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Designer &
Emerging Drugs
of Abuse2015
Daniel Castellanos, MDMedical Director South Florida behavioral health Network
Founding Chair, Department of Psychiatry & Behavioral Health Professor of Psychiatry & Behavioral Health and Pediatrics
Herbert Wertheim College of Medicine, Florida International University
Disclosures
Assistant Dean of Graduate Medical EducationFounding Chair, Department of Psychiatry & Behavioral Health
Professor of Psychiatry & Behavioral Health and PediatricsHerbert Wertheim College of Medicine, Florida International University
Castellanos Designer & Emerging Drugs of Abuse 2015
Identify the types of designer drugs, including “flakka”, ecstasy, synthetic cannabinoids and others
Recognize the prevalence of use of these drugs
Recognize the psychoactive and physical effects secondary to use of these drugs
Learning Objectives
Castellanos Intro Child & Adol Psychiatry 2015
Epidemiology/Prevalence
Castellanos Designer & Emerging Drugs of Abuse 2015
Children aged
3-17 yrs currently
had:
Source: MMWR, 2013
ADHD 6.8%
Behavioral or conduct disorder
3.5%
Anxiety 3.0%
Depression
2.1%
Castellanos Designer & Emerging Drugs of Abuse 2015
Epidemiology
Disorders in which the majority of cases begin in childhood:
ADHD (attention-deficit/hyperactivity disorder)
Autism Spectrum Disorders & Intellectual Disability
Anxiety Disorders
Oppositional Defiant Disorder (ODD)
Most of the childhood-onset disorders have more male than female cases
(Rutter M, Caspi A, Moffitt T, 2003)
Castellanos Designer & Emerging Drugs of Abuse 2015
Lifetime Prevalence of Behavioral Health Disorders Adolescents
Source: Meriknagas,et al, 2010
Castellanos Designer & Emerging Drugs of Abuse 2015
Epidemiology
Disorders that usually begin in adolescence: Social anxiety disorder
Panic disorder
Substance use disorders
Depressive disorders
Anorexia nervosa & bulimia nervosa
Most adolescent disorders have more female than male cases
(Rutter M, Caspi A, Moffitt T, 2003)
Castellanos Designer & Emerging Drugs of Abuse 2015
Reported Drinking Patterns Among 8th, 10th & 12th Grade Students: 2013
Castellanos Designer & Emerging Drugs of Abuse 2015
Past Month Use of Tobacco Products
Castellanos Designer & Emerging Drugs of Abuse 2015
Top Drugs Among 8th & 12th Graders, Past Year Use
Castellanos Designer & Emerging Drugs of Abuse 2015
Adolescents -Annual Prevalence of Use for Various Illicit Drugs 2013
Castellanos Designer & Emerging Drugs of Abuse 2015
Adolescents -Trends in Annual Prevalence of an Illicit
Drug Use
Castellanos Designer & Emerging Drugs of Abuse 2015
Castellanos Designer & Emerging Drugs of Abuse 2015
Annual Prevalence of Designer Drug Use by US 8th, 10th & 12th Graders, 2013
Source: Johnson LD et al, Monitoring the Future National Survey on Drug Use,
2014
%
Synthetic
Marijuana
MDMA GHB Ketamine
0
1
2
3
4
5
6
7
8
4
1.1
7.4
3.6
7.9
4
11.4
8th10th12th%
Castellanos Designer & Emerging Drugs of Abuse 2015
% of Florida High School Students who used Club Drugs* & Synthetic
Marijuana, 2013
Lifetime Past 30 Days Lifetime Past 30 Days
Club Drugs* Synthetic Marijuana
*Ecstasy, Rohypnol, GHB, KetamineSource: 2013 Florida Youth Substance Abuse Survey
0
2
4
6
8
10
12
14
16
2.1
0.3unk unk
4.6
1.1unk unk
5.3
1.8
14.8
1.8
8th
10th
12th
Castellanos Designer & Emerging Drugs of Abuse 2015
Any Dru
g Exc
ept M
ariju
ana
Mar
ijuan
a
Synth
etic M
ariju
ana
Inhala
nts
Hallucin
ogen
tsLSD
Hallucin
ogen
s Oth
er T
han L
SDPCP
Ectasy
(MDM
A)
Cocain
e
Crack
0
2
4
6
8
10
Thirty-Day Prevalence of Use of Various Types Drugs
Ages 19-30, 2014
Castellanos Designer & Emerging Drugs of Abuse 2015Source: Monitoring the Future Survey Results on Drugs Use 1975-2014
18.3
Thirty-Day Prevalence of Use of Various Types Drugs
Ages 19-30 by gender, 2014
Any Illic
it Dru
g
Any Dru
g Exc
ept M
ariju
ana
Mar
ijuan
a
Synth
etic M
ariju
ana
Inhala
nts
Hallucin
ogen
tsLSD
Hallucin
ogen
s Oth
er T
han L
SDPCP
Ectasy
(MDM
A)
Cocain
e
Crack
0
1
2
3
4
5
Male
FemaleCastellanos Designer & Emerging Drugs of Abuse 2015
19.4
24.4
21.6
24.4 8
.7
16
Adolescents Differ from Adults in Substances Most Abused
Castellanos Designer & Emerging Drugs of Abuse 2015
Adults lifetime
prevalence
Source: Kessler, et al, National Comorbidity Survey, 2005
Any substance
use disorder14.6%
Any anxiety disorder
28.8%Major
depression 16.6%
ADHD8.1%
PTSD6.8%
Bipolar Disord
er3.9%OCD
1.6%
Castellanos Designer & Emerging Drugs of Abuse 2015
The adolescent brain is often likened to a car with a fully functioning gas pedal (the reward system) but weak brakes (the prefrontal cortex).
Teenagers are highly motivated to pursue pleasurable rewards and avoid pain, but their judgment and decision-making skills are still limited.
Importance of
the Teenage
Years
Castellanos Designer & Emerging Drugs of Abuse 2015
This affects their ability to weigh risks accurately and make sound decisions, including decisions about using drugs.
For these reasons, adolescents are a major target for prevention messages promoting healthy, drug-free behavior and giving young people encouragement and skills to avoid the temptations of experimenting with drugs.
Importance of
the Teenage
Years
Castellanos Designer & Emerging Drugs of Abuse 2015
The teenage years are a critical window of vulnerability to substance use disorders, because the brain is still developing and malleable (a property known as neuroplasticity).
Some brain areas are less mature than others.The parts of the brain that process feelings of
reward and pain are the first to mature during childhood.
Importance of
the Teenage
Years
Castellanos Designer & Emerging Drugs of Abuse 2015
What remains incompletely developed during the teen years are the prefrontal cortex and its connections to other brain regions.
The prefrontal cortex is responsible for assessing situations, making sound decisions, and controlling our emotions and impulses; typically this circuitry is not mature until a person is in his or her mid-20s.
Importance of
the Teenage
Years
Castellanos Designer & Emerging Drugs of Abuse 2015
Images of Brain Development in Healthy Youth (Ages 5-20)
Themature brain regions at each developmental stage are indicated in blue/purple.
The prefrontal cortex, which governs judgment and self-control, is the last part of the brain to mature.
Source: PNAS 101:8174–8179, 2004.
.
Castellanos Designer & Emerging Drugs of Abuse 2015
Substance Related
& Addictive Disorders
Castellanos Designer & Emerging Drugs of Abuse 2015
Substance Use
Disorders
Qualifiers used in the category: Use replaces both abuse and dependence Intoxication remains sameWithdrawal remains same
SUDs will be coded with DSM-IV substance
dependence codes
Castellanos Designer & Emerging Drugs of Abuse 2015
Substance Related
& Addictive DisordersRenamed:
Nicotine Related renamed Tobacco Use Disorder
Added:Caffeine WithdrawalCannabis WithdrawalGambling Disorder: “reflects the increasing and consistent evidence that some behaviors, such as gambling, activate the brain reward system with effects similar to those of drugs of abuse and that gambling disorder symptoms resemble substance use disorders to a certain extent.”
Discontinued:Polysubstance Abuse categories
Castellanos Designer & Emerging Drugs of Abuse 2015
Substance Use
Disorders (cont’d)Alcohol
Opioid Sedative, Hypnotic or Anxiolytic Cocaine Cannabis
Use DisorderOther Hallucinogen Inhalant Tobacco Amphetamine Phencyclidine
Castellanos 2014Castellanos Designer & Emerging Drugs of Abuse 2015
Substance Use
Disorders
There are two major changes to the new DSM-5 criteria for substance use disorder:
“Recurrent legal problems” criterion for substance abuse has been deleted from DSM-5
A new criterion has been added: craving or a strong desire or urge to use a substance
Castellanos Designer & Emerging Drugs of Abuse 2015
Substance Use
Disorder Criteria
1. Taking the substance in larger amounts or for longer than the you meant to
2. Wanting to cut down or stop using the substance but not managing to
3. Spending a lot of time getting, using, or recovering from use of the substance
4. Cravings and urges to use the substance5. Not managing to do what you should at work,
home or school, because of substance use6. Continuing to use, even when it causes
problems in relationships
Castellanos Designer & Emerging Drugs of Abuse 2015
Substance Use
Disorder Criteria
7. Giving up important social, occupational or recreational activities because of substance use
8. Using substances again and again, even when it puts the you in danger
9. Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance
10.Needing more of the substance to get the effect you want (tolerance)
11.Development of withdrawal symptoms, which can be relieved by taking more of the substance
Castellanos Designer & Emerging Drugs of Abuse 2015
Severity specifiers of the SUDs is based on the number of criteria endorsed: 2–3 criteria = mild disorder 4–5 criteria = moderate disorder 6 or more = severe disorder
Substance Use
DisorderCriteria
Castellanos Designer & Emerging Drugs of Abuse 2015
Designer &
Club Drugs
Castellanos Designer & Emerging Drugs of Abuse 2015
Overview of
the Problem
Designer and club drug use has increased in popularity over the past 2-4 years
Serious medical and psychiatric consequences can result
We have seen an increase in ED visits associated with use of these drugs
Castellanos Designer & Emerging Drugs of Abuse 2015
Overview of
the Problem
The newest compounds on the street are chemically different than the first generation compounds.
They are potent, impairing and addictive, but their chemistry makes them invisible to older designer drug screens and traditional drug tests.
Data show newer designer drugs are increasingly associated with more medical complications and drug related deaths.
Although labeled as “not for human consumption,” these substances often come as a powder to be snorted, injected, smoked or vaped by users.
Castellanos Designer & Emerging Drugs of Abuse 2015
Overview of
the Problem
While local retail sales of these now mostly illegal drugs have diminished, new venues of illicit distribution were appearing, ranging from online orders to courier delivery services, as street and club sales also continued.
Manufacturers are constantly coming up with new compounds to stay ahead of the law and avoid detection.
Castellanos Designer & Emerging Drugs of Abuse 2015
Designer &
Club Drugs
GHBKetamineKratomDextromethorphanSizzurpPrescription drugsEcstasy / MDMASynthetic Marijuana/CannabinoidsBath Salts / Flakka
Castellanos Designer & Emerging Drugs of Abuse 2015
Castellanos Designer & Emerging Drugs of Abuse 2015
Symptoms &
Management Issues
Designer &
Emerging Drugs
Castellanos Designer & Emerging Drugs of Abuse 2015
Sizzurp
Castellanos Designer & Emerging Drugs of Abuse 2015
History of
SizzurpOriginated in Houston, Texas1960: It was first used by Blues singers in the in
order to perform and continue to workThey used Robitussin with beer and then when
wine coolers became popular they replaced it1980-1990: The recipe was changed to use it with
codeine promethazine cough syrup with a lemon lime soda and Jolly Ranchers
1990s: Made popular by a DJ in Houston and his music being played in a slow tempo as if they were on codeine and promethazine
This concoction caused his early death and it was then that is caught the attention of law enforcement
2012: It became popular in the hip hop communityCastellanos Designer & Emerging Drugs of Abuse 2015
Justin Bieber Guzzles High Quality Sizzurp1/19/2014 12:48 PM PST BY TMZ STAFF
Was Justin Bieber Drinking Sizzurp At His 20th Birthday Celebration?By Sophie Miskiw in Lifestyle / Showbiz on 04 March 2014
What is sizzurp? Justin Bieber reportedly addicted to dangerous drink favored by rappers like Lil Wayne The homemade concoction is well-known among young people due to its mention in hip-hop lyrics, and can even be deadly, experts say.BY Tracy Miller NEW YORK DAILY NEWSThursday, January 23, 2014, 1:00 PM
Overview of
Sizzurp
It’s a concoction which includes:Cough syrup with codeinePromethazineJolly Rancher candy or SkittlesSoda popUsually served in Styrofoam cup but also drank out
of the soda bottle
Castellanos Designer & Emerging Drugs of Abuse 2015
Other Names
Purple drank Purple leanPurple jellyTexas TeaSyrup
Castellanos Designer & Emerging Drugs of Abuse 2015
Physical &
Psychoactive Effects
of Sizzurp
Slow reaction timeSedationRelaxationDecreased respiratory rateWeight gain Tooth decayDizzinessLethargyDissociative feelingMotor skill impairment
Castellanos Designer & Emerging Drugs of Abuse 2015
Dangers of
Sizzurp
Seizures when mixed with alcohol or if person prone to seizures
Shut-off of the respiratory center in the brain
Castellanos Designer & Emerging Drugs of Abuse 2015
PrescriptionMedicati0ns
Castellanos Designer & Emerging Drugs of Abuse 2015
The 2011 National Youth Risk Behavior Survey (YRBS) (www.cdc.gov/yrbss) found that 1 in 5 high school students in the US have ever taken a prescription drug, such as OxyContin, Percocet, Vicodin, Adderall, Ritalin, or Xanax, without a doctor’s prescription.
Nonmedical use
of prescription
drugs
Castellanos Designer & Emerging Drugs of Abuse 2015
Top Drugs Among 8th & 12th Graders, Past Year Use
Castellanos Designer & Emerging Drugs of Abuse 2015
Castellanos Designer & Emerging Drugs of Abuse 2015
Castellanos Designer & Emerging Drugs of Abuse 2015
Ecstasy
Castellanos Designer & Emerging Drugs of Abuse 2015
Castellanos Designer & Emerging Drugs of Abuse 2015
If you think its “Molly”
it may actually be methylone
or ethylone
Molly is the street name for the synthetic drug MDMA
It’s called Molly because of the capsule or powder form it comes in, as opposed to tabs
The presumption is that the “molecular” form, or Molly for short, is more pure
Many drugs sold as Ecstasy (MDMA) are really something else
Eg, finding of methylone or ethylone, key ingredients in bath salts
Most drug users don’t know who designed their drugs
Castellanos Designer & Emerging Drugs of Abuse 2015
Emergency Room Visits,
Miami-Dade County
398 MDMA -involved ED visits for Miami-Dade County during 2011
Represents 2 percent of all ED visits among 6 categories of substances (cocaine, cannabinoids, illicit stimulants, MDMA, nonmedical use of prescription opioids & BZs
The 2011 total represented a 91 percent increase over the 209 MDMA reports in 2004
Castellanos Designer & Emerging Drugs of Abuse 2015
Castellanos Designer & Emerging Drugs of Abuse 2015
Ecstasy - MDMA
Castellanos Designer & Emerging Drugs of Abuse 2015
Overview of
Ecstasy
MDMA 3,4 -methylenedioxymethamphetamineHallucinogenic amphetamine Historical use in research and psychotherapyDEA ban on MDMA in 1985
Castellanos Designer & Emerging Drugs of Abuse 2015
Ecstasy- MDMA
MDMA doses range from 80 to 150 mg but doses as high as 300 mg have been detected.
Prices varies greatly. A single table is typically $10-25 but can cost as much as $50.
Onset 20 to 40 minutesEffects last less than 24 hoursStreet names: e, Adam, X, XTC, purest form
MOLLY (Usually white pill or powder)
Castellanos Designer & Emerging Drugs of Abuse 2015
Physical Effects
of Ecstasy /
MDMA
Castellanos Designer & Emerging Drugs of Abuse 2015
Physical Effects
of Ecstasy /
MDMA
Neurological:Increased restlessnessMotor ticsHeadachesNeurotoxicity - Damage of serotonin nerve endings
Cardiovascular: TachycardiaArrhythmias Hypertension
Castellanos Designer & Emerging Drugs of Abuse 2015
Physical Effects
of Ecstasy /
MDMAOphthalmologic (eyes):
Nystagmus
Kidney:Secondary to muscle breakdown (Rhabdomyolysis)
Muscular:Bruxism (teeth grinding) & jaw clenchingMuscle rigidity & breakdown: Rhabdomyolysis (breakdown products of damaged muscle cells are released into the bloodstream) can lead to kidney problems
Castellanos Designer & Emerging Drugs of Abuse 2015
Physical Effects
of Ecstasy /
MDMAOthers:Decreased appetiteElevated temperature (users frequently drink/carry bottles of water)
Hepatotoxicity (liver)
Castellanos Designer & Emerging Drugs of Abuse 2015
Psychoactive Effects
of Ecstasy /
MDMA
Castellanos Designer & Emerging Drugs of Abuse 2015
Psychoactive Effects
of Ecstasy /
MDMACognitive:Memory problems for at least 2 weeks after useAltered time perception
Affect:EuphoriaIncreased anxietyDepressed moodAnhedonia
Castellanos Designer & Emerging Drugs of Abuse 2015
Psychoactive Effects
of Ecstasy /
MDMABehavior:
Increased energyDecreased aggressionDecreased defensiveness/disinhibitionLethargy
Perceptual:Changes in visual perceptions
Castellanos Designer & Emerging Drugs of Abuse 2015
Psychoactive Effects
of Ecstasy /
MDMAOther:
Increased ability to interact with othersDecreased desire/motivation to perform mental or physical tasks
Increased or decreased libidoIncreased awareness of emotions
Castellanos Designer & Emerging Drugs of Abuse 2015
Synthetic Cannabinoids
Castellanos Designer & Emerging Drugs of Abuse 2015
Synthetic Cannabinoids
Castellanos Designer & Emerging Drugs of Abuse 2015
Overview of
Synthetic Cannabinoids
Product line marketed as incense, herbal or aromatic incense or potpourri
“Not for human consumption” All ingredients don’t have to be listed
Not “intended” for smoking but most of the products are smoked in hand-held pipes, water pipes or rolled in cigarette paper
Synthetic cannabinoid is sprayed on the product.Manufacturers are substituting more potent
synthetic cannabinoid products every day
Castellanos Designer & Emerging Drugs of Abuse 2015
Synthetic Cannabinoids Crime Lab Cases in Florida: 2010-2014
2010 2011 2012 2013 20140
200
400
600
800
1000
1200
1400
1600
1800
2000
2200 AM-2201
XLR-11
AB-FUBINACA
PB-22
UR-144
AB-PINACA
Various JWH
All Other Cannabinoids
301
Nu
mb
er o
f C
rim
e L
ab R
epo
rts
Source: Analysis of US DEA - National Forensic Laboratory System Data
9
1,209
2,087 1,996
Castellanos Designer & Emerging Drugs of Abuse 2015
Castellanos Designer & Emerging Drugs of Abuse 2015
Synthetic Cannabinoids
Physical Effects
Castellanos Designer & Emerging Drugs of Abuse 2015
Synthetic Cannabinoids
Physical EffectsA number of users experience hangover-like
effects the morning after use including dry mouth, intense headaches
Depending on the product, inhaled smoke is as harsh as marijuana smoke:Taste can vary from a very bad to very sweet tasteOne user described the taste as “sickly sweet”
Ophthalmologic (eyes):Conjunctival injectionMydriasisPhotosensitivityDry eyes
Castellanos Designer & Emerging Drugs of Abuse 2015
Synthetic
Cannabinoids Physical
Effects
Neuro-muscular: Tremors Numbness A warm sensation in the limbs Muscle spasms Seizures Impaired coordination Headaches or painless head pressure Light headedness
Cardiovascular: Tachycardia Increased blood pressure
Castellanos Designer & Emerging Drugs of Abuse 2015
Synthetic Cannabinoids
Physical Effects
Gastrointestinal: Nausea, vomitingIncreased appetite (“munchies”)Dry mouth
Castellanos Designer & Emerging Drugs of Abuse 2015
Synthetic Cannabinoids
Physical Effects
Others:Insomnia Paleness of skinListlessness / Lack of interestSweating
Castellanos Designer & Emerging Drugs of Abuse 2015
Synthetic Cannabinoids
Psychoactive Effects
Castellanos Designer & Emerging Drugs of Abuse 2015
Synthetic CannabinoidsPsychoactive
Effects Mood changes: Giddiness
Castellanos Designer & Emerging Drugs of Abuse 2015
Synthetic CannabinoidsPsychoactive
Effects Mood changes: EuphoriaAnxietyPanic attacksIrritabilityDepressionGiddiness
Castellanos Designer & Emerging Drugs of Abuse 2015
Synthetic CannabinoidsPsychoactive
Effects Cognitive changes: Impaired short term memory ConfusionCognitive dullingImpairment of linear thinkingTime distortion
Castellanos Designer & Emerging Drugs of Abuse 2015
Synthetic CannabinoidsPsychoactive
Effects Behavioral changes:
SedationExcitabilityAgitationAggressionSleep ChangesDelirium
Castellanos Designer & Emerging Drugs of Abuse 2015
Synthetic CannabinoidsPsychoactive
Effects Suicide: Multiple reports connecting SC use and suicide
can be found in the media and throughout the internet
Review of scientific literature discovered a handful of subjects in different studies and case reports describing suicide and suicidal behaviors with SC use
Relationship between SC use and suicide is unclear
Castellanos Designer & Emerging Drugs of Abuse 2015
Synthetic CannabinoidsPsychoactive
Effects Psychosis:Hallucinations- auditory & visualDisorganized thinkingDisorganized behaviorDelusions (paranoid)AgitationAggressionCan be new onset or exacerbation of previously stable psychotic disorders
Psychotic symptoms may persist beyond acute intoxication
Castellanos Designer & Emerging Drugs of Abuse 2015
Synthetic CannabinoidsPsychoactive
Effects Addiction/Dependence:Research on the addictive properties of SCs has produced varying results.
Case reports and users report symptoms of dependence such as cravings, continued use despite knowledge of physical or psychological harm, tolerance and withdrawal symptoms.
SCs have been shown to cause greater dopamine release than MDMA and may therefore have a greater abuse liability.
SO….. SCs can be addictive and continued, heavy usage could result in withdrawal/dependency symptoms
Castellanos Designer & Emerging Drugs of Abuse 2015
PsychosisNew onset Exacerbation of previously stable psychotic disorders
Extreme mood changesEffects persist beyond acute intoxicationTolerance, withdrawal & dependence may be
associated with long term use
Castellanos Designer & Emerging Drugs of Abuse 2015
Summaryof
Dangers of
Synthetic Cannabinoids
Clinical Presentations
Castellanos Designer & Emerging Drugs of Abuse 2015
Acute Care
Presentation
Some clinical symptoms similar to cannabis intoxication:
Reddened eyes Mild sedation Euphoria Giddiness Paranoia Perceptual distortions Memory deficits Impaired short-term memory
Castellanos Designer & Emerging Drugs of Abuse 2015
Acute Care
Presentation
Physical symptoms not typically seen with cannabis intoxication:
Seizures Hypokalemia Palpitations Hypertension Respiratory difficulties Abdominal/flank pain Acute kidney injury Nausea/vomiting Coma
Castellanos Designer & Emerging Drugs of Abuse 2015
Acute Care
Presentation
Psychoactive symptoms not typically seen with cannabis intoxication:
Agitation Violent behavior Impulsivity Disorganized thoughts Auditory & visual hallucinations Delusions, typically paranoid
Castellanos Designer & Emerging Drugs of Abuse 2015
Office Presentation
Typically: User not intoxicated at the time of office visit User typically denies use More readily agrees to tox screen/testing SCs not first drug used; most typically have
used marijuana before Living situation involves being monitored for
use (eg, teens who have found to be using marijuana)
Castellanos Designer & Emerging Drugs of Abuse 2015
Bath Salts / Synthetic
Cathinones /Flakka
Castellanos Designer & Emerging Drugs of Abuse 2015
History of
Bath Salts
First synthesized in the 1920sIn 2009-2010: they became popular in the
underground market2010: started to be marketed as “ not for
human consumption”2011: New York was one of the first states to
ban the sale of Bath salts2012: President Obama signed a bill that
amended the Federal drug policy of the United States to ban “bath salts”
Castellanos Designer & Emerging Drugs of Abuse 2015
History of
Bath Salts
Khat, a leafy plant native to East Africa and the Arabian Peninsula, is chewed for its stimulatory effects, mild euphoric and appetite suppression.
Khat is a natural cathinone.
First generation synthetic bath salts were comprised mainly of the synthetic cathinones mephedrone and MDPV (3,4 methylenedioxypyrovalerone).
These drugs were sometimes called the “poor man’s cocaine.”
Castellanos Designer & Emerging Drugs of Abuse 2015
History of
Bath Salts
Bath salts or synthetic cathinones continue to evolve.
Newer bath salts have been comprised of methylone, ethylone and alpha-pvp (alpha-pyrrolidinopentiophenone).
In reality, we don’t know what is contained in these drugs.
Castellanos Designer & Emerging Drugs of Abuse 2015
http://www.designerdrugtrends.org/documents/trendsreport2015_3.pdfCastellanos Designer & Emerging Drugs of Abuse 2015
Ethylone Candy
Castellanos Designer & Emerging Drugs of Abuse 2015
Include some of the latest designer drugsUsed as synthetic stimulantsIllegal in at least 41 states and pending
legislation in the othersPoison Control Center has received over
4,000 calls last year
Castellanos Designer & Emerging Drugs of Abuse 2015
Bath Salts
"Flakka” is the latest of these drugs to hit the street.
Flakka is thought to be mainly comprised of alpha-PVP, a novel psychoactive substance that has been on the recreational drug market since 2012.
Former street names include “Gravel”, which was allegedly alpha-PVP mixed with lorazepam, and other bath salts.
Castellanos Designer & Emerging Drugs of Abuse 2015
Flakka
Flakka is sometimes called a “second generation” bath salt.
The chemical structures of these drugs are constantly changing.
We expect for a “newer” compound to replace flakka sometime in the future.
Castellanos Designer & Emerging Drugs of Abuse 2015
Flakka
Typically sold as powder or crystals Approx $3-$40 Routes of administration:
Snorting Oral Injection Smoking Use with electronic cigarettes increasing
Desired effects last for a few hours Adverse side effects can last from hours to
days
Castellanos Designer & Emerging Drugs of Abuse 2015
Flakka
Flakka Hospital Cases: Broward Health June 1 – July 15, 2015
Time Period
Total Cases
Cases per Day
June 1 - 30
346 11.53
July 1 - 15
179 11.93
0
50100150200250300350 314
135
6016
Flakka Casesn = 525 Flakka Cases
June 1 – July 15, 2015
Source: Broward Health Medical Centers
Castellanos Designer & Emerging Drugs of Abuse 2015
Flakka Hospital Cases: Broward Health June 1 – July 15, 2015
Male
428
Fe-male 97
Flakka Cases by Gender
Flakka Cases by Ethnicity
White NH 208Black NH 297
White Hisp 20Asian 3
Black Hisp 1American Indian 1
Castellanos Designer & Emerging Drugs of Abuse 2015
Flakka Hospital Cases: Broward Health June 1 – July 15, 2015
12-19 yrs
20-29 yrs
30-39 yrs
40-49 yrs
50-59 yrs
60-69 yrs
70-79 yrs
80-89 yrs
90 yrs
020406080
100120140160180
10
177 180
98
44
10 2 1 1
Flakka Cases by Age
Nu
mb
er o
f F
lakk
a C
ases
Mean Age = 33 yearsAverage Age = 35.4 years
Castellanos Designer & Emerging Drugs of Abuse 2015
Flakka DeathsBroward County, Florida
September, 2014 – June 15, 2015
Castellanos Designer & Emerging Drugs of Abuse 2015
Castellanos Designer & Emerging Drugs of Abuse 2015
Sep Oct Nov Dec Jan Feb Mar Apr May Jun2014 2015
0
1
2
3
4
5
6
7
1 1 1
6
12
3 3
6
1
Broward County Flakka Related Deaths By Month/Year (9/14 - 6/15)
# F
lakk
a-R
elat
ed D
eath
s
Castellanos Designer & Emerging Drugs of Abuse 2015
Physical Effects
of Flakka /
Bath Salts
Castellanos Designer & Emerging Drugs of Abuse 2015
Physical Effects
of Flakka /
Bath SaltsPoor judgment and insightCardiovascular:
Tachycardia Hypertension
Endocrine: Increased temperature- Users will
frequently remove some/all of clothing
Castellanos Designer & Emerging Drugs of Abuse 2015
Physical Effects
of Flakka /
Bath SaltsMuscular: Bruxism (teeth grinding) & jaw clenching Muscle breakdown: Rhabdomyolysis
(breakdown products of damaged muscle cells are released into the bloodstream) can lead to kidney problems
Muscle spasms Difficulty with muscle coordination
Kidney:Secondary to muscle breakdown
(Rhabdomyolysis)
Castellanos Designer & Emerging Drugs of Abuse 2015
Psychoactive Effects
of Flakka /
Bath Salts
Castellanos Designer & Emerging Drugs of Abuse 2015
Psychoactive Effects
of Flakka /
Bath Salts
Behavior: Agitation Increased body strength Aggression Impulsivity
Affect: Anger, irritability Labile affect Blunting or flattening Distress
Castellanos Designer & Emerging Drugs of Abuse 2015
Psychoactive Effects
of Flakka /
Bath Salts
Speech: Yelling Repetitive speech Illogical speech
Psychosis: Hallucinations Paranoia Delusions
“Excited delirium”
Castellanos Designer & Emerging Drugs of Abuse 2015
What did you
observe on
this video?
Muscle spasmDifficulty with muscle coordinationAgitationLabile, inappropriate affectYelling, speech difficultiesDistressImpulsivityLack of Judgment and Insight?Hallucinations?Paranoia?Delusions
Castellanos Designer & Emerging Drugs of Abuse 2015
What did you
observe on
this video?
Muscle spasmDifficulty with muscle coordinationAgitationGaze (“crazed look”)Inappropriate affectYelling, speech difficultiesDistressImpulsivityLack of Judgment and Insight?Hallucinations?Paranoia?Delusions
Castellanos Designer & Emerging Drugs of Abuse 2015
Treatment/Interventions
Castellanos Designer & Emerging Drugs of Abuse 2015
Acute Treatment-
Intoxication
When multiple substances used, unclear which signs, symptoms are a result of which substance
Time of use to time of evaluation in ED varies; some symptoms persist others improve by the time the person is attended to in the ED
Literature:Is limited to anecdotal reports, single case reports, case series
Frequently based on self/family report of use; still limited toxicological confirmation
Castellanos Designer & Emerging Drugs of Abuse 2015
Acute treatment is supportive:Fluids- Individuals seen in the ED usually require IV fluids
Lower body temperature (frequently also associated with agitation)
Address kidney functioning to prevent more serious kidney problems
Acute Treatment-
Intoxication
Castellanos Designer & Emerging Drugs of Abuse 2015
Acute treatment is supportive:Address agitation; aggression:
Lorazepam is frequently used IM/IV/PO for acute improvement
Address psychosis:Short term use of antipsychotic meds can be beneficial
Sometimes psychosis lingers or doesn’t remit
AcuteTreatment-
Intoxication
Castellanos Designer & Emerging Drugs of Abuse 2015
Little or no research examining best treatment practices after the acute intoxication
Treatment:Frequently needs to address use of multiple substances
Needs to be multimodal Interventions are guided by the class the synthetic drug belongs to (eg, stimulants, hallucinogens)
Should address co-occurring psychiatric conditions (such as, psychosis if has not remitted after the acute intoxication)
OngoingTreatment
Castellanos Designer & Emerging Drugs of Abuse 2015
Castellanos Designer & Emerging Drugs of Abuse 2015
Take Home Points
Become familiar with:Types of newer drugs being abused Clinical symptoms of presentation
Evidence based practices should guide your evaluation and management
Castellanos Designer & Emerging Drugs of Abuse 2015
Castellanos Designer & Emerging Drugs of Abuse 2015
Parting Thoughts
Designer drug use will not go away.New drugs will continue to emerge.
No matter how designer drugs evolve,
we need to be ready