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Thug DrugsMark Garofoli, PharmD, MBA, BCGP, CPE
Faculty
Mark Garofoli, PharmD, MBA, BCGP, CPE
• Experiential Learning Director & Clinical Assistant Professor, WVU School of Pharmacy
• Clinical Pain Management Pharmacist, WVU Medicine Integrative Pain Center
• Coordinator, WV Pain Management Expert Panel (SEMP Guidelines)
• WV PDMP Advisory Panel Member
• CDC Grant Reviewer
Disclosures§Consultant/Independent Contractor: Daiichi Sankyo, Clinical Pharmacists
Advisory Panel, Member
This presentation was not a part of the presenter’s official duties at the WVU and does not represent the opinion of WVU
Learning Objectives
§Recognize commonly abused substances across the globe.
§Classify commonly abused substances based on each substance’s mechanism(s) of action.
§Explain how to provide guidance to the lay public on the anticipated effects of commonly abused substances.
ILLICIT SUBSTANCES
KROKODILBATH SALTS
Roboshake
Sizzurp
Russian Magic
Purple Drank
DAB
Spec
ial K
DEXTROMETHORPHANECSTASY
GRAVEL
HERO
INSkittle
sKETAMINE
KHAT
KRATOM
AMPHETAMINESLACED HEROIN
LSD
MARIJUANA
METHAMPHETAMINE
Magic Mushrooms
MXE
NBOME
OpioidsAg
ent O
rang
e
PCP
SALVIA
Pharming Parties
Scooby Snacks
COCAINE
Live Cacti
What are illicit substances?
1. Schedule 1 Controlled Substances• Illegal to make, sell, or use• No accepted medical use, dangerous, & potential severe dependence
2. Any Schedule Controlled Substance utilized for unintended people/uses
Laws are not uniform among states/countries
ØHeroin is LEGAL in the UK, Portugal, Canada, etc.
ØMarijuana is “LEGAL” in certain US states, yet Illegal on the Federal Level
!"#$%&'(#)*%+,,-.-$%/('#$01.)#%234567
Illicit Therapeutic Index
The Toxicity of Recreational Drugs. American Scientist. 2006. Volume 94, 206-208.
Word of Mouth
www.streetrx.comShows daily observed prices by location
Resource for addiction treatment centers by zip code(Links to SAMHSA)
Illicits de Venn
Illicit Substances Overview
Hallucinogens• NBOME• LSD• Ketamine•MXE• PCP• Psychedelic Mushrooms• Peyote Cacti• Ecstasy
Stimulants• Cocaine•Meth(amphetamine)• KHAT• Bath Salts & Gravel
Cannabis Products•Marijuana Plant• Synthetic Marijuana•Marijuana Extracts
Opioid-Related Products• Heroin• Laced Heroin• Krokodil• Kratom• Salvia• Dextromethorphan• Loperamide
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HALLUCINOGENS
!"##$%&'()*'+
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NBOMe !"# $%&'%()*+,-,.#/0*)1/23"#
LSD .55*%<+/,?F!G?H-/7*%*=<(4+
Ketamine HI,. .'<")('&+<J/,?B$?K ")('&+<J/L?H?,C7MJ/H"?N" N;"''*#/O#(%P*4+J/HQ LD'<;"+*/M';&6&<(4
MXE HI,./.'<")('&+</R/LL7M/SF!GT
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,-./0123/,4$)+/(5/.6$+*/7*+($4%*/8$&9*:/;<<=+>??@@@:9*":)(A?=4?B$#<&B*9&"C#&64"4D?=$6#&%"<&('+?94$)E(5E"6$+*:=95
PCP FG,./.'<")('&+<H/.'<&CI;(#&'*4)&%H/J/,(="B&'*
Psychedelic Mushrooms KC!L2. "'9 KC!L0. "'9/KC!L0I .)('&+<
Peyote Cacti K!LC0./7*%*=<(4+/J/,(="B&'*
Ecstasy (MDMA) K!L?,.?F-
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Nicknames !"H'I+J<''8I+J&"?I+KB"?I+"0+!"#"$+L1443
Mechanism MNO>G)>(+P+G$C!:$&&'B+KB"#H'0
MarketJ&"0;'8+L"?8'0+Q!"#$%R+%&#B18'=+Q&'()%R+STMA2U+"0+Q*+",%R+S.--A2U
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F7"=G'$>=7"'$#(7H NE & Dopamine
Khat NE & Dopamine
Bath Salts & Gravel
Synthetic CathinonesNE & Dopamine
Marijuana
Let’s Dive into the WEEDs…
https://www.analyticalcannabis.com/articles/cbd-vs-thc-what-are-the-main-differences-297486
THC CBDPain
NauseaVomitingAppetite
GlaucomaInsomniaAnxiety
Muscle Spasticity (Stiffness)
PainInflammation
SeizuresPsychosis
DepressionIBS
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Plant GHIJ$IK!J$0826
Synthetic L2--/B$LC=EMJ$N%MJ$L9420MJ$O0+=@$P*CQMJ$0826
Extractions !#KJ$K*8=C0$H=,7$R4@$SKHRTJ$H=,7$R4@J$H-C0B$R4@J$U$L7=880)
N! V@=C8;LBC870842$W=)4X*=C=J$G-/=22-J$-)$K#F#F#LO=205$<487$K*+$L9)=B
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!"##"$%#&%' !()*+!, !()*+!-, !()*./0UFTV4! W WUDTV4! W W!X( W W!XK W W
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“Medical” Marijuana States Timeline
1996
2006
2016
http://ohiovalleyresource.org/2016/07/15/medical-marijuana-laws/?_ga=1.210143126.2028368723.1468936668
California 1996Alaska 1998Oregon 1998
Washington 1998Maine 1999
Colorado 2000Hawaii 2000Nevada 2000Montana 2004Vermont 2004
Rhode Island 2006New Mexico 2007
Michigan 2008Arizona 2010
New Jersey 2010Washington, DC 2010
Delaware 2011Connecticut 2012
Massachusetts 2012Illinois 2013
New Hampshire 2013Maryland 2014Minnesota 2014New York 2014Arkansas 2016Florida 2016
North Dakota 2016Ohio 2016
Pennsylvania 2016West Virginia 2017
Oklahoma 2018
Opiates/Opioids
Opioid Abuse Transition
75% of Heroin Users Started with Legal
Prescription Opioids
Hydrocodone Combo Tablets
$5-10/Tab
Oxycodone Combo IR Products
$10-15/Tab
Oxycodone Sole ER/IR Products$1.50/mg
Heroin ($10/Bag)
Shah A, et al. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use – United States, 2006-2015. Weekly / March 17, 2017 / 66(10); 265–269.
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9::;<==>>>8"A577?8"/#$;?8"/=9:AB852A=%&7"F(G89:AB
Nicknames '$;"H*!H*I#$>&*J/0?#H*IB?5K*L?#H*JA?5KH*M*'#?0$&
Mechanism N/*O;%$%7*4"5";:$#1
Chemical '%C?5":DBCA$#;9%&"
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1. Purification of raw opium
2. Extractions of morphine from
opium
3. Morphine !Diacetylmorphine
Base
4. Diacetylmorphine Base !
Diacetylmorphine HCl Salt
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Nicknames N7++&1;,@1O&A #" P##",@1;Q+,4*"#&;
Mechanism @7 R=&#&%,N*A*=/#"+
MME Factor 2*;,<IH>
ChemicalS*+#5#"=3&;*,<%&T39%"#T%*+T#B9T5#"=3&;*>
P1/*;/*%,&;,IGMF,1+,P*"5#;&%,&;,?U&/V*"'1;%
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Nicknames Q;#D0R*Q;%&R S T?8&
MechanismI%$4D$*!BU<8%89
'+*)0%D81$VUWB+*)D$8B8D2A#&&#$%"C
Drug Interactions VXIYJ,*L)YR*+'ZR*S*-)+*[D;838$%"
ChemicalH8$"#0CD#*T<468%1#
Q"%<86#A*<A#D$*8D*6%2244*2#&8ACG#$8@4*$%*T%/$;4#1$*)18#
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Nicknames !"#$%")&%$%D2./AQ)R")H".%"Q)H"0%7)H%D<Q)2.)&%$%D5.S1)!"05
MechanismI2<5D<)TBU=%2%9
&*)(02D%1<'D927"DD"4%D2%9 H29/#"<2.
Drug Interactions VWIXJ+),(,Q)*V,OQ)*&YQ)Z)*',
Chemical!"05)=#"D<)MH%D<)["A%#CN
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!12,3456,!%789,&:,2;79",<"9&7%=",>7?@"A,($$)9BCCDDDA@"*A8&EC)%C'7F$?'"@?*GF?;%*%HC)7;F?=*$?&+9C@%78I&:I*;79"A)@:!"#$#%&"'()&*+&%,",-.'/$"#$0'1&2&3&405'6789
NicknamesJ?KK7%)L,M7%)F",!%*+NL,M7%)F",O&+?=<&;?$799?+,!/P! <&;&9(*N"!"F9H'P! 28"+$,Q%*+8"R&%?=?@?+,STMP! JN?$$F"9
MechanismU&+GJ"F"=$?E",J"%&$&+?+,<"7)$*N",V+(?;?$&%L
U/!2,2+$*8&+?9$L,Q)?&?@,J?8'*,28&+?9$L,W,2+"9$("$?=
Chemical ;#<0.0+&/,<5 /A)'<@/,<+4/534.0)B,<+4C'#'<@/534.0/'D
Chirality
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!"#$%&'()$
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Nicknames *""%+,&-./+,$01&)"-$+2+3'")(4'5
Mechanism *$%(#1$%&!+,467#("()+89"-(/0
Info :;<< ,"=$)+>%"'+?6@+0"+7A?
Illicit Substances Overview
Hallucinogens• NBOME• LSD• Ketamine•MXE• PCP• Psychedelic Mushrooms• Peyote Cacti• Ecstasy
Stimulants• Cocaine•Meth(amphetamine)• KHAT• Bath Salts & Gravel
Cannabis Products•Marijuana Plant• Synthetic Marijuana•Marijuana Extracts
Opioid-Related Products• Heroin• Laced Heroin• Krokodil• Kratom• Salvia• Dextromethorphan• Loperamide
Increased Neurotransmitter EffectsSerotonin (5HT) Dopamine (DA) Norepinephrine (NE) Opioid
Effects
Hostility/AgitationMuscle Rigidity
ShiveringGoose BumpsDilated Pupils
Fever/SweatingDiarrheaSeizures
RestlessnessTachycardia
“Reward & Pleasure”Schizophrenia
Muscle TwitchingAmnesiaInsomnia
Tachycardia
“Fight or Flight”Dilated PupilsTachycardiaDry Mouth
Urinary Retention
Constricted PupilsConfusion
Nausea/VomitingConstipationDry Mouth
Urinary RetentionRespiratory Depression
Substances
Peyote CactiCocaine
DXMEcstasyKratom
LSDPsychedelic Mushrooms
MXENBOMe
PMA
GravelPeyote Cacti
CocaineEcstasy
KetamineKhatLSD
Bath SaltsPCP
Salvia
GravelCocaineEcstasy
KhatLSD
Bath Salts
DXMHeroin
KetamineKratomKrokodil
SalviaU-47700
W-18
Dipiro J, et al. Pharmacotherapy: A Pathophysiological Approach. 10th Edition. McGraw-Hill Education. 2017.DEA 2017 Drugs of Abuse Resource Guide. https://www.dea.gov/pr/multimedia-library/publications/drug_of_abuse.pdf
Pharming & Punchbowl Parties
DEA 2017 Drugs of Abuse Resource Guide. https://www.dea.gov/pr/multimedia-library/publications/drug_of_abuse.pdf
!"#$%&'"#()$*'"*+&,+-*.($*(/00-'-+(1%2#+,*'"#
Support Groups
Alcoholics Anonymous (AA)vhttp://www.aa.org/v212-870-3400
Narcotics Anonymous (NA)vhttp://www.na.org/v1-818-773-9999
Nar Anon (Family & Friends)vwww.nar-anon.orgv1-800-477-6291
Audience Question #1
Which of the following illicit substances is a hallucinogen?a) Bath Saltsb) Khatc) Ketamined) Carfentanyl
Audience Question #1 (ANSWER)
Which of the following illicit substances is a hallucinogen?a) Bath Saltsb) Khatc) KETAMINEd) Carfentanyl
Audience Question #2While stopped at a cross-walk on Las Vegas Boulevard (i.e. “The Strip”) at 2am, you notice a college student next to you leaning against a stop light post, shaking, with a red-toned skin color, grinding her teeth, and profusely sweating. If she was to have ingested an illicit substance, which of the following would be the most likely of the listed substances.
a) Kratomb) Scooby Snaxc) Heroind) Ecstasy
Audience Question #2 (ANSWER)While stopped at a cross-walk on Las Vegas Boulevard (i.e. “The Strip”) at 2am, you notice a college student next to you leaning against a stop light post, shaking, with a red-toned skin color, grinding her teeth, and profusely sweating. If she was to have ingested an illicit substance, which of the following would be the most likely of the listed substances.
a) Kratomb) Scooby Snaxc) Heroind) ECSTASY
Audience Question #3
Which of the following are effects of various doses of dextromethorphan (i.e. DXM)?
a) Cough Suppressionb) Pain Suppressionc) Hallucinationsd) Euphoriae) All of the Above
Audience Question #3 (ANSWER)
Which of the following are effects of various doses of dextromethorphan (i.e. DXM)?
a) Cough Suppressionb) Pain Suppressionc) Hallucinationsd) Euphoriae) ALL OF THE ABOVE
Discussion
Mark Garofoli, PharmD, MBA, BCGP, CPELinkedIn: Mark Garofoli
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