new drugs of abuse: bath salts and synthetic cannabinoids
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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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
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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
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WHO AM I AND WHY AM I HERE?
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•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
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• Open 24 hours/day• Staffed by pharmacists & nurses
• Nationally certified Specialists in Poison Information
MPC: (continued)
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• Board certified Medical Director
• Board certified Director
• Masters in Public Health faculty
• Additional consultants available
MPC: Overview
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•Recognition and prevention of exposures through community education and outreach
•Professional education to optimize patient care
Other Functions
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•Data collection/reporting nationally
•Research to optimize patient care *
MPC: Overview
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•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?
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•Save Lives•Save Dollars
Bottom Line
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•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)
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•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:
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WHAT THE HECK ARE “BATH SALTS???
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The “Natural” Amphetamine• Cathinone; “Khat”
• Catha edulis• Native to Africa• Amphetamine like alkaloid• Chewed for the effects
Ann Pharmacother 2012;46:436-441.
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In the Market
http://www.whitehouse.gov/ondcp/ondcp-fact-sheets/synthetic-drugs-k2-spice-bath-salts. Accessed 7 Dec 2012.
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Former Fox TV Chair Beaten by Police
http://www.nj.com/business/index.ssf/2012/10/bath_salts_used_by_deutsche_ba.html
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Man Tries to Bite Police
http://www.huffingtonpost.com/2012/06/05/brandon-deleon-high-on-cloud-9_n_1570560.html
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Man Attacks Elderly Woman with a Shovel
http://www.huffingtonpost.com/2012/06/25/robert-william-white-la-bath-salts_n_1624688.html
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Woman Has Baby, Goes on Rampage
http://www.huffingtonpost.com/2012/07/06/carla-murphy-had-baby-smoked-bath-salts_n_1653979.html
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So… what is in “bath salts”?•Methylenedioxypyrovalerone (MDPV)•Mephedrone•Methylone•Methcathinone•Alpha-pyrillidonopropiophenone (α-PPP)
•Others
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Synthetic Cathinones
CathinoneBeta ketonated amphetamines
N-alkylated cathinones
Ring substituted methylenedioxy-phenethylamines
Clin Toxicol 2011;49:705-719.
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Structures and Similarities
Gerona RR, Wu AHB. Bath salts. Clin Lab Medicine 2012;32(3):415-27.
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Audience Question:What synthetic cathinone derivative carries a legal medical indication for use the U.S. and Europe?
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Answer: Bupropion
• Substituted cathinone• Indications:
• Depression• Smoking cessation
Cathinone
Clin Toxicol 2011;49:705-719.
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Bath Salts: Pharmacology•Structurally similar to amphetamines and hallucinogenic amphetamines (e.g., MDMA) as well as cathinones
•Functionally closer in effect to cocaine
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Clinical Effects•See typical stimulant effects•Hallucinogenic activity•Behavioral changes are common; may be persistent
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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.
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Management: Bath Salts Exposures•Airway, Breathing, Circulation•Charcoal: only for substantial, recent ingestions
•Calm environment•Benzodiazepines•Symptomatic care
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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.
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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
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Where to Buy?
http://legalhighs.net63.net/product.php?id_product=19
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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.
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Banned But Replaced
http://www.fridayflyer.com/2012/10/05/banned-bath-salts-replaced-with-new-products
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Replaced by…What???
http://www.ncbi.nlm.nih.gov/pubmed/22528592
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Synthetic Cannabinoids•What are they?•What are the effects on people?
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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
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Synthetic Cannabinoids: MPC
Year Total Cases
Deaths
2010 16 0
2011 150 0
2012 222 1*
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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.
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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.
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Synthetic Cannabinoids•Why use?
•avoid urine drug screen tests•Thought to be “safe” alternative to marijuana
•Avoid going to a drug dealer
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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
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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
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Synthetic Cannabinoids•Management:
Supportive care (ABC’s)
•NOTE: Symptoms may persist
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