November 29, 2010 (simone)
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November 29, 2010 (simone)

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This presentation was created by Karen Simone, PharmD, DABAT, Director, Northern New England Poison Center for the 11/29/10 CADCA town hall.

This presentation was created by Karen Simone, PharmD, DABAT, Director, Northern New England Poison Center for the 11/29/10 CADCA town hall.

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    November 29, 2010 (simone) November 29, 2010 (simone) Presentation Transcript

    • Northern New England Poison Center Teen Poisonings from RX Drugs to K2, Salvia and Monster Karen E. Simone, PharmD, DABAT simonk@mmc.org 1 207-662-7221
    • Contents• Overview of poisoning (abuse, suicide, other)• Types of teen substance abuse poisonings• Most commonly abuse substances (by teens)• Substances used in teen suicide attempts• Information about the substances abused 2
    • Northern New England Poison Center Staff• Physicians board-certified in Toxicology• PharmD board-certified in Toxicology• Nurses nationally-certified in Poison Information• Nurses in Training• Nurse Educators, some with Public Health Masters• EMTs and other providers (under supervision)• Administrative, including toxicsurveillance specialist 3
    • Northern New England Hotline Calls N = 107,533 Human Poisonings 30% Animal Poisonings 2% Confirmed Non- Exposures <1%Questions ME, NH, VT; 2009 68% 4
    • Types of Poisonings Hotline Call Reasons• Unintentional – General, environmental, misuse, therapeutic error, occupational, food poisoning, bite/sting• Intentional – Abuse, misuse, suicide attempt• Other – Malicious, tampering/contamination, withdrawal• Adverse effect – Drug, chemical, other• Unknown 5 – Drug, chemical, other
    • Types of Calls Question Types• Substance Abuse – Identification, effects, drug screens, withdrawal• Medication – Pharmacology, adverse effects, interactions, withdrawal• Toxicology – General, environmental, food poisoning, pregnancy/lactation• Prevention/safety – Plants, lectures/health fairs, printed materials• Occupation – Safety, monitoring• Medical/legal/other – Drug, chemical, other 6
    • Poisonings in Teens 13 - 18 years N=926 Suicide Attem pt 24%Unintentional: 26% therapeutic error 29% misuse Substance Abuse/Withdraw al 12% Other Intentional 11% Adverse /reaction 3% Unintentional Malicious/tam pering 47% 2% Unknow n 1% ME from July 2009 - June 2010 7
    • Substance Abuse/Withdrawal Children under 19 years N=156 substances Alcohol: Mostly unknown beverage, Other some vodka and 9% tequila, Listerine spray Dextrom ethorphan Plants/m ushroom s and hand sanitizer 4% 21% Antidepressants 5% Inhalants: Keyboard cleaner, disc cleaner,Antihistam ines spray paint, markers, 6% helium, nail polish remover, fire extinguisher Inhalants 6% Stim ulants/street drugs 18%Sedatives/hypnotics Plants: Nutmeg (3), 9% kratom (1) Alcohol Analgesics (opioid m ostly) 10% 12% Substance Abuse 8 ME from July 2009 - June 2010
    • Stimulants and Street Drugs Children under 19 years N=28 Cocaine K2 4% 7% Ecstasy and related 11% Marijuana 35%Caffeine (pills/drinks) 14% ADHD Medications Substance Abuse 29% 9 ME from July 2009 - June 2010
    • Analgesics Children under 19 years N=18 Unknow n opioid 6%Hydrocodone (Vicodin, Lortab) Buprenorphine (Suboxone) 6% 21% Tram adol (Ultram ) 11% Ibuprofen (Motrin) 11% Acetam inophen (Tylenol) 17% Codeine 11% Oxycodone (OxyContin, Percocet) Substance Abuse 17% 10 ME from July 2009 - June 2010
    • Sedatives/Hypnotics Children under 19 years N=14 Antipsychotic 21% Benzodiazepine (Xanax, Ativan, Valium , Klonopin) 43%Zolpidem (Am bien) 36% Substance Abuse 11 ME from July 2009 - June 2010
    • Suicide Attempts Children under 19 years N=336 substances Other Sedatives/hypnotics 9% 13% Antihistam ines 6% Cough and cold 5% AlcoholsAntidepressants 4% 19% Stim ulants/street drugs 4% Anticonvulsants 3% Vitam ins 2% Antibiotics 2% Cardiovascular Analgesics 2% 31% Suicide Attempts ME from July 2009 - June 2010 12
    • Analgesics Children under 19 years N=106 substances Aspirin 10%Acetam inophen (Tylenol) Opioids 30% 9% Acetam inophen w ith (diphenhydram ine, caffeine, m enstrual) 9% Acetam inophen and Aspirin 6% Other (phenazopyridine) 1% NSAIAs (ibuprofen, naproxen) 35% Suicide Attempts ME from July 2009 - June 2010 13
    • PCP (Phenycyclidine)-like• Dextromethorphan (DXM) +/- antihistamine – Slang: DXM, RoboTrip or Triple C – Products: Robitussin DM, Coricidin HBP for Cough and Cold, others• Dissociative analgesic/anesthetic in overdose – Caused by metabolite – dextrorphan – Dissociation of thalamoneocortical from limbic systems• Drowsiness or agitation – Coma or seizures possible but not common• Vertical or rotary nystagmus may be present• Large or small pupils possible 14
    • Amphetamines• Amphetamine brand names: Adderall, Dexedrine, Vyvanse• Amphetamine-like brand names: Ritalin, Concerta, Methylin, Focalin• Medical concerns: – Increased heart rate and blood pressure (irregular heart rhythm, heart attack, stroke) – Increased body temperature – Seizures – Psychosis Similar to cocaine – Addiction 15
    • What do all of these products have in common? 16
    • Caffeine 17
    • Caffeine – Dietary SupplementsYellow Swarm Extreme Energizer by Yellow Jacket• Yellow Swarm Extreme Energizer, Yellow Jacket• Ephedra Free,• Herbal Dietary Supplement,• Extreme Energy.• Yellow Swarm Extreme Energizer is a proprietary blend of herbs that combines Green Tea Extract, Yerba Mate, Guarana, Capsicum and Kola Nut. Yellow Swarm (Yellow Jacket) provides you with an extreme boost of energy when you need it.• Supplement Facts Serving Size: 1 capsule Amount Per Serving % Daily Value Caffeine (anhydrous) 300mg Proprietary Blend 211mg Green Tea Extract 60% (Leaves)(4.5 mg Caffeine Alkaloids), Yerba Mate (leaves), Guarana (Seeds), Capsicum Annuum (fruit), Kola Nut (seeds)(<1 mg Caffeine Group Alkaloids), Ginseng (Root) 18
    • Caffeine Content:• Tea (green-black) 40-50mg/8oz• Coffee 100mg/8oz• Starbucks Grande 330mg/16oz• Coca-Cola Classic 35mg/12oz• Mountain Dew 54mg/12oz• Red Bull 76mg/8.3oz• Monster 160mg/16oz• No Doz 200mg/tablet 19
    • What effects can occur?• Stomach: upset stomach and vomiting, sometimes abdominal pain and diarrhea• Nervous System: anxiety, agitation, irritability, tremor, headache, dizziness, hallucinations (not common) and seizures• Heart: rapid heartbeat, increased blood pressure, chest pain and irregular rhythms 20
    • Energy Drinks - Teenage Problem?• Large amounts are available in forms marketed to teens and young adults.• Teens and young adults often lack the good judgment to limit dosing.• Some ingest up to 5 cans of energy drink (equivalent to 8 cups of coffee) in one sitting. 21
    • What about caffeine with alcohol?• More risky behaviors (possibly)• Not safer to drive: performance not significantly better, in some ways worse• May not realize unsafe to drive: may have false sense of ability to drive safely 22
    • What about carbs and calories?• Sobe Adrenaline Rush 16 oz (2 servings): – Calories: 260 – Carbs: 68 g (22%) with 66 g as sugars• Red Bull 8.3 oz (1 serving) – double if 16.9 oz: – Calories: 110 – Carbs: 28 g (9%) with 27 g as sugars 23
    • Which has more carbs? 24
    • Winner – Most Carbs • Sobe Adrenaline Rush 16 oz (2 servings): – Calories: 260 – Carbs: 68 g (22%) with 66 g as sugars Coke and Pepsi have ~ 40 g carbs • Starbuck’s Grande Latte 16 oz: per 12 oz – Calories: 280 (150 calories) – Carbs: 36 (12%) with 34 g as sugars • Krispy Kreme Donut – Chocolate Iced Kreme Filled: – Calories: 350 – Carbs: 39 g (13%) with 23 g as sugars • McDonald’s Big Mac: – Calories: 540 – Carbs: 45 g (15%) with 9 g as sugarsCaloric intake (16 – 18 yrs): 1800 – 2400 (females), 2400 – 3200 (males)25
    • Mushrooms (Shrooms)• Timing: – Onset: 10 – 30 minutes – Duration: 4 – 5 hours – Back to normal: 6 – 12 hours• Effects: – Fast heart rate, increased blood pressure, large pupils, dry mouth, nausea/vomiting – Uncontrollable laughter, vivid hallucinations (bright colors and shapes) – Loss of sense of time, meditative 26
    • Salvia divinorum• Names: – Diviner’s sage, magic mint, Maria Pastoria• Use: – Ceremonial healing – Divination rituals – An entheogen (“that which causes god to be within a person”)• Component: salvinorin A – Type: ?dissociative hallucinogen? • Similar to: PCP, ketamine and DXM – Mechanism: Opioid kappa agonist • Similar to: butorphanol (Stadol®) and pentazocine (Talwin®) – Dose: 100 – 200 mcg 27
    • Salvia divinorum• Routes: – Oral: Chew leaves or drink extract from fresh leaves • Onset: 5 – 10 minutes • Peak: 1 hour • Duration: 2 hours – Inhalation: Smoke dried leaves • Onset: 30 seconds • Peak: 5 – 10 minutes • Duration: 20 – 30 minutes 28
    • Salvia divinorum• Hallucinogenic effects: – Type: out of body experience, entering another reality, time and space displacement – Effects: altered perceptions, hallucinations, ataxia, depersonalization, hysterical laughter, incoherent speech, unconsciousness – Onset/duration: rapid/an hour or so – Dose relationship (inhalation): • Hallucinations: 0.2 – 0.5 mg • Out-of-body experience: > 1 mg 29
    • K2 (Spice, Spice Gold)• Synthetic cannabinoid (JWH- 018 and JWH-073)• Anticipate similar effects to marijuana• Probably not illegal yet• Not anticipated to cross with marijuana screens 30
    • K2 (Spice, Spice Gold)• Rapid heart rate, elevated blood pressure• Anxiety/agitation/hallucinations• Drowsiness/slurred speech• Vomiting• Numbness/tingling, tremors/seizures• Pale appearance, dilated pupils Dried herbs sprayed with synthetic cannabinoid-like substance 31
    • Kratom – per label Stimulant and Depressant?Amazing legal high / herbal high!Low dose: stimulating and euphoricHigh dose: sedative at higher dosesPlant: mitragynaActive ingredient: mitragynineMechanism: stimulates delta opioid receptorsEffects:Calms the mind, lowers anxietyCauses to feel: happy, strong, and active, with astrong desire to do workOnset: 5 - 10 minutes after useDuration: several hours (longest with highest dose),positive afterglow effect possible 1 day after useHigh dose effect: a state of blissful euphoria with the 32possibility of mild visuals
    • Kratum (mambog) – per science• Mitragyna with mitragynine• Psychoactive, opioid substitute• Use: increase productivity and heat tolerance• “Therapeutic” effects: – Onset 5 – 10 minutes after chewing leaves – Type: mild euphoria and stimulation• Overdose: – Effects: nausea, vomiting, flushing, stupor, vertigo, giddiness, tremors of face, extremities and tongue, rombergism (loss of positional sense – unable to balance standing with feet together and eyes closed)• Chronic toxicity: – Effects: anorexia, weight loss, abdominal distension and constipation, skin discoloration (dry, unhealthy, tan without sun OR pallor), (numbness and twitching)• Withdrawal: – Effects: aggression, tearfulness, runny nose, muscle aches, “jerky” motions 33