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Clinical Experience of Novel Psychoactive Substances
Dr Richard Stevenson
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BackgroundLegal Highs -> Novel Psychoactive
Substances41 new substances in 2010 aloneDiverse collection of compounds
PiperazinesCathinonesSynthetic cannabinoidsIsolated compounds
Recreational problem identified in 2008/2009Varying legal status
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GRI Emergency Dept Experience12 AMT22 synthetic cannabinoids3 cathinone2 methoxetamine1 salvia
9 life threatening toxicities
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Why are people taking them?Legal statusPerception of safetyDifficult to detect
Point of care urine testingOdourless
AvailabilityInternet“Head shops”
Sold as other drugs
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AMT
5-IT
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Common ProblemsLack of reliable data“Not what is says on the tin”DosageInter-individual variabilityTime of onset to effectPolysubstance misuseInteractions ?
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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
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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
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PiperazinesDeveloped in 1950s – anti-helminthic agentsBZP “Benzo Fury”
Neurotransmitter release/reuptake inhibitionPhenylpiperazines
Direct serotonin receptor activationReversal of serotonin uptake
ClinicallySympathetic toxidromeSerotonin toxicity?
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Synthetic CannabinoidsAnnihilation, Black Mamba, Spice, K2Structurally dissimilar to THCHerbal material sprayed with chemicalsClinical effects
Nausea +++CollapseSome psychotropic effects
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MethoextamineStructurally similar to ketamineNMDA receptor agonistClinically (dose related)
Excitation, tachycardia, euphoriaHallucinationsDissociationProlonged neurological effects - ataxia
Supportive management
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AMT/5-ITAMT – Alphamethyltryptamine5-IT – 5-aminopropylindoleAMT researched as antidepressant in 1960’sNon-specific MAOI
Hallucinations +++Psychomotor agitation +++Serotonin toxicity
High risk of toxicity
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Serotonin ToxicityExposure to a
serotonergic drugClinical features
ConfusionAutonomic
instabilityHyperkinetic
musculoskeletal system
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Treatment of Serotonin ToxcityMorbidity & Mortality related to
hyperthermiaTemp ≥40 oCDuration
ConsequencesRhabdomyolysisAcute kidney injuryAcidosisCerebral damage
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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
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The Future?Market flooded with NPSDifficult to legislate/controlLong term effects?