Screens and tests for NPS

Dr Paul SmithConsultant Clinical Scientist and Forensic Toxicologist

paul.r.smith@uhl-tr.nhs.uk

Screens and tests for NPS

Where we are now

Scope for the future

Potential for treatment / antidotes

Opportunities in LLR

‘£10 legal high made me parade naked through Tesco’

NPS Many different terms

- legal highs, designer drugs,

research chemicals

Stimulant pills / powders Herbal smoking mixes Cheap Readily available Increasing prevalence Perception that legal = safe Many now illegal Cases of acute toxicity and death

EMCDDA Report 2015

Drug seizures

Immunoassay and GC-MS

• Uses commercial libraries of drugs and metabolites

• ~1000 drugs and metabolites• Custom the library

Drug screen by LC-MS/MS

NOT able to detect synthetic cannabinoids

  DRUG

1 4-MEC2 6-MAM3 Amphetamine4 Benzoylecgonine5 Buprenorphine6 Cocaethylene7 Cocaine8 Codeine9 Diazepam10 Dihydrocodeine11 EDDP12 Gabapentin13 MDA14 MDEA15 MDMA16 Mephedrone (MCAT)17 Methadone18 Methamphetamine19 Methylecgonine20 Midazolam21 Morphine22 Nitrazepam23 Norbuprenorphine24 Nordiazepam25 Oxazepam26 Oxycodone27 Oxymorphone28 Pholcodine29 Pregabalin30 Temazepam31 THC-COOH32 Zopiclone

NPS screen by LC-MS/MS (post-mortem)• 4-Fluoroamphetamine• Paramethoxyamphetamine (PMA)• Paramethoxymethamphetamine (PMMA)• 4-Methylthioamphetamine (4-MTA)• Methiopropamine• Cathinone• Cathine• Methcathinone• Flephedrone (4-fluoromethcathinone) • Mephedrone (4-methylmethcathinone)• 4-MEC (4-methylethcathinone)• Methedrone (4-methoxymethcathinone)• Benzedrone• Methylone (beta-keto MDA)• Ethylone (beta-keto MDMA)• Butylone• Clephedrone (4-chloromethcathinone)• Benzylpiperazine (BZP)• Trifluoromethylphenylpiperazine (TFMPP)• 3-Chlorophenylpiperazine (MCPP)• 2-Aminoindane• Methylenedioxyaminoindane (MDAI)• 5-Aminopropylindane (5API)• Alpha-methyltryptamine (AMT)• 5-Iodoaminoindane (5IAI)• Methylenedioxypyrovalerone (MDPV)

• 5-APB / 6-APB

• Naphyrone

• Propylhexedrine

• Methoxetamine

• MBDB

• DOM

• DOET

• DOB

• Diclofensine

• Dimethocaine

• Desoxypipradol

• Ethylphenidate

• Etizolam

• Phenazepam

NOT able to detect synthetic cannabinoids

Herbal products containing synthetic cannabinoids

Black Mamba-type products are usually sold as herbal prep- arations containing inert herbal material (leaf etc.) saturated with synthetic cann- abinoids (SCs). The pure SC powder can also be bought online.

1st generation synthetic cannabinoids

John W. Huffman, Ph.D, Over 400 JWH compounds

“I always had a hunch that someday somebody would say: ‘Hey, let’s try smoking them.’ And lo and behold, that’s what happened.”

2nd generation synthetic cannabinoids

3rd generation synthetic cannabinoids

High resolution mass spectrometry

Expensive equipment Specialist analysis Targeted and non-

targeted screens High resolution as

opposed to nominal mass (e.g. 271.5684 not 271)

Full scan mode Capable of retrospective

compound searching

Clinical cases

Case HistorySynthetic cannabinoid detected Other drugs detected

       

1 Extreme agitation in a psychiatric patient

5F-PB-22 None

2Prisoner found collapsed and fitting. History of black mamba use.

5F-AKB-48, 5F-PB-22, MDMB-CHMICA

Mirtazapine, propofol, lignocaine, atracurium

Post mortem cases

Case HistorySynthetic cannabinoid detected Other drugs detected

       

1 Mixed drug intake 5F-AKB-48Diazepam, heroin, cocaine, mirtazapine, propranolol, phenytoin, olanzapine

2 Collapse 5F-AKB-48, 5F-PB-22 None

3 Agitation 5F-AKB-48, 5F-PB-23 Amphetamine, cocaine

4 Agitation 5F-AKB-48, MDMB-CHMICAHeroin, buprenorphine, promethazine, procyclidine, diazpeam, gabapentin, lorazepam

5 Heroin and mixed drugs 5F-AKB-48, 5F-PB-22 Cocaine, heroin, amphetamine,

6 Hanging 5F-AKB-48, 5F-PB-23 Ethanol

7 Death in custody 5F-AKB-48, MDMB-CHMICA Diazepam, mirtazapine, amitriptyline, heroin, cocaine, thc

8 Dead on sofa5F-AKB-48, MDMB-CHMICA, THJ2201 Morphine, lorazepam, 2 aminoindane

9 Drowning AKB-48 THC, promethazine

10 Assault 5F-AKB-48, 5F-PB-22 THC, papracetamol

11 Unknown JWH-018 MDPV, ethanol

12 Prison death MDMB-CHMICA Dihydrocodeine

13 Prison death MDMB-CHMICA Mirtazapine, alfentanil, prochlorperazine, lignocaine, atracurium,

14 Unknown MDMB-CHMICA Ibuprofen

Signs and symptoms CNS: agitation, tremor, anxiety, confusion, somnolence, syncope,

hallucinations, changes in perception, acute psychosis, nystagmus, convulsions and coma.

Cardiac: tachycardia, hypertension, chest pain, palpitations, ECG changes.

Renal: acute kidney injury.

Muscular: hypertonia, myoclonus, muscle jerking and myalgia.

Other: cold extremities, dry mouth, dyspnoea, mydriasis, vomiting and hypokalaemia.

Long term effect: no documented evidence

Treatment

Supportive – NO ANTIDOTE Observe patient ECG U&Es, creatinine and CK Agitation and delirium - diazepam, haloperidol Convulsions - diazepam

Rapid drug test kit

NPT devices do exist but are limited to specific compounds JWH-018 JWH-073

Opportunities in LLR

Funding required for equipment to increase understanding and recognition of NPS including synthetic cannabinoids

Epidemiology studies

Patient monitoring

Potential to assist treatment decisions

K2/Spice