Cathinones - Henry Ford Health System

Designer stimulants
Susan Smolinske, PharmD, BCPS, DABAT
Children’s Hospital of Michigan Poison Center
800-222-1222
1
MSP Date October 2012
k2
PE
DMT
BZP
MXE
2
"Those who cannot remember the past, are
condemned to repeat it,“ - Santayana

MPTP:
• 1976, a MD chemist made MPPP, injected
himself, and developed Parkinson’s 3 days
later
• 1982, 7 addicts used MPPP and developed
Parkinson’s; 2 had neural tissue transplant
• Case of the Frozen Addict
3
“Some mistakes are too much fun
to only make once.” - Paisley
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1979: 13 deaths related to “China White”,
heroin containing α-Methylfentanyl
1981: placed on Schedule I
10 new analogs created
2002: Moscow theater 170 died after
gassed with 3-methylfentanyl
2013: acetylfentanyl found in heroin in
Rhode Island/PA – 50 deaths
4
“It is not worthwhile to try to keep history from
repeating itself, for man's character will always make
the preventing of the repetitions impossible”
- Mark Twain

Police Believe a Drug Abuser in Ann Arbor
Stumbled Across the Recipe While
Researching Amphetamines. He Passed it to
a Student at Northern Michigan University in
Marquette, who Began Making CAT in his
Apartment.

An Informant Tipped Police, who Raided the
Makeshift Lab in 1991

29 labs raided in the UP in 1993
5
“Bath Salt” Media Trends
6
Bath Salt Headlines
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5/26/12: Miami 'zombie Causeway Cannibal' attack
by Rudy Eugene the start of bath salts upswing,
experts say
6/2/12: Karl Laventure was High on Bath Salts
During His Zombie Attack
6/4/12: Montreal Cops May Have Found Head of
Cannabilism Victim
6/6/12:Carl Jacquneaux bit a chunk Of Face Off
Victim Todd Credeur In Louisiana, Cops Say
6/8/12:N.Y. mom on possible bath-salt bender dies
after Tasing
6/18/12:Giovanni Martinez Bit, Spit Blood, And
Threatened To Eat Faces 'Like The Miami Guy,' Cops
6/21/12:Another zombie attacks? Fla man Strips
Naked Bites flesh out of victim’s arm!
7
New diagnostic code?
Ataxic Neurodegenerative Satiety Deficiency Syndrome, or
ANSD coined by Harvard professor. ANSD occurs when the
frontal lobe, responsible for executive functioning, is
infected, leading the patient to be somewhat impulsive,
because he or she becomes entirely driven by the amygdala
and anterior cingulate cortex, those reptilian centers of
irrational rage, which we inherited from our evolutionary
predecessors. This problem is compounded by cerebellar
and basal ganglia dysfunction, and mirror neurons which
make us believe we are zombies when we watch zombie
movies.
8
One month later…..
CNN 6/27/12:Tests in cannibalism
case: Zombie-like attacker used pot,
not 'bath salts'
9
phenethylamine
Cathinone
10
NH2
Phenethylamine
OH
N
H
Methamphetamine
N
H
O
HO
MDMA
Epinephrine
NH2
MeO
Br
O
N
H
HO
OMe
2-CB
Which of the following is a
cathinone?
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JWH 018
Bupropion
Methamphetamine
Epinephrine
12
“Bath Salts”/Cathinones
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Plant food
Fertilizer
Pond scum cleaner
Research chemical
Novelty item
Bath Salt
Cleaner/deodorizer
Ladybug attractant
13
Common Names
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White Lightning
Super Coke
Magic
Cloud 9, Cloud 10
Hurricane Charlie
Ivory Wave
Raving Dragon
Energy 1
Ivory Snow
Bliss
Vanilla Sky
White Rush
Blue Silk
14
Physical Properties
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White to Light Brown
Hydrophilic
Crumbly powder
Slight odor
No plant material
15
What is Molly?
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Pure MDMA
MDMA + additives
A cathinone
A cannabinoid
16
What is Molly?
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Capsule containing
a “molecule”
White powder in a
capsule
Pure MDMA? NOT
Methylone in most
recent MI seizures
4-MEC in most
recent DEA report
It’s a cathinone!!!!!
17
What was in Bath Salts?
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MDPV (White Rush, Speed
Freak Ultra, Ivory Wave)
Methylone (Ocean Snow)
Ethylone
Pentylone (bk-MBDP)
Ephedrone (4-MEC) (Speed
Freak, Red Dove)
PMMA (Mind Candy)
MDPBP (Mind Candy)
α-yrrolidinopentiophenone
or α-PVP (Speed Freak,
Mind Candy, Red Dove)
3',4'-Methylenedioxy-αpyrrolidinopropiophenone
(MDPPP) (Speed Freak,
Red Dove)
4-methylephedrine
(mephedrone precursor)
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TFMPP (Vector
Extreme Bliss)
Caffeine (Vector
Extreme Bliss)
Lidocaine (Ocean
Snow)
18
Bath Salt Route of exposure
Michigan
Route
2011
Inhalation
42 (35%)
Ingestion
28 (23%)
Parenteral
38 (32%)
Rectal/vaginal
0
Dermal
1
19
Underlying psych history
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35 patients investigated in Marquette
69% had a self-reported history of drug abuse
• 31% polysubstance abuse
• 34% intravenous drug abuse
46% had a history of mental illness (e.g., bipolar
disorder, schizophrenia, or depression) in their
medical records
17% had suicidal thoughts or suspected attempts
that might have been related to "bath salts" abuse. 1
death from CO poisoning after mental health
discharge.
MMWR: 2011 / 60(19);624-627
20
Effects
Good
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Euphoria
Anorexia
Increased Energy
Increased
Alertness
Increased Sex
Drive
Bad
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Tachycardia
Hypertension
Headache
Sweating
Nausea/Vomiting
Anxiety
Agitation
Psychosis
Insomnia
Anorgasmia
21
Cannabinoids vs Cathinones
• Cannabinoids
•
•
•
•
•
•
•
•
•
•
Agitation 33%
Increased HR 40%
Hallucinations 15%
Increased BP 14%
Confusion 17%
Seizures 4%
1 death in Michigan
Pulmonary toxicity
Renal failure
Couch lock
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Cathinones
Agitation 62%
Increased HR 55%
Hallucination 33%
Increased BP 26%
Confusion 20%
Seizures 2%
Death 0.6%
• 9 in Midwest
22
NH2
Phenethylamine
OH
N
H
Methamphetamine
N
H
O
HO
MDMA
Epinephrine
NH2
MeO
Br
O
N
H
HO
OMe
2-CB
19yoM found down on campus
Wild and combative with WSU police
 5 guards to restrain him in resus
 No further history available
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24
2C
25
2C-T
26
2C-T-7
27
Positive
•
•
•
•
2C-T on Erowid
sense of well-being (enhanced
lucidity, sense of inner peace)
emotional opening
significant closed and open eye
visuals
increased appreciation of music
Neutral
Negative
•
sexual dysfunction
•
arrhythmia
•
paranoia
•
psychotic break
•
nausea and vomiting
•
muscle tension
•
insomnia
muscle tremors and/or
convulsions
general change in consciousness
(as with most psychoactives)
•
•
pupil dilation
•
memory loss (at higher doses)
•
change in perception of time
•
potential trigger of HPPD
•
visual hallucinations
•
•
auditory hallucinations
•
delirium (at higher doses)
(potentially dangerous)
•
violent behavior (at higher doses)
•
tachycardia
28
My dealer said it was “da bomb”
Also known as “25I” or “smiles”
 Strong affinity for 5HT2a receptors
 More potent hallucinogen than LSD
 Nanogram amounts on blotter paper
 Euphoric effects from serotonin
 Toxidrome: sympathomimetic +
serotonin syndrome
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29
2C-I-NBOMe
5
O
Me
B
N
I
2
30
31
I have got to get my hands on
this…
Where’d that bottle
go?!
32
25i NBOMe
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Phenethylamine related to 2CI
• Strong visuals occur (small patterns begin
moving and some objects may appear as 2D)
• Feelings of love, as well as sexual thoughts
• Unpleasant chemical taste in your mouth (not
eased by drinking any liquids)
• Mild anxiety
• Nausea, abdominal pain
• Time perception is affected
• Confusion (extreme confusion and panic in
higher doses)
33
25i NBOMe cases
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19 yo in ER hallucinating with repeated
seizures, followed by a transient right
sided hemiparesis.
Three cases in Minnesota, two fatal
(maybe same batch of drug). The patient
was found in cardiac and respiratory
arrest by paramedics, resuscitated
although suffered an anoxic insult and
expired on hospital day 3.
34
Michigan cases
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1/31/12: 4 teens, 3 seizures, 1 AKI)
June 2012: 1 teen
Sept 2012: 2 cases
Oct 2012: 1 case
Nov 2012: 6 cases, 1 “couch lock”,
seizures
Feb 2013: 1 case
July 2013: 1 case
35
2C-I-NBOMe cases
5 teens @ Fillmore, 11/7/12:
bassnectar
 “random guy” with a nasal spray
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• “wanna try?”
17yoM immediately seizes
 18yoF has a panic attack, ends up in
DRH ICU overnight with Serotonin
Syndrome
 Other 3 in obs unit milder sx’s
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36
Serotonin syndrome
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Which of these drug abuse classes
can cause serotonin syndrome?
• Cannabinoids
• Cathinones
• Dextromethorphan (DXM)
• Both cathinones and DXM
37
Other new stimulants
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Methoxetamine
(arylcyclohexylamine)
N,N-Dially-5-Methoxytryptamine (5Methoxy-Dalt) (tryptamine)
2, 5 Dimethoxy-4chloroamphetamine
(phenethylamine/amphetamine)
Dimethocaine
Alpha-PVP
38
Gravel?????
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Alpha-PVP
Mixed with other
Could have
ammonium nitrate
Plant fertilizer
PARANOIA
Used like crack
39
“dietary supplements”
Velocity = MDPPP
Zumos = alpha PVP
40
Synthetic Cocaine
dimethocaine
3-(p-fluorobenzoyloxy)tropane
(pFBT)
cocaine
41
What is in my Ecstasy pill?
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2C-B
2C-E
Alpha PVP
BTCP
BZP
DMT
Ketamine
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Methamphetamine
Methylone
MDPV
PMAA
TFMPP
Recent DEA testing of over 1400 “Ecstasy”
tablets purchased in Detroit revealed no MDMA,
but instead, methylone, BZP and TMFPP with
caffeine. MDMA is increasingly being detected in
combination with methamphetamine (Meth X).
42
Methoxetamine (MXE)
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Compulsive re-dosing
Taking more than planned
More catatonia
43
DMAA
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Stimulant found in:
Work out
supplements
• Jack3d
• Pump it
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Weight loss aids
• Oxyelite Pro
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“Party Pills”
Energy Boosters
44
What is it?
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DMAA, aka
• 1,3
dimethylamylamine
• Geranamine
• Methylhexanamine
• Forthane
45
Case Study - NZ
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11:30 pm, 21 yo male takes 2 tablets of “Party
Pills” labeled as 99.9% DMAA, also ingests
• 150mg tablet caffeine
• “One can of beer”
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Within 30 minutes, developed global HA,
nausea, vomiting, incontinent of urine
Fell asleep, next day (6pm) taken by friends to
ED
On arrival, pt was A, Ox2, slurred speech, right
sided weakness
“No Sympathomimetic Toxicity” BP – 126/66
HR - 65
46
More cases in NZ
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3 patients with
cerebral
hemorrhage
47
Case Study NZ
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Pills later analyzed,
278mg DMAA per
capsule
Later angiography
showed no evidence
of aneurysm
No caffeine,
amphetamine, or
other stimulants
found in pills
48
Case – US Army
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Summer 2011, 22 year old soldier
collapses after training run
Fall 2011, 32 year collapses after
fitness test
Same army base – southwest US
Both had DMAA identified in
toxicology reports
Amount/Dose/co-ingestion unknown
49
Stimulant Laboratory testing
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Laboratory testing: these agents WILL NOT BE detected
by standard drugs of abuse screening.
Testing (send out) can be done by:
o Beaumont-Royal Oak. Please contact Mike Smith in
their toxicology laboratory
o Redwood Toxicology (Santa Rosa, CA) has two panels
of urine drug screens for these
substances. A comprehensive GC-MS is also available.
1. Expanded designer stimulant panel
2. MDVP and mephedrone
800-255-2159
o NMS Labs can determine mephedrone and MDPV and
has an expanded cathinone and phenylethylamine panels
(866-522-2216) in blood (serum/plasma) and urine
50
Prevention
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New imminent danger law allow the
poison center to assist MDCH to detect
and act upon new hazards
Everyone here has a key role in
preventing Rx and OTC drug abuse
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800-222-1222 Nationwide PCC number
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Report a vendor 1-855-MICHTIP statewide
51
Stimulant treatment options
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Treatment
• Supportive
 Sedation
• BZD or Barbs
• Benzo Hammer
 Consider
neuroleptic if
severely psychotic
• Check ECG
 External cooling
 Hydration
BENZOS
Double dose every 10 minutes
until sedated
52