new drugs of abuse: bath salts and synthetic cannabinoids

NEW DRUGS OF ABUSE: BATH SALTS AND SYNTHETIC CANNABINOIDS

Bruce D. Anderson, PharmD, DABAT

Director of Operations

Associate Professor

University of Maryland School of Pharmacy

Objectives

• Know what the commonly encountered substances called “bath salts” usually contain

• Understand the basic pharmacology of bath salts and synthetic cannabinoids

• Be able to describe the usual acute clinical effects from users of bath salts and from synthetic cannabinoids

• Be able to describe the potential psychiatric impact of bath salts use

WHO AM I AND WHY AM I HERE?

•Service program of the University of Maryland School of Pharmacy since 1972

•First year of operations, received 5,600 calls

• In 2012, MPC received ~62,000 calls

MPC Overview

• Open 24 hours/day• Staffed by pharmacists & nurses

• Nationally certified Specialists in Poison Information

MPC: (continued)

• Board certified Medical Director

• Board certified Director

• Masters in Public Health faculty

• Additional consultants available

MPC: Overview

•Recognition and prevention of exposures through community education and outreach

•Professional education to optimize patient care

Other Functions

•Data collection/reporting nationally

•Research to optimize patient care *

MPC: Overview

•The mission of the Maryland Poison Center is to decrease the cost and complexity of poisoning and overdose care while maintaining and/or improving patient outcomes.

What’s the Mission?

•Save Lives•Save Dollars

Bottom Line

•Save lives by providing emergency triage and treatment information to all callers.

•Save dollars by managing vast majority of patients (~75%) safely and inexpensively at home.

Bottom Line (continued)

•Last year, ~29,432 poisoning patients were safely managed at home.

•Usual charge for ED evaluation and treatment: ~$1,000 per patient

•Estimated cost savings:~$29,432,000 per year

Fiscal Impact:

WHAT THE HECK ARE “BATH SALTS???

The “Natural” Amphetamine• Cathinone; “Khat”

• Catha edulis• Native to Africa• Amphetamine like alkaloid• Chewed for the effects

Ann Pharmacother 2012;46:436-441.

In the Market

http://www.whitehouse.gov/ondcp/ondcp-fact-sheets/synthetic-drugs-k2-spice-bath-salts. Accessed 7 Dec 2012.

Former Fox TV Chair Beaten by Police

http://www.nj.com/business/index.ssf/2012/10/bath_salts_used_by_deutsche_ba.html

Man Tries to Bite Police

http://www.huffingtonpost.com/2012/06/05/brandon-deleon-high-on-cloud-9_n_1570560.html

Man Attacks Elderly Woman with a Shovel

http://www.huffingtonpost.com/2012/06/25/robert-william-white-la-bath-salts_n_1624688.html

Woman Has Baby, Goes on Rampage

http://www.huffingtonpost.com/2012/07/06/carla-murphy-had-baby-smoked-bath-salts_n_1653979.html

So… what is in “bath salts”?•Methylenedioxypyrovalerone (MDPV)•Mephedrone•Methylone•Methcathinone•Alpha-pyrillidonopropiophenone (α-PPP)

•Others

Synthetic Cathinones

CathinoneBeta ketonated amphetamines

N-alkylated cathinones

Ring substituted methylenedioxy-phenethylamines

Clin Toxicol 2011;49:705-719.

Structures and Similarities

Gerona RR, Wu AHB. Bath salts. Clin Lab Medicine 2012;32(3):415-27.

Audience Question:What synthetic cathinone derivative carries a legal medical indication for use the U.S. and Europe?

Answer: Bupropion

• Substituted cathinone• Indications:

• Depression• Smoking cessation

Cathinone

Clin Toxicol 2011;49:705-719.

Bath Salts: Pharmacology•Structurally similar to amphetamines and hallucinogenic amphetamines (e.g., MDMA) as well as cathinones

•Functionally closer in effect to cocaine

Clinical Effects•See typical stimulant effects•Hallucinogenic activity•Behavioral changes are common; may be persistent

Clinical Effect # Patients (%)Agitation 194 (82%)

Combative/violent behavior 134 (57%)

Tachycardia 132 (56%)

Hallucinations 94 (40%)

Paranoia 86 (36%)

Confusion 83 (34%)

Myoclonus 45 (19%)

Hypertension 41 (17%)

Chest pain 40 (17%)

Mydriasis 31 (13%)

Spiller HA et al. Clinical experience with and analytical confirmation of bath salts and legal highs in the United States. Clin Toxicol 2011;49:499-505.

Management: Bath Salts Exposures•Airway, Breathing, Circulation•Charcoal: only for substantial, recent ingestions

•Calm environment•Benzodiazepines•Symptomatic care

Typical Case: Bath Salts• 38 year old presents to ED with altered mental status• Hyperverbal, talking out of his head and making no

sense• BP 160s/100s; HR 120s; unable to get EKG• Hallucinating, sweating, agitated• Given 10 mg haloperidol, 2 mg lorazepam, 20 mg

ziprazidone, 10 mg olanzepine without response; in 4 point restraints

• Admitted to ICU, placed on dexmedetomidine; remains confused, agitated, diaphoretic, hypertensive

• 3 hours later, the patient is A&O * 3, VSS, just observing.

Bath Salts in Maryland

68.5% Male

Age:

Range: 9-60

Mean: 29

Med: 27

79.5 % Abuse

75% Male

Age:

Range: 16-48

Mean: 26

Med: 25

84.1% Abuse

2011 2012

Maryland Poison Center

2011: 73 cases

5 major effect

2 deaths

2012: 44 cases

0 major effects

0 deaths

Where to Buy?

http://ivory-wave.com/

Where to Buy?

http://legalhighs.net63.net/product.php?id_product=19

Regulation StatusFebruary 24, 2010:

First report of bath salt exposure.

October 21, 2011:

DEA emergency scheduling

December 8th, 2011:

Synthetic Drug Control Act

(HR 1254)July 9, 2012:

Synthetic Drug Abuse

Prevention Act

http://www.justice.gov/dea/druginfo/drug_data_sheets/Bath_Salts.pdf. Accessed 7 Dec 2012. http://www.deadiversion.usdoj.gov/drugs_concern/mdpv.pdf. Accessed 7 Dec 2012.

http://www.govtrack.us/congress/bills/112/s3189. Accessed 7 Dec 2012.

Clin Toxicol 2012;50:911-1164.

Banned But Replaced

http://www.fridayflyer.com/2012/10/05/banned-bath-salts-replaced-with-new-products

Replaced by…What???

http://www.ncbi.nlm.nih.gov/pubmed/22528592

Synthetic Cannabinoids•What are they?•What are the effects on people?

Synthetic Cannabinoids

http://sfgyc.com/k2-and-spice-now-illegal-tools-for-parents/2012/07/03/

http://www.noozhawk.com/article/053112_police_wary_florida_face_eating_incident/

http://www.mystoresupplier.com/L-A-SPICE-HERBAL-INCENSE-1-5-GRAM-32-COUNT-p/af079.htm

Synthetic Cannabinoids: MPC

Year Total Cases

Deaths

2010 16 0

2011 150 0

2012 222 1*

Synthetic Cannabinoids: Effects

• Altered mental status

• Paranoia • Psychosis• Seizures• Tachycardia• Hypertension

• Nausea and vomiting

• Loss of consciousness

• Acute pain• Hypokalemia• Acute kidney injury

Bhanushali GK, Jain G, Fatima H, et al. AKI associated with synthetic cannabinoids: a case series. Clin J Am Sco Nephrol 2012;ePud ahead of print Dec 14.

Typical Case: Synthetic Cannabinoids

• Call from ED regarding a 15 year old who presents after smoking synthetic cannabinoids

• On presentation, patient was combative, screaming, and hallucinating

• Treated with haloperidol and alprazolam• After 4 hours of observation, patients symptoms subsided and he was discharged home.

Synthetic Cannabinoids•Why use?

•avoid urine drug screen tests•Thought to be “safe” alternative to marijuana

•Avoid going to a drug dealer

Synthetic Cannabinoids•Synthetic Drug Abuse Prevention Act of 2012 Specified “cannabinimimetic agents” as Schedule I substances

•Producers have changed formulations to avoid the law and are still selling online, convenience stores and in head shops

1st quarter 2011

2nd quarter 2011

3rd quarter 2011

4th quarter 2011

1st quarter 2012

2nd quarter 2012

3rd quarter 2012

4th quarter 2012

0

10

20

30

40

50

60

70

Synthetic Drug Abuse Prevention Act 2012

Cases of intentional abuse or misuse of synthetic cannabinoids reported to the Maryland Poison Center over time.

Time

Number of cases

Synthetic Cannabinoids•Management:

Supportive care (ABC’s)

•NOTE: Symptoms may persist