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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

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Disclosures*

Dr. Wilens has served as a consultant or has received grant support from the following:

• NIH (National Institute on Drug Abuse) • Ironshore, Neurovance (Euthymics), Sunovion, Tris • National Football League (ERM), Minor/Major League Baseball • Bay Cove Human Services, Phoenix House (Clinical Services) • (Co)Edited Straight Talk About Psychiatric Medications for Kids (Guilford

Press); ADHD Across the Lifespan (Cambridge Univ Press); Comprehensive Clinical Psychiatry; Psychopharmacology & Neurotherapeutics (Elsevier)

• 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

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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

http://www.drugabuse.gov/publications/drugfacts/mdma-ecstasy-or-molly

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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

http://www.drugabuse.gov/publications/drugfacts/mdma-ecstasy-or-molly

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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

• ????

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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

http://www.drugabuse.gov/publications/drugfacts/synthetic-cathinones-bath-salts

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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

http://www.drugabuse.gov/publications/drugfacts/synthetic-cathinones-bath-salts

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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

http://www.drugabuse.gov/publications/drugfacts/synthetic-cathinones-bath-salts

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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

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Case of Joe

• Joe is a 17 yo 11th grader with history of untreated ADHD

• 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

• He has a history of smoking marijuana from age 14 on

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Case of Joe

• Physical exam notable for BP 150/1000, 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

• Toward the end of your exam the patient has a brief clonic-tonic seizure

• Stat urine toxicology is negative

• ????

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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)

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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.

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Recent “Synthetic” Drugs of Abuse

• Synthetic Marijuana (spice, K2, herbal incense)

– Reactions: agitation, convulsions/seizures, 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

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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

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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)

– 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

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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