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Update on Drugs of Abuse
Trends in Florida
Melissa Parsons, MD
Department of Emergency Medicine
University of Florida College of Medicine-Jacksonville
Learning Objectives
1. Understand general trends for drugs of abuse
in Florida
2. Become familiar with toxidromes
3. Recognize excited delirium syndrome and
factors that increased morbidity/mortality
NO FINANCIAL DISCLOSURES
CASE 1
CASE 1
CASE 1
• What do you want to do now?
RSI ?
Naloxone ?
OPIOIDS
Opioids
TOXIDROME
• CNS sedation
• Hypothermia
• Hypotension
• Hyporeflexia
• Bradycardia
• Miosis (pinpoint pupils)
• Respiratory depression
• Seizures
– Meperidine (Demerol), Tramadol
• Rigidity, myoclonus
– Fentanyl
Opioids
Management
• Supportive
• Naloxone
– Indication: reverse respiratory
depression
– Adults: 0.4mg—2mg
– Pediatrics <5 years 0.1 mg/kg
– Max 10 mg
– May need high doses for
fentanyl
– IV, SC, IM, IN, IO
– Half life: 1 hour
Spike in deaths due to heroin and fentanyl
447
538
0
100
200
300
400
500
600
2006 2007 2008 2009 2010 2011 2012 2013 2014
Deathsfromheroinandfentanyl
Heroin
Fentanyl
Florida Medical Examiners Commission Annual Drug Reports
2007-2014
Crack down on
“pill mills” and
opioid prescribing
208
271
250
230
150
109
78 93
119
95
48 57
108
199
447
0
50
100
150
200
250
300
350
400
450
500
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
HeroinDeaths Number of Heroin Deaths in Florida: 2000-2014
2014 Florida Medical Examiners Commission Annual Drug Report
Fentanyl
• Synthetic opiate
– 100 times more powerful than
morphine
– 30-50 times more powerful
than heroin
• “Breaking Bad” “Blue Drop”
“Theraflu” “China White”
• Imported from Mexico and
China
Fentanyl
CASE 2
CASE 2 – Patient feels like this…
CASE 2
• What do you do now?
•Let her refuse
transport?
•Sedate her?
CANNABINOIDS
SYNTHETIC CANNABINOIDS
Cannabinoids
 Compounds found in the marijuana plant
 THC is the most psychoactive (strong hallucinogen).
 Street names: “ganja,” “MJ,” “ragweed,” “reefer” and “grass.
Clinical Effects
 Psychological
 Alterations in perception, feelings of
well-being, increased appetite
 Physiological
 Acute: Increased HR and BP
 Chronic: Decreased HR and blood
pressure
 Decreased coordination
 Delay in psychomotor skills
 CNS depression (especially peds)
 Slurred speech
 Rare: apnea, cyanosis, hypotonia
Marijuana Ingestion
• Marijuana Wax, “Budder,” or Butane hash oil,
or “Ear wax hash”
90% THC
Marijuana wax
20% THC
Marijuana joint
Marijuana or “Vap” pens
Synthetic Cannabinoids…
Abuse of Synthetic Drugs an Epidemic
Abuse of Synthetic Drugs an Epidemic
• 2012 Synthetic Drug Abuse Prevention Act
– Places 26 synthetic drugs including types of
cannabinoids and cathinones under Schedule 1
– Illegal drug makers have 100s more to take their place
– NO quality control (Russian Roulette)
– Often products labeled “not for human
consumption”
• Unknown chemicals
• Unknown potency
• Constantly changing
Russian Roulette
Mystery packages
Drug makers constantly producing new synthetic
cannabinoids products to evade laws on older
compounds… impossible to keep up.
2015: >30
compounds
Synthetic Cannabinoids
• Synthetic chemicals sprayed onto dried plants
• They are 5-45 times more potent than THC
and more toxic to brain and the heart
Synthetic Marijuana is a misnomer
Marijuana User
Synthetic Cannabinoid User
Man decapitated his wife, killed two dogs, cut off his left hand, and gouged his right eye out
Man kills two women using a knife and
tomahawk while trying to find the ‘portal to
hell” in their backyard shed
Synthetic Cannabinoids
Symptoms:
• Seizures
• Psychosis
– Patients without psych history
– Paranoia, agitation and anxiety
– Suicidal or homicidal ideation
• CV events
– Tachycardia and
tachydysrhythmias
– MI
– Stroke
• Respiratory failure
• Acute kidney injury
• Hyperthermia
• Hyperemesis
Management:
• Supportive care
• Sedation
– Benzodiazepines
– Ketamine
– Avoid antipsychotics
• IVFs for AKI or rhabdomyolysis
• Low stimulus environment
Risk Factors for increased mortality:
1. New Psychosis/ Excited delirium with use
• Trauma or injury
• Restraint procedures by law enforcement
• Chemically sedate… avoid restraints
2. Pre-existing cardiovascular conditions
3. Co-ingestions
CASE 3
CASE 3
• What do you want to do now?
EXCITED DELIRIUM SYNDROME
Excited Delirium Syndrome
Clinical Features:
• Hyper-aggression/agitation
– Catecholamine surge and acidosis
– Superhuman strength
• Autonomic dysfunction
• Hyperthermia
• Acidosis
• Rhabdomyolysis, hyperkalemia
• Acute kidney injury
• Can be difficult to
recognize and manage in
prehospital setting.
• May mimic other medical
conditions
• Attempt de-escalation
techniques
• Personal safety issue for
first responders
Excited Delirium Syndrome
• Management:
– Agitation: chemical and physical restraint
– Hyperthermia: Active and passive cooling
– Hypoxia: Airway support
– Acidosis: IVF, Bicarb if severe
– Rhabdo/Hyperkalemia: IVF, Calcium chloride,
Bicarb
Excited Delirium Syndrome
KETAMINE:
• 4-5 mg/kg IM or 2 mg/kg IV
• Rare side effects
• Increased oral secretions,
• Laryngospasm,
• Hypertension,
• Distress from emergence phenomena
BENZO’s:
• Effective.
• Potential for respiratory depression
ANTIPSYCHOTICS:
• Potential lethal side effects
• Increased QTc & risk for sudden
death
• Anticholinergic syndrome
Management of Excited
Delirium Syndrome
MDMA
SYNTHETIC CATHINONES
3,4-methylenedioxymethamphetamine
(MDMA)
• Ecstasy
– Often adulterated with caffeine,
methamphetamine, and other harmful drugs
– Typically in tablet form
• Molly
– Slang for "molecular"
– Supposedly a “purer” form of MDMA sold as
powder or capsule
Synthetic Cathinones
• Synthetic chemicals
related to cathinone, an
amphetamine-like
stimulant found
naturally in the Khat
plant.
Synthetic Cathinones
• MDPV (Methylenedioxypyrovalerone)
– most common synthetic cathinone found in the
blood and urine of ED patients reportedly taking
"bath salts”
• Alpha-PVP
• Methylone
• Ethylone
• Butylone
• Many more
United Way of Broward County Commission on Substance Abuse Annual Drug Trends Report June 2015
United Way of Broward County Commission on Substance Abuse Annual Drug Trends Report June 2015
Alpha-PVP aka Flakka
Special considerations:
• Paranoia
• Pursued or chased
• Extreme hyperthermia (105-106)
• Excited Delirium Syndrome
8 Duval
2 Clay
1 St Johns
1 Putnam
http://interactive.sun-sentinel.com/flakka-case/
Number of Flakka Cases in Florida 2015
http://interactive.sun-sentinel.com/flakka-case/
“In recent weeks in Florida, this new drug has led to a man trying to
break down the door to a police station, a man impaling himself while
trying to scale a fence, and an armed and naked man shouting about
hallucinations from a rooftop” – CBS
Synthetic Cathinones
Clinical effects
 CNS:
 Euphoria
 Decreased need for food and sleep
 Increase in alertness and awareness
 Heightened sexual desire
 Anxiety/agitation
 Paranoia
 Violent behavior
 Hallucinations (auditory or tactile)
 Suicidal thoughts
 Excited Delirium Syndrome (ExDS)
Synthetic Cathinones
Clinical Effects
 Cardiovascular:
 Hypertension
 Tachycardia
 Chest pain
 Hyperthermia
 Hyponatremia
 Nausea/Vomiting
 Liver failure
 Kidney failure
 Rhabdomyolysis
 Compartment syndrome
Synthetic Cathinones
• Self-harm and bizarre/at risk behavior without
evidence of psychosis or depression is the
SECOND leading cause of death with use
Take Home Points
• Florida is seeing increased heroin/fentanyl use as opioid
prescription drugs become harder to acquire
– You may need larger doses of naloxone to reverse synthetic opioids
like fentanyl.
– Don’t give up if 0.4mg doesn’t work…
• Higher potency forms of marijuana and synthetic forms of
cannabinoids can lead to more severe clinical effects
– Synthetic cannabinoids do NOT equal marijuana
Take Home Points
• New synthetic drugs constantly being produced, which are
potentially more toxic and dangerous.
– It doesn’t matter what the compound is…treat them symptomatically
• Control of agitation/psychosis in Excited Delirium Syndrome is
high priority to reduce mortality.
– Use chemical sedation.
– Avoid restraints.
– Don’t forget to cool their hyperthermia.
– Get labs to check for end-organ dysfunction.
THE END

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Update on Drugs of Abuse Trends in Florida

  • 1. Update on Drugs of Abuse Trends in Florida Melissa Parsons, MD Department of Emergency Medicine University of Florida College of Medicine-Jacksonville
  • 2. Learning Objectives 1. Understand general trends for drugs of abuse in Florida 2. Become familiar with toxidromes 3. Recognize excited delirium syndrome and factors that increased morbidity/mortality
  • 6. CASE 1 • What do you want to do now? RSI ? Naloxone ?
  • 8. Opioids TOXIDROME • CNS sedation • Hypothermia • Hypotension • Hyporeflexia • Bradycardia • Miosis (pinpoint pupils) • Respiratory depression • Seizures – Meperidine (Demerol), Tramadol • Rigidity, myoclonus – Fentanyl
  • 9. Opioids Management • Supportive • Naloxone – Indication: reverse respiratory depression – Adults: 0.4mg—2mg – Pediatrics <5 years 0.1 mg/kg – Max 10 mg – May need high doses for fentanyl – IV, SC, IM, IN, IO – Half life: 1 hour
  • 10.
  • 11.
  • 12.
  • 13.
  • 14. Spike in deaths due to heroin and fentanyl 447 538 0 100 200 300 400 500 600 2006 2007 2008 2009 2010 2011 2012 2013 2014 Deathsfromheroinandfentanyl Heroin Fentanyl Florida Medical Examiners Commission Annual Drug Reports 2007-2014 Crack down on “pill mills” and opioid prescribing
  • 15. 208 271 250 230 150 109 78 93 119 95 48 57 108 199 447 0 50 100 150 200 250 300 350 400 450 500 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 HeroinDeaths Number of Heroin Deaths in Florida: 2000-2014 2014 Florida Medical Examiners Commission Annual Drug Report
  • 16.
  • 17.
  • 18. Fentanyl • Synthetic opiate – 100 times more powerful than morphine – 30-50 times more powerful than heroin • “Breaking Bad” “Blue Drop” “Theraflu” “China White” • Imported from Mexico and China
  • 20.
  • 22. CASE 2 – Patient feels like this…
  • 23. CASE 2 • What do you do now? •Let her refuse transport? •Sedate her?
  • 25. Cannabinoids  Compounds found in the marijuana plant  THC is the most psychoactive (strong hallucinogen).  Street names: “ganja,” “MJ,” “ragweed,” “reefer” and “grass. Clinical Effects  Psychological  Alterations in perception, feelings of well-being, increased appetite  Physiological  Acute: Increased HR and BP  Chronic: Decreased HR and blood pressure  Decreased coordination  Delay in psychomotor skills  CNS depression (especially peds)  Slurred speech  Rare: apnea, cyanosis, hypotonia
  • 26. Marijuana Ingestion • Marijuana Wax, “Budder,” or Butane hash oil, or “Ear wax hash”
  • 27. 90% THC Marijuana wax 20% THC Marijuana joint
  • 30. Abuse of Synthetic Drugs an Epidemic
  • 31. Abuse of Synthetic Drugs an Epidemic • 2012 Synthetic Drug Abuse Prevention Act – Places 26 synthetic drugs including types of cannabinoids and cathinones under Schedule 1 – Illegal drug makers have 100s more to take their place – NO quality control (Russian Roulette) – Often products labeled “not for human consumption” • Unknown chemicals • Unknown potency • Constantly changing Russian Roulette Mystery packages
  • 32.
  • 33. Drug makers constantly producing new synthetic cannabinoids products to evade laws on older compounds… impossible to keep up. 2015: >30 compounds
  • 34. Synthetic Cannabinoids • Synthetic chemicals sprayed onto dried plants • They are 5-45 times more potent than THC and more toxic to brain and the heart Synthetic Marijuana is a misnomer
  • 36. Synthetic Cannabinoid User Man decapitated his wife, killed two dogs, cut off his left hand, and gouged his right eye out Man kills two women using a knife and tomahawk while trying to find the ‘portal to hell” in their backyard shed
  • 37. Synthetic Cannabinoids Symptoms: • Seizures • Psychosis – Patients without psych history – Paranoia, agitation and anxiety – Suicidal or homicidal ideation • CV events – Tachycardia and tachydysrhythmias – MI – Stroke • Respiratory failure • Acute kidney injury • Hyperthermia • Hyperemesis Management: • Supportive care • Sedation – Benzodiazepines – Ketamine – Avoid antipsychotics • IVFs for AKI or rhabdomyolysis • Low stimulus environment
  • 38. Risk Factors for increased mortality: 1. New Psychosis/ Excited delirium with use • Trauma or injury • Restraint procedures by law enforcement • Chemically sedate… avoid restraints 2. Pre-existing cardiovascular conditions 3. Co-ingestions
  • 40. CASE 3 • What do you want to do now?
  • 42. Excited Delirium Syndrome Clinical Features: • Hyper-aggression/agitation – Catecholamine surge and acidosis – Superhuman strength • Autonomic dysfunction • Hyperthermia • Acidosis • Rhabdomyolysis, hyperkalemia • Acute kidney injury
  • 43. • Can be difficult to recognize and manage in prehospital setting. • May mimic other medical conditions • Attempt de-escalation techniques • Personal safety issue for first responders Excited Delirium Syndrome
  • 44. • Management: – Agitation: chemical and physical restraint – Hyperthermia: Active and passive cooling – Hypoxia: Airway support – Acidosis: IVF, Bicarb if severe – Rhabdo/Hyperkalemia: IVF, Calcium chloride, Bicarb Excited Delirium Syndrome
  • 45. KETAMINE: • 4-5 mg/kg IM or 2 mg/kg IV • Rare side effects • Increased oral secretions, • Laryngospasm, • Hypertension, • Distress from emergence phenomena BENZO’s: • Effective. • Potential for respiratory depression ANTIPSYCHOTICS: • Potential lethal side effects • Increased QTc & risk for sudden death • Anticholinergic syndrome Management of Excited Delirium Syndrome
  • 47. 3,4-methylenedioxymethamphetamine (MDMA) • Ecstasy – Often adulterated with caffeine, methamphetamine, and other harmful drugs – Typically in tablet form • Molly – Slang for "molecular" – Supposedly a “purer” form of MDMA sold as powder or capsule
  • 48. Synthetic Cathinones • Synthetic chemicals related to cathinone, an amphetamine-like stimulant found naturally in the Khat plant.
  • 49. Synthetic Cathinones • MDPV (Methylenedioxypyrovalerone) – most common synthetic cathinone found in the blood and urine of ED patients reportedly taking "bath salts” • Alpha-PVP • Methylone • Ethylone • Butylone • Many more
  • 50. United Way of Broward County Commission on Substance Abuse Annual Drug Trends Report June 2015
  • 51. United Way of Broward County Commission on Substance Abuse Annual Drug Trends Report June 2015
  • 52. Alpha-PVP aka Flakka Special considerations: • Paranoia • Pursued or chased • Extreme hyperthermia (105-106) • Excited Delirium Syndrome
  • 53. 8 Duval 2 Clay 1 St Johns 1 Putnam http://interactive.sun-sentinel.com/flakka-case/ Number of Flakka Cases in Florida 2015
  • 54. http://interactive.sun-sentinel.com/flakka-case/ “In recent weeks in Florida, this new drug has led to a man trying to break down the door to a police station, a man impaling himself while trying to scale a fence, and an armed and naked man shouting about hallucinations from a rooftop” – CBS
  • 55. Synthetic Cathinones Clinical effects  CNS:  Euphoria  Decreased need for food and sleep  Increase in alertness and awareness  Heightened sexual desire  Anxiety/agitation  Paranoia  Violent behavior  Hallucinations (auditory or tactile)  Suicidal thoughts  Excited Delirium Syndrome (ExDS)
  • 56. Synthetic Cathinones Clinical Effects  Cardiovascular:  Hypertension  Tachycardia  Chest pain  Hyperthermia  Hyponatremia  Nausea/Vomiting  Liver failure  Kidney failure  Rhabdomyolysis  Compartment syndrome
  • 57. Synthetic Cathinones • Self-harm and bizarre/at risk behavior without evidence of psychosis or depression is the SECOND leading cause of death with use
  • 58. Take Home Points • Florida is seeing increased heroin/fentanyl use as opioid prescription drugs become harder to acquire – You may need larger doses of naloxone to reverse synthetic opioids like fentanyl. – Don’t give up if 0.4mg doesn’t work… • Higher potency forms of marijuana and synthetic forms of cannabinoids can lead to more severe clinical effects – Synthetic cannabinoids do NOT equal marijuana
  • 59. Take Home Points • New synthetic drugs constantly being produced, which are potentially more toxic and dangerous. – It doesn’t matter what the compound is…treat them symptomatically • Control of agitation/psychosis in Excited Delirium Syndrome is high priority to reduce mortality. – Use chemical sedation. – Avoid restraints. – Don’t forget to cool their hyperthermia. – Get labs to check for end-organ dysfunction.

Editor's Notes

  1. Name MP Dept of EM I’m not a pharmacologist or toxicologist but after enough night shifts on 8th street I’m qualified to give this talk
  2. Discuss the street drug trends were seeing across the state since that impacts us clinically Review the patient presentation as well as management and treatment options Define excited delirium and be able to recognize factors that increase mortality
  3. Case 1 Patient found down with laceration to scalp at home. 911 called by a friend. Unresponsive in the field. On EMS arrival to scene, patient with a respiratory rate of 4. Active airway assistance started. Breath sounds clear bilaterally. Good peripheral pulses – radial and dorsalis pedis – noted bilaterally. Scalp hematoma without active bleeding noted. GCS 3.
  4. EMS attempts to establish IV access and prepares for intubation. Paramedic notices multiple track marks to both arms. Pupils pinpoint bilaterally.
  5. Great…yes this appears to be a trauma patient, but could this also be an opioid overdose with trauma secondary to use? Obvious when you find the patient with an IV in the arm, but not always so obvious
  6. Lets talk a little bit about the opioids
  7. Most of us recognize pinpoint pupils as the tell tale sign of opioid use They can also have BRADYCARDIA, HYPOTENSION, HYPOTHERMIA, SEIZURES and muscle rigidity Propoxyphene is Darvon or Darvocet Meperidine = Demerol
  8. Narcan is indicated to reverse respiratory depression DETAILS.. Fentanyl requires much higher doses b/c increased potency… naloxone has to replace 50% of receptors Half life is an hour so patients can resedate…
  9. Looking at recent trends in the state of Florida
  10. Rise in Fentanyl, Heroin and Morphine…
  11. Decrease in Methadone & Oxycodone
  12. Rx opioids tougher to get  ppl turn to heroin  heroin seems to be much more potent (ppl requesting XXX) Why are we seeing this surge in heroin deaths? Prescription drug monitoring program in Florida “Eforsce database” Crack down on “pill mills”
  13. Chart shows a huge spike in heroin related deaths from 2013 to 2014
  14. Spike continues into 2015
  15. Jacksonville is in the orange… 17-24 cases per million population
  16. May take additional narcan Counties have also seen Carfentanil use – used to sedate elephants (100 times more potent than fentanyl)
  17. lethal dose of heroin vs fentanyl
  18. Counties have also seen Carfentanil use – used to sedate elephants (100 times more potent than fentanyl) and 10,000 times more potent than morphine. Medical examiners have to carry narcan because if they even come into contact with carfentanil can experience overdose symptoms…
  19. 36 yo F requiring extrication from an MVC. She was the restrained driver that crashed into a telephone pole at approximately 55 mph. +airbag deployment. Significant front end damage. 25 minute extrication time. Only significant trauma is head lac.
  20. During extrication, patient is argumentative, refusing transport. Appears paranoid. As EMS transfers her to rescue, a packet labeled “Spice” falls out of her clothing. When asked about it, the patient sits up, climbs off the stretcher, and tries to abscond.
  21. This case is not to bring up medico-legal issues of AMA. Just to make us all think about the use of these synthetic cannabinoids. They can make a patient unevaluable just like EtOH. Just because they may or may not be legal doesn’t mean they don’t alter the patient and the patient’s perception of pain etc. On this patient, you may not have enough information to decide whether or not the patient can leave AMA.
  22. Marijuana typically causes SLOWING of symptoms – CNS depression, delayed psychomotor skills, slurred speech
  23. Much higher concentration of THC than smoking. Produced by soaking marijuana plant material in a solvent such as butane which extracts various cannabinoids of the plant. Then drying it out which leaves a sticky substance that can be placed on a traditional cig, e-cig, MJ joint Hash - resin collected from the flowers of the cannabis plant
  24. Different concentrations of THC between typical joint and wax Wax proponents state you take in much less smoke/other chemicals by using wax to get the same effect…
  25. Vaporizes the marijuana Considered a less harmful method of ingestion, easy to use in public places
  26. Now a note on the synthetic drugs – includes synthetic cathinones also Graphs show the increased percentage of synthetic drugs of the total drugs seized in broward county from 2012-2015 Huge increase from 5% to 31 % in only 4 years… number continues to rise
  27. 2012 Obama administration passed the Synthetic drug abuse prevention act List 26 specific compounds , however drug makers have 100s more to take their place These drugs are not tested – there is no quality control, unknown potency so can be dangerous - To get around these laws, tweaks to drug structure are performed and then drugs are packaged “not for human consumption”
  28. These drugs were created as the federal ban was being passed and are not illegal…
  29. THC is only a partial agonist at the cannabinoid receptors, these compounds are full agonists More potent and efficacious at cannabinoid receptors Have active metabolites Often contain contaminants like synthetic cathinones, methylxanthines, clenbuterol
  30. Increased risk of sudden death with hog-tied or taser use by law enforcement… Patients are at high risk for trauma or other injuries. How we restrain them can cause harm… Study was done on people with excited delirium dying in police custody – showed that all (21) of them had restraint for violent behavior either in prone position or with pressure on the neck, so we should sedate these people in an expedited fashion and get them out of restraints that could exacerbate their condition and put them at risk for sudden death Pollanen MS, Chiasson DA, Cairns JT, Young JG. Unexpected death related to restraint for excited delirium: a retrospective study of deaths in police custody and in the community. CMAJ: Canadian Medical Association Journal. 1998;158(12):1603-1607. Labay LM et al. Synthetic cannabinoid drug use as a cause or contributory cause of death. Forensic Science International 2016(260):31–39
  31. EMS is called for a 34 yo M in police custody with concerns for suicide attempt. Police found the patient in someone’s front yard, naked from the waist down and wrapped in a garden hose with lacerations to both wrists. It is requiring multiple officers to restrain the patient, despite handcuffs and being hogtied. There is pulsatile bleeding from one of the wrist lacerations.
  32. You’re putting a bleeding tazmanian devil in the back of your rig… or in your trauma bay. Where do you transport the patient? Sedation? Wound treatment?
  33. ExDS is characterized by delirium, agitation, and hyperadrenergic autonomic dysfunction, typically in the setting of acute on chronic drug abuse or serious mental illness.  These patients are reported to have superhuman strength and to be susceptible to further agitation by external stimulus
  34. ExDS is characterized by delirium, agitation, and hyperadrenergic autonomic dysfunction, typically in the setting of acute on chronic drug abuse or serious mental illness.  These patients are reported to have superhuman strength and to be susceptible to further agitation by external stimulus Temperatures greater than 104 Tachycardia including HR in the 150’s-170s , HTN
  35. ExDS has been linked to sudden death, often associated with prolonged ‘hog-tie’ or ‘hobble-position’ or electroshock weapons (i.e. Taser use) (D).  MIMIC OTHER THINGS_ THYROID STORM, NMS, SEROTONIN SYNDROME Table shows symptoms associated with INCREASED MORTALITY
  36. We already talked about synthetic cannabinoids causing ExDS, the synthetic cathinones can as well. Lets talk a little about MDMA and these other synthetics commonly referred to as “bath salts”
  37. Only 13% of the Molly seized in New York from 2011-2015 actually contained any MDMA Hundreds of Molly capsules tested in South Florida crime labs in 2012 contained methylone, a synthetic cathinone.
  38. http://www.i24news.tv/en/news/culture/130906-british-somalis-dread-herbal-high-khat-ban
  39. Increase in methylone and etyhlone as well as alpha PVP DROP IN MDMA
  40. Synthetic drug similar to flakka made to look like sour patch kids found in florida – individually wrapped
  41. Data from 2015
  42. Hangings are the most common form of fatal self-harm Gunshots Stabbings Self-lacerations Jumping from bridges