Clinical Experience of Novel Psychoactive Substances Dr Richard Stevenson.
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Transcript of Clinical Experience of Novel Psychoactive Substances Dr Richard Stevenson.
Clinical Experience of Novel Psychoactive Substances
Dr Richard Stevenson
BackgroundLegal Highs -> Novel Psychoactive
Substances41 new substances in 2010 aloneDiverse collection of compounds
PiperazinesCathinonesSynthetic cannabinoidsIsolated compounds
Recreational problem identified in 2008/2009Varying legal status
GRI Emergency Dept Experience12 AMT22 synthetic cannabinoids3 cathinone2 methoxetamine1 salvia
9 life threatening toxicities
Why are people taking them?Legal statusPerception of safetyDifficult to detect
Point of care urine testingOdourless
AvailabilityInternet“Head shops”
Sold as other drugs
AMT
5-IT
Common ProblemsLack of reliable data“Not what is says on the tin”DosageInter-individual variabilityTime of onset to effectPolysubstance misuseInteractions ?
Challenges in Clinical CareAcute
Identification of xenobioticLack of toxicological data
Mechanism of action Duration Clinical effects
Appropriate treatmentChronic
Long term psychological effectsLong term physical effects
CathinonesSynthetic variations of natural cathinones in KhatMephedrone, methedrone, naphyroneIvory wave, meow-meow, bubbles, ocean snow,
NRGSympathetic Toxidrome
↑HR, RR, BP, tempTremor, agitation, paranoia, hallucinations, seizures***duration 24 – 48 hours***
TreatmentsBenzodiazepines +/- haloperidol
PiperazinesDeveloped in 1950s – anti-helminthic agentsBZP “Benzo Fury”
Neurotransmitter release/reuptake inhibitionPhenylpiperazines
Direct serotonin receptor activationReversal of serotonin uptake
ClinicallySympathetic toxidromeSerotonin toxicity?
Synthetic CannabinoidsAnnihilation, Black Mamba, Spice, K2Structurally dissimilar to THCHerbal material sprayed with chemicalsClinical effects
Nausea +++CollapseSome psychotropic effects
MethoextamineStructurally similar to ketamineNMDA receptor agonistClinically (dose related)
Excitation, tachycardia, euphoriaHallucinationsDissociationProlonged neurological effects - ataxia
Supportive management
AMT/5-ITAMT – Alphamethyltryptamine5-IT – 5-aminopropylindoleAMT researched as antidepressant in 1960’sNon-specific MAOI
Hallucinations +++Psychomotor agitation +++Serotonin toxicity
High risk of toxicity
Serotonin ToxicityExposure to a
serotonergic drugClinical features
ConfusionAutonomic
instabilityHyperkinetic
musculoskeletal system
Treatment of Serotonin ToxcityMorbidity & Mortality related to
hyperthermiaTemp ≥40 oCDuration
ConsequencesRhabdomyolysisAcute kidney injuryAcidosisCerebral damage
Treatment of Serotonin ToxicityAggressive coolingAntipyretics do not work!Control muscular activity
High dose benzodiazepinesHaloperidol for severe non-responders
Appropriate fluid controlBP control agentsAnaesthesia with muscle paralysis
The Future?Market flooded with NPSDifficult to legislate/controlLong term effects?