Hey Dude! How Hey Dude! How Did I Get Here?Did I Get Here?

Melinda Lucas, M.S., M.D., Melinda Lucas, M.S., M.D., F.A.A.P.F.A.A.P.

SouthWest Virginia Pediatric SouthWest Virginia Pediatric Conference, August 4-5, 2012Conference, August 4-5, 2012

Disclosure Statement of Disclosure Statement of Financial InterestFinancial Interest

Melinda Lucas DOES NOT have a Melinda Lucas DOES NOT have a financial interest/arrangement or financial interest/arrangement or affiliation with one or more affiliation with one or more organizations that could be organizations that could be perceived as a real or apparent perceived as a real or apparent conflict of interest in the context of conflict of interest in the context of the subject of this presentation. the subject of this presentation.

Conflict of InteConflict of Interrest est DisclosureDisclosure

All individuals who participate in sponsored All individuals who participate in sponsored activities are expected to disclose any significant activities are expected to disclose any significant financial relationships that may pose a conflict financial relationships that may pose a conflict with the principles of balance and independence.with the principles of balance and independence.

In the past 12 months neither Melinda Lucas nor In the past 12 months neither Melinda Lucas nor any member of her family has had a financial or any member of her family has had a financial or beneficial relationship with one or more of the beneficial relationship with one or more of the following commercial entities: grant/research following commercial entities: grant/research support, other remuneration (Speaker’s Bureau, support, other remuneration (Speaker’s Bureau, honoraria, travel expenses, etc.), Major honoraria, travel expenses, etc.), Major Stock/share holder (not mutual funds), Advisory Stock/share holder (not mutual funds), Advisory Board; Ownership or PartnershipBoard; Ownership or Partnership. .

Learning ObjectivesLearning Objectives Develop a differential diagnosis for Develop a differential diagnosis for

patients with hallucinations and an patients with hallucinations and an altered state of consciousnessaltered state of consciousness

Understand the impact of social Understand the impact of social media on illicit drug usagemedia on illicit drug usage

Become familiar with the toxidromes Become familiar with the toxidromes for 2 designer drugs. for 2 designer drugs.

Alice In WonderlandAlice In Wonderland 11 Year Old Female11 Year Old Female Fever, cough, Coryza, & Myalgias for 3 Fever, cough, Coryza, & Myalgias for 3

daysdays Night-time Audio and Visual Night-time Audio and Visual

HallucinationsHallucinations Pictures Zoomed in and out which Pictures Zoomed in and out which

scared her scared her Alleged her parents were talking and Alleged her parents were talking and

moving in very, very slow motionmoving in very, very slow motion

Alice in WonderlandAlice in Wonderland Negative PMH; No MigrainesNegative PMH; No Migraines Family History negative for Migraines, Family History negative for Migraines, Tamiflu (oseltamivir phosphate) for 24 hoursTamiflu (oseltamivir phosphate) for 24 hours Vital Signs: Temp 36.8Vital Signs: Temp 36.8ooC, Heart Rate 107 C, Heart Rate 107

bpm, BP 92/68 mm Hg, Pulse Ox 98% Room bpm, BP 92/68 mm Hg, Pulse Ox 98% Room AirAir

Physical Exam: no meningeal irritation; Physical Exam: no meningeal irritation; Cranial Nerves 2-12 Normal, Cerebellar Cranial Nerves 2-12 Normal, Cerebellar Function Normal Motor and Sensory Function Normal Motor and Sensory Systems NormalSystems Normal

Alice in WonderlandAlice in Wonderland Labs:Labs:

CBC & diff NormalCBC & diff Normal CMP NormalCMP Normal EBV Serology NegativeEBV Serology Negative H1N1 PCR PositiveH1N1 PCR Positive

Clinical Course: Clinical Course: Flu symptoms resolved in 2 daysFlu symptoms resolved in 2 days Neurological symptoms resolved in 2 daysNeurological symptoms resolved in 2 days

Tamiflu stopped after 5 day course.Tamiflu stopped after 5 day course.

Alice in WonderlandAlice in Wonderland First Described by John Todd, an First Described by John Todd, an

English psychiatrist, in 1955English psychiatrist, in 1955 Disorienting Neurological ConditionDisorienting Neurological Condition Temporary ConditionTemporary Condition

Alice in WonderlandAlice in Wonderland Visual Distortions Visual Distortions

MicropsiaMicropsia MacropsiaMacropsia

Distorted Perception of other Distorted Perception of other Sensory modalitiesSensory modalities TimeTime TouchTouch SoundSound

Alice in WonderlandAlice in Wonderland Associated withAssociated with

MigrainesMigraines Brain TumorsBrain Tumors Psychoactive DrugsPsychoactive Drugs Initial Presentation of Epstein-Barr Initial Presentation of Epstein-Barr

VirusVirus InfluenzaInfluenza

Usually Influenza AUsually Influenza A Can be H1N1Can be H1N1

Alice in WonderlandAlice in Wonderland Take Home MessagesTake Home Messages

Medical Illnesses can present with Medical Illnesses can present with visual and auditory changes or visual and auditory changes or hallucinationshallucinations

Mental Health Problems can present Mental Health Problems can present with hallucinationswith hallucinations

Psychotropic Drugs can also cause Psychotropic Drugs can also cause hallucinations and/or visual & auditory hallucinations and/or visual & auditory changeschanges

The Spice GirlThe Spice Girl 17 year old girl 11 weeks gestation17 year old girl 11 weeks gestation Bipolar Disorder and Depression Bipolar Disorder and Depression

HistoryHistory Stayed at friend’s house until afternoonStayed at friend’s house until afternoon Slept 2-6 p.m. Slept 2-6 p.m. Awoke with Nausea, dizziness, thirst, Awoke with Nausea, dizziness, thirst,

heart racing, unable to void heart racing, unable to void Visual and Auditory HallucinationsVisual and Auditory Hallucinations Medications: Prenatal VitaminsMedications: Prenatal Vitamins

The Spice GirlThe Spice Girl PMH: PMH:

Cutting BehaviorsCutting Behaviors 2 Inpatient Psychiatric Admissions2 Inpatient Psychiatric Admissions Psychiatric Medications self-discontinuedPsychiatric Medications self-discontinued Last Psychiatric Visit > 1 year agoLast Psychiatric Visit > 1 year ago Prior user of Cocaine and CannabisPrior user of Cocaine and Cannabis SmokerSmoker Prenatal Care started 2 weeks ago Prenatal Care started 2 weeks ago

SH SH Broke up with boyfriend recently Broke up with boyfriend recently

(father of unborn child)(father of unborn child)

The Spice GirlThe Spice Girl PE:PE:

Denies suicidal & homicidal tendenciesDenies suicidal & homicidal tendencies Denies thoughts of wanting to hurt unborn childDenies thoughts of wanting to hurt unborn child Vital Signs: Temp 97Vital Signs: Temp 97ooF; HR 150; BP 115/51 mm F; HR 150; BP 115/51 mm

Hg; Pulse Oximeter 100% Room AirHg; Pulse Oximeter 100% Room Air Alert, Anxious, awakeAlert, Anxious, awake Warm, Dry Skin without flushingWarm, Dry Skin without flushing PERRLA, No nystagmus, Pupils 3 mmPERRLA, No nystagmus, Pupils 3 mm Dry MouthDry Mouth Normal ThyroidNormal Thyroid Tachycardia without MurmurTachycardia without Murmur Normal Neurological Exam except for visual and Normal Neurological Exam except for visual and

auditory hallucinationsauditory hallucinations

The Spice GirlThe Spice Girl Lab:Lab:

Normal Urine Drug Screen for Normal Urine Drug Screen for amphetamines, barbiturates, amphetamines, barbiturates, benzodiazepines, cocaine, opiates, benzodiazepines, cocaine, opiates, phencyclidine, cannabis using kinetic phencyclidine, cannabis using kinetic interactions of micro particles techniqueinteractions of micro particles technique

Negative blood tests for ethanol, Negative blood tests for ethanol, acetaminophen, salicylatesacetaminophen, salicylates

EKG with 130 beats per minute, QRS EKG with 130 beats per minute, QRS interval 86 milli seconds, QTc interval of interval 86 milli seconds, QTc interval of 380 milliseconds, no ischemia, 380 milliseconds, no ischemia, NOT SVTNOT SVT

The Spice GirlThe Spice Girl TreatmentTreatment

20 mL/kg Normal Saline IV20 mL/kg Normal Saline IV Ultrasound of Pelvis with single live Ultrasound of Pelvis with single live

intrauterine pregnancy at 12 weeks 2 daysintrauterine pregnancy at 12 weeks 2 days Admitted for ObservationAdmitted for Observation 2 Episodes of hypotension (70/30 mm Hg) 2 Episodes of hypotension (70/30 mm Hg)

treated with IV NS – 20 mL/kg eachtreated with IV NS – 20 mL/kg each Hallucinations Resolved over 2 daysHallucinations Resolved over 2 days

Confessed to ingestion of a powder from Confessed to ingestion of a powder from her mother’s spike rack to get high her mother’s spike rack to get high instructions on T.V. instructions on T.V.

The Spice GirlThe Spice Girl NutmegNutmeg

Abortifacient by American & English Abortifacient by American & English women in late 19women in late 19thth & early 20 & early 20thth century. century.

Euphoric and Hallucinogenic effects Euphoric and Hallucinogenic effects with low cost and ease of availabilitywith low cost and ease of availability

Spice obtained by grating the kernel Spice obtained by grating the kernel within the fruit of the nutmeg tree.within the fruit of the nutmeg tree.

Mace is made from the red-laced Mace is made from the red-laced membrane surrounding the seed.membrane surrounding the seed.

The Spice GirlThe Spice Girl Nutmeg comes from the evergreen tree, Nutmeg comes from the evergreen tree,

Myristica fragransMyristica fragrans, & is a mixture of , & is a mixture of compounds:compounds: Aromatic (myristicin, elemicin, and safrole)Aromatic (myristicin, elemicin, and safrole) Terpene (eugenol and mace)Terpene (eugenol and mace) Compositions vary with differences in Compositions vary with differences in

quality, storage, purifying and processingquality, storage, purifying and processing Elemicin chemically closely resembles Elemicin chemically closely resembles

mescalinemescaline Myristicin is closely related to 3-methoxy-4,5 Myristicin is closely related to 3-methoxy-4,5

methylenedioxyamphetamine.methylenedioxyamphetamine.

The Spice GirlThe Spice Girl Atropine-Like Syndrome or mistaken Atropine-Like Syndrome or mistaken

for pure antichoinergic toxicityfor pure antichoinergic toxicity Dry mouthDry mouth Facial flushingFacial flushing NauseaNausea Unsteadiness (dizzy)Unsteadiness (dizzy) Epigastric PainEpigastric Pain Urinary RetentionUrinary Retention Blurred VisionBlurred Vision

The Spice GirlThe Spice Girl Sympathomimetic and Serotonergic Sympathomimetic and Serotonergic

EffectsEffects Cardiovascular EffectsCardiovascular Effects

Sinus TachycardiaSinus Tachycardia PalpitationsPalpitations HypotensionHypotension

Central Nervous System EffectsCentral Nervous System Effects Hallucinations - 14% of usersHallucinations - 14% of users PsychosisPsychosis AnxietyAnxiety DrowsinessDrowsiness FearFear ParesthesiasParesthesias

The Spice GirlThe Spice Girl SymptomsSymptoms

Ingestions of >10 g of nutmegIngestions of >10 g of nutmeg 1-3 whole nuts or 1-2 TBSP ground nutmeg1-3 whole nuts or 1-2 TBSP ground nutmeg

Appear 3-6 hours after ingestionAppear 3-6 hours after ingestion Duration of 24-48 hoursDuration of 24-48 hours

TreatmentTreatment Supportive care for agitation, Supportive care for agitation,

hypotension, and psychiatric symptomshypotension, and psychiatric symptoms

Legal HighsLegal Highs Nutmeg Nutmeg (Myristica fragrans)(Myristica fragrans) Morning glory Morning glory (Ipomoea violecea): (Ipomoea violecea):

lysergic acid amide, a hallucinogenlysergic acid amide, a hallucinogen Kava kava Kava kava (Piper methysticum(Piper methysticum))

Kava lactones = sedation & hallucinations Kava lactones = sedation & hallucinations Kratom Kratom (Mitragyna speciosa)(Mitragyna speciosa)

mitragynine, a low dose stimulent & high dose narcoticmitragynine, a low dose stimulent & high dose narcotic Jimson Weed Jimson Weed (Datura stramonium)(Datura stramonium)

Belladonna alkaloids, atropine, scopolaine, hyoscyamine Belladonna alkaloids, atropine, scopolaine, hyoscyamine = delerium, hallucinations, anticholinergic syndrome= delerium, hallucinations, anticholinergic syndrome

Salvia divinoriumSalvia divinorium Salvinorin A: subtle high to vivid psychedelic Salvinorin A: subtle high to vivid psychedelic

experienceexperience

The Spice GirlThe Spice Girl Take Home MessageTake Home Message

Sources of information may be from unverified Sources of information may be from unverified sources such as T.V., sources such as T.V., online encyclopediasonline encyclopedias, , You Tube, online “trip reports”, tweets & You Tube, online “trip reports”, tweets & blogs, and “how-to” information on the Webblogs, and “how-to” information on the Web

Conventional intoxicants and “legal highs” are Conventional intoxicants and “legal highs” are a trend with adolescents.a trend with adolescents.

Reliable web sites:Reliable web sites: www.herbmed.org; ;

www.mskcc.org/aboutherbswww.mskcc.org/aboutherbs

Mountain Mike Mountain Mike 15 year old brought to ER by EMS 15 year old brought to ER by EMS

for violence, crazy behavior, and for violence, crazy behavior, and visual hallucinations.visual hallucinations.

15 minutes prior to calling EMS he 15 minutes prior to calling EMS he took a Single Bong Hit from a water took a Single Bong Hit from a water pipe.pipe.

Prior History of being high before, Prior History of being high before, but not like thisbut not like this

Mountain MikeMountain Mike Physical ExamPhysical Exam

Restless, anxiousRestless, anxious Oriented to person, place, timeOriented to person, place, time Complains legs feel numb and twitchy Complains legs feel numb and twitchy Vital Signs: HR 120 bpm; BP 135/85 mm Vital Signs: HR 120 bpm; BP 135/85 mm

Hg; afebrile; pulse oximeter 98% room airHg; afebrile; pulse oximeter 98% room air PERRLA, EOMs intact, Pupils slightly PERRLA, EOMs intact, Pupils slightly

dilateddilated Moist MembranesMoist Membranes Normal ThyroidNormal Thyroid

Mountain MikeMountain Mike PEPE

Chest exam normalChest exam normal CV exam no murmur or gallop; otherwise CV exam no murmur or gallop; otherwise

normalnormal Abdominal exam normalAbdominal exam normal Skin: sweaty, no flushing of skin, no rashSkin: sweaty, no flushing of skin, no rash Neurological: Normal cranial nerves, no Neurological: Normal cranial nerves, no

clonus, normal strength and sensation in clonus, normal strength and sensation in extremities; extremities; fasciculationsfasciculations in quadricep in quadricep muscles.muscles.

Mountain MikeMountain Mike LabLab

Glucose normal – not elevated or lowGlucose normal – not elevated or low CMP: CMP: Potassium 2.9 mEq/Potassium 2.9 mEq/L; normal L; normal

otherwiseotherwise Ethanol negativeEthanol negative Urine radioimmunoassay (RIA) for Urine radioimmunoassay (RIA) for

amphetamines, barbiturates, amphetamines, barbiturates, benzodiazepines, cocaine, opiates , and benzodiazepines, cocaine, opiates , and phencyclidine (PCP) is negative. phencyclidine (PCP) is negative. Positive Positive for Tetrahydrocannabiolfor Tetrahydrocannabiol

Mountain MikeMountain Mike TreatmentTreatment

Lorazepam 2 mg IVLorazepam 2 mg IV HR decreases to 95 bpmHR decreases to 95 bpm CalmerCalmer

Observation for 6 hoursObservation for 6 hours Confused as to how he got to hospitalConfused as to how he got to hospital

3 Friends taken to same hospital after 3 Friends taken to same hospital after trying a new marijuana for the first trying a new marijuana for the first timetime

Mountain MikeMountain Mike Acute Marijuana IntoxicationAcute Marijuana Intoxication

Increase Heart RateIncrease Heart Rate Increase Blood PressureIncrease Blood Pressure Euphoria and a Sense of DetachmentEuphoria and a Sense of Detachment Unpleasurable experience rare Unpleasurable experience rare

inconsistent with patient’s prior historyinconsistent with patient’s prior history Dysphoria with Large Doses and Dysphoria with Large Doses and

assosciated with panic, anxiety or assosciated with panic, anxiety or depression – Not agitationdepression – Not agitation

Agitation NOT TYPICALAgitation NOT TYPICAL Hypokalemia NOT TYPICAL unless Hypokalemia NOT TYPICAL unless

malnourished in a habitual drug usermalnourished in a habitual drug user

Mountain MikeMountain Mike New MarijuanaNew Marijuana

? Grown with advanced horticultural techniques which ? Grown with advanced horticultural techniques which have increased psychoactive potencyhave increased psychoactive potency

? Marijuana with addition of another psychoactive ? Marijuana with addition of another psychoactive substance such as substance such as

EcstasyEcstasy Clenbuterol : B-adrenergic agonistClenbuterol : B-adrenergic agonist PCP: cyrstal joint, supergrass, dipper, illy, fry, wetPCP: cyrstal joint, supergrass, dipper, illy, fry, wet Freebase or Powdered Cocaine: dusting, snowcappingFreebase or Powdered Cocaine: dusting, snowcapping

? Different botanical entity being smoked? Different botanical entity being smoked Salvia divinorumSalvia divinorum: legal marijuana, herbal smoke, herbal marijuana: legal marijuana, herbal smoke, herbal marijuana Mephedrone derived from khat plan (Mephedrone derived from khat plan (catha eduliscatha edulis))

? Chemical entity being smoked? Chemical entity being smoked Herbal incense, herbal smoke Herbal incense, herbal smoke PotpourriPotpourri IncenseIncense Mixture of 1 or more synthetic cannabinoids Mixture of 1 or more synthetic cannabinoids

Mountain MikeMountain Mike Synthetic CannabinoidsSynthetic Cannabinoids

Different chemical structure than 11-nor-9-Different chemical structure than 11-nor-9-carboxytetrahydrocannabinolcarboxytetrahydrocannabinol

Most common molecule tested in UDSMost common molecule tested in UDS Gas chromatography-mass spectrometry in Gas chromatography-mass spectrometry in

highly specialized laboratorieshighly specialized laboratories 4 Selected synthetic cannabinoids4 Selected synthetic cannabinoids

JWH-018 JWH-018 JWH-073JWH-073 CP-47,497CP-47,497 HU-210HU-210

Mountain MikeMountain Mike Synthetic CannabinoidsSynthetic Cannabinoids

Brand NamesBrand Names K 2 after second highest mountain on earthK 2 after second highest mountain on earth

(28,251 ft (28,251 ft Deadly to inexperienced climbersDeadly to inexperienced climbers

Spice after spice from Frank Herbert’s book Spice after spice from Frank Herbert’s book DuneDune JWH-018JWH-018

Sold over the Internet to a private residence Sold over the Internet to a private residence for research laboratory purposes only and for research laboratory purposes only and comes with a disclaimercomes with a disclaimer

Sold at certain “convenience” storesSold at certain “convenience” stores Sold at “head shops” or drug paraphenalia Sold at “head shops” or drug paraphenalia

shopsshops

Mountain MikeMountain Mike K-2 or Spice ToxidromeK-2 or Spice Toxidrome

HypokalemiaHypokalemia TremorsTremors AgitationAgitation HallucinationsHallucinations AnxietyAnxiety TachycardiaTachycardia Elevated Blood PressureElevated Blood Pressure PallorPallor VomitingVomiting

Mountain MikeMountain Mike Take Home MessageTake Home Message

Anticipatory GuidanceAnticipatory Guidance Manufacture not regulatedManufacture not regulated Full range of immediate adverse effects unknownFull range of immediate adverse effects unknown Long-term consequences of synthetic cannabinoids and Long-term consequences of synthetic cannabinoids and

the derivatives are unknownthe derivatives are unknown Tolerance and physiological withdrawal have been Tolerance and physiological withdrawal have been

reportedreported If the symptoms do not add up, suspect “incense”If the symptoms do not add up, suspect “incense” State-specific guidelines about possession existState-specific guidelines about possession exist FDA bans sale and importation FDA bans sale and importation

Aggressive AndyAggressive Andy 14 year old with ADHD brought to ED 14 year old with ADHD brought to ED

for a mental status exam by policefor a mental status exam by police Police called to residence by mother Police called to residence by mother

because patient threatening to kill her because patient threatening to kill her and destroying walls and furnitureand destroying walls and furniture

Mother states patient was in bedroom Mother states patient was in bedroom and emerged with intermittent and emerged with intermittent confusion and aggressionconfusion and aggression

May have been hallucinating for May have been hallucinating for several days, and seems to be hiding several days, and seems to be hiding from someone, but no one aroundfrom someone, but no one around

Aggressive AndyAggressive Andy Patient uncomfortable and Patient uncomfortable and

complains of chest pain and his complains of chest pain and his heart racingheart racing

Intermittent racing of heart for Intermittent racing of heart for several daysseveral days

Thoughts race through his brainThoughts race through his brain Panicking as thoughts racePanicking as thoughts race Very hungry but cannot eat Very hungry but cannot eat

Aggressive AndyAggressive Andy No medicationsNo medications

Self-stopped medications for ADHD years ago Self-stopped medications for ADHD years ago because they were costlybecause they were costly

SH denies substance abuse initially but SH denies substance abuse initially but later admits to alcohol (three 12 packs each later admits to alcohol (three 12 packs each weekend), cigarettes (1 ppd), K-2 or Spice weekend), cigarettes (1 ppd), K-2 or Spice if horticultural marijuana not available (2-4 if horticultural marijuana not available (2-4 joints 2 times a day), mother’s Xanax, tried joints 2 times a day), mother’s Xanax, tried meth and cocaine recentlymeth and cocaine recently

Admits to taking mother’s Xanax tonight Admits to taking mother’s Xanax tonight and also the “white powder” she uses when and also the “white powder” she uses when upset and needs to laughupset and needs to laugh

Aggressive AndyAggressive Andy Physical ExamPhysical Exam

HR 250HR 250 BP 161/110 mm HgBP 161/110 mm Hg Temp 37.6Temp 37.6ooCC RR 22-30/minuteRR 22-30/minute Restless - hands & feet in constant motion Restless - hands & feet in constant motion No eye ContactNo eye Contact Very short attention spanVery short attention span Exasperated with all questionsExasperated with all questions

Aggressive AndyAggressive Andy PEPE

Dilated, reactive pupils without nystagmusDilated, reactive pupils without nystagmus Normal nares, nasal septum, oral pharynxNormal nares, nasal septum, oral pharynx No goiterNo goiter Chest clearChest clear CV with tachycardia, but normal pulses CV with tachycardia, but normal pulses

and perfusion and warm pink extremitiesand perfusion and warm pink extremities No liver or spleen enlargement No liver or spleen enlargement Sweaty skinSweaty skin

Aggressive AndyAggressive Andy PEPE

Cranial Nerves 2-12 intact, Motor Cranial Nerves 2-12 intact, Motor strength and tone normal, normal DTR, strength and tone normal, normal DTR, alert and able to answer questions but alert and able to answer questions but concerned about chest pain, concerned about chest pain,

Tremor in outstretched handsTremor in outstretched hands

Aggressive AndyAggressive Andy LabLab

CMP normalCMP normal Glucose NormalGlucose Normal Ethanol Not detectedEthanol Not detected Commercial radioimmunoassay of urine for Commercial radioimmunoassay of urine for

amphetamines, benzodiazepines, amphetamines, benzodiazepines, barbiturates, cannabis, cocaine, opoids was barbiturates, cannabis, cocaine, opoids was negativenegative

CXR NormalCXR Normal CT head NormalCT head Normal

EKG: SVTEKG: SVT

Aggressive AndyAggressive Andy TreatmentTreatment

IVF with 20 mL/kg Normal saline bolusIVF with 20 mL/kg Normal saline bolus Adenosine X 2 with HR converting for Adenosine X 2 with HR converting for

20 seconds 20 seconds Response to Cardizem (diltiazem) with Response to Cardizem (diltiazem) with

HR 220.HR 220.

Aggressive AndyAggressive Andy Impression:Impression:

Compensated SVTCompensated SVT Hypertension unusual for SVTHypertension unusual for SVT Agitation and Aggression Worrisome for Agitation and Aggression Worrisome for

Safety of Health Care Providers, safety of Safety of Health Care Providers, safety of patientpatient

Overdose/Ingestion of ? Bath Salts or K-2Overdose/Ingestion of ? Bath Salts or K-2 Binge Drinking and habitual substance Binge Drinking and habitual substance

abuseabuse ADHDADHD

Aggressive AndyAggressive Andy Transfer to PICU requested - utilizing HelicopterTransfer to PICU requested - utilizing Helicopter Patient refused stretcher and restraints and became Patient refused stretcher and restraints and became

aggressive and threateningaggressive and threatening Helicopter Pilot refuses to fly uncooperative patientHelicopter Pilot refuses to fly uncooperative patient Ativan 4 mg IV given X 2 and patient settlesAtivan 4 mg IV given X 2 and patient settles Ground transport with EMS and helicopter crew Ground transport with EMS and helicopter crew

transports patient to PICUtransports patient to PICU Patient restrained and cooperative in SVT with talk Patient restrained and cooperative in SVT with talk

downdown 2-4 hours later patient converts from “stable SVT” to 2-4 hours later patient converts from “stable SVT” to

NSR after maximum dose of cardizem bolus and drip NSR after maximum dose of cardizem bolus and drip used.used.

Admits to snorting some saltAdmits to snorting some salt Leaves AMA 2 days later with Mother and GF’s Leaves AMA 2 days later with Mother and GF’s

assistanceassistance

Aggressive AndyAggressive Andy Diagnosis of ExclusionDiagnosis of Exclusion

Urine Toxicology for PCP, Cocaine, AmphetaminesUrine Toxicology for PCP, Cocaine, Amphetamines Serum Alcohol LevelSerum Alcohol Level BMP for Electrolyte ImbalancesBMP for Electrolyte Imbalances Bedside GlucoseBedside Glucose ABG as metabolic acidosis seen with ABG as metabolic acidosis seen with

sympathomimetic toxicologysympathomimetic toxicology CBC & Diff for infection or severe anemiaCBC & Diff for infection or severe anemia CT head for subarachnoid hemorrhage or CT head for subarachnoid hemorrhage or

hydrocephalushydrocephalus 12 – Lead EKG for arythmia or ischemia12 – Lead EKG for arythmia or ischemia Consider Troponin, CPK-MB, MyoglobinConsider Troponin, CPK-MB, Myoglobin

Aggressive AndyAggressive Andy Definitive DiagnosisDefinitive Diagnosis

Specific high performance liquid Specific high performance liquid chromatography/tandem mass chromatography/tandem mass spectroscopy of the urine for MDPV and spectroscopy of the urine for MDPV and MephedroneMephedrone

Aggressive AndyAggressive Andy Other ComplicationsOther Complications

Cardiac (up to 2 weeks later)Cardiac (up to 2 weeks later) TachycardiaTachycardia Hypertension Hypertension

HyperthermiaHyperthermia Renal: Renal:

RhabdomyolysisRhabdomyolysis RespiratoryRespiratory

Aspiration PneumoniaAspiration Pneumonia Delerium Delerium

Aggressive AndyAggressive Andy Other Complications:Other Complications:

Neurological: Neurological: SeizuresSeizures Intracerebral HemorrhageIntracerebral Hemorrhage

MyopathyMyopathy Critical Illness Myopathy/PolyneuropathyCritical Illness Myopathy/Polyneuropathy GI: intestinal GI: intestinal infarction/ischemiainfarction/ischemia

Other polydrug usage complications/contaminants Manganism from potassium permanganate

exposure

Aggressive AndyAggressive Andy Contaminants/Contaminants/

Levamisole: Levamisole: agranulocytosis/thrombotic eventsagranulocytosis/thrombotic events

Hallucinations Hallucinations Prolonged AnxietyProlonged Anxiety SeizuresSeizures Panic AttacksPanic Attacks Deaths Deaths

Aggressive AndyAggressive Andy Bath SaltsBath Salts

Not Epsom salts or spa-type bath saltsNot Epsom salts or spa-type bath salts Drugs of abuse marketed with an innocent Drugs of abuse marketed with an innocent

namename Bypass current U.S. drug laws Bypass current U.S. drug laws

Known as White Rush Bath SaltsKnown as White Rush Bath Salts Sold as “plant food”Sold as “plant food” Sold as “insect repellant”Sold as “insect repellant” Sold over the internetSold over the internet Sold at small convenience gas station marketsSold at small convenience gas station markets Sold at selective stores like “head shops”Sold at selective stores like “head shops”

Aggressive AndyAggressive Andy Other Names for the bath saltsOther Names for the bath salts

BlissBliss Blue SilkBlue Silk Down2Earth White HorseDown2Earth White Horse Energizing AromatherapyEnergizing Aromatherapy Ivory WaveIvory Wave KamikazeKamikaze Purple WavePurple Wave Red DoveRed Dove Vanilla SkyVanilla Sky White LightningWhite Lightning

Aggressive AndyAggressive Andy Bath SaltsBath Salts

White, tan, or brown powderWhite, tan, or brown powder Usually “clumpy”Usually “clumpy” Encapsulated or crystalEncapsulated or crystal Packages of 50-200 mg or large vials of Packages of 50-200 mg or large vials of

500 mg of “cathinone”500 mg of “cathinone” Pharmacological Effect depends on purity, Pharmacological Effect depends on purity,

concentration, and filler propertiesconcentration, and filler properties POPO, Rectal insertion, , Rectal insertion, SnortedSnorted

(insufflated), Injected or Smoked (insufflated), Injected or Smoked Onset of action, Peak, and Duration Onset of action, Peak, and Duration

depends on route of administrationdepends on route of administration

Aggressive AndyAggressive Andy Sympathomimetic ToxidromeSympathomimetic Toxidrome

InsomniaInsomnia AgitationAgitation Tachycardia/ SVTTachycardia/ SVT HypertensionHypertension MydriasisMydriasis DiaphoresisDiaphoresis TremorTremor

Aggressive AndyAggressive Andy Other Substances Causing Other Substances Causing

Sympathomimetic ToxidromesSympathomimetic Toxidromes AmphetamineAmphetamine MethamphetamineMethamphetamine CocaineCocaine Prescription Drugs for ADHDPrescription Drugs for ADHD

Aggressive AndyAggressive Andy DEA DEA

Schedule 1Schedule 1 Ecstasy (MDMA)Ecstasy (MDMA) Mushrooms (psilocybin)Mushrooms (psilocybin) LSDLSD Mescaline (peyote active ingredient)Mescaline (peyote active ingredient)

October 2011October 2011 Illegal to possess or sell the chemicals in bath Illegal to possess or sell the chemicals in bath

salts or products containing them in the U.S. salts or products containing them in the U.S. for 1 yearfor 1 year

Studies to be done to weigh whether they Studies to be done to weigh whether they should be permanently bannedshould be permanently banned

Aggressive AndyAggressive Andy Federal Analog Act: Any chemical Federal Analog Act: Any chemical

“substantially similar” to a Schedule I “substantially similar” to a Schedule I (heroin and lysergic acid diethylamide (LSD) (heroin and lysergic acid diethylamide (LSD) ) or Schedule II (methadone and injectable ) or Schedule II (methadone and injectable methamphetamine) to be treated as if it is methamphetamine) to be treated as if it is also a controlled substance, with the caveat also a controlled substance, with the caveat that the chemical has to be intended for that the chemical has to be intended for human consumption.human consumption.

Marketed with the label “NOT FOR HUMAN Marketed with the label “NOT FOR HUMAN CONSUMPTION”CONSUMPTION”

Aggressive AndyAggressive Andy Bath SaltsBath Salts

Stimulant derivatives of Schedule I chemical Stimulant derivatives of Schedule I chemical cathinone (bata-ketoamphetamine) from the cathinone (bata-ketoamphetamine) from the Khat shrub, Khat shrub, Catha edulis Catha edulis

Mephedrone = 4-methylmethcathinone: popularMephedrone = 4-methylmethcathinone: popular Structurally like cocaine, amphetamine, & MDMA (ectasy)Structurally like cocaine, amphetamine, & MDMA (ectasy)

MDPV = 3,4-methylenedioxypyrovalerone: potentMDPV = 3,4-methylenedioxypyrovalerone: potent Inhibit reuptake of norepinephrine and Inhibit reuptake of norepinephrine and

dopaminedopamine Promote release of dopamine, noradrenalin, & Promote release of dopamine, noradrenalin, &

serotoninserotonin

Aggressive AndyAggressive Andy Six ChemicalsSix Chemicals

MDPV MDPV 3,4-methylenedioxypyrovalerone3,4-methylenedioxypyrovalerone

Mephedrone, 4-MMCMephedrone, 4-MMC 4-methylmethcathinone4-methylmethcathinone

Methylone, MDMCMethylone, MDMC 3,4-methylenedioxymethcathinone3,4-methylenedioxymethcathinone

Flephedrone, 4-FMCFlephedrone, 4-FMC 4-fluoromethcathinone4-fluoromethcathinone

3-FMC3-FMC 3-fluoromethcathinone3-fluoromethcathinone

Methedrone, BK-PMMA, PMMCMethedrone, BK-PMMA, PMMC 4-methoxymethcathinone4-methoxymethcathinone

Aggressive AndyAggressive Andy European Club Scene in 2010European Club Scene in 2010

40% of 2,000 clubbers had used bath salts40% of 2,000 clubbers had used bath salts 30% of 2,000 clubbers used them in past month30% of 2,000 clubbers used them in past month Use of ecstasy declinedUse of ecstasy declined

MDMA unavailableMDMA unavailable Instability of ecstasy marketInstability of ecstasy market

Internet English – Language sites selling bath Internet English – Language sites selling bath saltssalts

30 in 12/200930 in 12/2009 70 in 3/201070 in 3/2010

Poison Control Centers in U.S. Poison Control Centers in U.S. 2009: No calls2009: No calls 2010: 303 Calls2010: 303 Calls July 31, 2011: 4,100 callsJuly 31, 2011: 4,100 calls

Aggressive AndyAggressive Andy Recreational Users reportRecreational Users report

EuphoriaEuphoria EmpathyEmpathy Increased AlertnessIncreased Alertness Improved Concentration and ability to focusImproved Concentration and ability to focus Higher energy levelsHigher energy levels Sense of well-being (decreased hostility?)Sense of well-being (decreased hostility?) No hangover, or comedown or depression No hangover, or comedown or depression

like amphetamines, cocaine, and ecstasylike amphetamines, cocaine, and ecstasy

Aggressive AndyAggressive Andy Health Care Providers Report Health Care Providers Report

Severe ParanoiaSevere Paranoia Severe AnxietySevere Anxiety Severe psychosisSevere psychosis Severe AgitationSevere Agitation Bizarre BehaviorBizarre Behavior TremorsTremors DelusionsDelusions Persecutory HallucinationsPersecutory Hallucinations Signs and Symptoms last for several DAYS Signs and Symptoms last for several DAYS

Aggressive AndyAggressive Andy Health Care Providers Report Health Care Providers Report

PalpitationsPalpitations Shortness of BreathShortness of Breath DiaphoresisDiaphoresis Hot FlashesHot Flashes HeadachesHeadaches HyperthermiaHyperthermia Overwhelming ThirstOverwhelming Thirst PolydipsiaPolydipsia Jaw pain from bruxism (ecstasy & amphetamines)Jaw pain from bruxism (ecstasy & amphetamines) Signs & Symptoms like Amphetamine & Cocaine Signs & Symptoms like Amphetamine & Cocaine

Intoxication – sympathetic nervous system Intoxication – sympathetic nervous system stimulationstimulation

Aggressive AndyAggressive Andy Health Care Providers Notice InitiallyHealth Care Providers Notice Initially

CombativeCombative Self-DestructiveSelf-Destructive SuicidalSuicidal HomicidalHomicidal Violent Behavior without WarningViolent Behavior without Warning

Health Care Providers Notice FinallyHealth Care Providers Notice Finally Suicidal Thoughts & ActionsSuicidal Thoughts & Actions Extreme SadnessExtreme Sadness DepressionDepression

Aggressive AndyAggressive Andy Greatest Risk for Adverse Psychiatric Greatest Risk for Adverse Psychiatric

ReactionsReactions Underlying Neurological ConditionsUnderlying Neurological Conditions Underlying Psychiatric ConditionsUnderlying Psychiatric Conditions

Greatest Risk for Healthcare-directed Greatest Risk for Healthcare-directed ViolenceViolence MaleMale History of Violent Behavior, Psychiatric History of Violent Behavior, Psychiatric

Illness, and/or drug or alcohol abuseIllness, and/or drug or alcohol abuse

Aggressive AndyAggressive Andy Warning Signs for Patients at High Warning Signs for Patients at High

Risk for Acting OutRisk for Acting Out Speaking increasingly LoudlySpeaking increasingly Loudly Abusive LanguageAbusive Language Clenched FistsClenched Fists Avoidance of eye contactAvoidance of eye contact Tense PosturingTense Posturing Pacing Pacing

Aggressive AndyAggressive Andy Successful ManagementSuccessful Management

Verbal Deescalating Techniques may Verbal Deescalating Techniques may not be successful if patient psychoticnot be successful if patient psychotic

Sedation and nonrestrictive methods of Sedation and nonrestrictive methods of restraint should be tried firstrestraint should be tried first

Physical restraints probably needed Physical restraints probably needed POLICE USE TAZERS!!POLICE USE TAZERS!!

Aggressive AndyAggressive Andy ManagementManagement

Sedatives in large doses & intubate to maintain airwaySedatives in large doses & intubate to maintain airway Diazepam = ValiumDiazepam = Valium Lorazepam = AtivanLorazepam = Ativan

Antipsychotic Medications Antipsychotic Medications Haloperidol = HaldolHaloperidol = Haldol Ziprasidone = GeodonZiprasidone = Geodon

Monitor temperatureMonitor temperature Fatal Hyperthermia (Mephedrone)Fatal Hyperthermia (Mephedrone) Serotonin Syndrome-Induced Hyperthermia Serotonin Syndrome-Induced Hyperthermia

RhabdomyolysisRhabdomyolysis RenalFailureRenalFailure Metabolic AcidosisMetabolic Acidosis DDIC – disseminated intravascular coagulationDDIC – disseminated intravascular coagulation ComaComa DeathDeath

Aggressive AndyAggressive Andy Management: Management:

Protect CaregiversProtect Caregivers 50% ED staff become victims of patient violence50% ED staff become victims of patient violence 5% violent patient possess a concealed weapon5% violent patient possess a concealed weapon

Emergency Psychiatric Evaluation As Soon Emergency Psychiatric Evaluation As Soon As PossibleAs Possible

Body & Possession Search to remove Body & Possession Search to remove objects of potential harmobjects of potential harm

Notify SecurityNotify Security Keep Exit to room available for providersKeep Exit to room available for providers

““safety sitter” safety sitter”

Aggressive AndyAggressive Andy TreatmentTreatment

Anticipatory GuidanceAnticipatory Guidance Unclear as to effects of metabolitesUnclear as to effects of metabolites Unclear as to chemicals included in “bath salts”Unclear as to chemicals included in “bath salts” No quality-control scrutinyNo quality-control scrutiny Variable Potency leading to unintentional overdoseVariable Potency leading to unintentional overdose Long-term consequences on brain function unknown Long-term consequences on brain function unknown

Psychiatric ReferralPsychiatric Referral Consider Alcohol and Drug Withdrawal Consider Alcohol and Drug Withdrawal

ProgramProgram Law Enforcement: Charges for possession or Law Enforcement: Charges for possession or

for assault for assault

Aggressive AndyAggressive Andy Increasing ConcernsIncreasing Concerns

ParentsParents FlashbacksFlashbacks AddictionAddiction

Healthcare WorkersHealthcare Workers Personal SafetyPersonal Safety

Government OfficialsGovernment Officials Legal SystemLegal System

Schedule I Schedule I Criminal ActivityCriminal Activity

Aggressive AndyAggressive Andy Take Home MessageTake Home Message

Designer Drugs are distributed in different Designer Drugs are distributed in different waysways

The Internet makes the distribution of The Internet makes the distribution of designer drugs spread more rapidly.designer drugs spread more rapidly.

The web makes alterations in drugs “easy” The web makes alterations in drugs “easy” and readily available for the “chemist”and readily available for the “chemist”

Bath Salts are not benign but are readily Bath Salts are not benign but are readily available and can be deadlyavailable and can be deadly

Web Site: www.erowid.orgWeb Site: www.erowid.org

Thank youThank you

Any Questions?Any Questions?

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A, et al. Low cost, high risk: accidental A, et al. Low cost, high risk: accidental nutmeg intoxication. nutmeg intoxication. Emerg Med J. Emerg Med J. 2005; ;22:223-225.2005; ;22:223-225.

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