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“Novel Psychoactive Substances”What to know and what to doWhat to know and what to doWhat to know and what to doWhat to know and what to do
RCP Northern
Update in Medicine
27th November 2017
Dr Simon Hill
Disclosures
• I have no financial disclosures
• All images are either:
– Freely reusable under creative commons
– Used with permission
– My own
Objectives
1. Define ‘NPS’
2. Make the case that this an important problem
3. Provide a structured approach to patient
assessment
4. Outline acute patient management
5. Discuss novel fentanyls
6. Provide take home messages
7. Provide self assessment
WHAT ARE THEY?
Legal Legal Legal Legal HighsHighsHighsHighs‘‘‘‘Designer drugs’Designer drugs’Designer drugs’Designer drugs’
‘Research Chemicals’‘Research Chemicals’‘Research Chemicals’‘Research Chemicals’‘Party pills‘Party pills‘Party pills‘Party pills’’’’
‘Novel Psychoactive ‘Novel Psychoactive ‘Novel Psychoactive ‘Novel Psychoactive Substances’Substances’Substances’Substances’
Novel Psychoactive Substances
(NPS)
• Formal definition– Harmful substances not controlled by UN Conventions
• A practical definition– ‘New stuff’
• May have been legal
• Modified classical drugs
• Unknown pharmacology, toxicity, safety
• Quite a variety– >500 different chemicals
IS THIS IMPORTANT?
Mortality
2011 2012 2013 2014 2015 2016
NPS 31 55 63 82 114 123
Source: ONS. Deaths related to drug poisoning in England and Wales: 2016 registrations
Mortality
2011 2012 2013 2014 2015 2016
All 2652 2597 2955 3346 3674 3744
NPS 31 55 63 82 114 123
Mortality
2011 2012 2013 2014 2015 2016
All 2652 2597 2955 3346 3674 3744
NPS 31 55 63 82 114 123
Cocaine 112 139 169 247 320 371
Heroin /
Morphine
596 579 765 962 1201 1209
MDMA 13 31 43 50 57 n/a
Cannabis 7 14 11 28 21 n/a
Age-standardised mortality rate for deaths related to
drug misuse, by country and region, registered in 2016
Newcastle NPS activity – January 2016
• North East Ambulance Service reported– 263 calls in January 2016 linked to ‘legal highs’
– 97 in February – after a range of targeted activity
• Police reported– 225 calls linked to ‘legal highs’ in January
– 71 between 1 Feb and 21 Feb
• Hospital involvement mainly dealt with by acute
services
PATIENT ASSESSMENT &
MANAGEMENT
Why might it be helpful to know what
they took?
• Risk assessment
– Location and duration of care
– Anticipate complications
– Guide specific management
• Differential diagnosis
– Acute psychosis, thyrotoxicosis, sepsis, encephalopathy, encephalitis, phaeochromocytoma, withdrawal syndromes
What did they take?
The problem with Products
• Constituents vary
• Quality
• Multiple chemicals
Testing
• Immunoassays
– Availability
– Limited scope
– False negatives
– False positives
• LC-MS/MS
– Availability
– Cost
Toxidrome approach
Stimulant Depressant
HallucinogenSynthetic
cannabinoid
NPS
Stimulants
Presentation
• Pill, snorted powder, IV
• Agitated, paranoid, violent
• Chest pain
• BP 185/113
• HR 126/min
• Dilated pupils
• Catecholamine excess
Stimulants
NPS Examples
• Substituted amphetamines
• Cathinones
– Mephedrone
– MDPV
• NBOMe
• Ethylphenidate
Stimulant
Management
• Benzodiazepines
• Aggressive cooling
• Critical care
• Manage agitation
Caution
• Serotonin syndrome
• Hyperthermia / MOF
• Vasoconstriction & Vascular
complications
• Agitation / Psychosis
• Beta-blocker caution
Depressant
Presentation
• Tablets, ‘Blues’, IV
• GCS 8/15
• Respiratory rate 9/ min
• pH 7.22, PaC02 8.9
• Opioid or GABA receptor
agonism
NPS Examples
• Opioids
– Fentanil derivatives
– AH-7921, U47700
• Benzodiazepines
– Etizolam, Diclazepam
• Dissociatives
– Methoxetamine
Depressant
Management
• Airway management
• Naloxone 400microg IV
• Flumazenil with caution
Caution
• Oxygen
• Early discharge
• Novel opioids / naloxone
failure
• Flumazenil
Hallucinogen
Presentation
• Visual, auditory, tactile
• Behavioural
• Few physiological changes
– Tachycardia
– Mydriasis
– Hyperthermia
– Platelet dysfunction
• Serotonin 2a receptor agonism
NPS Examples
• 1p-LSD
• AMT
• NBOMe
Hallucinogen
Management
• Calm & keep safe
• Benzodiazepines
• Antipsychotics
Caution
• Agitation / Psychosis
• Ketamine
• AMT
Hallucinogen
SCRA
Presentation
• Smoked
• Reduced GCS
• Respiratory depression
• Acidosis
• Agitation/psychosis
• CVS disturbance
– Tachy or bradycardia
• Seizure
• Mydriasis
NPS Examples
• MDMB-CHMICA
• AB-FUBINACA
• AKB-48
SCRA
Management
• Calm & keep safe
• Benzodiazepines
• Airway protection
• Manage acidosis
Caution
• Mental health disturbances
• Reduced GCS
• Acidosis
• Social
IONA study
• 24 sites in the UK
• Severe toxicity due to suspected NPS
• Consent
• Clinical data collection
• Linked-anonymised
• Bio-fluid analysis by non-targeted LC-MS/MS
CI - Professor Simon Thomas
Fentanyl derivatives
EMCDDA notifications – fentanyls
Example: Illicit drug overdose deaths with
fentanyl detected, British Columbia , Canada
Rodent toxicology data
Take home messages
• No “legal highs” since PSA 2016
• People take drugs, you probably won’t know which on admission
• Use a Toxidromes approach to risk assess and manage– Stimulant
– Depressant
– Hallucinogen
– SCRA
• Hyperthermia, CVS derangement and acute mental health disturbances require caution
• Fentanyl derivatives of increasing concern
• NPIS can help
TOXBASE®
Image attributions
• http://freeforcommercialuse.org/photos/cup-coffee/
• https://pixabay.com/en/cigarette-smoking-smoke-ash-1359562/
• Guardian – written permission
• 2.0 Graham Richardson from Plymouth, England. https://commons.wikimedia.org/wiki/File:SWAS-ambo-shout.jpg
• 2.0 Ivaan Kotulsky via Toronto History from Toronto, Canada.https://commons.wikimedia.org/wiki/File:Man_lying_on_street.jpg
• NPIS annual report 2014/15 front cover
• https://commons.wikimedia.org/wiki/File:Ketamine.JPG
• Nutschig at the English language wikipedia. https://commons.wikimedia.org/wiki/File:Dilated_pupils_2006_(cropped).jpg
• moodygroove at the English language wikipedia. https://commons.wikimedia.org/wiki/File:SinusTach.jpg
• https://commons.wikimedia.org/wiki/File:Trippy.jpg
• https://commons.wikimedia.org/wiki/File:25C-NBOMe_blotter.jpg
• https://commons.wikimedia.org/wiki/File:USMC-100201-M-3762C-001.jpg
SELF ASSESSMENT
Toxidromes: self-assessmentConnect the presentation with the correct Toxidrome
Presentation
• Homeless. GCS 9/15, mydriasis, smoked ‘something’, PaC02 6.8
• Violent, HR 145/min, Temp 41.2°C
• GCS 15/15, HR 96/min, says ‘I can smell colours’
• GCS 3/15 paramedic but improved to 15 without treatment after 1 hour. Has been raped, HR 52/min
Toxidrome
• Stimulant
• Depressant
• Hallucinogen
• SCRA
True or false?
1. The duration of action of naloxone is longer than the
effects of novel opioids
2. Ketamine is the first line agent for severe agitation due to
NPS
3. If intubation and ventilation is required for stimulant
toxicity avoid fentanils in anaesthesia / sedation
4. Heroin remains the most potent abused opioid
5. SCRA can cause respiratory drive suppression
6. If a novel opioid is suspected increase naloxone initial dose
to 2g IV
7. NPS use is less common in those with mental health
problems
True or false?
1. The duration of action of naloxone is longer than the
effects of novel opioids False
2. Ketamine is the first line agent for severe agitation due to
NPS False
3. If intubation and ventilation is required for stimulant
toxicity avoid fentanils in anaesthesia / sedation True
4. Heroin remains the most potent abused opioid False
5. SCRA can cause respiratory drive suppression True
6. If a novel opioid is suspected increase naloxone initial dose
to 2g IV False
7. NPS use is less common in those with mental health
problems False