Designer DrugsAn Awareness Presentation

Kristine Nutt, LCSW, LCAS, CSI

DisclaimerThis presentation is meant to provide basic awareness

information on herbal incense products and bath salts.There are hundreds of products being smoked for

cannabis-like effectsManufacturers constantly change product ingredients

and market products under new names to circumvent the law.

Constantly moving targetProduct names and lists, as well as the list of

synthetic cannabinoids, in this presentation are not all inclusive.

“SMILES”

“SMILES”

• 2C-1 Hallucinogen synthetic drug• Part of the 2C family of drugs • Powder or Pill form• Often mixed with chocolate and candy• Schedule 1 class of drug • According to LAPD, there has been an increase of overdose

deaths from this drug recently. Popular with teens and college students.

• Formulas were published in book “PiHKAL: A chemical Love Story” (Transform Press, 1991)

“Smiles” • Dessa Bergen-Cisco, a Professor of Public

Health at Syracuse University stated, “Basically, it’s a pure and potent form of ecstasy or MDMA”.

• Effects are compared to a potent combination of MDMA and LSD with terrifying hallucinations and overwhelming anxiety.

• Overdoses have been reported in California, Ohio, and other states.

“Smiles”

smiles drug johnny lewis you tube - Bing Videos.url

“SMILES”

• Recently in the news due to Johnny Lewis, 28, who was known for his role in the television show, “Sons of Anarchy” killed 81 year old landlady and her cat before jumping to his death. No evidence of drugs were found in his system.

• One 17 year old in North Dakota overdosed and was observed shaking, growling, and foaming at the mouth. Another teen died the night before from this drug.

• Does not show up on toxicology screens.

Effects

• Anxiety leading to panic attacks. • Nausea and Vomiting.• Terrifying auditory and visual hallucinations. • Increased heart rate. Can cause strokes• Can cause seizures and kidney failure• Elevated body temperature.• Giddiness, Empathy, and Relaxed State.

Bath Salts Video Clip

NBCNews.com video Chris Hansen investigates bath salts.url

BATH SALTS

• Derivatives of cathinone found naturally in the herbal stimulant khat.

• Part of phenethylamine family that includes, amphetamines, methamphetamine, and ecstasy.

BATH SALTS• First developed in research labs and became a popular

party drug in Europe and UK • Spread overseas around 2008, and began to show up

mostly in states like Louisiana, Kentucky, and Tennessee. Some had regional names like “Hurricane Charlie” and “Bayou”.

• Other product names include Bliss, Blizzard, Blue Silk, Ivory Snow, Vanilla Sky and Ivory Wave.

• Became highly publicized with the cannibalistic attack in Miami and other reports of violence.

BATH SALTS

BATH SALTS

BATH SALTS

MarketingSold commercially as bath salts, plant fertilizer, toy cleaner, pond cleaner, cell

phone cleaner, jewelry cleaner, insect repellant, glass cleaner, toilet cleaner, and ladybug attractant.

Sold as tablets, capsules, and white or beige crystals/powder. Capsules may be sold in combination with caffeine or amphetamine. Has been sold as ecstasy.

Sold mainly on the internet buy also in “head shops”, convenience stores, and gas stations. Some people have bought on e-bay. Low cost and readily available.

It is not the stuff you find at Bath and Body Works!!!

BATH SALTS

Marketed as legal alternative to LSD, cocaine, ecstasy, and methamphetamine.

Labeled not for human consumption but the sole purpose is human consumption.

Video of Bath Salts Sale

Manger of chain of smoke shops arrested for selling bath salts - Atlanta News, Weather, Traffic, and Sports FOX 5.url

Chemical Makeup

• There are several synthetic cathinones. The most common found in “Bath Salts” are MDPV (methylenendioxypyrovalerone), mephedrone(4-MMC), or methylone. Found in 98% of tested products.

• Advertised as above 95% purity but samples tested in Italy were only 40 – 50% pure. Some purchased online had benzocaine, lidocaine, and caffeine. Users truly don’t know what they are getting or how much.

Bath Salts

Costs anywhere from $40 - $100 per gram.

Taken orally, IV, nasal inhalation, intramuscular, or rectally. Snorting and swallowing are the most common. Users may combine 2 methods (oral and inhalation) to obtain more rapid and prolonged effects.

High risk for overdose due to packages containing varying amounts of the chemicals.

BATH SALTS

Marketed as legal alternative to LSD, cocaine, and amphetamines. May imply safety for user.

Labeled not for human consumption but that is the sole purpose!

Naphyrone• Referred to as “Cosmic Blast” and marketed as

jewelry cleaner. Contains MDPV and Naphydrone. Reuptake inhibitor of serotonin.

• Stays in system for long periods. Body temperatures of up to 107 degrees have been reported.

BATH SALTS

Users do not know how much or what they are getting.

Package labeling implies “relaxation” but not stimulant effects.

Video Effects

Bath Salts Craze Caught on Tape - YouTube.url

Trends in Use

• Mostly males with a mean age of mid-late twenties.

• 2012 Monitoring the Future Survey reported .9% annual prevalence of use among students in grades 8,10, and 12 combined.

• Google Trends (2013) showed rapid increase in Internet searches for “buy Mephedrone” in Europe and “bath salts” in the U.S. in 2012.

MDPV

• Phenethylamine and norephinephrine-dopamine reuptake inhibitor. Hallucinogenic effects. Lasts longer than Mephedrone or Methylone.

• Similar form of this was developed in 1960’s to treat chronic fatigue syndrome but rejected due to issues with dependency.

• Doses of 5 - 20 mg can produce effects with oral and inhalation.

Mephedrone

• Derived from cathinone and increases dopamine, serotonin, and norephinephrine levels.

• Users report longer and better high than cocaine. Users report it is like using cocaine and ecstasy together. Effects last about an hour. Known as meow-meow.

• Users usually ingest capsules, dissolve in water, snort, or use rectally (bombing).

Methylone

• Stimulant in the phenethylamine class. More potency in terms of serotonin reuptake inhibition. Similar structure to MDMA.

• After oral, nasal, or rectal use, effects occur within 20 minutes, and last about 2 hours.

• *Low concentrations of endogenous phenethylamine have been found in people with ADHD and high concentrations have correlation with incidence of schizophrenia.

Bath salts vs. Cocaine/Meth• Like Amphetamines, Bath Salts release dopamine from

cells, while blocking the reuptake of dopamine into the cell similar to cocaine.

• MDPV is ten times stronger than cocaine.

• Taking Bath Salts is like taking Cocaine and Meth together.

• Time delay – MDPV is able to cross blood-brain barrier which may impact onset of action and toxicity.

• Pbs.org – September 2012

Bath Salts and The Brain

Why Do People Use Them?

• Increased energy, alertness, and concentration.• Sexual stimulation and mood enhancement.• Decreased appetite and need for sleep.• Low cost and advertised to users as “they will

never fail a drug test”. • Readily available and accessible.

Effects• Patients reporting to ER’s have cardiovascular

complications, such as tachycardia, chest pains, and hypertension.

• Dizziness, jaw clenching, and confusion. • Body temperatures of up to 107 degrees have been

reported. Often people take their clothes off.• Jerking eye movements and foaming at the mouth have

been reported. Vomiting and nosebleeds.• Restlessness and inability to sit still. • Insomnia – sleep deprivation * - Some people take

Xanex and other drugs to try to sleep.

EFFECTS• Auditory and Visual Hallucinations with common

themes of monsters, demons, aliens, and God. This leads to paranoid delusions and violent behavior in response to hallucinations.

• Irritability, suicidal ideation, self-harm behaviors, and prolonged anxiety. “Excited Delirium”.

• Begin 10 – 20 minutes, peak 45 – 90, last 2-3 hours then decrease. Users reported effects after 24 hours. Nonpsychiatric symptoms usually resolve in 1 to several days, but psychosis can persist.

ConcernsA Marquette County, Michigan ER reported 35 admissions

from November 2010 to March 2011. This prompted Law Enforcement to seize all bath salts from a local convenience store. The products tested all contained MDPV.

17 out of 35 were hospitalized. Median age was 28 years (range 20 -55 years). One death reported. 63% used by injection.

54% were Men, 69% self-reported a history of drug abuse, 46% or 16 patients had a history of mental illness(bipolar disorder, schizophrenia and depression), and 17% reported suicidal thoughts/attempts related to use of bath salts.

“Morbidity and Mortality Weekly Report, Vol 60, May 20, 2011, 624 - 627

Concerns

• According to the Bangor Daily News, domestic violence calls have increased in Maine due to use of Bath Salts.

• Cookeville Regional Medical Center in TN has treated over 160 people since 2010.

Dangers and DependencyA research study led by UNC professor CJ Malanga,

MD found that Mephedrone, like cocaine, has a high potential for abuse and addiction.

Study by Scripps Research Institute in California suggests that Bath Salts are more addictive than Meth. Rats averaged 60 level presses for meth versus 600 for MDPV. Some even pressed 3000 times for a single hit. Exhibited obsessive behavior, such as, licking, biting, and sniffing their cages.

NIDA.org 2012 Sydney Herald 2013.

Acute Toxicity of Substituted Cathinone Product.

Use Compiled From 2 US Case Series Reports (n = 271)*• Signs and Symptoms Percentage• Agitation 66-82• Tachycardia 56-63• Combative violent behavior 57• Delusions/hallucinations 40• Paranoia 36• Confusion 34• Seizures tremor 29• Drowsiness 23• Hypertension 17-23• Paranoia 20• Mydriasis 13-20• Myoclonus 19• Chest pain 17

Dangers

• Users report repeated dosing and binging over several days leading to tolerance.

• Acute toxicity may be linked to larger binge consumption, using multiple substances, and other individual use patterns.

• Journal of Addiction Medicine, May/June 2013

Legality

The Synthetic Drug Prevention Act signed by President Obama on July 9, 2012. This act bans 29 chemicals found in Bath Salts and Synthetic THC and makes them Schedule I.

States will have to incorporate these into their drug scheduling list and update the list as new substances are discovered.

Operation “Logjam”

Nationwide drug sweep - YouTube.url

Operation logjam

• July 26, Operation “Logjam” seized 5 million packets of synthetics and arrested 90 people in a nationwide effort to crackdown on these drugs.

• Tested products contained anywhere from 17 milligrams to 2000 milligrams of chemicals.

Poison Control Center DataCALLS TO POISON CONTROL: 304 in 2010, 6,138 in 2011, 2065 in 2012, Ages <6 to over 59. Most ages 20 – 29. January – 228/301 July – 361/680February – 230/487 August – 173/602March – 264/639 September – 119/512April – 285/600 October – 98/401May – 295/720 November – 86(2012)June – 415/743 December – 78(2012)www. aapnc.org 1-800-222-1222

TREAMENT

• Often eat up Emergency Room resources as it takes multiple nurses and doctors to treat users.

• Difficult to know what someone has taken unless they self-report or someone else reports.

• Does not show up on typical toxicology screens and can not be detected by drug dogs. There are now drug tests that do test for Bath Salts. Ammon labs, Redwood Toxicology, and Dominion Diagnostic offer these drug screens.

TREATMENT• Low dose antipsychotics to treat psychosis• Benzodiazepines, usually Ativan, to decrease agitation

is first treatment. • Ten to twenty times the normal dose of sedatives have

been used.• Try to avoid using restraints, but speak reassuringly to

people who are agitated and paranoid• Move to a quiet room with low light to help calm

patient. • Avoid loud noises and try medications prior to

restraint.

TREATMENT

• Monitor the person for depression and suicidal ideation even after they have stopped using the drug. Address both mental health and addiction issues. Follow guidelines for treatment of stimulant users.

• Psychotic symptoms often persist after treatment• Enhance coping skills to assist the person in

dealing with anger and other emotions. • Train staff to deal with specialized issues and

incorporate questions into intake and assessment.

Movie Madness

• BATH SALT ZOMBIES• Available on DVD February 19• is a new horror film directed and co-written

by Dustin Wayde Mills (Puppet Monster Massacre, Zombie A-Hole, Ballad of Skinless Pete) and produced and co-written by Clint Weiler of Aggronautix. The movie sensationalizes the recent bath salt  epidemic and the attacks surrounding them

“Zombie Apocalypse”

• The shocking wave of attacks associated with Bath Salts has sparked fears of a real-life zombie outbreak in the south. This led to The Center for Disease Control and Prevention releasing a statement saying it is not aware of any virus that can cause zombie-like behaviour.

What next?

• Partnerships and networks between the community and law enforcement have made an impact in the sale and distribution of this drug.

• Education regarding the dangers of Bath Salts.

Spice / K2

What is Spice and K2?• Spice and K2 refer to commercially available

products sprayed with chemicals called synthetic cannabinoids. These products claim to be a mixture of herbs but often do not have herbs in them. They include other ingredients that are unknown and not listed.

• Many have warning labels as not intended for human consumption, but are solely intended for human consumption. Marketed as incense. Resembles potpourri.

Synthetic Cannabinoids

• Synthetic Cannabinoid products are manufactured in Asia and sold in US in many different arenas (gas stations, liquor stores, smoke shops and internet)

• Sold under different brand names: “K2, Spice, Spice Gold, Spice Black, Mr. Nice Guy, Yucatan Fire and many others”

• Since the national ban on five synthetic cannabinoids, new brand names have developed, such as K2 Sky, K3, and K4

What is a Synthetic Cannabinoid?

• A class of synthetic substances that bind to the cannabinoid receptors(CB1 and CB2) in the body. When used they create a high similar to THC. Bind more strongly than THC. There are hundreds of synthetic cannabinoids.

• Used in an attempt to avoid laws that make marijuana illegal. National Ban on five cannabinoids began in March 2011.

History of Spice and K2? The cannabinoid-like chemicals were first developed

in research laboratories to study receptors in the body and brain and for other research purposes. The five banned cannabinoids are JWH-018, 073, 200, CP 47, and 497.

JWH-018 was first made in 1995 by Dr. John Walter Huffman at Clemson University. Manufacturers read research and copied it to produce this cannabinoid and marketed it for commercial distribution.

Brand “Spice” was released in 2004 and gained popularity in 2006.

Spice and K2The company that started the “Spice” line went from

assets of 65,000 Euros in 2006 to 899,000 Euros in 2007. Spice was the dominant brand until 2008. Then competing brands like “K2” hit the market. Now there are many distributors of these products.

Rick Broider with North America Herbal Incense Trade Association estimates profits at 5 billion per year.

In 2011, Redwood Toxicology Lab developed testing for six synthetic cannabinoid chemicals. 72 hours for urine and 24 – 48 for saliva.

Spice Products

• Spice• Spice Gold• Spice Diamond• Spice Tropical Synergy• Spice Arctic Synergy• Spice Gold Spirit• PEP Spice

Many Faces of Spice

K-2/SPICE

Other Herbal Incense ProductsGenieYucatan FireDreamEx-sesBlaze

Spike 99BlazeSparkFusionMANY others!

Spice IngredientsOne or more synthetic cannabinoid compounds. Can be

different mix each time.JWH-018, CP 47, 497, C8, JWH-073, and JWH-250

have been found most often in spice products. Other legal substances such as Pink Lotus, Dwarf

Skullcap, Indian Warrior, and Lion’s Tail Potentiate or add to effectsCreate different effects between productsMany have psychoactive effects on their ownSome used as marijuana substitutes in the past.Cost $30 - $40 per 3 gram bag.

Other Synthetic CannabinoidsHU named after Hebrew University where they were created.• HU-210

– Various studies show it is anywhere from 66-800 times more potent than ∆9 THC1

– Schedule I under CSA: Illegal in U.S.• HU-211

– Studies tentatively show no ∆9 THC-like effects– Used to research treatment of brain damage related to stroke, brain

trauma, glaucoma, and multiple sclerosis• HU-311

– Has potent antineoplastic and antiproliferative activity (cancer fighting drug)

1 J. Med. Chem.35 (11): 2065–9.

BIZARRO - ZENCENSE

BIZARRO

Bizarro• At a glance:• Out of all the varieties of incense that I have burned,

a fairly large number, Bizarro is my personal favorite. That being said, I wouldn’t recommend Bizarro to just anyone. It is for experienced users and is not to be underestimated. As with other brands of herbal potpourri, the psychoactive effects from Bizarro should not be set alongside cannabis. They are much more intense and harder to control. Bizarro is a great brand of incense if used correctly, but it can also render terrifying experiences to those who dive in too fast.

Synthetic CannabinoidsCP 47,497 and analogues (CP Created by Pfizer)

3 to 28 times more potent than ∆9 THC CP 55,940

45 times more potent than ∆9 THC JWH-015JWH-018 4-5 x more potent than THC and same

chemical structure shared with known cancer causing agents.

JWH-073WIN 55,212-2 (WIN is for Sterling Winthrop)

Used to research treatment for Alzheimer'sEffects milder and don’t last as long as ∆9 THC

Other Herbal Incense Ingredients (Not all inclusive)

Baybean Blue LotusLion's TailLousewortIndian WarriorDwarf ScullcapMaconha BravaIndian PennyworthCloveHopsTribulus Terrestris

Pink LotusMarsh MallowRed CloverRoseVanilla and Honey Fly AgaricSiberian MotherwortDamianaStevia LeafLemon GrassTurnera diffusa

Many other legal herbs and herbal extracts are used to enhance aroma, potency

Dangers of K-2/Spice Video

Dangers of K2 Spice - YouTube.url

Why Do People Use It?• Legal substitute to marijuana • Herbal incense products are smoked or snorted for marijuana-like effects• Other reasons: increase creativity, reduce

stress, experience euphoria, increase personal insight, and increase appreciation for the arts

• There are numerous blogs and websites the provide users the opportunity to share experiences.

Effects• Marijuana-like effects: euphoria, giddiness,

silliness, bloodshot eyes, impaired short-term memory and concentration, and “munchies.”

• Other common effects: cotton mouth, light sensitivity, a warm sensation in the limbs, dry eyes, paranoia, light headedness, auditory and visual hallucinations, painless head pressure, time distortion, panic attacks, delirium, impaired coordination, and sleeplessness

• Onset/duration: 5-10 minutes, and effects vary from 2 hours for JWH and 5-6 for CP. Can get high off a hit or two.

Effects

• A 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 sickly sweet.

Effects• One hospital reported a patient with a 1-3

gram a day habit and severe withdrawal symptoms (tremors, headache, nausea, vomiting and depression).

DangersLinked to 16 cases of kidney failure. All but one

experienced nausea and vomiting. Twelve reported abdominal, back, and neck pain. All but one were male and had healthy kidneys. Age range was 15 – 33. Traced to Spice Gold, Mad Monkey, Mr. Happy, Clown Legal, and Lava brand.

Another study found these products may create psychosis in patients with no history of psychiatric disorder.

Overdose potential from unknown amounts and ingredients in products.

ABC News, Nick Wasson , M.D. February 2013

Dangers

Poison Control Centers had 112 calls in 2009, 2906 in 2010, 6,959 in 2011, and 5200 by December 31, 2012.

Users are experimenting with combining different products, which can dramatically change or increase the effects. These cannabinoids were created for experimental use. Not tested on people. No one knows long term effects of these products.

Dangers• JWH-018 and others, have a shared chemical

structure with cancer causing agents, according to NIDA.

• A hospital in Kansas reported 8-10 people hospitalized in one month after smoking the products with hallucinations, seizures and bleeding from the nose and mouth.

• Three teens ages 16 and 18, showed up in ER with anxiety, agitation, excessive sweating, and inability to speak.

Dangers• Kids’ brains are still developing. • Across the US, people are showing up in

emergency rooms with aggressive and unusual behavior. Suicides have been reported.

• A NIDA study stated 11% of school seniors have used Spice/K-2 in 2011. Second most frequently used drug after THC.

• Medical personnel often don’t know what they are dealing with unless the person self-reports.

DANGERS

Appearance

• Most herbal incenses appear as an olive green leafy material very similar in appearance to marijuana, oregano

Paraphernalia• Herbal incense smokers will use the same or

similar products used by marijuana smokers– Pipes, bongs, hookahs– Rolling papers– Blunts (hollowed out cigars packed with product)

• Herbal incense specific paraphernalia– Vapor Genie– Grinders (to further grind into a finer mixture)

Hookah

Vapor Genie

Grinders

Controlled Substances Act

In Nov. 2010, the USDEA moved to ban 5 synthetic cannabinoids, placing them in Schedule I status due to high potential for abuse, and no known medical benefits. The ban would be in effect for one year.

The ban was delayed due to companies stating the ban was unconstitutional.

On March 1, 2011 the National Ban was enacted. This means that is illegal to possess and sell products

containing these. Before the ban, 15 states had already taken action to

control one or more of these five chemicals.

Challenges - Manufacturing

• Manufacturing occurs in countries where synthetic cannabinoids are legal.

• As detection catches up with manufacturing, makers will alter ingredients. They are using new ingredients which are not illegal at this time.

• Federal bans target larger distributors. States will need to go after smaller distributors.

Challenges - Marketing

• Product will not cause positive drug test• “There's never been a case reported by our clients

that any of our Herbal Smoke Blends caused them to fail a test”

• “YOU'LL NEVER FAIL A DRUG TEST”• Why would this be an issue for a product marketed

as incense and not for human consumption?

Challenges - Marketing• Ingredients1

– Synthetic cannabinoids not listed– Listed ingredients are not necessarily in the

product– Consumers don’t know what they are actually

getting– Raises questions of consumer protection and

product misrepresentation

1 Understanding the ‘Spice’ Phenomenon Thematic Paper, European Monitoring Centre for Drugs and Drug Addiction, 2009, Portugal

ENERGY DRINKS

ENERGY DRINKS• American Association of Poison Control Centers – (

www.aapnc.org) urges the public to use caution using these products.

• Highly concentrated amounts of sugar, caffeine, and other ingredients. Was mixed with alcohol in the past and sold next to bath salts.

• Caution for children and adolescents. Children should not have it and adolescents should not have more than 100 mg of caffeine per day = one cup of coffee*

*Journal of Pediatrics

Energy Drinks

• Due to labels, it is often hard to know how much caffeine is in the drink.

• Drinks contain natural caffeine-containing ingredients that are not separately listed, such as, yerba mate, cacao, and guarana.

• These drinks are considered dietary supplements and not regulated by the FDA so there is no limit to amount of caffeine that can be in them.

• Drinking too many at one time or too fast ……..

EFFECTS

• Nausea and vomiting Seizures• Insomnia Kidney Problems• Delirium Mood Changes• Headache Increased BP• Altered and increased heart rhythm• Withdrawal• Chest Pains• Dehydration• Sweating

BATH SALTS & ENERGY DRINKS

• A 28 year old man was found passed out in a random person’s driveway, and was taken to the hospital. It was discovered that the man had overdosed on energy drinks and bath salts.

• According to a report by the Caledonia Police, officers found the man lying on the floor of his van.

• An individual said he found the van in his own driveway. The individual stated the engine was off and that no keys were found in the ignition. The victim was found slouched over the steering wheel. There was a cell phone in the man’s possession, and the last dialed contact was that of his mother.

POISON CONTROL CENTER

• 2607 calls to Poison Control Centers related to the use of Energy Drinks through October 31, 2012

Resources

• Life Center of Galax is equipped to treat persons using these substances. Our confidential referral and assessment number is 1-800-345-6998. We are available 24/7 to speak with anyone.

Thank You