THE SYNTHETIC DRUGS. Timothy E. Wilens, MD

Transcription

1 THE SYNTHETIC DRUGS Timothy E. Wilens, MD Director, Center for Addiction Medicine Chief, Division of Child and Adolescent Psychiatry, Massachusetts General Hospital Harvard Medical School

2 Disclosures* Grant Support: NIH (NIDA), Euthymics/Neurovance, Ironshore, Sunovion, TRIS, US National Football League (ERM Associates), U.S. Minor/Major League Baseball, Bay Cove Human Services, Phoenix House (Clinical Services) Royalties: Guilford Press, Cambridge Press, Elsevier, co/owner of a copyrighted diagnostic questionnaire (Before School Functioning Questionnaire), licensing agreement with Ironshore (BSFQ Questionnaire) Some of the medications discussed may not be FDA approved in the manner in which they are discussed including diagnosis(es), combinations, age groups, dosing, or in context to other disorders (e.g. substance use disorders) * Past 3 years

3 Ecstasy MDMA (3,4-methylenedioxy-methamphetamine) More potent ecstasy also referred to as Molly (may indicate a higher composition of methamphetamine or combination with other drugs) Referred to as an empathogenic drug (prosocial, emotional) Typically taken orally-lasts 6-8 hours; RAVE drug acts/mdma-ecstasy-or-molly

4 Ecstasy May be used in combination with cocaine, GHB, methamphetamine, ketamine, and sildenafil (Viagra) Affects serotonin, dopamine, norepinephrine Intoxication: prosocial, talkative, empathic, emotional After effect: confusion, depression, sleep problems, drug craving, and anxiety may occur immediately to weeks after ingestion acts/mdma-ecstasy-or-molly

5 Case of Elsie Elsie is a 21 yo unemployed WF with depression You are called by her parents because she is freaked out. Parents indicate she is uncharacteristically very anxious, hyperaroused, and is having repeated panic attacks, sweating, and somewhat paranoid. You see her and she is as above. Physical exam notable for BP 140/90, HR 110 reg, temp 99.5F, diaphoretic, dilated pupils; otherwise no major abnormal findings. Mental status exam notable for hyperaroused, paranoid, not depressed or suicidal Stat urine toxicology is negative????

6 Recent Synthetic Drugs of Abuse Bath Salts Related set of compounds to the canthinones Derived from Khat plant (Meth)amphetamine-like stimulant naturally occurring Methylenedioxypyrovalerone (MDPV), mephedrone ( Drone, Meph, or Meow Meow ), and methylone are prototype acts/synthetic-cathinones-bath-salts

7 Recent Synthetic Drugs of Abuse Bath Salts Affects dopamine > norepinephrine > other neurotransmitters Bath salts are typically taken orally, inhaled, or injected Stimulant-like euphoria of 6 to 8 hours (PO, smoke, IV) Enhanced sensations, sexual experiences, arousal acts/synthetic-cathinones-bath-salts

8 Recent Synthetic Drugs of Abuse Bath Salts Typically a white or brown crystalline powder sold in small plastic or foil packages labeled not for human consumption. Sometimes marketed as plant food, jewelry cleaner or phone screen cleaner Sold online and in drug paraphernalia stores under a variety of brand names: Ivory Wave," "Bloom," "Cloud Nine," "Lunar Wave," "Vanilla Sky," "White Lightning," and Scarface. In October 2011, the DEA placed three common synthetic cathinones under emergency ban, and in July 2012, President Obama signed legislation permanently making two of them mephedrone and MDPV acts/synthetic-cathinones-bath-salts

9 Recent Synthetic Drugs of Abuse Bath Salts Stimulant-like effects: tachycardia, hypertension, arrhythmias, hyperthermia, sweating, seizures Excited delirium Panic attacks, anxiety, agitation, paranoia, psychosis Not detected by routine drug screens

10 Case of Joe Joe is a 19 yo living at home and working marginally You are covering the ER and are called to see him. He is brought in by his parents because they suspect something is going on with him he is taking drugs. They note he is was somewhat agitated earlier but now seems out of it, and high and report he has been in this current state for almost six hours. Previously he has been getting increasingly paranoid He has a history of smoking marijuana from age 14 on

11 Case of Joe Physical exam notable for BP 150/100, HR 120 reg, temp 99F, noninjected conjunctiva, otherwise no major abnormal findings. Mental status exam notable for somewhat sedated, not depressed or suicidal, some concerns of quasi-psychotic symptoms and prominent paranoia Toward the end of your exam the patient has a brief clonic-tonic seizure Stat urine toxicology is negative????

12 Recent Synthetic Drugs of Abuse Synthetic Marijuana (spice, K2, herbal incense) Cannabis-like high Synthetic marijuana derivate chemicals sprayed on herbs Target the cannabinoid type 1 receptor (CB1R) in the brain (endogenous cannabinoid system)

13 Recent Synthetic Drugs of Abuse Synthetic Marijuana (spice, K2, herbal incense) As of March 2011 many components are Schedule I controlled substance act (illegal) These synthetic drugs are manufactured in clandestine labs (mostly in China) for export around the globe. Typically sold inexpensively in foil packets with constantly changing brand names like Spice, K2, Black Mamba, Cloud Nine, Maui Wowie, Mr. Nice, Guy and others As molecules are identified and banned, drug labs reformulate their products to stay a step ahead.

14 Recent Synthetic Drugs of Abuse Synthetic Marijuana (spice, K2, herbal incense) Reactions: agitation, convulsions/seizures, paranoia and psychosis May result in hyperthermia, tachycardia, rhabdomyolosis, coma, death Protracted and more severe withdrawal states after persistent use (than marijuana) Not detected by routine drug screens (does NOT result in positive cannabis) In October 2011, the DEA in July 2012, President Obama signed legislation permanently banning synthetic marijuana Mandeville teen in ICU after synthetic marijuana overdose FOX 8 News WVUE-TV - Oct 23, 2015

15 Treatment of Synthetics Active intoxication Reduce stimulation, monitor mental status examination Avoid use of other agents if possible Physically, monitor and symptomatically treat abnormal vital signs (e.g. severe hypertension, hyperpyremia/fever), hydration status, circulatory, renal, and cardiovascular systems

16 Treatment of Synthetics Chronic, outpatient care Utilize Motivational interviewing, cognitive behavioral therapies Remove from offending agent(s) (e.g. residential, peer group) and cues (e.g. RAVES) Treat co-morbid psychopathology (use in schizophrenics increasing) No specific pharmacotherapies For severe paranoia, low dose antipsychotics For severe persistent panic, buspirone, SNRI, hydroxyzine (Vistaril) Anticraving: sometimes topiramate, N-acetylcysteine (NAC), modafinil can be helpful

17 Synthetics: Summary Widely available Used by young people Not routinely found on urine toxicology screens Can be quite psychologically addictive Treatment varies based on presentation