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Jay Lance Kovar, MD, FACEPTomball Regional Medical Center                   EMS WEEK                          2012
• Review new synthetic substances of abuse• Discuss pharmacology and clinical  presentations• Identify emergency treatment...
Just when you weregetting used todrunks and junkies…
•   synthetic product•   contains hallucinogenic, mind-    altering chemicals•   similar in structure to those    also fou...
•       Sold as:    •     a bath salt,    •     or plant food•       Labeled:    •      “for novelty use only”    •      “...
Ivory Wave is the most popular brand of this product  •   Vanilla Sky         • Ocean Burst  •   Fly                 • Lun...
• MDPV (methylene-dioxy-pyro-valerone)  usually referred to as pyro-valerone, (Super  Coke)  • powerful psychoactive chemi...
• Purposely designed in a way that will mimic the  effects of:  • Cocaine  • Crack  • Ecstasy• Most often used by snorting...
• It is sold most frequently  • on-line  • tobacco/smoke shops  • as a novelty item “not for human consumption”  • $30 for...
• Poison Control calls 2009       0• Poison Control calls 2010       303• Poison Control calls 2011       4,100Samples sei...
• Multiple manufactures sources  • Vary in purity, concentration, and fillers• Sold in  • packages 50mg to 200mg  • vials ...
Effects  • Onset, peak, and duration depends upon route  Major source seems to be China, routed through   New Orleans and ...
• Effects of amphetamines, cocaine, and ecstacy without  hangover, comedown, or depression commonly following  the use of ...
• Appears to be extremely addictive with many  users reporting an “almost uncontrollable urge  for another hit” immediatel...
• Acute psychosis  • Severe anxiety, paranoia, agitation, bizzarre behavior, tremors,    persecutory hallucinations• Sympa...
•   muscular pain/spasms•   emotional fragility•   acute paranoid psychosis•   sore jaw•   kidney failure•   loss of bowel...
• West Virginia woman scratched herself “to pieces”  over several days because she thought there was  something under her ...
 November 2010 - Louisiana man sliced his throat  and said, "I cant handle what this drug has done to  me. Im never going...
• January 2011 - Florida woman attacked and  attempted to behead her 71 year-old mother with a  machete.• March 2011 - Pen...
• May 2011 - West Virginia man killed his neighbors  goat. Man was found semi-dressed in womens  clothing in his bedroom w...
• K2
•       K2/Spice products are a mixture of herbal/spice plant        products sprayed with potent psychotropic drugs    • ...
• Symptoms/Side-Effects may include:  • mimics marijuana “high” (often induced more quickly/more intense    than “real” ma...
• Symptoms/Side-Effects may include:  •   increased respiration rate  •   elevated blood pressure (reported up to 200/100)...
•   Depending on synthetic compound in specific    commercial brand, can be anywhere from 4    times to over 100 times mor...
Price averages $45 for 3 grams (about equal to 3    sugar packets)-higher than good grade    marijuana•       Most often s...
• Developed by Dr. John W. Huffman, a Clemson University professor,  as part of research for National Institute for Drug A...
• Majority of the compounds were identified  as JWH related varieties  •   JWH-018 (63%)  •   JWH-250 (14%)  •   JWH-073 (...
• Nothing is known about metabolism of the  chemical compounds in K2/Spice drugs  • some may be toxic  • pharmacologically...
 There are hundreds more of these chemical  compounds containing strong, active  cannabinoid receptors agonists Increasi...
“hijacking the part of the brain important for many  major functions: temperature control, food  intake, perception, memor...
• Source primarily Mid-West US• Recent increase in sales from app. $1000 daily  up to $10, 000 daily.• Rapid and powerful ...
• The NEW Pot• Ancient drug (natural product)  • Psychoactive, dissociative, hallucinogenic• Non alkaloyd drug with simila...
• Uncontrollable laughter• Past memories, such as revisiting places from childhood  memory• Sensations of motion, or being...
• Controlled Substances Act amendment for Schedule I  status in 2002 did not pass• Texas banned 2011, Class A misdemeanor ...
• An imminently life threatening medical emergency…• Massive release of epinephrine, norepinephrine,  dopamine, serotonin ...
• Agitation or Excitement = Increased activity and intensity  • Aggressive, threatening or combative – gets worse when    ...
• Delirium = Confusion  • Disoriented     • Person, place, time, purpose  • Rapid onset over a short period of recent time...
• Psychotic = bizarre behavior  •   Thought content inappropriate for circumstances  •   Hallucinations (visual or auditor...
• Alcohol intoxication or withdrawal• Other drug use problems    • Example: Cocaine psychosis•   Pure psychiatric disease•...
•   Combative•   Self destructive•   Homicidal/suicidal•   Agitation followed by severe depression
• Differential  •   PCP  •   LSD  •   Cocaine  •   Methamphetamines  •   Alcohol  •   Hypoglycemia  •   Hypoxia  •   Head ...
• Urine Tox  • r/o routine street drugs + “polypharmacy”• BMP  • Hypoglycemia, metabolic acidosis• CBC  • Infection and an...
No AntidoteSupportive therapies• Sympathetic Overdrive  • Alpha and beta receptor stimulation  • Sustained endogenous nore...
No AntidoteSupportive therapies• Psychosis  • Benzodiazepines     • Versed, Valium, Ativan  • Antipsychotics     • Haldol,...
•   Unpredictable dose and duration•   Psychiatric evaluation when clear•   Home•   Jail•   Psychiatric facility
• Many European countries ban sale and use• Kansas was first state to ban use• 15 states so far to officially ban the sale...
 The Texas House passed a bill banning K2 or spice, a  synthetic marijuana The Texas Department of State Health Services...
Certain synthetic compounds deceptively labeled as “bath salts” and synthetic marijuana products (K2 or spice) have been a...
JWH-004;   JWH-193;   JWH-196;   JWH-203;        I, II, III, IV,JWH-007;   JWH-198;   JWH-197;   JWH-204;        IX, X, XI...
• If the patient has illegal substances, is using substances  illegally, or is under the influence of these substances,  a...
1.   They are harmless2.   They are neither food or drug3.   They have been marked “not for human consumption”4.   There i...
1.   Cocaine2.   Ecstasy3.   Methamphetamine4.   Mr. Bubble
1. Alcohol intoxication or withdrawal or Cocaine   psychosis2. Pure psychiatric disease3. Head injury or Dementia (Alzheim...
1. Developing a differential of causes and addressing   appropriately2. Administering the Bath Salt antidote3. Incomplete ...
1.   Bath salts are legal for purchase2.   Bath salts are legal to sell3.   Bath salts are legal to possess4.   Bath salts...
1.   32.   43.   54.   15.   4
Kovar/PHI Tcep 2012 bath salts
Kovar/PHI Tcep 2012 bath salts
Kovar/PHI Tcep 2012 bath salts
Kovar/PHI Tcep 2012 bath salts
Kovar/PHI Tcep 2012 bath salts
Kovar/PHI Tcep 2012 bath salts
Kovar/PHI Tcep 2012 bath salts
Kovar/PHI Tcep 2012 bath salts
Kovar/PHI Tcep 2012 bath salts
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Transcript of "Kovar/PHI Tcep 2012 bath salts"

  1. 1. Jay Lance Kovar, MD, FACEPTomball Regional Medical Center EMS WEEK 2012
  2. 2. • Review new synthetic substances of abuse• Discuss pharmacology and clinical presentations• Identify emergency treatment options for care
  3. 3. Just when you weregetting used todrunks and junkies…
  4. 4. • synthetic product• contains hallucinogenic, mind- altering chemicals• similar in structure to those also found in cocaine and ecstasy• depending on which brand or form is purchased.
  5. 5. • Sold as: • a bath salt, • or plant food• Labeled: • “for novelty use only” • “not for human consumption” • to by- pass FDA regulations-not being sold as food or drug product.• Sold in: • either 250 or 500 mg packets depending on brand or form purchased.
  6. 6. Ivory Wave is the most popular brand of this product • Vanilla Sky • Ocean Burst • Fly • Lunar Wave • Snow • Ivory • Lady Bubbles • Charge • Arctic Blast • Ivory Coast • Sextacy • Purple Wave • Disco • Cristalius • Magic • Snow Leopard • Ocean Blue • Natural NRG • Columbian Salts • Tranquility • Bolivian Salts
  7. 7. • MDPV (methylene-dioxy-pyro-valerone) usually referred to as pyro-valerone, (Super Coke) • powerful psychoactive chemical similar to Ritalin • acts as a stimulant that inhibits re-uptake of dopamine & norepinephrine • minimal effects on serotonin levels. • most versions of these products as containing Lidocaine • may also contain similar components to 2-DPMP or MDMA (aka ecstasy).
  8. 8. • Purposely designed in a way that will mimic the effects of: • Cocaine • Crack • Ecstasy• Most often used by snorting. • i.e. perfect for high school promotion
  9. 9. • It is sold most frequently • on-line • tobacco/smoke shops • as a novelty item “not for human consumption” • $30 for a small package • in bulk (50-100 packets) for a discount rate.Bath salts have increased in “club scene” use as ecstasy availability and use have declined
  10. 10. • Poison Control calls 2009 0• Poison Control calls 2010 303• Poison Control calls 2011 4,100Samples seized from different regionsreveal a great deal of variance despitethe same labels and producers
  11. 11. • Multiple manufactures sources • Vary in purity, concentration, and fillers• Sold in • packages 50mg to 200mg • vials 500mg• Consumed • orally, rectal, insufflated, injected, or smoked
  12. 12. Effects • Onset, peak, and duration depends upon route Major source seems to be China, routed through New Orleans and out I-10 corridor • Houston #1 • Montgomery County Top 10
  13. 13. • Effects of amphetamines, cocaine, and ecstacy without hangover, comedown, or depression commonly following the use of those drugs• Elevates mood, decreases hostility, raises energy levels, improves sense of well-being, improves attentions span and attention to detail, euphoria, empathy, and sexual stimulation.
  14. 14. • Appears to be extremely addictive with many users reporting an “almost uncontrollable urge for another hit” immediately, stating that its effects are several times stronger than cocaine when snorted.
  15. 15. • Acute psychosis • Severe anxiety, paranoia, agitation, bizzarre behavior, tremors, persecutory hallucinations• Sympathetic overdrive • Palpitations, shortness of breath, diaphoresis, hot flashes, headaches, hyperthermia, overwhelming thirst• Bruxism
  16. 16. • muscular pain/spasms• emotional fragility• acute paranoid psychosis• sore jaw• kidney failure• loss of bowel control• intense high followed by painful hangover• suppressed appetite
  17. 17. • West Virginia woman scratched herself “to pieces” over several days because she thought there was something under her skin.• August 2010 - UK man died after he experienced severe hallucinations and jumped off a cliff top.
  18. 18.  November 2010 - Louisiana man sliced his throat and said, "I cant handle what this drug has done to me. Im never going to touch anything again." Hours later he shot and killed himself when he had visions of army men swarming his house. December 2010 - Mississippi man shot and killed Tippah County Deputy Sheriff DeWayne Crenshaw at a disturbance call. It took six men more than half an hour to wrestle the man into an ambulance. He ripped through gurney straps and heavy medical tape.
  19. 19. • January 2011 - Florida woman attacked and attempted to behead her 71 year-old mother with a machete.• March 2011 - Pennsylvania man broke into a monastery and stabbed a priest.• March 2011 - Pennsylvania couple almost slashed their 5 year-old daughter with knives as they attacked “voices in the walls”.
  20. 20. • May 2011 - West Virginia man killed his neighbors goat. Man was found semi-dressed in womens clothing in his bedroom with blood everywhere. The goat was dead on the floor next to a pornographic photo.• June 2011 - Indiana man climbed a roadside flagpole and jumped into traffic.• July 2011 - Arizona man seriously burned his child’s hands because the child had touched his Bible. The man stated that voices told him the child was possessed.
  21. 21. • K2
  22. 22. • K2/Spice products are a mixture of herbal/spice plant products sprayed with potent psychotropic drugs • often contaminated with unidentified toxic substances which contribute to various adverse health effects • cause hallucinogenic effects similar to effects of PCP.• Marketed under variety of names • K2, Spice, Pep Spice, Spice Silver, Spice Gold, Spice Diamond, Smoke, Sence, Skunk, Yucatan Fire, Genie & Zohai• sold in variety of colors/flavors- usually sold in foil packaging
  23. 23. • Symptoms/Side-Effects may include: • mimics marijuana “high” (often induced more quickly/more intense than “real” marijuana) • hallucinations • seizures/tremors • coma/unconsciousness • vomiting • numbness/tingling • Paranoia amplified 4-10x
  24. 24. • Symptoms/Side-Effects may include: • increased respiration rate • elevated blood pressure (reported up to 200/100) • elevated heart rate (reported up to rate of 150) • increased level of anxiety/agitation leading to panic attacks (possible suicide attempts)
  25. 25. • Depending on synthetic compound in specific commercial brand, can be anywhere from 4 times to over 100 times more potent than marijuana (THC)• Sold in tobacco shops, head shops, and convenience stores• Sold as “incense” marked “not for human consumption”• Internet source from China
  26. 26. Price averages $45 for 3 grams (about equal to 3 sugar packets)-higher than good grade marijuana• Most often smoked but can be mixed in with food or drink• Most likely users: • 14-27 yr. olds • Prisoners/probationers • Military (use now banned by all military branches) • 50% of 2010 users were from mid-west US
  27. 27. • Developed by Dr. John W. Huffman, a Clemson University professor, as part of research for National Institute for Drug Abuse (NIDA) on endogenous cannabinoid receptors-but never tested on humans nor approved by FDA • “It is like Russian roulette to use these drugs. We don’t know a darn thing about them for real.” “It shouldn’t be out there.”• JWH-018 & many of its “cousins” such as HU-210/211, JWH-073 & CP 47/497 found in these drugs have a chemical structure shared with known cancer-causing agents.• All effects of K2/Spice drugs may not be known for very long time because of long time period that body stores them.
  28. 28. • Majority of the compounds were identified as JWH related varieties • JWH-018 (63%) • JWH-250 (14%) • JWH-073 (9%) • JWH-081 (5%) • JWH-200 (2%) • JWH-019, JWH-210, JWH-251, RCS-4, AM- 2201, AM-694, CP-47, CP-497, AM-356
  29. 29. • Nothing is known about metabolism of the chemical compounds in K2/Spice drugs • some may be toxic • pharmacologically active-differing from batch to batch in kind/amount applied • higher risk of accidental overdosing which has already been seen • increase numbers of ER incidents reported
  30. 30.  There are hundreds more of these chemical compounds containing strong, active cannabinoid receptors agonists Increasing challenges for toxicology testing, law enforcement and medical professionals. Causing difficulties for law enforcement agencies, probation & parole, as well as drug courts due to difficulties in testing for presence  one lab test now known to detect it in system but at cost of $50 & will probably not test positive for all the known variations
  31. 31. “hijacking the part of the brain important for many major functions: temperature control, food intake, perception, memory and problem solving. Many people taking these high-potency drugs are affecting important functions throughout their bodies-hormone functions for example.”Drugs may involve acute toxicity levels, possibly long term, as well as impacting cannabinoid receptors that regulate body’s immune system.
  32. 32. • Source primarily Mid-West US• Recent increase in sales from app. $1000 daily up to $10, 000 daily.• Rapid and powerful addiction on a level not usually found among smokers of “real” marijuana.• Recently linked to over 352 nationwide emergency room incidents • suicide attempts, extremely elevated heart rate/blood pressure, comas, seizures, and anxiety attacks.
  33. 33. • The NEW Pot• Ancient drug (natural product) • Psychoactive, dissociative, hallucinogenic• Non alkaloyd drug with similar effects to LSD • Most potent natural hallucinogen, low toxicity• 2006-2007 saw use grow from 750,000 to > 1,000,000 US persons• Chewed, tinctured, or smoked
  34. 34. • Uncontrollable laughter• Past memories, such as revisiting places from childhood memory• Sensations of motion, or being pulled or twisted by forces• Visions of membranes, films and various two-dimensional surfaces• Merging with or becoming objects• Overlapping realities, such as the perception of being in several locations at once• Youtube effect has mobilized• Communities to ban.
  35. 35. • Controlled Substances Act amendment for Schedule I status in 2002 did not pass• Texas banned 2011, Class A misdemeanor $4,000 fine• Banned by various branches of the U.S. military and some military bases
  36. 36. • An imminently life threatening medical emergency…• Massive release of epinephrine, norepinephrine, dopamine, serotonin in the body and brain.• Severe delirium and agitation 42
  37. 37. • Agitation or Excitement = Increased activity and intensity • Aggressive, threatening or combative – gets worse when challenged or injured • Amazing feats of strength • Pressured loud incoherent speech • Sweating (or loss of sweating late) • Dilated pupils/less reactive to light • Rapid breathing 43
  38. 38. • Delirium = Confusion • Disoriented • Person, place, time, purpose • Rapid onset over a short period of recent time • “He just started acting strange” • Easily distracted/lack of focus • Decreased awareness and perception • Rapid changes in emotions (laughter, anger, sadness) 44
  39. 39. • Psychotic = bizarre behavior • Thought content inappropriate for circumstances • Hallucinations (visual or auditory) • Delusions (grandeur, paranoia or reference) • Flight of ideas/tangential thinking • Makes you feel uncomfortable 45
  40. 40. • Alcohol intoxication or withdrawal• Other drug use problems • Example: Cocaine psychosis• Pure psychiatric disease• Head injury• Dementia (Alzheimer’s Disease)• Hypoglycemia• Hyperthyroidism 46
  41. 41. • Combative• Self destructive• Homicidal/suicidal• Agitation followed by severe depression
  42. 42. • Differential • PCP • LSD • Cocaine • Methamphetamines • Alcohol • Hypoglycemia • Hypoxia • Head trauma • CNS infection
  43. 43. • Urine Tox • r/o routine street drugs + “polypharmacy”• BMP • Hypoglycemia, metabolic acidosis• CBC • Infection and anemia• CT Head • Intracranial hemorrhage, hydrocephalus• 12 lead EKG• Biomarkers, myoglobin, lactic acid• Temperature monitoring
  44. 44. No AntidoteSupportive therapies• Sympathetic Overdrive • Alpha and beta receptor stimulation • Sustained endogenous norepinephrine release • Beta blocker caution?• Metabolic dysfunction • Hepatic metabolism of bath salts • Hyperthermia
  45. 45. No AntidoteSupportive therapies• Psychosis • Benzodiazepines • Versed, Valium, Ativan • Antipsychotics • Haldol, Inapsine • Geodon • Ketamine
  46. 46. • Unpredictable dose and duration• Psychiatric evaluation when clear• Home• Jail• Psychiatric facility
  47. 47. • Many European countries ban sale and use• Kansas was first state to ban use• 15 states so far to officially ban the sale & use of these products statewide.• October 2011 DEA made it illeagal to possess or sell the chemicals or products containing the chemicals found in bath salts in the US for 1 year pending a review of permanently banning them• Bath Salts are a Schedule 1 substance
  48. 48.  The Texas House passed a bill banning K2 or spice, a synthetic marijuana The Texas Department of State Health Services outlawed the fake pot last month after the Drug Enforcement Agency issued an emergency ban for a year. The possession of K2 a misdemeanor, but manufacturers and sellers would be charged with a felony effective September 2011
  49. 49. Certain synthetic compounds deceptively labeled as “bath salts” and synthetic marijuana products (K2 or spice) have been added to Penalty Group 2 of the Texas Controlled Substances Act.
  50. 50. JWH-004; JWH-193; JWH-196; JWH-203; I, II, III, IV,JWH-007; JWH-198; JWH-197; JWH-204; IX, X, XI,JWH-009; JWH-200; JWH-199; JWH-205; XII, XIII,JWH-015; JWH-210; JWH-030; JWH-206; XV, andJWH-016; JWH-211; JWH-145; JWH-207; XVI;JWH-018; JWH-212; JWH-146; JWH-208; delta-9-JWH-019; JWH-213; JWH-147; JWH-209; THC;JWH-020; JWH-234; JWH-150; JWH-237; delta-8-JWH-046; JWH-235; JWH-156; JWH-248; THC;JWH-047; JWH-236; JWH-243; JWH-249; Nabilone;JWH-048; JWH-239; JWH-244; JWH-250; HU-210;JWH-049; JWH-240; JWH-245; JWH-251; HU-211;JWH-050; JWH-241; JWH-246; JWH-252; andJWH-070; JWH-242; JWH-292; JWH-253; WIN-JWH-071; JWH-262; JWH-293; JWH-302; 55,212-2.JWH-072; JWH-386; JWH-307; JWH-303;JWH-073; JWH-387; JWH-308; JWH-304;JWH-076; JWH-394; JWH-346; JWH-305;JWH-079; JWH-395; JWH-348; JWH-306;JWH-080; JWH-397; JWH-363; JWH-311;JWH-081; JWH-398; JWH-364; JWH-312;JWH-082; JWH-399; JWH-365; JWH-313;JWH-094; JWH-400; JWH-367; JWH-314;JWH-096; JWH-412; JWH-368; JWH-315;JWH-098; JWH-413; JWH-369; JWH-316;JWH-116; JWH-414; JWH-370; CP-55,940;JWH-120; JWH-415; JWH-371; CP-47,497;JWH-122; JWH-175; JWH-373; andJWH-148; JWH-184; JWH-392; analoguesJWH-149; JWH-185; JWH-176; of CP-JWH-180; JWH-192; 47,497,JWH-181; JWH-167; JWH-194; JWH-201; includingJWH-182; JWH-195; VII, V, VIII,JWH-189; JWH-202;
  51. 51. • If the patient has illegal substances, is using substances illegally, or is under the influence of these substances, are we required to report that to the police?• No• Are we violating patient rights (HIPAA) if we report it?• No, commission of acrime invalidates HIPAAin Texas
  52. 52. 1. They are harmless2. They are neither food or drug3. They have been marked “not for human consumption”4. There is a popular demand
  53. 53. 1. Cocaine2. Ecstasy3. Methamphetamine4. Mr. Bubble
  54. 54. 1. Alcohol intoxication or withdrawal or Cocaine psychosis2. Pure psychiatric disease3. Head injury or Dementia (Alzheimer’s Disease)4. Hypoglycemia or Hyperthyroidism5. All of the above6/21/2012
  55. 55. 1. Developing a differential of causes and addressing appropriately2. Administering the Bath Salt antidote3. Incomplete without 5 large policemen to restrain the patient4. A contraindicated condition for Ketamine use.
  56. 56. 1. Bath salts are legal for purchase2. Bath salts are legal to sell3. Bath salts are legal to possess4. Bath salts sale, purchase, and possession are a felony
  57. 57. 1. 32. 43. 54. 15. 4
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