Kristine Nutt, LCSW, LCAS, CSI

DisclaimerThis presentation is meant to provide basic

awareness information on herbal incense products and bath salts.

There are hundreds of products being smoked for cannabis-like effects

Manufacturers constantly change product ingredients and market products under new names to circumvent the law.

Constantly moving targetProduct names and lists, as well as the list of

synthetic cannabinoids, in this presentation are not all inclusive.

“SMILES”

“SMILES”2C-1 Hallucinogen synthetic drugPart of the 2C family of drugs Powder or Pill formOften mixed with chocolate and candySchedule 1 class of drug in July 2012According to LAPD, there has been an increase of overdose

deaths from this drug recently. Popular with teens and college students.

Formulas were published in book “PiHKAL: A chemical Love Story” (Transform Press, 1991)

“Smiles” Dessa Bergen-Cisco, a Professor of Public

Health at Syracuse University stated, “Basically, it’s a pure and potent form of estacy or MDMA”.

Effects are compared to a potent combination of MDMA and LSD with terrifying hallucinations and superhuman strength.

Overdoses have been reported in California, Ohio, and other states.

“SMILES” Recently in the news due to Johnny Lewis, 28,

who was known for his role in the television show, “Sons of Anarchy” killed 81 year old landlady and her cat before jumping to his death. No evidence of drugs were found in his system.

One guy began beating his head into the ground.One 17 year old in North Dakota overdosed and

was observed shaking, growling, and foaming at the mouth. Another teen died the night before from the drug.

Does not show up on drug screens

EffectsAnxiety leading to panic attacks, seizures,

distortions of time. HyperventilationNausea and VomitingTerrifying auditory and visual hallucinations and

feelings of fear and panic. Last hours to days. Increased heart rate (arrhythmia). Can cause

strokesCan cause seizures and kidney failureCauses muscles to contract Elevated body temperaturesGiddiness and relaxed state

BATH SALTS• Refers to products

containing synthetic cathinones, that are chemically similar to cathinone, an organic stimulant, that occurs naturally in the Khat plant.

Highly pure white or brown powder or crystal form. Mostly seen in powder form.

BATH SALTSFirst developed in research labs and became a

popular party drug in Europe and UK Spread overseas around 2010 and began to

show up mostly in states like Louisiana, Kentucky, and Tennessee. Some had regional names like “Hurricane Charlie” and “Bayou”.

Other product names include Bliss, Blizzard, Blue Silk, Ivory Snow, Vanilla Sky and Ivory Wave.

Highly publicized as of late with the cannibalistic attack in Miami.

BATH SALTS

BATH SALTS

BATH SALTS

MarketingSold commercially as bath salts, plant fertilizer, toy

cleaner, pond cleaner, cell phone cleaner, jewelry cleaner, insect repellant, glass cleaner, and toilet cleaner. Newest is ladybug attractant.

Chemicals imported mainly from China.

Sold mainly on the internet buy also in “head shops”, convenience stores, and gas stations.

It is not the stuff you find at Bath and Body Works!!!

Chemical MakeupThere are several synthetic cathinones. The

most common found in “Bath Salts” are MDPV (methylenendioxypyrovalerone), mephedrone(4-MMC), or methylone. The primary ingredient in most bath salts is MDPV, which is a CNS stimulant and increases dopamine and serotonin.

MDPV – at least 4x potency of ritalin or concerta.

15-30 minutes to onset, peak effect around 1.5 hours and last around 6 – 8 hours.

Bath Salts People can get an effect from 3 – 5 mg. The

average dose is 5 – 20 mg.

Taken orally, IV, nasal inhalation, or rectally. Snorting and swallowing are the most common methods of use.

High risk for overdose due to packages containing as much as 500 mg. Each packet contains varying amounts of the chemical.

BATH SALTS Marketed as legal

alternative to LSD, cocaine, ecstacy, and methamphetamine. Chemists say it has the worst attributes of these.

Labeled not for human consumption but the sole purpose is for human consumption.

Bath Salts – Generation 2New type of bath salt called Amped has been

reported by users in Virginia.

Six people recently reported to hospitals in Virginia that they ingested this drug.

It is being marketed as ladybug attractant.

NaphyroneReferred to as “Cosmic Blast” and

marketed as jewelry cleaner. Contains MDPV and Naphydrone, which is 0-2482 and Naphthylpyrovalerone derived from Pyrovalerone. Reuptake inhibitor of serotonin.

Stays in system for long periods. Body temperatures of up to 107 degrees have been reported.

BATH SALTS

Users do not know how much or what they are getting. Cost about $25 - $50 per 50 mg packet. Very inexpensive and readily available high.

EFFECTS

Adrenaline rush for hours and superhuman strength. Users often become paranoid that they are being attacked and experience a “excited delirium”. This includes fearlessness, rage, and strength, as well as, delusions of invulnerability. Stops neurons in the brain from reabsorbing dopamine and norephinephrine immediately after secreting them so leads to triggering of survival behaviors.

WHAT DO THEY DO?“MDP V increases the body’s concentration of

adrenaline-like hormones that prepare the heart and muscle tissue for “flight or fight” response”, explained Thomas Penders an associate professor at ECU.

"One system of circuits in our brains are wired to detect and respond to threats. Overstimulation of this circuit leads to overestimation of actions by others as threatening. When the system becomes overwhelmed, as it does [from an overdose of] 'bath salts,' a condition develops known as 'excited delirium,'" he said

WHAT DO THEY DO?Overdoses of crack cocaine, methamphetamine,

ecstasy and PCP can also induce "excited delirium." It's a state of paranoid fearfulness and rage mixed with seemingly superhuman strength, as more oxygen is delivered to muscles, increasing their power. "This, to some extent, explains the bizarre aggressive behaviors we have seen during the recent rash of 'bath salt' cases," Penders said *

“Science” on nbcnews.com 6/4/2012

EFFECTSIncreased dopamine and serotonin and

affects mood and perception.Cold fingers and an intolerance to painBody temperatures of up to 107 degrees have

been reported. Often people take their clothes off.

Jerking eye movements and foaming at the mouth have been reported.

Restlessness and inability to sit still.

EFFECTSIncreased heart rate and blood pressure.Panic attacks and chest pains are often why

people show up in ER’s. Auditory and Visual Hallucinations with common

themes of monsters, demons, aliens, and God. Irritability, suicidal thoughts, and self-harm

behaviors. Diminished thirstCan relapse into hallucinations and paranoia

weeks after last use.

BATH SALTS

Dangers and Dependency

ConcernsA Marquette County, Michigan ER reported 35

admissions from November 2010 to March 2011. This prompted Law Enforcement to seize all bath salts from a local convenience store. The products tested all contained MDPV.

17 out of 35 were hospitalized. Median age was 28 years (range 20 -55 years). 54

54% were Men, 69% self-reported a history of drug abuse, 46% or 16 patients had a history of mental illness, and 17% reported suicidal thoughts/attempts related to use of bath salts.

ConcernsUS Army Medic, David Stewart, killed his wife and 5

year old son in April 2011 after he and his wife were using bath salts. He shot his wife and suffocated his son the day before. He was using “Lady Bubbles” bath salts.

7 people under the age of 27 died in 2 Cleveland Hospitals after using the drug.

According to the Bangor Daily News, domestic violence calls have increased in Maine due to use of Bath Salts.

Cookeville Regional Medical Center in TN has treated 160 people since 2010.

Store was broken into four times in one month.

Dangers and DependencyA research study led by UNC professor CJ

Malanga, MD found that mephedrone, like cocaine, has a high potential for abuse and addiction.

“The effects on the brain’s reward circuit are comparable to similar doses of cocaine”

The rodents in the study worked harder to get less reward. The drug activated the brain’s reward circuit involved in positive reinforcement.

NIDA.org 2012

LegalityThe Synthetic Drug Prevention Act signed by

President Obama on July 9, 2012. This act bans the synthetic compounds found in synthetic THC and Bath Salts, and makes them Schedule I.

States will have to incorporate these into their drug scheduling list and update the list as new substances are discovered.

Poison Control Center DataCALLS TO POISON CONTROL: 304 in 2010, 6,138 in 2011, and 2,468 as of October 31, 2012. Ages <6 to over 59. Most ages 20 – 29. January – 228/301 July – 361/680February – 230/487 August – 173/602March – 264/639 September – 119/512April – 285/600 October – 98/401May – 295/720June – 415/743

www. aapnc.org 1-800-222-1222

Ppp Bpp

Poison Control Centers Data

TREAMENTOften eat up Emergency Room resources as it

takes multiple nurses and doctors to treat users. Difficult to know what someone has taken unless

they self-report or someone else reports. Does not show up on typical toxicology screens

and can not be detected by drug dogs. There are now drug tests that do test for Bath Salts. Ammon labs, Redwood Toxicology, and Dominion Diagnostic offer these drug screens.

TREATMENTAntipsychotics to treat psychosisBenzodiazepines to decrease agitationTen to twenty times the normal dose of sedatives

have been used.Try to avoid using restraints, but speak

reassuringly to people who are agitated and paranoid

Move to a quiet room with low light to help calm patient.

Avoid loud noises and try medications prior to restraint.

TREATMENTMonitor the person for suicidal ideation even

after they have stopped using the drug. Address both mental health and addiction issues.

Psychotic symptoms often persist after treatmentEnhance coping skills to assist the person in

dealing with anger and other emotions.No standard treatment protocol for MD’s or

others so treat symptoms of the individual. Train staff to deal with specialized issues and

incorporate questions into intake and assessment.

Movie MadnessBATH SALT ZOMBIESAvailable on DVD February 19Bath Salt Zombies is a new horror film

directed and co-written by Dustin Wayde Mills (Puppet Monster Massacre, Zombie A-Hole, Ballad of Skinless Pete) and produced and co-written by Clint Weiler of Aggronautix. The movie sensationalizes the recent bath salt  epidemic and the attacks surrounding them

“Zombie Apocalypse”The shocking wave of attacks associated with

Bath Salts has sparked fears of a real-life zombie outbreak in the south. This led to The Center for Disease Control and Prevention releasing a statement saying it is not aware of any virus that can cause zombie-like behavior.

What next?Partnerships and networks between the

community and law enforcement have made an impact in the sale and distribution of this drug.

Education regarding the dangers of Bath Salts.

Spice / K2

What is Spice and K2?Spice and K2 refer to commercially available

products sprayed with chemicals called synthetic cannabinoids. These products claim to be a mixture of herbs but often do not have herbs in them. They include other ingredients that are unknown and not listed.

Many have warning labels as not intended for human consumption, but are solely intended for human consumption. Marketed as incense. Resembles potpourri.

Synthetic CannabinoidsSynthetic Cannabinoid products are

manufactured in Asia and sold in US in many different arenas (gas stations, liquor stores, smoke shops and internet)

Sold under different brand names: “K2, Spice, Spice Gold, Spice Black, Mr. Nice Guy, Yucutan Fire and many others”

Since the national ban on five synthetic cannabinoids, new brand names have developed, such as K2 Sky, K3, and K4

What is a Synthetic Cannabinoid?

A class of synthetic substances that bind to the cannabinoid receptors(CB1 and CB2) in the body. When used they create a high similar to THC. Bind more strongly than THC. There are hundreds of synthetic cannabinoids.

Used in an attempt to avoid laws that make marijuana illegal. National Ban on five cannabinoids began in March 2011.

History of Spice and K2? The cannabinoid-like chemicals were first

developed in research laboratories to study receptors in the body and brain and for other research purposes. The five banned cannabinoids are JWH-018, 073, 200, CP 47, and 497.

JWH-018 was first made in 1995 by Dr. John Walter Huffman at Clemson University. Manufacturers read research and copied it to produce this cannabinoid and marketed it for commercial distribution.

Brand “Spice” was released in 2004 and gained popularity in 2006.

Spice and K2The company that started the “Spice” line went

from assets of 65,000 Euros in 2006 to 899,000 Euros in 2007. Spice was the dominant brand until 2008. Then competing brands like “K2” hit the market. Now there are many distributors of these products.

Rick Broider with North America Herbal Incense Trade Association estimates profits at 5 billion per year.

In 2011, Redwood Toxicology Lab developed testing for six synthetic cannabinoid chemicals. 72 hours for urine and 24 – 48 for saliva.

Spice ProductsSpiceSpice GoldSpice DiamondSpice Tropical SynergySpice Arctic SynergySpice Gold SpiritPEP Spice

Many Faces of Spice

K-2/SPICE

Other Herbal Incense ProductsGenieYucatan FireDreamEx-sesBlaze

Spike 99BlazeSparkFusionMANY others!

Spice IngredientsOne or more synthetic cannabinoid compounds.

Can be different mix each time.JWH-018, CP 47, 497, C8, JWH-073, and JWH-250

have been found most often in spice products. Other legal substances such as Pink Lotus,Dwarf

Skullcap, Indian Warrior, and Lion’s Tail Potentiate or add to effectsCreate different effects between productsMany have psychoactive effects on their ownSome used as marijuana substitutes in the past.Cost $30 - $40 per 3 gram bag.

Other Synthetic CannabinoidsHU named after Hebrew University where they were created.HU-210

Various studies show it is anywhere from 66-800 times more potent than ∆9 THC1

Schedule I under CSA: Illegal in U.S.HU-211

Studies tentatively show no ∆9 THC-like effects Used to research treatment of brain damage related to

stroke, brain trauma, glaucoma, and multiple sclerosisHU-311

Has potent antineoplastic and antiproliferative activity (cancer fighting drug)

1 J. Med. Chem.35 (11): 2065–9.

Synthetic CannabinoidsCP 47,497 and analogues (CP Created by Pfizer)

3 to 28 times more potent than ∆9 THC CP 55,940

45 times more potent than ∆9 THC JWH-015JWH-018 4-5 x more potent than THC and same

chemical structure shared with known cancer causing agents.

JWH-073WIN 55,212-2 (WIN is for Sterling Winthrop)

Used to research treatment for Alzheimer'sEffects milder and don’t last as long as ∆9 THC

Other Herbal Incense Ingredients (Not all inclusive)

Baybean Blue LotusLion's TailLousewortIndian WarriorDwarf ScullcapMaconha BravaIndian PennyworthCloveHopsTribulus Terrestris

Pink LotusMarsh MallowRed CloverRoseVanilla and Honey Fly AgaricSiberian MotherwortDamianaStevia LeafLemon GrassTurnera diffusa

Many other legal herbs and herbal extracts are used to enhance aroma, potency

Why Do People Use It?Herbal incense products are smoked or

snorted for marijuana-like effectsLegal substitute to marijuana Other reasons: increase creativity, reduce

stress, experience euphoria, increase personal insight, and increase appreciation for the arts

There are numerous blogs and websites the provide users the opportunity to share experiences.

EffectsMarijuana-like effects: euphoria, giddiness,

silliness, bloodshot eyes, impaired short-term memory and concentration, and “munchies.”

Other common effects: cotton mouth, light sensitivity, a warm sensation in the limbs, dry eyes, paranoia, light headedness, auditory and visual hallucinations, painless head pressure, time distortion, panic attacks, delirium, impaired coordination, and sleeplessness

Onset/duration: 5-10 minutes, and effects vary from 2 hours for JWH and 5-6 for CP. Can get high off a hit or two.

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 smokeTaste can vary from a very bad to sickly sweet.

EffectsOne hospital reported a patient with a 1-3

gram a day habit and severe withdrawal symptoms (tremors, headache, nausea, vomiting and depression).

One person reported spending $2000 in the last month on Spice and Bath Salts.

DangersA Boston University School of Medicine study

suggests that use may cause increase in paranoia, hearing voices, disorganized behavior, and panic symptoms.

Psychotic symptoms may last for a few days to months.

Another study found these products may create psychosis in patients with no history of psychiatric disorder.

Overdose potential from unknown amounts and ingredients in products.

Ppp Bpp

Poison Control Centers Data

Dangers Poison Control Centers had 112 calls in 2009, 2906 in 2010, 6,959 in 2011, and 4,161 by September 10, 2012. Users are experimenting with combining different products, which can dramatically change or increase the effects. These cannabinoids were created for experimental use. Not tested on people. No one knows long term effects of these products.Public health concern over possible metal residue in these products.

DangersJWH-018 and others, have a shared chemical

structure with cancer causing agents, according to NIDA.

A hospital in Kansas reported 8-10 people hospitalized in past month after smoking the products with hallucinations, seizures and bleeding from the nose and mouth.

Three teens ages 16 and 18, showed up in ER with anxiety, agitation, excessive sweating, and inability to speak.

DangersKids’ brains are still developing. Across the US, people are showing up in

emergency rooms with aggressive and unusual behavior. Suicides have been reported.

A NIDA study stated 11% of school seniors have used Spice/K-2 in 2011. Second most frequently used drug after THC.

Medical personnel often don’t know what they are dealing with unless the person self-reports.

DANGERS

Appearance

Most herbal incenses appear as an olive green leafy material very similar in appearance to marijuana, oregano

ParaphenaliaHerbal incense smokers will use the same or

similar products used by marijuana smokersPipes, bongs, hookahsRolling papersBlunts (hollowed out cigars packed with

product)Herbal incense specific paraphernalia

Vapor GenieGrinders (to further grind into a finer mixture)

Hookah

Grinders

Controlled Substances Act

In Nov. 2010, the USDEA moved to ban 5 synthetic cannabinoids, placing them in Schedule I status due to high potential for abuse, and no known medical benefits. The ban would be in effect for one year.

The ban was delayed due to companies stating the ban was unconstitutional.

On March 1, 2011 the National Ban was enacted. This means that is illegal to possess and sell

products containing these. Before the ban, 15 states had already taken action

to control one or more of these five chemicals.

Challenges - Manufacturing

Manufacturing occurs in countries where synthetic cannabinoids are legal.

As detection catches up with manufacturing, makers will alter ingredients. They are using new ingredients which are not illegal at this time.

Federal bans target larger distributors. States will need to go after smaller distributors.

Challenges - MarketingProduct will not cause positive drug test“There's never been a case reported by our

clients that any of our Herbal Smoke Blends caused them to fail a test”

“YOU'LL NEVER FAIL A DRUG TEST”Why would this be an issue for a product

marketed as incense and not for human consumption?

Challenges - MarketingIngredients1

Synthetic cannabinoids not listedListed ingredients are not necessarily in the

productConsumers don’t know what they are actually

gettingRaises questions of consumer protection and

product misrepresentation

1 Understanding the ‘Spice’ Phenomenon Thematic Paper, European Monitoring Centre for Drugs and Drug Addiction, 2009, Portugal

ENERGY DRINKS

ENERGY DRINKSAmerican Association of Poison Control Centers –

(www.aapnc.org) urges the public to use caution using these products.

Highly concentrated amounts of sugar, caffeine, and other ingredients. Was mixed with alcohol in the past and sold next to bath salts.

Caution for children and adolescents. Children should not have it and adolescents should not have more than 100 mg of caffeine per day = one cup of coffee*

*Journal of Pediatrics

Energy DrinksDue to labels, it is often hard to know how

much caffeine is in the drink.Drinks contain natural caffeine-containing

ingredients that are not separately listed, such as, yerba mate, cacao, and guarana.

These drinks are considered dietary supplements and not regulated by the FDA so there is no limit to amount of caffeine that can be in them.

Drinking too many at one time or too fast ……..

EFFECTSNausea and vomiting SeizuresInsomnia Kidney ProblemsDelirium Mood ChangesHeadache Increased BPAltered and increased heart rhythmWithdrawalChest PainsDehydrationSweating

BATH SALTS & ENERGY DRINKSA 28 year old man was found passed out in a

random person’s driveway, and was taken to the hospital. It was discovered that the man had overdosed on energy drinks and bath salts.

According to a report by the Caledonia Police, officers found the man lying on the floor of his van.

An individual said he found the van in his own driveway. The individual stated the the engine was off and that no keys were found in the ignition. The victim was found slouched over the steering wheel. There was a cell phone in the man’s possession, and the last dialed contact was that of his mother.

POISON CONTROL CENTER

2607 calls to Poison Control Centers related to the use of Energy Drinks through October 31, 2012

Resources Life Center of Galax is equipped to treat persons using these substances. Our confidential referral and assessment number is 1-800-345-6998. We are available 24/7 to speak with anyone.

Thank You