designer & emerging drugs of abuse 2015 daniel castellanos, md medical director south florida...

Designer &

Emerging Drugs

of Abuse2015

Daniel Castellanos, MDMedical Director South Florida behavioral health Network

Founding Chair, Department of Psychiatry & Behavioral Health Professor of Psychiatry & Behavioral Health and Pediatrics

Herbert Wertheim College of Medicine, Florida International University

Disclosures

Assistant Dean of Graduate Medical EducationFounding Chair, Department of Psychiatry & Behavioral Health

Professor of Psychiatry & Behavioral Health and PediatricsHerbert Wertheim College of Medicine, Florida International University

Castellanos Designer & Emerging Drugs of Abuse 2015

Identify the types of designer drugs, including “flakka”, ecstasy, synthetic cannabinoids and others

Recognize the prevalence of use of these drugs

Recognize the psychoactive and physical effects secondary to use of these drugs

Learning Objectives

Castellanos Intro Child & Adol Psychiatry 2015

Epidemiology/Prevalence


Children aged

3-17 yrs currently

had:

Source: MMWR, 2013

ADHD 6.8%

Behavioral or conduct disorder

3.5%

Anxiety 3.0%

Depression

2.1%


Epidemiology

Disorders in which the majority of cases begin in childhood:

ADHD (attention-deficit/hyperactivity disorder)

Autism Spectrum Disorders & Intellectual Disability

Anxiety Disorders

Oppositional Defiant Disorder (ODD)

Most of the childhood-onset disorders have more male than female cases

(Rutter M, Caspi A, Moffitt T, 2003)


Lifetime Prevalence of Behavioral Health Disorders Adolescents

Source: Meriknagas,et al, 2010


Epidemiology

Disorders that usually begin in adolescence: Social anxiety disorder

Panic disorder

Substance use disorders

Depressive disorders

Anorexia nervosa & bulimia nervosa

Most adolescent disorders have more female than male cases

(Rutter M, Caspi A, Moffitt T, 2003)


Reported Drinking Patterns Among 8th, 10th & 12th Grade Students: 2013


Past Month Use of Tobacco Products


Top Drugs Among 8th & 12th Graders, Past Year Use


Adolescents -Annual Prevalence of Use for Various Illicit Drugs 2013


Adolescents -Trends in Annual Prevalence of an Illicit

Drug Use


Annual Prevalence of Designer Drug Use by US 8th, 10th & 12th Graders, 2013

Source: Johnson LD et al, Monitoring the Future National Survey on Drug Use,

2014

%

Synthetic

Marijuana

MDMA GHB Ketamine

0

1

2

3

4

5

6

7

8

4

1.1

7.4

3.6

7.9

4

11.4

8th10th12th%


% of Florida High School Students who used Club Drugs* & Synthetic

Marijuana, 2013

Lifetime Past 30 Days Lifetime Past 30 Days

Club Drugs* Synthetic Marijuana

*Ecstasy, Rohypnol, GHB, KetamineSource: 2013 Florida Youth Substance Abuse Survey

0

2

4

6

8

10

12

14

16

2.1

0.3unk unk

4.6

1.1unk unk

5.3

1.8

14.8

1.8

8th

10th

12th


Any Dru

g Exc

ept M

ariju

ana

Mar

ijuan

a

Synth

etic M

ariju

ana

Inhala

nts

Hallucin

ogen

tsLSD

Hallucin

ogen

s Oth

er T

han L

SDPCP

Ectasy

(MDM

A)

Cocain

e

Crack

0

2

4

6

8

10

Thirty-Day Prevalence of Use of Various Types Drugs

Ages 19-30, 2014

Castellanos Designer & Emerging Drugs of Abuse 2015Source: Monitoring the Future Survey Results on Drugs Use 1975-2014

18.3

Thirty-Day Prevalence of Use of Various Types Drugs

Ages 19-30 by gender, 2014

Any Illic

it Dru

g

Any Dru

g Exc

ept M

ariju

ana

Mar

ijuan

a

Synth

etic M

ariju

ana

Inhala

nts

Hallucin

ogen

tsLSD

Hallucin

ogen

s Oth

er T

han L

SDPCP

Ectasy

(MDM

A)

Cocain

e

Crack

0

1

2

3

4

5

Male

FemaleCastellanos Designer & Emerging Drugs of Abuse 2015

19.4

24.4

21.6

24.4 8

.7

16

Adolescents Differ from Adults in Substances Most Abused


Adults lifetime

prevalence

Source: Kessler, et al, National Comorbidity Survey, 2005

Any substance

use disorder14.6%

Any anxiety disorder

28.8%Major

depression 16.6%

ADHD8.1%

PTSD6.8%

Bipolar Disord

er3.9%OCD

1.6%


The adolescent brain is often likened to a car with a fully functioning gas pedal (the reward system) but weak brakes (the prefrontal cortex).

Teenagers are highly motivated to pursue pleasurable rewards and avoid pain, but their judgment and decision-making skills are still limited.

Importance of

the Teenage

Years


This affects their ability to weigh risks accurately and make sound decisions, including decisions about using drugs.

For these reasons, adolescents are a major target for prevention messages promoting healthy, drug-free behavior and giving young people encouragement and skills to avoid the temptations of experimenting with drugs.

Importance of

the Teenage

Years


The teenage years are a critical window of vulnerability to substance use disorders, because the brain is still developing and malleable (a property known as neuroplasticity).

Some brain areas are less mature than others.The parts of the brain that process feelings of

reward and pain are the first to mature during childhood.

Importance of

the Teenage

Years


What remains incompletely developed during the teen years are the prefrontal cortex and its connections to other brain regions.

The prefrontal cortex is responsible for assessing situations, making sound decisions, and controlling our emotions and impulses; typically this circuitry is not mature until a person is in his or her mid-20s.

Importance of

the Teenage

Years


Images of Brain Development in Healthy Youth (Ages 5-20)

Themature brain regions at each developmental stage are indicated in blue/purple.

The prefrontal cortex, which governs judgment and self-control, is the last part of the brain to mature.

Source: PNAS 101:8174–8179, 2004.

.


Substance Related

& Addictive Disorders


Substance Use

Disorders

Qualifiers used in the category: Use replaces both abuse and dependence Intoxication remains sameWithdrawal remains same

SUDs will be coded with DSM-IV substance

dependence codes


Substance Related

& Addictive DisordersRenamed:

Nicotine Related renamed Tobacco Use Disorder

Added:Caffeine WithdrawalCannabis WithdrawalGambling Disorder: “reflects the increasing and consistent evidence that some behaviors, such as gambling, activate the brain reward system with effects similar to those of drugs of abuse and that gambling disorder symptoms resemble substance use disorders to a certain extent.”

Discontinued:Polysubstance Abuse categories


Substance Use

Disorders (cont’d)Alcohol

Opioid Sedative, Hypnotic or Anxiolytic Cocaine Cannabis

Use DisorderOther Hallucinogen Inhalant Tobacco Amphetamine Phencyclidine

Castellanos 2014Castellanos Designer & Emerging Drugs of Abuse 2015

Substance Use

Disorders

There are two major changes to the new DSM-5 criteria for substance use disorder:

“Recurrent legal problems” criterion for substance abuse has been deleted from DSM-5

A new criterion has been added: craving or a strong desire or urge to use a substance


Substance Use

Disorder Criteria

1. Taking the substance in larger amounts or for longer than the you meant to

2. Wanting to cut down or stop using the substance but not managing to

3. Spending a lot of time getting, using, or recovering from use of the substance

4. Cravings and urges to use the substance5. Not managing to do what you should at work,

home or school, because of substance use6. Continuing to use, even when it causes

problems in relationships


Substance Use

Disorder Criteria

7. Giving up important social, occupational or recreational activities because of substance use

8. Using substances again and again, even when it puts the you in danger

9. Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance

10.Needing more of the substance to get the effect you want (tolerance)

11.Development of withdrawal symptoms, which can be relieved by taking more of the substance


Severity specifiers of the SUDs is based on the number of criteria endorsed: 2–3 criteria = mild disorder 4–5 criteria = moderate disorder 6 or more = severe disorder

Substance Use

DisorderCriteria


Designer &

Club Drugs


Overview of

the Problem

Designer and club drug use has increased in popularity over the past 2-4 years

Serious medical and psychiatric consequences can result

We have seen an increase in ED visits associated with use of these drugs


Overview of

the Problem

The newest compounds on the street are chemically different than the first generation compounds.

They are potent, impairing and addictive, but their chemistry makes them invisible to older designer drug screens and traditional drug tests.

Data show newer designer drugs are increasingly associated with more medical complications and drug related deaths.

Although labeled as “not for human consumption,” these substances often come as a powder to be snorted, injected, smoked or vaped by users.


Overview of

the Problem

While local retail sales of these now mostly illegal drugs have diminished, new venues of illicit distribution were appearing, ranging from online orders to courier delivery services, as street and club sales also continued.

Manufacturers are constantly coming up with new compounds to stay ahead of the law and avoid detection.


Designer &

Club Drugs

GHBKetamineKratomDextromethorphanSizzurpPrescription drugsEcstasy / MDMASynthetic Marijuana/CannabinoidsBath Salts / Flakka


Symptoms &

Management Issues

Designer &

Emerging Drugs


Sizzurp


History of

SizzurpOriginated in Houston, Texas1960: It was first used by Blues singers in the in

order to perform and continue to workThey used Robitussin with beer and then when

wine coolers became popular they replaced it1980-1990: The recipe was changed to use it with

codeine promethazine cough syrup with a lemon lime soda and Jolly Ranchers

1990s: Made popular by a DJ in Houston and his music being played in a slow tempo as if they were on codeine and promethazine

This concoction caused his early death and it was then that is caught the attention of law enforcement

2012: It became popular in the hip hop communityCastellanos Designer & Emerging Drugs of Abuse 2015

Justin Bieber Guzzles High Quality Sizzurp1/19/2014 12:48 PM PST BY TMZ STAFF

Was Justin Bieber Drinking Sizzurp At His 20th Birthday Celebration?By Sophie Miskiw in Lifestyle / Showbiz on 04 March 2014

What is sizzurp? Justin Bieber reportedly addicted to dangerous drink favored by rappers like Lil Wayne The homemade concoction is well-known among young people due to its mention in hip-hop lyrics, and can even be deadly, experts say.BY Tracy Miller NEW YORK DAILY NEWSThursday, January 23, 2014, 1:00 PM

http://www.nydailynews.com/authors?author=Tracy-Miller

Overview of

Sizzurp

It’s a concoction which includes:Cough syrup with codeinePromethazineJolly Rancher candy or SkittlesSoda popUsually served in Styrofoam cup but also drank out

of the soda bottle


Other Names

Purple drank Purple leanPurple jellyTexas TeaSyrup


Physical &

Psychoactive Effects

of Sizzurp

Slow reaction timeSedationRelaxationDecreased respiratory rateWeight gain Tooth decayDizzinessLethargyDissociative feelingMotor skill impairment


Dangers of

Sizzurp

Seizures when mixed with alcohol or if person prone to seizures

Shut-off of the respiratory center in the brain


PrescriptionMedicati0ns


The 2011 National Youth Risk Behavior Survey (YRBS) (www.cdc.gov/yrbss) found that 1 in 5 high school students in the US have ever taken a prescription drug, such as OxyContin, Percocet, Vicodin, Adderall, Ritalin, or Xanax, without a doctor’s prescription.

Nonmedical use

of prescription

drugs


Top Drugs Among 8th & 12th Graders, Past Year Use


Ecstasy


If you think its “Molly”

it may actually be methylone

or ethylone

Molly is the street name for the synthetic drug MDMA

It’s called Molly because of the capsule or powder form it comes in, as opposed to tabs

The presumption is that the “molecular” form, or Molly for short, is more pure

Many drugs sold as Ecstasy (MDMA) are really something else

Eg, finding of methylone or ethylone, key ingredients in bath salts

Most drug users don’t know who designed their drugs


Emergency Room Visits,

Miami-Dade County

398 MDMA -involved ED visits for Miami-Dade County during 2011

Represents 2 percent of all ED visits among 6 categories of substances (cocaine, cannabinoids, illicit stimulants, MDMA, nonmedical use of prescription opioids & BZs

The 2011 total represented a 91 percent increase over the 209 MDMA reports in 2004


Ecstasy - MDMA


Overview of

Ecstasy

MDMA 3,4 -methylenedioxymethamphetamineHallucinogenic amphetamine Historical use in research and psychotherapyDEA ban on MDMA in 1985


Ecstasy- MDMA

MDMA doses range from 80 to 150 mg but doses as high as 300 mg have been detected.

Prices varies greatly. A single table is typically $10-25 but can cost as much as $50.

Onset 20 to 40 minutesEffects last less than 24 hoursStreet names: e, Adam, X, XTC, purest form

MOLLY (Usually white pill or powder)


Physical Effects

of Ecstasy /

MDMA


Physical Effects

of Ecstasy /

MDMA

Neurological:Increased restlessnessMotor ticsHeadachesNeurotoxicity - Damage of serotonin nerve endings

Cardiovascular: TachycardiaArrhythmias Hypertension


Physical Effects

of Ecstasy /

MDMAOphthalmologic (eyes):

Nystagmus

Kidney:Secondary to muscle breakdown (Rhabdomyolysis)

Muscular:Bruxism (teeth grinding) & jaw clenchingMuscle rigidity & breakdown: Rhabdomyolysis (breakdown products of damaged muscle cells are released into the bloodstream) can lead to kidney problems


Physical Effects

of Ecstasy /

MDMAOthers:Decreased appetiteElevated temperature (users frequently drink/carry bottles of water)

Hepatotoxicity (liver)



of Ecstasy /

MDMA



of Ecstasy /

MDMACognitive:Memory problems for at least 2 weeks after useAltered time perception

Affect:EuphoriaIncreased anxietyDepressed moodAnhedonia



of Ecstasy /

MDMABehavior:

Increased energyDecreased aggressionDecreased defensiveness/disinhibitionLethargy

Perceptual:Changes in visual perceptions



of Ecstasy /

MDMAOther:

Increased ability to interact with othersDecreased desire/motivation to perform mental or physical tasks

Increased or decreased libidoIncreased awareness of emotions


Synthetic Cannabinoids


Overview of


Product line marketed as incense, herbal or aromatic incense or potpourri

“Not for human consumption” All ingredients don’t have to be listed

Not “intended” for smoking but most of the products are smoked in hand-held pipes, water pipes or rolled in cigarette paper

Synthetic cannabinoid is sprayed on the product.Manufacturers are substituting more potent

synthetic cannabinoid products every day


Synthetic Cannabinoids Crime Lab Cases in Florida: 2010-2014

2010 2011 2012 2013 20140

200

400

600

800

1000

1200

1400

1600

1800

2000

2200 AM-2201

XLR-11

AB-FUBINACA

PB-22

UR-144

AB-PINACA

Various JWH

All Other Cannabinoids

301

Nu

mb

er o

f C

rim

e L

ab R

epo

rts

Source: Analysis of US DEA - National Forensic Laboratory System Data

9

1,209

2,087 1,996



Physical Effects



Physical EffectsA number of users experience hangover-like

effects the morning after use including dry mouth, intense headaches

Depending on the product, inhaled smoke is as harsh as marijuana smoke:Taste can vary from a very bad to very sweet tasteOne user described the taste as “sickly sweet”

Ophthalmologic (eyes):Conjunctival injectionMydriasisPhotosensitivityDry eyes


Synthetic

Cannabinoids Physical

Effects

Neuro-muscular: Tremors Numbness A warm sensation in the limbs Muscle spasms Seizures Impaired coordination Headaches or painless head pressure Light headedness

Cardiovascular: Tachycardia Increased blood pressure



Physical Effects

Gastrointestinal: Nausea, vomitingIncreased appetite (“munchies”)Dry mouth



Physical Effects

Others:Insomnia Paleness of skinListlessness / Lack of interestSweating


Synthetic CannabinoidsPsychoactive

Effects Mood changes: Giddiness



Effects Mood changes: EuphoriaAnxietyPanic attacksIrritabilityDepressionGiddiness



Effects Cognitive changes: Impaired short term memory ConfusionCognitive dullingImpairment of linear thinkingTime distortion



Effects Behavioral changes:

SedationExcitabilityAgitationAggressionSleep ChangesDelirium



Effects Suicide: Multiple reports connecting SC use and suicide

can be found in the media and throughout the internet

Review of scientific literature discovered a handful of subjects in different studies and case reports describing suicide and suicidal behaviors with SC use

Relationship between SC use and suicide is unclear



Effects Psychosis:Hallucinations- auditory & visualDisorganized thinkingDisorganized behaviorDelusions (paranoid)AgitationAggressionCan be new onset or exacerbation of previously stable psychotic disorders

Psychotic symptoms may persist beyond acute intoxication



Effects Addiction/Dependence:Research on the addictive properties of SCs has produced varying results.

Case reports and users report symptoms of dependence such as cravings, continued use despite knowledge of physical or psychological harm, tolerance and withdrawal symptoms.

SCs have been shown to cause greater dopamine release than MDMA and may therefore have a greater abuse liability.

SO….. SCs can be addictive and continued, heavy usage could result in withdrawal/dependency symptoms


PsychosisNew onset Exacerbation of previously stable psychotic disorders

Extreme mood changesEffects persist beyond acute intoxicationTolerance, withdrawal & dependence may be

associated with long term use


Summaryof

Dangers of


Clinical Presentations


Acute Care

Presentation

Some clinical symptoms similar to cannabis intoxication:

Reddened eyes Mild sedation Euphoria Giddiness Paranoia Perceptual distortions Memory deficits Impaired short-term memory


Acute Care

Presentation

Physical symptoms not typically seen with cannabis intoxication:

Seizures Hypokalemia Palpitations Hypertension Respiratory difficulties Abdominal/flank pain Acute kidney injury Nausea/vomiting Coma


Acute Care

Presentation

Psychoactive symptoms not typically seen with cannabis intoxication:

Agitation Violent behavior Impulsivity Disorganized thoughts Auditory & visual hallucinations Delusions, typically paranoid


Office Presentation

Typically: User not intoxicated at the time of office visit User typically denies use More readily agrees to tox screen/testing SCs not first drug used; most typically have

used marijuana before Living situation involves being monitored for

use (eg, teens who have found to be using marijuana)


Bath Salts / Synthetic

Cathinones /Flakka


History of

Bath Salts

First synthesized in the 1920sIn 2009-2010: they became popular in the

underground market2010: started to be marketed as “ not for

human consumption”2011: New York was one of the first states to

ban the sale of Bath salts2012: President Obama signed a bill that

amended the Federal drug policy of the United States to ban “bath salts”


History of

Bath Salts

Khat, a leafy plant native to East Africa and the Arabian Peninsula, is chewed for its stimulatory effects, mild euphoric and appetite suppression.

Khat is a natural cathinone.

First generation synthetic bath salts were comprised mainly of the synthetic cathinones mephedrone and MDPV (3,4 methylenedioxypyrovalerone).

These drugs were sometimes called the “poor man’s cocaine.”


History of

Bath Salts

Bath salts or synthetic cathinones continue to evolve.

Newer bath salts have been comprised of methylone, ethylone and alpha-pvp (alpha-pyrrolidinopentiophenone).

In reality, we don’t know what is contained in these drugs.


http://www.designerdrugtrends.org/documents/trendsreport2015_3.pdfCastellanos Designer & Emerging Drugs of Abuse 2015

Ethylone Candy


Include some of the latest designer drugsUsed as synthetic stimulantsIllegal in at least 41 states and pending

legislation in the othersPoison Control Center has received over

4,000 calls last year


Bath Salts

"Flakka” is the latest of these drugs to hit the street.

Flakka is thought to be mainly comprised of alpha-PVP, a novel psychoactive substance that has been on the recreational drug market since 2012.

Former street names include “Gravel”, which was allegedly alpha-PVP mixed with lorazepam, and other bath salts.


Flakka

Flakka is sometimes called a “second generation” bath salt.

The chemical structures of these drugs are constantly changing.

We expect for a “newer” compound to replace flakka sometime in the future.


Flakka

Typically sold as powder or crystals Approx $3-$40 Routes of administration:

Snorting Oral Injection Smoking Use with electronic cigarettes increasing

Desired effects last for a few hours Adverse side effects can last from hours to

days


Flakka

Flakka Hospital Cases: Broward Health June 1 – July 15, 2015

Time Period

Total Cases

Cases per Day

June 1 - 30

346 11.53

July 1 - 15

179 11.93

0

50100150200250300350 314

135

6016

Flakka Casesn = 525 Flakka Cases

June 1 – July 15, 2015

Source: Broward Health Medical Centers



Male

428

Fe-male 97

Flakka Cases by Gender

Flakka Cases by Ethnicity

White NH 208Black NH 297

White Hisp 20Asian 3

Black Hisp 1American Indian 1



12-19 yrs

20-29 yrs

30-39 yrs

40-49 yrs

50-59 yrs

60-69 yrs

70-79 yrs

80-89 yrs

90 yrs

020406080

100120140160180

10

177 180

98

44

10 2 1 1

Flakka Cases by Age

Nu

mb

er o

f F

lakk

a C

ases

Mean Age = 33 yearsAverage Age = 35.4 years


Flakka DeathsBroward County, Florida

September, 2014 – June 15, 2015


Sep Oct Nov Dec Jan Feb Mar Apr May Jun2014 2015

0

1

2

3

4

5

6

7

1 1 1

6

12

3 3

6

1

Broward County Flakka Related Deaths By Month/Year (9/14 - 6/15)

# F

lakk

a-R

elat

ed D

eath

s


Physical Effects

of Flakka /

Bath Salts


Physical Effects

of Flakka /

Bath SaltsPoor judgment and insightCardiovascular:

Tachycardia Hypertension

Endocrine: Increased temperature- Users will

frequently remove some/all of clothing


Physical Effects

of Flakka /

Bath SaltsMuscular: Bruxism (teeth grinding) & jaw clenching Muscle breakdown: Rhabdomyolysis

(breakdown products of damaged muscle cells are released into the bloodstream) can lead to kidney problems

Muscle spasms Difficulty with muscle coordination

Kidney:Secondary to muscle breakdown

(Rhabdomyolysis)



of Flakka /

Bath Salts



of Flakka /

Bath Salts

Behavior: Agitation Increased body strength Aggression Impulsivity

Affect: Anger, irritability Labile affect Blunting or flattening Distress



of Flakka /

Bath Salts

Speech: Yelling Repetitive speech Illogical speech

Psychosis: Hallucinations Paranoia Delusions

“Excited delirium”


What did you

observe on

this video?

Muscle spasmDifficulty with muscle coordinationAgitationLabile, inappropriate affectYelling, speech difficultiesDistressImpulsivityLack of Judgment and Insight?Hallucinations?Paranoia?Delusions


What did you

observe on

this video?

Muscle spasmDifficulty with muscle coordinationAgitationGaze (“crazed look”)Inappropriate affectYelling, speech difficultiesDistressImpulsivityLack of Judgment and Insight?Hallucinations?Paranoia?Delusions


Treatment/Interventions


Acute Treatment-

Intoxication

When multiple substances used, unclear which signs, symptoms are a result of which substance

Time of use to time of evaluation in ED varies; some symptoms persist others improve by the time the person is attended to in the ED

Literature:Is limited to anecdotal reports, single case reports, case series

Frequently based on self/family report of use; still limited toxicological confirmation


Acute treatment is supportive:Fluids- Individuals seen in the ED usually require IV fluids

Lower body temperature (frequently also associated with agitation)

Address kidney functioning to prevent more serious kidney problems

Acute Treatment-

Intoxication


Acute treatment is supportive:Address agitation; aggression:

Lorazepam is frequently used IM/IV/PO for acute improvement

Address psychosis:Short term use of antipsychotic meds can be beneficial

Sometimes psychosis lingers or doesn’t remit

AcuteTreatment-

Intoxication


Little or no research examining best treatment practices after the acute intoxication

Treatment:Frequently needs to address use of multiple substances

Needs to be multimodal Interventions are guided by the class the synthetic drug belongs to (eg, stimulants, hallucinogens)

Should address co-occurring psychiatric conditions (such as, psychosis if has not remitted after the acute intoxication)

OngoingTreatment



Take Home Points

Become familiar with:Types of newer drugs being abused Clinical symptoms of presentation

Evidence based practices should guide your evaluation and management



Parting Thoughts

Designer drug use will not go away.New drugs will continue to emerge.

No matter how designer drugs evolve,

we need to be ready

designer & emerging drugs of abuse 2015 daniel castellanos, md medical director south florida...

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