The Real Dangers of Synthetic Drugs in The 21st Century

Ken Dickinson, M.S., R.Ph.kdickinson@gaudenzia.org

610-291-3109

Introductions

Presenter:Ken

• Attendees– Experience with “Bath Salts” and K2/Spice– Expectations or goals for this workshop

Objectives• • Describe the current trend of synthetic drugs of abuse

being marketed as “legal” household products;

• • Identify the compounds referred to as “bath salts” and K2/synthetic marijuana; 

• • Demonstrate the effects on users with emphasis on the high incidence of psychosis;

• • Review the legal aspects and current legislation aimed at regulating and limiting access to these chemicals;

• • Discuss prevention and treatment approaches

Please Take Note

• Very little science • Very little research• Now accumulating data & science• Today’s information anecdotal

– Face to face with users, Law Enforcement, etc – Forums & discussions on web

• Some research

Designer Drugs: Background

• Trend started in late 1970’s• Drugs of abuse are classified by DEA• Drugs of abuse work according to structure• Analogs

– Can “design” an analog to have same or similar activity but not listed as a “controlled substance”

– Not subject to legal penalties and restrictions

Mephedrone & Methamphetamine

Designer Drugs: Evolution

• Internationally do not have such laws– Being manufactured in other countries

• Many “designer drugs” do not test (+)• A way to “Beat the Bladder Police”

Designer Drugs

• Today’s trend– Make an analog that is not listed in laws– Since legal can make an distribute as an

everyday household product e.g. “Bath Salts” “Plant Food”, potpourri, incense, jewellery cleaner, hummingbird attractant, etc.

– Then label “not for human consumption”– Market via social media and retail outlets

European Drug Monitoring

• #24 new psychoactive drugs 2009• #41 in 2010• #49 in 2011• #57 in 2012• Since 2012 more than one a week• Synthetic cathinones & synthetic

cannabinoids make up more than 2/3 of new drugs

Schematic highlighting the major families and subfamilies of research chemicals, and some of their most prominent members.

Phenylethylamines I Have Known & Loved

• Alexander Shulgin & Ann Shulgin• Book: PiHKAL A Chemical Love Story (1991)

– Lists #179 psychoactive compounds– “A prerequisite to the psychedelic experience– The book is arranged into two parts:

• A fictionalized autobiography of the couple. • Detailed synthesis instructions for over 200 psychedelic

compounds (most of which Shulgin discovered himself), including bioassays, dosages, and other commentary.

Historical Background

• All drugs of abuse started out as legal (uncontrolled) substances in US– Heroin, LSD, Cocaine, Amphetamine,

Marijuana and MDMA (ecstasy)• Many sat on the shelf for years before

becoming abused• A mixture of rumor, myth and science

have all contributed to changes in the legal status of these substances

Web Sites

• www.k2info.org• www.bluelight.ru• www.drugs-forum.org• www.erowid.org• www.lycaeum.org

K2 Products

• Mixture of herbal and spice plant products– Leaf can be: marshmallow leaf, parsley, etc.

• Sprayed with synthetic cannabinoids• Marketed as incense and “not for human

consumption”• No regulations to list ingredients or age

requirements to purchase• First generation called K2 or “Spice”• Second generation called K3 or “Splice”

Description of the Drug

Synthetic Marijuana (JWH- 018)

K2 originated at Clemson University, where researchers developed synthetic cannabinoids in an effort to create therapeutic drugs. But the cannabinoids also have effects akin to THC, the key ingredient in marijuana

• K2 is largely created by individual sellers, it's anyone's guess what else is added to the mix.

Synthetic Cannabinoids Pharmacology

• Research supported by NIDA-John W.Huffman• Two cannabinoid receptors in human brain CB1

and CB2• CB2 affects inflammatory pain (target of NIDA

study)• JWH analogs target both receptors• Huffman: “JWH is easiest to make outside of a

lab only need two commercial products”• Transferring to plant material only requires using

acetone

• Yes. Until a drug is tested, it cannot be considered safe. Not only have synthetic cannabinoids not been tested, nearly all were created for experimental use in animals and cell cultures, not tested for use in humans.

• JWH-018 inventor John W. Huffman, PhD, puts it bluntly: "It is like Russian roulette to use these drugs. We don't know a darn thing about them for real."

• These synthetic cannabinoids have been associated with impaired driving incidents, attempted suicides, and emergency department visits, and have been linked to such adverse effects as increased anxiety, panic attacks, heart palpitations, respiratory complications, aggression, mood swings, altered perception, and paranoia.

Dangers Involved in K2

• Recent reports (Jan 2013) of kidney failure• Reports of cardiac events such as heart

attack in young male users• Medical reports indicate that K2/Spice

drugs potentially result in users developing a rapid and powerful addiction on a level not usually found among smokers of “real” marijuana.

Teens & K2 Effects in ER• One 16-year-old girl was catatonic, unable to

speak or respond to any touch, when she arrived in the emergency room. A urine drug test showed she had cannabinoids in her system.

• Another teen, a 16-year-old boy, had problems with movement and trouble with his speech. Although he was alert, he seemed confused, and could only answer simple questions.

• And an 18-year-old boy was brought to the emergency room agitated and excessively sweating. He was restless, aggressive and uncooperative.

Alarming Fact

• Tests show that even the same brand may have different drugs– in different amounts-at different times

• User has no way of knowing what or how much they are taking

K2 Data

• American Association of Poison Control Centers

• Reported in article June 2012 • Year 2010 #2,

906• Year 2011 #6,959• Year 2012 #5,205

Spice is typically smoked like marijuana

On Line Reported K2 Effects

• Strong dysphoria-Panic attacks-Heavy body load-Extreme nausea -Fear, Panic, Anxiety-Strong aural hallucinations--Racing heart (higher doses)– Heart attack

On Line Reported K2 Effects

• Self mutilation• Paranoia• Auditory & visual hallucinations• Delirium• Agitation

On Line Reported K2 Effects

• Marijuana-like effects– Euphoria– Giddiness– Silliness– Impaired short-term memory and

concentration– Increased appetite

K2 Products

Scooby Snacks: K2

What Are Spice Users Saying?• But when I smoked this sonic boom stuff, I was

completely high. I was trippin’ for over an hour. It’s insane but fun. I got to the point where my vision kept zooming in and out.

• But I do not recommend this drug if you are a first time smoker or you don’t like weed. This stuff gives you an intense head high, thus starting to trip and having hallucinations.

• This is very similar to the marijuana high but just a bit stronger. The only bad thing about this is that it is very bad for you because it’s an incense.

Source: Various Blog Sites

What Are Spice Users Saying?

• Spice is nowhere near as dangerous as some people say it is.

• Sure it’s in no way good for you and it would kill you from the carcinogens eventually but that’s about it.

• If you’re responsible and just smoke a little every now and again you’re not going to die and you’re definitely not going to get addicted.

• I have literally taken a drug test the day after smoking it and passed no problem.

Source: Various Blog Sites

Why the Discrepancy in Reports?

• Use of other drugs with incense• Varying potency• Overdose• Presence of different cannabinoids• Knock-offs• User/environment characteristics

– Set & setting, etc.

Spice Withdrawal

• Unrest & Agitation• Anxiety & Panic

Attacks• Tremors• Heart Palpitations• Nausea Vomiting

• Sweating• Nightmares• Cravings• Depression

K2 Treatment Issues

• High rates of addiction (K2info.org)• Withdrawal due to physical addiction

– Treated with sedatives and clonidine• Before D&A treatment need to be medically

and psychiatrically safe and stable• Residual effects for weeks (or months) due

to long half-life & fat storage• Unpredictable

K2 Testing

• Many labs have a test for the first generation JWH chemicals

• In February 2010, Redwood Labs, California developed a saliva test for JWH-018, JWH-073 and JWH-250

• Saliva and urine tests recently developed for second generation JWH’s

• http://www.redwoodtoxicology.com/documents/services/3369_sc_sellsheet.pdf

K2 Testing

• Following a single low dose exposure, synthetic cannabinoids can be detected up to 72 hours in human urine.

• In case of chronic exposure the window of detection is much longer

http://www.redwoodtoxicology.com/services/synthetic_cannabinoid_testing.html

When Done Right, Drug Testing Works!

• Traditional lab-based drug testing methods work at detecting synthetic marijuana, including:– Urine– Oral fluid• However, the lab will not conduct a traditional test for

THC… it’s a different test to detect chemical structure of synthetic marijuana… but it can be detected with lab-based oral fluid and urine.

• So far, no evidence that instant urine testing devices, including products marketed as “home” drug test kits, work at detecting synthetic marijuana.

Then Came Oral Fluid Testing…

• Well, it’s not urine• Easy to administer internally• Virtually impossible to adulterate• Legal in most jurisdictions• Legally defensible• Rapidly increasing in popularity

Oral Fluid Testing…

• Drugs are detected immediately after use• “Under the influence” indicator• Less invasive collection process• Comparable to blood• Science continues to progress and get better• Flexible… sample can be collected any time,

anywhere• There are FDA cleared oral fluid collection and

testing products (for laboratory based testing)

Source: Myths & Facts About Oral Fluid Drug Testing, On File OraSure Technologies, 3/2011

Cheating• Urine tests are susceptible to drug test cheating• Oral fluid is very difficult to adulterate• Collection takes place in the presence of both

the donor and the administrator of the test• Typical cheating methods such as switching

samples or adding something to a sample are virtually impossible to successfully pull off

• A search of the Internet will find thousands of hits for cheating on a urine drug test… only a handful for oral fluid testing

CheatingA good website for oral fluid drug test cheating is wikihow.com/pass-a-drug-test. Quoting directly from the website:“Try to avoid the test. If one is being tested and has used in the past 3 days you will need to overcome the saliva collection. To do this you will have to avoid submitting saliva and perform the steps requested of you by the instructor.” Another offers this advice:“To pass this [an oral fluid test] you should always know the detection time of the drug you have taken. Marijuana can be detected via saliva drug testing from an hour after ingestion up to 24 hours depending on use. Between these periods of time, you must avoid being screened or you will surely test positive.”

Dignity

• No urine, no bathroom… no humiliating observed collections, no gender match-up issues, no threats of drug test cheating

• Donor and administrator observe the collection together

• Specimen never leaves the donor’s sight• Embarrassing shy bladder issues are eliminated• There’s virtually no way to cheat

The testing process protects the dignity and privacy of the donor.

Testimonials“We find the ability to test quickly and to collect the sample with minimal exposure to staff is a great advantage”. --Janet Ward, Former Drug Court Coordinator, Anne Arundel County (MD) District Court“We are a very client-focused program and oral fluid testing allows us to concentrate on building the relationship rather than on drug testing”. -- Keith Spare, Former Director of Rodgers South Drug Treatment, Kansas City, MO“Intercept® is more sensitive to patient’s needs by being less embarrassing and easier for patients to provide an oral fluid sample compared to that of urine”. -- Dr. Beny Primm, Addiction & Research Treatment Corp, New York City

OraSure… Intercept ®

• Intercept® Oral Fluid Collection Device

• Oral Fluid Drug Assays Used in Laboratory

K2 Overview

• No quality control• Manufacturing process may be associated with

adverse effects• Subjective effects most closely resemble those

of very powerful marijuana• Almost complete lack of scientific study• Street information very inconsistent

Mitragyna Speciosa

• Used in:– Malaysia– Thailand– Indonesia

• Local names:– Ithang– Biak Biak– Ketum– Kakuam

Kratom Pharmacology

• Mitragynine• Structurally similar to some hallucinogens• No hallucinogenic activity or effects• Acts on opioid receptors

Kratom & Opioid Treatment

• Currently used for heroin and methadone dependence in some countries– New Zealand– Thailand

• Used in detox to manage withdrawal symptoms from opioids

• Millenium Labs announced test Aug. 2012

Kratom & Opioid Treatment

• www.bluelight.ru– Forum with much Kratom info– Participants using Kratom to week off of oxy,

heroin, Bup, etc.– Majority unable to ween off of Kratom– Descriptions of withdrawal– Descriptions of how to prepare & dosage– Descriptions of which to buy and where

Kratom

• Seems to be a stimulant in lower doses– Mitragynine

• Seems to be sedative in higher doses– 7 hydroxymitragynine

• Often produces a mixed effect• Onset 5 t o 10 minutes• Duration several hours

Kratom Side Effects

• Short term (immediate)– Dry mouth– Increased or decrease urination– Loss of appetite– Nausea and/or vomiting

• Side effects– Anorexia/weight loss– Depression– Addiction

Kratom EFFECTS

•Kratom is often described as producing simultaneous, contradictory effects- both an opiate-like sedation and coca-like stimulation. The stimulating effects tend to predominate at low dose levels, which may cause alertness, energy, and mild euphoria. Higher level doses are usually more tranquilizing, causing an opiate-like dreamy effect. Excessive doses can cause severe nausea. As with opium, it is known for causing constipation, and is sometimes used as a treatment for diarrhea.

Onset •When taken orally, the effects of kratom usually become noticeable in 15-20 minutes and clearly apparent in 30-60 minutes. Strong doses tend to have a more quicker, more dramatic onset.

Duration •A moderate dose of kratom may cause strong effects that last 2-4 hours, with residual effects lasting hours longer.

KratomVisual Effects •Some visual effects have been reported, including both open-eye and closed-eye effects. Effects reported include wavering, shifting, and strobing in the visual field. There was also some patterning with eyes closed, as well as increased closed-eye visualizations. PROBLEMS •Kratom is not known to be toxic, but can cause unpleasant symptoms at high doses such as nausea and vomiting. Regular use can lead to physical dependency. Kratom use can cause constipation similar to that caused by opiates. Chronic heavy use is reported to cause darkening of skin, insomnia, dry mouth, and anorexia. Addiction Potential •There are reports of physical dependency after frequent, heavy kratom use. Individuals who use it regularly or in large doses may have trouble quitting. Withdrawal symptoms include irritability, yawning, diarrhea, runny nose, and pain in the joints or muscles. •http://www.bing.com/videos/search?q=You+Tube+Kratom&view=detail&mid=EC48A0AFEDFBEA20762AEC48A0AFEDFBEA20762A&first=0&FORM=LKVR16

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Mephedrone(4-Methylmethcathinone)

Bath Salts

• Toxic psychoactive drugs “disguised” or “pretending” to be “Bath Salts”

• They are NOT• Some people have snorted real BS’s

“Bath Salts” Are

Khat

• Native to tropical East Africa and the Arabian Peninsula

• Fresh Leaves/tops chewed or consumed as tea

• Stimulation and euphoria• Part of social culture in many countires

(coffee, tea, coca or khat)

Khat

• Coca ---------------cocaine• Khat ----------------cathinone (Schedule I)• Cathinones: Structure similar to

amphetamines– Euphoria– Anorexia– Stimulation– Dilated pupils– Hypnagogic hallucinations when wearing off

What are Synthetic Cathinones?

• Synthetic cathinones are related to the parent compound cathinone.

• Since the mid-2000s, unregulated ring-substituted cathinone derivatives have appeared in the European and American recreational drugs market.

What are Synthetic Cathinones?• The most commonly available synthetic cathinones

sold on the recreational market in the period up to 2012 appear to be 3, 4-Methylenedioxypyrovalerone (MDPV), mephedrone, and methylone.

• These products are usually encountered as highly pure white or brown powders. Cathinone derivatives are claimed to have effects similar to those of cocaine, amphetamine or MDMA (ecstasy), but little is known of their detailed pharmacology.

Mephedrone Background

• Discovered 1929• Rediscovered 2003 web site “The Hive”• Was a replacement for Ecstasy• Sold as “plant food” & later “bath salts”• Manufactured in clandestine labs• Methylenedioxypyrpvalerone (MDPV)• Known as substituted cathinones

MDPV Timeline• MDPV was developed in the 1960s, and has been used

for the treatment of chronic fatigue, but caused problems of abuse and dependence.

• 1969: Boehringer Ingelheim files a patent application for MDPV.

• 2005: MDPV appears as a recreational drug; first mention on Drugs-Forum.

• 2007: First seizure of MDPV as a recreational drug, by customs officials in the German state of Saxony. The drug had been shipped from China.

• 2008: First seizure of MDPV in the United States.

MDPV Timeline• 2009: MDPV made illegal in Denmark.• 2010: MDPV made a controlled drug in the UK, Sweden,

Germany, Australia and Finland. First reports of the widespread retail marketing of 'bath salts' containing MDPV in the US. The US considers both Mephedrone (July, 2010) and MDPV (December, 2010) "a drug and chemical of concern".

• 2011& 2012: MDPV sale and possession are banned in most US states with legislation being introduced in Maryland and other states.

•

Bath Salts (Cathinones) Appearance

• Distinctive odor– Fishy– Vanilla– Stale urine– Bleach– Circuit boards

Cathinones Use

• Capsules, tablets or white granuels• Can be swallowed, smoked, snorted,

injected• Prominent use in Europe• Out of 70 Dutch users of mephedrone, 58

described it as an overall pleasant experience and 12 described it as an unpleasant experience

Cathinones Effects

• Duration– Total 2 – 5 hours– Onset 15-45 minutes– Coming up 15 – 30 minutes– Plateau 15 – 30 minutes– Coming down 30 – 90 minutes– After effects 2 – 4 hours

Cathinones Desired Effects

• Mental and physical stimulation • Euphoria, mood lift • Feelings of empathy, openness • Increase in sociability, desire to talk with

others • Pleasurable rushing • Sense of being sped up

Cathinones General Effects

• General change in consciousness (as with most psycho-actives)

• Decreased appetite • Pupil dilation • Unusual body sensations (facial flushing, chills,

goose bumps, body energy) • Change in body temperature regulation • Sweating • Increase in heart rate and blood pressure

Cathinones General Effects

• Sleep deprivation• Bruxism• Motor automatisms (compulsive repeated

hand washing)• Hyper-alertness

Cathinones Toxic Effects

• Strong desire to re-dose, craving to recapture initial euphoric rush

• Uncomfortable changes in body temperature (sweating/chills)

• Heart palpitations, sense of racing heart • Impaired short term memory • Insomnia• Skin lesions (?)

Cathinones Toxic Effects

• Severe paranoia• Psychosis (Excited Delirium)• Hypersexuality• Aggression• Hallucinations• Anxiety and depression• Seizures

Bath Salt Data

• American Association of Poison Control Centers # of calls

• June 9, 2012 report• Year 2010 #304• Year 2011 #6,138• Year 2012 #2,656• Year 2013 Jan-April #350

Cathinones Treatment Issues

• Similar to strong amphetamine addiction• Similar to PCP abuse/addiction• Non-psychotic withdrawal use Benzo’s• Stabilization and Safety highest priority

– Safety of client– Safety of staff and others

Cathinones Treatment Issues

• If psychotic or dissociated need to medicate– Neuroleptics:

• Haldol for emergency stabilization• Atypicals (Seroquel/Respirdol/etc.) for ongoing

stabilization

• Decease sensory exposure– “Rock or Rave” medicine– Talking down bad trips– De-escalation techniques

Cathinones Treatment Issues

• Once stable and safe be aware of cognitive impairment

• May need “tincture of time” to grasp recovery

• Supportive non threatening environment• Screen for COD (high probability)

– Buproprion for concurrent depression

Synthetic Cathinones Effects Summary Sheet

Aggression Agitation Breathing difficulty Bruxism (grinding

teeth) Confusion Dizziness Extreme anxiety

sometimes progressing to violent behavior

Fits and delusions Hallucinations Headache

Hypertension (high blood pressure)

Increased alertness/awareness

Increased body temperature, chills, sweating

Insomnia Kidney pain Lack of appetite Liver failure Loss of bowel

control Muscle spasms Muscle tenseness Vasoconstriction

(narrowing of the blood vessels)

Nausea, stomach cramps, and digestive problems

Nosebleeds Psychotic delusions Pupil dilation Renal failure Rhabdomyolysis

(release of muscle fiber contents [myoglobin] that could lead to kidney problems)

Severe paranoia Suicidal thoughts Tachycardia (rapid

heartbeat) Tinnitus

Synthetic Drug Abuse Prevention Act of 2012

• July 10, 2012 President signed Law making temporary law permanent

• October 1, 2012 Synthetic Drugs now listed as Schedule I

• All substituted cathinones now Schedule I• Chemists working on making non-

cathinone stimulants

http://www.ncsl.org/issues-research/justice/synthetic-drug-threats.aspx

Prevention For K2 & Bath Salts• Heighten awareness via Education

– Schools, parent groups, community groups, law enforcement, medical & treatment, etc.

• Legislation against precursor chemicals• Legislation making drugs Schedule I

– Patrick Meehan “Synthetic Drug Control Act”• Goes into effect October 1, 2012!!!

• “Hit the retailers in their pocket book”– Civil suits by victims (users and families)– Authorities appealing to retailers with amnesty if stop

and destroy

Urine Detection Information• Redwood Toxicology Laboratory shows

currently they have detection for MDPV and Mephedrone. (see w.K2info.org/drugtesting)

• June 11, 2012 Redwood expanded to test for #21 designer stimulants

• http://www.redwoodtoxicology.com/services/designer_stimulant_testing.html

• Atlantic Labs- Bensalem, PA Bath Salts $20.00 and K2 $15.00.

• Most labs now testing – Check with your lab

On-Site Testing

• Many labs now have available• On site urine may be useful in treatment• Problem: labs report as high as 35-40%

false negatives with on-site.– On-site shows no use but when testing for

accuracy they send to lab for confirm and up to 40% tested positive

• Saliva test available

2C-1 or “Smiles”

• Reports now in Mid-Atlantic states (Sept 2012)

• Prevalent on YouTube (users)• Similar to a mix of ecstasy & LSD but with

longer high & higher potency than either• Unusual & unpredictable effects• Not detectable like bath salts• Potency not consistent from batch to batch

2C-1 or Smiles

• Usually sold in white powder form and can be melted into chocolate candy, but can also be taken as a tablet

• Also sold as breath mint or drops• Both a hallucinogen and a stimulant- has

been linked to recent teen deaths• Can cause heart to beat out of control,

seizures and foaming at the mouth

Krokodil

• Opioid- desomorphine• Result of attempt to extract codeine • Injected can be used by other routes• Russia & spreading through Europe• Tissue breakdown• Highly addicting- Usually fatal

Desomorphine

• 8-10 X more potent than morphine• First discovered in 1932• Sedative & opioid effects• Made from codeine, red phosphorous &

Iodine (similar to methamphetamine)• Made in 30 minutes & injected

immediately• Produces gangrene & phlebitis

Molly’s

• Pure “molecule” of MDMA• Popular in rap music lyrics• Used at parties and raves• Lately Molly’s have contained cathinones• Familiar effects of XTC

– Bruxism, hyperthermia, anxiety, depression, dehydration, etc

Salvia divinorum• Regulated in PA• Legal for over 21 y.o. in MD• Not regulated by Feds• Dissociative effects

– Visions and hallucinations• Purchased on internet or locally• Most potent hallucinogen mg by mg• Smoked

Benzo Fury

• 6- APB• Entactogenic phenylethylamine• Not scheduled and not approved for

human consumption by FDA• Use is rapidly on rise• Number of websites selling on the rise• Sold as “research chemical”

Benzo Fury

• Effects including both positive and negative ones.Increased happiness, euphoria, extreme mood lift, increased self-acceptance, feelings of a peace and love toward others, increased intimacy and closeness with others, closed-eye hallucinations, ability to discuss topics with others that would not normally be discussed, pleasurable body rushes, increased sexual interest,

Weed Oil or “Honey”

• Recent resurgence• Butane method popular

– Fires & explosions • Solvent with heat extracts the THC

– 30% and higher THC• Recipes & cook books on web• YouTube demonstrations

Weed Oil or “Honey”

• Onset of action longer 45 to 60 minutes• Duration of action 6 hours and maybe

longer• Intensity of high greater due to high THC• Can also be smoked• Vaporizers used

Weed Oil or “Honey”

• Edible Marijuana• Ice Cream

Points to Ponder

• WHAT– Did I learn today? – What do I think about it?– How do I feel about it?

• So WHAT– Does this information mean to me

professionally and personally?????