Legal (and not so legal) Highs

Tom HeapsConsultant Acute Physician

Legal Highs Research Chemicals

Novel Psychoactive Substances (NPS)

Designer Drugs

Herbal Highs

BubbleLuvPlant Foods

Incense

Bath Salts

Party Pills‘Psychoactive drugs, newly

available in the UK, which are not

prohibited by the United Nations

Drug Conventions but which may

pose a public health threat

comparable to that posed by

substances listed in these

conventions.’

-NPS Expert Review Panel Report, 2014

Legal Highs: the basics Often manufactured in laboratories in China Readily available on the internet or in ‘headshops’ Often marketed as ‘research chemicals / powders’, ‘bath

salts’, ‘herbal incense’ or ‘plant foods’ Disclaimers ‘for research purposes only’ or ‘strictly not for

human consumption’ No quality control or guarantee of purity Often adulterated with illegal substances and / or cut with

other (toxic) substances e.g. caffeine, benzocaine, detergents

Actual constituents often differ markedly to ingredients listed on packet

‘Same’ product / brand name may contain completely different chemicals

Black Mamba

2011

- AM-2201

2014

- 5F-PB-22- 5F-AKB48

Green Rolex ‘legal’ ecstasy tablets

caffeineMDMAcaffeine

5-MeO-DALTPMAPMMA

Legal Highs: a growing problem?

INCB Annual Report 2013

UK has 5th largest market for legal highs in the world

56% increase in UK hospital admissions from 2009-2012

20% of all websites selling legal highs are hosted on servers in the UK

EMCDDA European Drugs Report 2015

10% of 15-24 year-olds in the UK have used legal highs

ROI has highest prevalence (22% of 15-24 yo) of legal high use in Europe

Toxbase Statistics

Novel NPS detected by EMCDDA

2010 2011 2012 2013 20140

20

40

60

80

100

120

Deaths from NPS in the UK

2007 2008 2009 2010 2011 2012 2013 20140

20

40

60

80

100

120

Gogaine (ethylphenidate)

Geeb (GBL, gamma butyrolactone)

Green Beans (AMT)

Benzo Fury (5-APB)

Blue Cheese (SCRA)

Mexxie (MXE, methoxetamine)

Krokodil (desomorphine)

Salvia divinorum

Drugs and their ‘families’Stimulant

Depressant

Hallucinogen

Empathogen

Synthetic Cannabinoid (SCRA)

Dissociative

Opioid

Ethnobotanical

The Drugs Wheel

www.thedrugswheel.com

Stimulants Bath salts, research powders / pills, plant foods

Cathinones, MPA, PMA/PMMA, MDPV, ethylphenidate, 2-AI, BZP, khat

Gogaine, Ching, Chang, Charly Sheen, Charles, China White

Insufflated (powders), swallowed (tablets or ‘bombs’) or injected

Elevate levels of adrenaline, noradrenaline and dopamine

PMA/PMMA have strong serotonergic properties

Similar chemical structure and toxicity to amphetamines

Chemical Structures

Mephedrone 4-methylmethcathinone, 4-MMC, MCAT Bubbles, Meow Meow, Drone Cathinone which occurs naturally in ‘khat’ (Catha Edulis) First synthesized in 1929 (from pseudoephedrine) but

recreational use prominent since 2007 Usually taken by nasal insufflation (‘snorting’) or swallowed

(‘bombing’) Increasingly injected (high rates of soft tissue and vascular

complications) Stimulant and entactogenic/empathogenic properties Anxiety/agitation, seizures, cardiovascular and serotonergic

toxicity Heavy use associated with significant ‘comedowns’, psychosis

and dependency Class B under MDA in April 2010 (responsible for 29 deaths)

Synthetic Cannabinoid Receptor Agonists (SCRAs)

incense, pot pourri, herbal blend, spice

AKB48, 5F-AKB48, PB-22, 5F-PB22, JWH-018 etc.

Spice, K2, Black Mamba, Blue Cheese, Psyclone, Exodus Damnation, Clockwork Orange, Pandora’s Box

Usually smoked (sprayed onto herbal blends or put into e-liquids)

Many times more potent than THC (higher affinity for CB-1 receptor)

Do not give a positive urine test result for cannabis

Anxiety, hallucinations, delirium, seizures, agitation / aggression, hypokalaemia and AKI

Clinical Case 24-year-old male with no relevant past medical history

Admitted to AMU with severe anxiety / agitation, vomiting and sweating

ED clerking states that he had been given a ‘legal high’ at a party the previous night

BP 162/97, HR 121 (sinus tachycardia on ECG)

No obvious confusion / delirium

Pupils symmetrically dilated

Mild metabolic acidosis on VBG

HOW SHOULD YOU PROCEED?

Difficulties in Management Multiple drugs may be co-ingested (often with alcohol)

Patients often do not know exactly what they have taken

Even if they can provide you with the name / packaging of the legal high….

- Impossible to ascertain dosing

- Ingredients listed on packet may not be representative of actual contents

- Same ‘brand’ may contain completely different chemicals in differing quantities

- Unknown toxins often present

Toxicological databases and clinical experience of managing toxicity cannot keep pace with the development of novel compounds

DOES THIS MATTER?

So What Can You Do? Attempt to identify chemical compound / group

responsible for toxicity

- Collateral history / packaging

- Formulation / route of administration

- Toxbase

- WEDINOS

- Google and other websites

Determine the predominant toxidrome and manage accordingly

Toxidromes associated with legal highs

Stimulant

tachycardia, hypertension, dilated pupils, sweating, seizures, agitation +/- signs of serotonin syndrome

history of smoking a ‘herbal’ product, mild stimulant / hallucinogenic features, seizures

reduced conscious level and hypoventilation +/- bradycardia and constricted pupils

visual, auditory or tactile hallucinations, agitation, confusion. +/- mild-moderate stimulant features

primarily neuropsychiatric features including ‘out of body’ experiences, agitation, analgesia, drowsiness, nystagmus, ataxia, coma, seizures

Hallucinogen

Dissociative

Depressant

SCRA

Stimulant

Hallucinogen

Dissociative

Depressant

SCRA

General Management Principles

ABCDE approach ECG, bloods (including clotting and CK) and VBG Monitoring (observations, GCS, CBG, cardiac monitoring)

Agitation / anxiety / delirium: benzodiazepines

Hyperthermia: benzodiazepines, active cooling, dantrolene, paralysis

Hypotension: IV fluids, vasopressors

Hypertension: benzodiazepines, IV GTN, labetalol

Metabolic acidosis: oxygen, IV fluids, IV sodium bicarbonate

Seizures: benzodiazepines, (phenytoin), thiopental

QRS / QTc prolongation: IV bicarbonate / IV magnesium

Respiratory depression: naloxone, (flumazenil), airway and respiratory support

Refer to www.toxbase.org for more specific management

Legal Highs: summary

Rapidly growing public health problem in the UK

Legal highs are not necessarily legal and may not give you a high!

Legal does not mean safe (legislation just hasn’t caught up yet)

Systems of classification (e.g. the drug wheel) can be informative

Often very difficult to know exactly what compounds have been taken….

…..manage according to toxidrome

Psychoactive Substances Bill 2015 currently going through House of Commons but refer to experience in ROI…..