NEW(ER) DRUGS ON THE STREET STUFF YOU CAN BUY ON-LINE. Paul Stromberg, MD Carilion Clinic VACEP 2017

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1 NEW(ER) DRUGS ON THE STREET STUFF YOU CAN BUY ON-LINE Paul Stromberg, MD Carilion Clinic VACEP 2017

2 FINANCIAL DISCLOSURES None

3 OBJECTIVES Current Drugs of Abuse = Old + Newer Traditional Drugs of Abuse + Emerging Drugs of Abuse

4 UTILITY OF DRUG SCREEN Is it helpful? No (and yes) Interpret with CAUTION! Many DOA are not screened for Frequent false positives Negative screen negative tox Exposure intoxication

5 THESE SCREEN NEGATIVE! Opioids Fentanyl Methadone, meperidine Tramadol +/- semi-synthetics Others: Many benzo s Bath salts * Designer amphetamines* Synthetic cannabinoids*

6 OPIOIDS Opiate Opioid

7 OPIOIDS WITH ADDITIONAL TOXICITIES Opioid Propoxyphene Meperidine Tramadol Methadone Toxicity TCA-like Seizures, 5-HT, may have normal pupils Seizures, 5-HT QTc, dysrhythmias Long duration!!

8 CARFENTANIL: OCTOBER 26, 2002

9 OPIOID TOXIDROME Miosis Respiratory Depression CNS Depression

10 CARFENTANIL : over 52,000 lethal overdoses involving opioids in the US August 2016: 200 overdoses in 1 week in Hamilton Co. Had been averaging 90 per month 300 deaths in 8 states in 1 month Multiple doses of naloxone required to reverse overdoses, carfentanil found in heroin supply

11 CARFENTANIL Only opioid approved in US for immobilizing large animals (elephants, rhinos, wolves, seals, and polar bears) 10 ug/kg typical dose to immobilize seal Can be given IV, IM, Orally, Transmucosal Highly lipid soluble Can see redistribution, may cause delayed renarcotizing after treatment (2-24 hrs)

12 OPIOID POTENCIES

13 CASE PRESENTATION 46 yo M CC: SOB 111, 163/88, 18, 98% RA, T: 35.9 C Noted to be jittery Clear lungs

14 CASE CONTINUED Hx of HIV, Carpal Tunnel, XOL, HTN Monthly cocaine use since age 18 2 day use of internet product Muscle aches, dark urine

15 LABS, IMAGING, ETC Na 129, K 4.6, CO 2 16, BUN 90, Cr 3.16, CK 26,000 Head CT negative ST 101, PR 138 ms, QRS 80 ms, QTc 482 ms Tox Screen: negative

16 SYNTHACAINE? Online synthetic cocaine Possibly dimethocaine Local anesthetic

17

18 SD BRANDT, 2010 BMJ 17 Products 12 Websites 6 weeks after ban on mephedrone Contents analyzed

19 BMJ, CONT DMC included purported to contain dimethocaine No dimethocaine found

20 CASE WRAP-UP g Synthacaine Benzos and IVF Large septal perforation CK peak 84,000

21 METHOXETAMINE

22 Pharmacology NMDA (glutamate) antagonist Similar mechanism to what drugs?? Serotonergic (5-HT) Clinical Presentation?: 1. Tachycardia + Hypertension 2. Nystagmus 3. Altered mental status 4. Look for signs of serotonin toxicity

23 Case Presentation 45 year-old Male presents via EMS for seizure HR: 95, BP: 141/87, SpO2: 98% RA, FSBS: 109 Initially combative for EMS, now AO x4, no recall of event

24 HPI/PMHx/Meds Preparing for 29 mile bike race, bending over to stretch, came-to with people standing over him Hx of Anxiety and IBS, no hx of seizures Takes Buspar and Nortriptyline Social Hx: Denies x3 (?hx of Prescription drug abuse per nursing)

25 Other Hx Admits to taking OTC herbal energy supplement Bought at tobacco shop Took 3 vials in car 20 mins before event Product named Kratom

26 Kratom What is it? What is it used for? What are the active compounds?

27 Kratom Mitragyna speciosa Korth Native to swampy regions of Africa and Asia Leaves chewed or brewed into tea Used by manual labor classes

28 Dual Properties At low doses has stimulant properties like coca leaves combat fatigue, enhance tolerance High doses opium-like effect Used to combat withdrawal Onset: 5-10 min Duration: up to 1 hour

29 Active Compounds More than 25 alkaloids Percent composition depends on geographic location and season Mitragynine most abundant Structurally similar to yohimbine Thought to be responsible for opioid-like effects

30 13 X the potency of morphine Supraspinal mu and delta activity May stimulate postsynaptic α 2 May block 5-HT 2A Mitragynine

31 Is it Addictive? Cross-sectional study 88% reported daily use 90% drank as tea 87% admitted inability to stop using Abstinence has similar symptoms of opioid-withdrawal

32 Case Presentation 33 yo M Hx of Schizophrenia, polysubstance abuse Found in road, agitated T: 100.4, P: 78, BP: 137/74, RR: 14 (Vent)

33 Labs, imaging, etc. X-rays: multiple fractures Na 146, K 3.6, Cl 105, CO2 25, Gluc 92, BUN 15, Cr 1.3 Cocaine, Benzos, THC, Opiates Mom gives hx of Kratom and Chacruna use

34 Psychotria viridis Amazon basin Healers, shamans, religious ceremonies N,N-dimethyltryptamine

35 DMT Naturally occurring Indolealkylamine Serotonin, melatonin Potent, short-acting Hallucinogen

36 Toad Lickers 5-MeO-DMT Venom gland Tetrodotoxin

37 Other Tryptamines- Synthetic N,N-diisopropylmethoxytryptamine AMT (IT-290)

38 Toxicokinetics: DMT Typically smoked, snorted, injected Businessman s trip Peak 5-20 min DOA: min

39 5-HT 2A Site of action

40 Physiologic changes Often precede percepetual changes Sympathetic effects Predictable nausea and diarrhea makes it a very unlikely club drug

41 Risks Dysphoria, emotional labiltiy Trauma Psychiatric effects Rhabdo, renal failure

42 Production Mimosa tenuiflora root bark Lye Acetic acid Naphtha (short chain hydrocarbon)

43 WRAP-UP Interpret drug screens with caution Opioid abuse continues to be a hurcluean problem Treat carfentanil like other opioids but may need more naloxone Synthacaine is treated like other sympathomimetics Think of Methoxetamine as Ketamine Treat kratom withdrawal like opioid withdrawal Seizures reported with kratom use DMT is a hallucinogen, treat like other hallucinogens

44 THANKS

45 REFERENCES Goldfrank s Toxicological Emergencies, 9 th Edition Riba, et al. Human Pharmacology of Ayahuasca: Subjective and Cardiovascular Effects, Monoamine Metabolite Excretion, and Pharmacokinetics. J. Pharmacology and Experimental Therapeutics Gable RS. Risk Assessment of Ritual Use of Oral DMT and harmala alkaloids. Addiction Barker SA, et al. A Critical Review of Reports of Endogenous Psychedelic N,N -dimethyltyptamines in humans: Drug Test Analysis Micromedex Goldfrank s Toxicological Emergencies 9 th Edition Takayama H. Chemistry and Pharmacology of Analgesic Indole Alkaloids from the Rubiaceous Plant, Mitragyna speciosa. Chem. Pharm. Bull. 52 (8) (2004) Nelson JL, Lapoint J, Hodgman MJ, Albous KM. Seizure and coma following Kratom (Mitragynina speciosa Korth) Exposure. J. Med Toxicol. (2010) 6: Rosenbaum CD, Carreiro SP, Babu KM. Here Today, Gone Tomorrow and Back Again? J. Med Toxicol. (2012). 8: Boyer EW, Babu KM, Adkins JE, McCurdy CR, Halpern JH. Self-treatment of opioid withdrawal using kratom. Addiction. (2008) 103: Konstrand R, Roman M, Thelander G, Eriksson A. Unintentional Fatal Intoxications with Mitragynine and O- Desmethyltramadol from Herbal Blend Krypton. Journal of Analytical Toxicology. (2011) 35:242 Amad K, Aziz Z. Mitragyna speciosa usine in the northern states of Malaysia: a cross-sectional study. J Ethnopharmacol. (2012) 7:141: Babu KM, McCurdy CR, Bowyer EW. Opioid receptors and legal highs: Salvia divinorum and Kratom. Clinical Toxicology (2008) 46: PM Wax, et al. Ann Emerg Med. 2003; 41: