Substance Abuse. Disclosures. Objectives 10/2/2013. AAP/NJ Annual School Health Conference School Challenges: Preparing for the Unexpected

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1 Substance Abuse AAP/NJ Annual School Health Conference School Challenges: Preparing for the Unexpected October 17, 2013 Hoover Adger, Jr., MD, MPH Professor of Pediatrics Disclosures I have no relevant disclosures. Objectives Discuss the epidemiology of current drugs of abuse. Discuss the trends in the most common drugs of abuse. Discuss several emerging and dangerous drugs that are hitting the market. 1

2 THE GOOD NEWS/ AOD USE IN YOUTH Cigarette and alcohol use among 8 th,10 th and 12 th graders, are at the lowest point since Five-year trends show significant decreases in alcohol use among nearly all grades and across all prevalence periods. Binge use of alcohol declined among 8 th, 10 th and 12 graders over the past year. In 2012, there was an increase in perceived risk of smoking among 8 th, 10 th and 12 th graders. The use of inhalants continued its decline among individuals in 8 th, 10 th, and 12 th grades. THE BAD NEWS/ AOD USE IN YOUTH Alcohol & other drugs are readily available. One out of 2 seniors has tried an illicit drug; 7 out of 10 have used alcohol at some time. Students as young as those in grades 3 and 4 have used alcohol and tobacco; many even younger have been exposed to illicit drugs by peers, older siblings and parents. Five-year trends show significant increases in marijuana use, which now exceeds tobacco use. After marijuana, prescription OTC medications account for most of the illicit drug use by teens. Epidemiology 2

3 Drug use remains highest among 12th graders. Almost 50 percent of seniors have tried an illicit drug, and one in four are current users. Percent Reporting Use of Any Illicit Drug By the time they are seniors, one out of five youth are current marijuana users and 1 in 15 use every day. Marijuana Percent Reporting Use 3

4 Cocaine use is less prevalent, but almost 1 in 20 seniors have used cocaine during their lifetime. Cocaine Percent Reporting Use Heroin use among students is low, but any use among students is a cause for great concern. Heroin Percent Reporting Use 4

5 Alcohol is a serious problem among youth over 20 percent of high school seniors and roughly 15 percent of 10th graders are heavy, binge drinkers. Alcohol Percent Reporting Use Alcohol use is a serious problem. 5

6 The number of adolescents who report having been drunk is of great concern. Alcohol Use, Percent Reporting Been Drunk Despite significant declines, still one out of every ten high school seniors are daily smokers. Cigarettes Percent Reporting Use Energy Drinks 6

7 Energy drinks are being consumed by about one third of teens, with the highest use among younger teens. Energy Drinks Percent Reporting Use Trends in Drug Use The general trend had shown a decline over the past decade, with a recent increase due primarily to a rise in marijuana. Current (past month) Use of Any Illicit Drug Source: Monitoring the Future Study,

8 Percent Percent 10/2/2013 Percent of Students Reporting Past Month Use of Any Illicit Drug Has Increased 14% Increase Non-Medical Use of Rx Drugs Percent of 12th Graders Reporting Nonmedical Use of OxyContin and Vicodin in the Past 12 Months Oxycontin Monitoring the Future, Vicodin Marijuana is the most common illicit drug used. 25 Current (past month) Marijuana Use th th th

9 Percent 10/2/2013 Marijuana Use is on the Rise The Percent of 12th Graders Reporting Daily use of Marijuana is at a 30 Year High th Graders 12th Graders Monitoring the Future,

10 Percent 10/2/2013 MDMA/ecstasy use decreased significantly from the rapid rise seen in earlier years but appears to be on the rise, again. Current (past month) MDMA/ecstasy Use. Illicit Drugs Declining in Use Inhalants Powder/Crack Cocaine Vicodin Adderall ( 12 graders*) Sedatives (barbiturates) Tranquilizers Cough and Cold Medications Monitoring the Future, 2013 Inhalant Use Percent of 8 th, 10 th and 12 th Graders Reporting Lifetime Use of Inhalants 10

11 Trends in 30-day use of alcohol, the most common drug of abuse, have decreased significantly among 8 th, 10 th and 12 th graders. Current (past month) Alcohol Use Cumulative alcohol and marijuana initiation, by age: Seattle Social Development Project, Percent Am J Pub Health, 90(3): 361, 2000 Age of Drinking Onset Predicts Future Alcohol Abuse and Dependence Grant BF, Dawson, DA. Journal of Substance Abuse, 1998 Young people who began drinking before age 15 are four times more likely to develop alcohol dependence than those who began drinking at age 21. The risk of alcohol abuse was double for persons who began drinking before age 15 compared to those who began drinking at age

12 Percent 10/2/2013 Tobacco Use Percent of 8 th, 10 th and 12 th Graders Reporting Past Month Use of Cigarettes While the rates of cigarette use is going down, rates of use of small cigars and tobacco use by hookahs (waterpipes) is increasing. Drugs Holding Steady in 2012 Illicit drugs other than marijuana LSD and other Hallucinogens Salvia Heroin Oxycontin Amphetamines and Ritalin Club Drugs (Rohypnol, GHB, Ketamine) Provigil 12

13 Synthetic Marijuana is On the Rise In 2012, one in every nine high school seniors (11.3%) reported using this drug in the past 12 months. Synthetic Cannabinoids- K2, Spice marketed as herbal incense or potpourri, with trade names such as K2, Spice, Black Mamba, Voodoo, and Kronic (> 140 brand name products) Mixtures of herbal and plant material or spices that serve as marijuana look-alikes that are sprayed with a solvent that contains synthetic cannabinoids Packaged in colorful packets. By mandate they are labeled as Not for Human Consumption. Synthetic Cannabinoid Products (SCPs) Cannabinoids are a class of diverse chemical compounds that activate cannabinoid receptors. These include the: endocannabinoids, produced naturally in the body by humans and animals; phytocannabinoids, such as 9-THC, which are found in cannabis plants and are responsible for the high associated with marijuana smoking; and synthetic cannabinoids, which are produced chemically by humans. All three classes of compounds are thought to exert their effects through binding to two primary cannabinoid receptors(cb1 and CB2). 13

14 Synthetic Cannabinoid Products (SCPs) Typically smoked in a pipe or as a cigarette Unlike cannabis, the SCPs cause a host of different sympathomimetic and psychoactive effects A growing body of literature suggests significant health consequences from toxicity associated with these compounds Synthetic Cannabinoid Products (SCPs) One common group of SCPs is referred to as the JWH compounds John W. Huffman(JWH-18, JWH-073). Many were developed as test compounds in the investigation of drug-receptor interactions in the study of the endocannabinoid system. Because of their higher binding affinity, SCPs may be more potent than their plant-based counterparts. Synthetic Cannabinoids Psychoactive Effects Euphoria Irritability Anxiety Aggression/Apathy Sedation Memory changes Paranoia Hallucinations Psychosis Physical Signs/Symptoms Conjunctival injection Dry mouth Tachycardia Change in appetite Muscle pain and weakness Rhabdomyolysis Myocardial infarction Seizure 14

15 MMWR -Acute Kidney Injury Associated with Synthetic Cannabinoid Use Multiple States, 2012 February 15, 2013 / 62(06);93-98 After the Wyoming Department of Health launched an investigation and issued an alert, a total of 16 cases of AKI after SC use were reported in six states. Toxicologic analysis of product samples and clinical specimens (available from seven cases) identified a fluorinated SC previously unreported in synthetic marijuana products: (1-(5-fluoropentyl)-1H-indol-3- yl)(2,2,3,3-tetramethylcyclopropyl) methanone, also known as XLR-11. Six of eight patients with a renal biopsy demonstrated acute tubular injury, and 3 of 8 demonstrated features of acute interstitial nephritis; 5 of the 16 patients required hemodialysis. Myocardial Infarction Associated With Use of the Synthetic Cannabinoid K2 A Mir, A Obafemi, A Young and C Kane, Pediatrics 2011;128;e1622 We report here the first (to our knowledge) cases of myocardial infarction (MI) after smoking K2. Three patients presented separately to the emergency department complaining of chest pain within days after the use of K2. Acute MI was diagnosed in each case on the basis of electrocardiogram changes and elevated troponin levels. Coronary angiography was performed, and the results were normal for the first 2 patients. The incidence of ST-elevation MI is low among teenagers, and association with drug use should be suspected. Public education and awareness need to be heightened about the possible health implications of K2. Clinical Presentation of Intoxication Due to Synthetic Cannabinoids, Pediatrics 2012;129;e1064; March 19, 2012; Case 1-A 16-year-old girl, transferred from an outside hospital for altered mental status, refusing to speak after being out with her boyfriend, who reported use of K2. (pt awake, eyes open, not responding to verbal or painful stimuli, HR-105, BP 118/73, vertical nystagmus, urine screen + for MJ. Case 2-18-yo boy brought to ED after found agitated and diaphoretic and in an altercation at a party. (c/o headache, dizziness, found to be uncooperative, restless, and aggressive, T 37.6 C, HR 131, RR 24,BP 131/89, appeared anxious, conjunctivae were mildly injected, urine tox-neg. Case 3-16-yo male group home resident presented to ED with altered mental status. He was brought in by his case worker, who noticed that his face seemed frozen and his speech was slowed. He was agitated, had visual hallucinations and reported smoking Spice 5 hours before (which he bought from a local convenience store). In the ED, he was alert but confused, agitated, dysarthric, pressured speech. T 37.0 C, HR 62, BP 110/52, conjunctivae injected, CV, Pulm-wnl, but hyper-refelxic. He received 1 L NS bolus and 4 mg of lorazepam IV. Urine Tox-neg. 15

16 Synthetic Cathinones: Bath Salts Emerging and Dangerous Products Cathinones are amphetamine-like compounds that are found both naturally and made commercially. The Khat plant produces leaves that release cathinones when chewed. Synthetic cathinones have recently gained popularity and are marketed as "bath salts" or "plant food. They are packaged in small packets and often sell for about $25. Synthetic Cathinones: Bath Salts Synthetic powder sold online and in paraphernalia stores (Ivory Wave, Purple Wave, Red Dove, Blue Silk, Zoom, Bloom, Cloud, Cloud Nine, White Lightning, Scarface) Contain amphetamine-like chemicals such as methylenedioxypyrovalerone (MPDV), mephedrone and pyrovalerone. Administered orally, inhaled (snorted), or IV Bath Salts: Emerging and Dangerous Products High risk for overdose Acts in the brain like stimulant drugs High risk for adverse medical health effects Chest pain, increased BP, increased HR, agitation, hallucinations, extreme paranoia, and delusions Linked to alarming rise in ED visits and call to poison control 16

17 Synthetic Cathinones - Bath Salts Psychoactive Effects Agitation Anxiety Anger/Aggression Extreme Paranoia Depression Increased sexual drive Compulsive behavior Insomnia Self-injurious behavior Violent behavior Hallucinations Psychosis Physical Signs/Symptoms Tachycardia Vasoconstriction/HBP Diaphoresis Hyperthermia Mydriasis Muscle spasms Rhabdomyolysis Respiratory distress Stroke Myocardial Infarction Seizure Calls Related to Bath Salts and Synthetic Cannabinoid Use 304 Data from American Association of Poison Control Centers, August 30, 2012 Laboratory Testing Standard urine toxicology tests for marijuana detect only THC, making the synthetic cannabinoids undetectable on routine screen. Assays for SCPs can be obtained through some commercial laboratories and are increasingly used, although not yet routine in ED settings. Assays for bath salts also must be specially ordered and are not yet readily available in most clinical settings. Although SCPs and cathinones are not detectable by most standard urine immunoassay tests, they can be detected through testing by GC-Mass Spec. 17

18 Treatment for Acute Intoxication Supportive care Intravenous hydration rhabdomyolysis, HR Minimize stimuli and confrontation Quiet environment Short acting benzodiazepines for severe agitation or violent behavior Cardiovascular complication and seizures should be treated accordingly Role of the Health Care Provider SCPs and cathinones are readily available and abused by adolescents and young adults. Health providers should educate their patients & families about the dangers of these substances. Suspect the use of these substances in those who show signs or have histories consistent with intoxication yet negative urine toxicology screens. Management for acute intoxication is primarily supportive and symptomatic care. Advocating for policy changes that limit access to these substances may have a role. Summary The use of tobacco, alcohol and other drugs remains a major health concern among youth. There is room for optimism and the good news is the documented declines in the rates of use of both alcohol and tobacco among adolescents. Despite the good news there is concern about other emerging and dangerous drugs that are hitting the market. 18

19 References 1. Castellanos D, Thornton G. Synthetic cannabinoid use: recognition and management. J Psychiatr Pract. 2012;18(2): Castellanos D, Singh S, Thornton G, Avila M, Moreno A. Synthetic cannabinoid use: a case series of adolescents. J Adolesc Health. 2011;49(4): Fattore L, Fratta W. Beyond THC: the new generation of cannabinoid designer drugs. Front Behav Neurosci. 2011;5: Cohen J, Morrison S, Greenberg J, Saidinejad M. Clinical presentation of intoxication due to synthetic cannabinoids. Pediatrics. 2012;129(4):e1064-e Spiller HA, Ryan ML, Weston RG, Jansen J. Clinical experience with and analytical confirmation of "bath salts" and "legal highs" (synthetic cathinones) in the United States. Clin Toxicol (Phila). 2011;49(6): Hu X, Primack BA, Barnett TE, Cook RL. College students and use of K2: an emerging drug of abuse in young persons. Subst Abuse Treat Prev Policy. 2011;6:16. References (continued) 7. Prosser JM, Nelson LS. The toxicology of bath salts: a review of synthetic cathinones. J Med Toxicol. 2012;8(1): Penders TM. How to recognize a patient who's high on "bath salts." J Fam Pract. 2012;61(4): Winder GS, Stern N, Hosanagar A. Are "bath salts" the next generation of stimulant abuse? J Subst Abuse Treat Epub ahead of print. 10. Coppola M, Mondola R. Synthetic cathinones: chemistry, pharmacology and toxicology of a new class of designer drugs of abuse marketed as "bath salts" or "plant food." Toxicol Lett. 2012;211(2): Johnston LD, O'Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future: National Results on Adolescent Drug Use. Overview of Key Findings, Ann Arbor, MI: Institute for Social Research, University of Michigan; Mir A, Obafemi A, Young A, Kane C. Myocardial infarction associated with use of the synthetic cannabinoid K2. Pediatrics. 2011;128(6):e1622-e Rodgman C, Kinzie E, Leimbach E. Bad Mojo: use of the new marijuana substitute leads to more and more ED visits for acute psychosis. Am J Emerg Med. 2011;29(2): Ross EA, Reisfield GM, Watson MC, Chronister CW, Goldberger BA. Psychoactive "bath salts" intoxication with methylenedioxypyrovalerone. Am J Med. 2012;125(9): Grabenauer M, Krol WL, Wiley JL, Thomas BF. Analysis of synthetic cannabinoids using high-resolution mass spectrometry and mass defect filtering: implications for nontargeted screening of designer drugs. Anal Chem. 2012;84(13):