under international control
that they are designed to mimic.
9 NPS substance groups have been
identified.
Synthetic cannabinoids (e.g. JWH-018151)
are mimetics of THC (delta-9Tetrahydrocannabinol), the main
psychoactive substance of cannabis.
NPS
Several NPS mimicking the effects of ATS
belong to the synthetic cathinone group
which have stimulant and empathogenic
properties,
and the phenethylamine group which
includes substances that can induce
stimulant and hallucinogenic effects.
UNODC 2015
East, South-East Asia and Oceania 
- the largest number of ATS
(excl. “ecstasy”) users worldwide
at almost 9.5 million users
- the largest number of “ecstasy” users
at 3.9 million.
The scope and availability of NPS has rapidly
expanded
NPS - Narkoba Jenis Baru
NPS - Narkoba Jenis Baru
Distribusi NPS
Market – Rave Party
Head/Smart Shop
Online Smart Shop
Katinon dan Derivat Katinon
Cathinone
Amfepramone (diethylpropion)
Mephedrone
Methylone
Methcathinone
MDPV
Methedrone
Penggolongan NPS
NPS in Indonesia – 41 substances (2016)
Bath Salts – Garam Mandi
Bath Salts
 “Legal High”
 Synthetic cathinone
 Paranoid, hallucination, hyperthermia,
HR elevated, death
Bath Salts
 Includes MDPV, 4-MMC,
mephedrone, or methylone
 Sold on-line with little info on
ingredients, dosage, etc.
 Advertised as ‘research chemicals’, ‘plant food’,
‘bath salts’ or ‘glass cleaner’
 Taken orally or by inhaling, sometimes injected
 desired effects are increase in energy, empathy,
openness, and libido
 Little known of detailed pharmacology
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Bath Salts
Bath Salts
Bath Salts
Bath Salts - Mephedrone
Mephedrone
4-methylmethcathinone (Miaow)
effect profile similar to MDMA
Effects short lived and dose dependent
Repeated administration common
42
Mephedrone
Severe adverse effects appear dose
related but are rare at typical levels of use
Interactions with other substances may be
significant in risk profile
student survey of mephedrone users,
more than half reported adverse effects
first fatality Sweden 2008
Most fatalities associated with the use of
other substances
43
Mephedrone-related
44
Party Pills – Benzylpiperazine-BZP
Party Pills - Benzylpiperazine
Benzylpiperazine
Forbidden in NZ, Australia, US, Ireland
Euphoria, hyper energy, hyperactive
Vomit, anxiety, tachycardia
Seizure, metabolic acidose, death
JArgon
Ganja Sintetik
Gorilla
Hanoman
Nataradja
Ganja Sintetik - Synthetic Cannabinoid -Spice
Ganja Sintetik - Synthetic Cannabinoid -Spice
Ganja Sintetik
SOURCE: Fattore & Fratta. (2011). Frontiers in Behavioral Neuroscience, 5(60), 1-12.
Ganja Sintetik
K2
Spice Diamond, Spice Gold, Spice Silver,
Yucatan Fire, Smoke
 Smoking, shisha (water pipe)
 HR and pulse rate >>
Delirium
Hallucination, anxiety, agitation, tentamen
suicidum
Penggolongan Ganja Sintetik
Naphthoylindoles (misalnya JWH-018, JWH-073
dan JWH-398)
Naphthylmethylindoles
Naphthoylpyrroles
Naphthylmethyl Indenes
Fenilasetil Indole (yaitu benzoylindoles,
misalnya JWH-250)
Cyclohexylphenol (misalnya CP 47.497 dan
homolog dari CP 47.497)
Classic cannabinoids (misalnya HU-210)
http://www.emcdda.europa.eu/publications/drug-profiles/syntheticcannabinoids
Cannabis versus Cannabinoids
• Most symptoms
similar to cannabis
intoxication:
–
–
–
–
–
–
–
Tachycardia
Reddened eyes
Mild sedation
Anxiousness
Memory deficits
Hallucinations
Acute psychosis
• Symptoms not
typically seen after
cannabis intoxication:
–
–
–
–
–
–
–
Nausea/vomiting
Agitation
Violent behavior
Hypertension
Seizures
Hypokalemia
Coma
Hermanns-Clausen et al. (In Press), Addiction; Rosenbaum et al. (2012). Journal of Medical Toxicology; Forrester et al. (2011). J
ournal of Addictive Disease; Schneir et al. (2011). Journal of Emergency Medicine.
SOURCES:
Rare Events
Reports of suicides associated with
preceding use
Seizures
Tachyarrhythmias
May be carcinogenic
56
Krokodil – Putaw Murah
Dihydrodesoxymorhine = desomorphine
Codein, iodine, gasoline, HCl acid
“Cheap heroin” = putaw murah
 Inject
Krokodil – Clinical appearance
Krokodil- Flesh Eating Drugs
Lessons Learned
• UK (15 September 2011)
Temporary Class Drug Orders” allows temporary ban
have been introduced into the Misuse of Drugs Act
• Finland (1 June 2011)
Risk assessment has been added to 2008
Narcotics Act
• Sweden (1 April 2011)
Enhanced powers to police and customs
• Poland (2010)
‘Substitute drugs’, umbrella definition
• Ireland (2010)
Psychoactive substances, umbrella definition
Lessons Learned
• UN Drugs Conventions
EMCDDA, DEA…evaluation every 6 mo
Japan.……………evaluation every 3 mo
Drug monitoring  costly
Summary
Legal highs, herbal highs, research chemicals
Many have stimulant and hallucinogenic
properties
Showing evidence of dependence forming
potential
Best legislative framework still evolving
(UU Narkotika –Psikotropika, BNN,
Kemenkes)
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