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The legal highs

Dr Ioana Vlad
Synthetic / emerging drugs
• What are they?
• How do patients present?
• How do we treat?
• What is all the fuss about?
Issues
- readily available in retail stores and online
- cheap
- highly attractive packaging
- perceived as safe drugs
- p...
Synthetic / emerging drugs
• Synthetic cannabinoids

• Synthetic cathinones

• Novel psychedelics / synthetic LSD
Synthetic cannabinoids
Synthetic cannabinoids
• Usually marketed as incense sticks
• Smoked or ingested “with a carrier high in
fat content”
• La...
Synthetic cannabinoids
•
•
•
•
•
•
•

Spice
K2
Happy Tiger Incense
Blueberry spice
Purple rush
Banana cream nuke
Kronic
Synthetic cannabinoids ( ~ 460)
Naphthoylindoles
JWH-018
JWH-081
JWH-250
AM-2201
JWH-073
JWH -200

Cyclohexylphenoles

CP-...
Synthetic cannabinoids
• 1984 John Huffman
University of Clemson
(USA)

• 2004 “Spice” appeared
in London - The Psyche
Del...
Advertised effects

• Euphoria / relaxation / laughter / feelings of joy
Clinical presentations
• Agitation / paranoid psychosis
• Seizures
• Nausea, vomiting
• Acute kidney injury
• Hypokalaemia...
Synthetic cathinones
Synthetic cathinones
- chemically similar to
cathinone found
in the khat plant of
eastern Africa
- manufactured in China
-...
3, 4-Methylenedioxypyrovalerone
(MDPV) & other synthetic cathinones
 effects similar to cocaine /
amphetamines / MDMA
- s...
MDPV timeline
 Developed in the 1960s for the
treatment of chronic fatigue, but
abandoned due to abuse and dependence

 ...
MDPV timeline

 2007: first seizure of MDPV as a recreational drug, by
customs officials in Germany (shipped from China)
...
 Sold as bath salts / insect repellant / research
chemical / plant food

 Sold mostly on the internet,
but can also be f...
 Red Dove
 Blue Silk
 Cloud Nine
 Ocean Snow
 Lunar Wave
 Vanilla Sky
 Ivory Wave
 White Lightning
 Scarface
 Pu...
Advertised effects
 Euphoric
 Anorectic
 Aphrodisiac
 Anxiogenic
 Increases alertness
 Inhibits sleep
Advertised effects
“ Swim says he finds MDPV a wonderful compund for getting things
done, like cleaning the flat, getting ...
Clinical presentation

dopamine-noadrenaline reuptake inhibitors (NDRI)
- Agitation / aggression / paranoid delusions with...
MDPV

 quick onset

 peak effects for 3 - 4 hours

 tachycardia, hypertension, and mild stimulation
last 6 - 8 hours
MDPV’s chemical ‘cousins’
 α-pyrrolidinopropiophenone (α-PPP)
- detected in Germany in seized "ecstasy" tablets

 4'-met...
Gen 2, 3 etc. of “bath salts”
• Naphyrone / O-2482 / naphthylpyrovalerone
– “Cosmic Blast” - marketed as a jewelry
cleaner...
What are the issues with MDPV?
What are the issues with MDPV?
"MDPV is the most compulsive drug swim has ever done, he
just can't stop hitting that pipe,...
What are the issues with MDPV?
"MDPV is like the bastard with a whip you've got to obey
or you get hurt. Then you obey and...
Novel psychedelics / NBOMe

Alexander Shulgin

Albert Hofmann
Novel psychedelics / NBOMe
Novel psychedelics or synthetic LSD
 25B-NBOMe / 25I-NBOMe
 derivatives of the 2C family of phenethylamine
psychedelics
...
Advertised effects
 90s – replacement for ecstasy

 Colourful hallucinations
 Feelings of empathy
 Feelings of closene...
Effects
• Aggitation / extreme behaviours
• Tahycardia, hypertension
• Hyperthermia
• Seizures
• Metabolic acidosis
• Mult...
Effects

- onset ~15 min
- may last 6-10 hours
- active at very low doses
Treatment
- Supportive care - benzodiazepines for agitation,
seizures, tachycardia, and hypertension
- Significant hyperth...
Legislation issues
- June 2011 – synthetic cannabinoids banned in WA /
QLD / VIC and then federal
- October 2011 – MDPV ba...
DMEC
Methedrone
Ethedrone
3-MOMC
2-FMC
2-FEC
3-FMC
3-FEC
3-CMC
3-BMC
Flephedrone
4-FEC
Brephedrone
FMMC
2,5-DMOMC
bk-MDA
2...
• Urine drug screens will not pick them up

• Blood tests available
– Expensive
– Only for identified structures
Legislation issues

- Sept 2013 – NSW law banning “manufacture, supply
and advertising of psychoactive substances (schedul...
Take home messages
- drugs of abuse are forever changing
- manipulation of basic chemical structures to
avoid legal ramifi...
Emerging illicit drugs of abuse
Emerging illicit drugs of abuse
Emerging illicit drugs of abuse
Emerging illicit drugs of abuse
Emerging illicit drugs of abuse
Emerging illicit drugs of abuse
Emerging illicit drugs of abuse
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Emerging illicit drugs of abuse

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Emerging illicit drugs of abuse

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  • {"38":"Psychedelic crisis; also seizures\n","27":"Also highly addictive\n","44":"Also highly addictive\n","28":"Also highly addictive\n","17":"four times the potency of Ritalin and Concerta\n","6":"Peanut butter, full fat milk, cream\n","45":"Also highly addictive\n","34":"CNS transmitter; low levels – ADHD, high levels - schizophrenia\n","35":"Also highly addictive\n","24":"other drugs with a similar chemical structure to MDPV\n","41":"Also highly addictive\n","3":"Also highly addictive\n","42":"2009 – 23 new drugs detected by the European Centre for Monitoring Drugs and Drug Abuse; 2011 - 49\n","20":"other drugs with a similar chemical structure to MDPV\n","9":"in the 80s to study interaction between drugs and brain receptors in research related to AIDS, MS, chemotherapy\n","37":"Psychedelic crisis; also seizures\n","26":"Also highly addictive\n","15":"four times the potency of Ritalin and Concerta\n","32":"Vasoconstrictor / PPH deriv. ergotamine;  PiHKAL and TiHKAL - standing for Phenethylamines and Tryptamines I Have Known And Loved), which extensively described their work and personal experiences with psychedelic drugs\n"}
  • Transcript of "Emerging illicit drugs of abuse"

    1. 1. The legal highs Dr Ioana Vlad
    2. 2. Synthetic / emerging drugs • What are they? • How do patients present? • How do we treat? • What is all the fuss about?
    3. 3. Issues - readily available in retail stores and online - cheap - highly attractive packaging - perceived as safe drugs - party pills / herbal highs / legal highs / nutritional supplements - not easily detectable in urine or blood samples
    4. 4. Synthetic / emerging drugs • Synthetic cannabinoids • Synthetic cathinones • Novel psychedelics / synthetic LSD
    5. 5. Synthetic cannabinoids
    6. 6. Synthetic cannabinoids • Usually marketed as incense sticks • Smoked or ingested “with a carrier high in fat content” • Labeled “not for human consumption”
    7. 7. Synthetic cannabinoids • • • • • • • Spice K2 Happy Tiger Incense Blueberry spice Purple rush Banana cream nuke Kronic
    8. 8. Synthetic cannabinoids ( ~ 460) Naphthoylindoles JWH-018 JWH-081 JWH-250 AM-2201 JWH-073 JWH -200 Cyclohexylphenoles CP-47497 CP 47 CP 497 • structurally different from THC but same effect on cannabinoid receptors
    9. 9. Synthetic cannabinoids • 1984 John Huffman University of Clemson (USA) • 2004 “Spice” appeared in London - The Psyche Deli company
    10. 10. Advertised effects • Euphoria / relaxation / laughter / feelings of joy
    11. 11. Clinical presentations • Agitation / paranoid psychosis • Seizures • Nausea, vomiting • Acute kidney injury • Hypokalaemia / hyperglycaemia • Hyperthermia • SVT / cardiomyopathy / acute LVF / AMI • Hypertension
    12. 12. Synthetic cathinones
    13. 13. Synthetic cathinones - chemically similar to cathinone found in the khat plant of eastern Africa - manufactured in China - tablets or powder / swallowed, snorted or injected - most common - 3,4 methylenedioxypyrovalerone (MDPV), mephedrone, methylone
    14. 14. 3, 4-Methylenedioxypyrovalerone (MDPV) & other synthetic cathinones  effects similar to cocaine / amphetamines / MDMA - sometimes labeled as legal cocaine or legal amphetamines
    15. 15. MDPV timeline  Developed in the 1960s for the treatment of chronic fatigue, but abandoned due to abuse and dependence  1969: Boehringer Ingelheim files a patent application for MDPV  2005: MDPV on recreational drugs markets and mentioned on Drugs forum
    16. 16. MDPV timeline  2007: first seizure of MDPV as a recreational drug, by customs officials in Germany (shipped from China)  2009: MDPV made illegal in Denmark 2010: UK 2011: USA, Australia
    17. 17.  Sold as bath salts / insect repellant / research chemical / plant food  Sold mostly on the internet, but can also be found in adult or herbal shops  Labeled “not for human consumption.”
    18. 18.  Red Dove  Blue Silk  Cloud Nine  Ocean Snow  Lunar Wave  Vanilla Sky  Ivory Wave  White Lightning  Scarface  Purple Wave  Star Dust  Hurricane Charlie
    19. 19. Advertised effects  Euphoric  Anorectic  Aphrodisiac  Anxiogenic  Increases alertness  Inhibits sleep
    20. 20. Advertised effects “ Swim says he finds MDPV a wonderful compund for getting things done, like cleaning the flat, getting long boring e-mails written and sent and working through shitloads of Uni-grade maths at hyperspeed. The lack of euphoria is almost concieved as positive by SWIM as it doesn't distract him from the task at hand." "...lower doses of MDPV produces a clarity of thought far superior to just about every other stimulant I've ever tried."
    21. 21. Clinical presentation dopamine-noadrenaline reuptake inhibitors (NDRI) - Agitation / aggression / paranoid delusions with violent behaviour / increased alertness/awareness / insomnia - Headache, confusion, seizures - Movement disorders - bruxism / muscle spasms - Abdominal pain - Rhabdomyolysis, renal failure; hyponatraemia - Tachycardia, hypertension, vasoconstriction – STEMI - Tachyarrhythmias - Hyperthermia
    22. 22. MDPV  quick onset  peak effects for 3 - 4 hours  tachycardia, hypertension, and mild stimulation last 6 - 8 hours
    23. 23. MDPV’s chemical ‘cousins’  α-pyrrolidinopropiophenone (α-PPP) - detected in Germany in seized "ecstasy" tablets  4'-methyl-α-pyrrolidinopropiophenone (MPPP) - Germany late 1990s / early 2000s  3',4'-methylenedioxy-α-pyrrolidinopropiophenone (MDPPP) - Germany late 1990s / early 2000s - imitation ecstasy
    24. 24. Gen 2, 3 etc. of “bath salts” • Naphyrone / O-2482 / naphthylpyrovalerone – “Cosmic Blast” - marketed as a jewelry cleaner – triple reuptake inhibitor (serotonin / noradr / dopamine) – anecdotal reports of prolonged toxicity and severe hyperthermia • Pentedrone, Alpha-PVP, 3,4-DMMC
    25. 25. What are the issues with MDPV?
    26. 26. What are the issues with MDPV? "MDPV is the most compulsive drug swim has ever done, he just can't stop hitting that pipe, it's worse than fucking crack! He's been at it since 11am, 16 hours ago, and in that time he's done 150mg so far, solely via the pipe, far too much!! He's still got over 300mg left, aargh!!! ...He's not even sure if he's still enjoying it, don't think he is, but still he can't stop hitting that pipe for some reason (though he does know why really, dopamine = reward innit). Bloody strange substance! Any swimer fancy coming round and freeing swim of this bloody pipe?"
    27. 27. What are the issues with MDPV? "MDPV is like the bastard with a whip you've got to obey or you get hurt. Then you obey and get hurt even worse. Finally, it's "Thank you sir may I have another... thank you sir, may I have another... thank you sir, may I have another..." and you wonder why you've come to enjoy feeling like shit nearly every waking moment. You vow never to touch MDPV again, then an hour or two after it wears off you find yourself eagerly using MDPV."
    28. 28. Novel psychedelics / NBOMe Alexander Shulgin Albert Hofmann
    29. 29. Novel psychedelics / NBOMe
    30. 30. Novel psychedelics or synthetic LSD  25B-NBOMe / 25I-NBOMe  derivatives of the 2C family of phenethylamine psychedelics  very potent partial agonists 5HT – 2A receptor  snorted or dissolved into a liquid and placed on blotter paper under the tongue
    31. 31. Advertised effects  90s – replacement for ecstasy  Colourful hallucinations  Feelings of empathy  Feelings of closeness with others
    32. 32. Effects • Aggitation / extreme behaviours • Tahycardia, hypertension • Hyperthermia • Seizures • Metabolic acidosis • Multiorgan failure
    33. 33. Effects - onset ~15 min - may last 6-10 hours - active at very low doses
    34. 34. Treatment - Supportive care - benzodiazepines for agitation, seizures, tachycardia, and hypertension - Significant hyperthemia may require passive or active cooling - Consider checking electrolytes, renal and liver function tests, cardiac markers, CK - Observe until resolution of abnormal vital signs, vomiting, and psychiatric symptoms
    35. 35. Legislation issues - June 2011 – synthetic cannabinoids banned in WA / QLD / VIC and then federal - October 2011 – MDPV banned in USA and most European countries - February 2012 – WA bans MDPV The problem: drugs could only be added to the list once identified
    36. 36. DMEC Methedrone Ethedrone 3-MOMC 2-FMC 2-FEC 3-FMC 3-FEC 3-CMC 3-BMC Flephedrone 4-FEC Brephedrone FMMC 2,5-DMOMC bk-MDA 2,3-MDMC Methylone Ethylone O-2384 α-PVP (O-2387) 4-MeMABP 4-Me-NEB 4-Methoxybuphedrone Butylone Eutylone BMDB bk-DMBDB 5-Methylmethylone 5-Methylethylone 2-Methylbutylone 5-Methylbutylone Pentylone MMP MEP bk-Methiopropamine αPhthalimidopropiophen one α-PPP α-PBP EDMC 3,4-DMMC
    37. 37. • Urine drug screens will not pick them up • Blood tests available – Expensive – Only for identified structures
    38. 38. Legislation issues - Sept 2013 – NSW law banning “manufacture, supply and advertising of psychoactive substances (schedule 9)”
    39. 39. Take home messages - drugs of abuse are forever changing - manipulation of basic chemical structures to avoid legal ramifications - the classes of drugs more important than names - effects: psychoactive and sympathomimetic - symptomatic management -BZDs are a useful adjunct
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