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  1. 1. Kristine Nutt, LCSW, LCAS, CSI
  2. 2. DisclaimerThis presentation is meant to provide basic awareness information on herbal incense products and bath salts.There are hundreds of products being smoked for cannabis-like effectsManufacturers constantly change product ingredients and market products under new names to circumvent the law.Constantly moving targetProduct names and lists, as well as the list of synthetic cannabinoids, in this presentation are not all inclusive.
  3. 3. “SMILES” 
  4. 4. “SMILES”2C-1 HalluCinogen syntHetiC drugPart of tHe 2C family of drugsPowder or Pill formoften mixed witH CHoColate and CandysCHedule 1 Class of drug in July 2012According to LAPD, there has been an increase of overdose deaths from this drug recently. Popular with teens and college students.Formulas were published in book “PiHKAL: A chemical Love Story” (Transform Press, 1991)
  5. 5. “Smiles” Dessa Bergen-Cisco, a Professor of Public Health at Syracuse University stated, “Basically, it’s a pure and potent form of estacy or MDMA”.Effects are compared to a potent combination of MDMA and LSD with terrifying hallucinations and superhuman strength.Overdoses have been reported in California, Ohio, and other states.
  6. 6. “SMILES” Recently in the news due to Johnny Lewis, 28, who was known for his role in the television show, “Sons of Anarchy” killed 81 year old landlady and her cat before jumping to his death. No evidence of drugs were found in his system.One guy began beating his head into the ground.One 17 year old in North Dakota overdosed and was observed shaking, growling, and foaming at the mouth. Another teen died the night before from the drug.Does not show up on drug screens
  7. 7. EffectsAnxiety leading to panic attacks, seizures, distortions of time. HyperventilationNausea and VomitingTerrifying auditory and visual hallucinations and feelings of fear and panic. Last hours to days.Increased heart rate (arrhythmia). Can cause strokesCan cause seizures and kidney failureCauses muscles to contractElevated body temperaturesGiddiness and relaxed state
  8. 8. BATH SALTS• Refers to products containing synthetic cathinones, that are chemically similar to cathinone, an organic stimulant, that occurs naturally in the Khat plant. Highly pure white or brown powder or crystal form. Mostly seen in powder form.
  9. 9. BATH SALTSFirst developed in research labs and became a popular party drug in Europe and UKSpread overseas around 2010 and began to show up mostly in states like Louisiana, Kentucky, and Tennessee. Some had regional names like “Hurricane Charlie” and “Bayou”.Other product names include Bliss, Blizzard, Blue Silk, Ivory Snow, Vanilla Sky and Ivory Wave.Highly publicized as of late with the cannibalistic attack in Miami.
  10. 10. BATH SALTS
  11. 11. BATH SALTS
  12. 12. BATH SALTS
  13. 13. MarketingSold commercially as bath salts, plant fertilizer, toy cleaner, pond cleaner, cell phone cleaner, jewelry cleaner, insect repellant, glass cleaner, and toilet cleaner. Newest is ladybug attractant.Chemicals imported mainly from China.Sold mainly on the internet buy also in “head shops”, convenience stores, and gas stations. It is not the stuff you find at Bath and Body Works!!!
  14. 14. Chemical MakeupThere are several synthetic cathinones. The most common found in “Bath Salts” are MDPV (methylenendioxypyrovalerone), mephedrone(4- MMC), or methylone. The primary ingredient in most bath salts is MDPV, which is a CNS stimulant and increases dopamine and serotonin.MDPV – at least 4x potency of ritalin or concerta.15-30 minutes to onset, peak effect around 1.5 hours and last around 6 – 8 hours.
  15. 15. Bath SaltsPeople can get an effect from 3 – 5 mg. The average dose is 5 – 20 mg.Taken orally, IV, nasal inhalation, or rectally. Snorting and swallowing are the most common methods of use.High risk for overdose due to packages containing as much as 500 mg. Each packet contains varying amounts of the chemical.
  16. 16. BATH SALTSMarketed as legalalternative to LSD,cocaine, ecstacy, andmethamphetamine.Chemists say it has theworst attributes ofthese.Labeled not for humanconsumption but thesole purpose is forhuman consumption.
  17. 17. Bath Salts – Generation 2New type of bath salt called Amped has been reported by users in Virginia.Six people recently reported to hospitals in Virginia that they ingested this drug.It is being marketed as ladybug attractant.
  18. 18. NaphyroneReferred to as “Cosmic Blast” and marketed as jewelry cleaner. Contains MDPV and Naphydrone, which is 0-2482 and Naphthylpyrovalerone derived from Pyrovalerone. Reuptake inhibitor of serotonin.Stays in system for long periods. Body temperatures of up to 107 degrees have been reported.
  19. 19. BATH SALTSUsers do not know howmuch or what they aregetting. Cost about $25- $50 per 50 mg packet.Very inexpensive andreadily available high.
  20. 20. EFFECTSAdrenaline rush for hours and superhuman strength.Users often become paranoid that they are being attackedand experience a “excited delirium”. This includesfearlessness, rage, and strength, as well as, delusions ofinvulnerability.Stops neurons in the brain from reabsorbing dopamineand norephinephrine immediately after secreting them soleads to triggering of survival behaviors.
  21. 21. WHAT DO THEY DO?“MDP V increases the body’s concentration of adrenaline- like hormones that prepare the heart and muscle tissue for “flight or fight” response”, explained Thomas Penders an associate professor at ECU."One system of circuits in our brains are wired to detect and respond to threats. Overstimulation of this circuit leads to overestimation of actions by others as threatening. When the system becomes overwhelmed, as it does [from an overdose of] bath salts, a condition develops known as excited delirium," he said
  22. 22. WHAT DO THEY DO?Overdoses of crack cocaine, methamphetamine, ecstasy and PCP can also induce "excited delirium." Its a state of paranoid fearfulness and rage mixed with seemingly superhuman strength, as more oxygen is delivered to muscles, increasing their power. "This, to some extent, explains the bizarre aggressive behaviors we have seen during the recent rash of bath salt cases," Penders said * “Science” on 6/4/2012
  23. 23. EFFECTSIncreased dopamine and serotonin and affects mood and perception.Cold fingers and an intolerance to painBody temperatures of up to 107 degrees have been reported. Often people take their clothes off.Jerking eye movements and foaming at the mouth have been reported.Restlessness and inability to sit still.
  24. 24. EFFECTSIncreased heart rate and blood pressure.Panic attacks and chest pains are often why people show up in ER’s. Auditory and Visual Hallucinations with common themes of monsters, demons, aliens, and God.Irritability, suicidal thoughts, and self-harm behaviors.Diminished thirstCan relapse into hallucinations and paranoia weeks after last use.
  25. 25. BATH SALTS
  26. 26. Dangers and Dependency
  27. 27. ConcernsA Marquette County, Michigan ER reported 35 admissions from November 2010 to March 2011. This prompted Law Enforcement to seize all bath salts from a local convenience store. The products tested all contained MDPV.17 out of 35 were hospitalized. Median age was 28 years (range 20 -55 years). 5454% were Men, 69% self-reported a history of drug abuse, 46% or 16 patients had a history of mental illness, and 17% reported suicidal thoughts/attempts related to use of bath salts.
  28. 28. ConcernsUS Army Medic, David Stewart, killed his wife and 5 year old son in April 2011 after he and his wife were using bath salts. He shot his wife and suffocated his son the day before. He was using “Lady Bubbles” bath salts.7 people under the age of 27 died in 2 Cleveland Hospitals after using the drug.According to the Bangor Daily News, domestic violence calls have increased in Maine due to use of Bath Salts.Cookeville Regional Medical Center in TN has treated 160 people since 2010.Store was broken into four times in one month.
  29. 29. Dangers and DependencyA research study led by UNC professor CJ Malanga, MD found that mephedrone, like cocaine, has a high potential for abuse and addiction.“The effects on the brain’s reward circuit are comparable to similar doses of cocaine”The rodents in the study worked harder to get less reward. The drug activated the brain’s reward circuit involved in positive 2012
  30. 30. LegalityThe Synthetic Drug Prevention Act signed by President Obama on July 9, 2012. This act bans the synthetic compounds found in synthetic THC and Bath Salts, and makes them Schedule I.States will have to incorporate these into their drug scheduling list and update the list as new substances are discovered.
  31. 31. Poison Control Center DataCALLS TO POISON CONTROL: 304 in 2010, 6,138 in2011, and 2,468 as of October 31, 2012. Ages <6 to over59. Most ages 20 – 29.January – 228/301 July – 361/680February – 230/487 August – 173/602March – 264/639 September – 119/512April – 285/600 October – 98/401May – 295/720June – 415/743www. 1-800-222-1222
  32. 32. Ppp BppPoison Control Centers Data
  33. 33. TREAMENTOften eat up Emergency Room resources as it takes multiple nurses and doctors to treat users.Difficult to know what someone has taken unless they self-report or someone else reports.Does not show up on typical toxicology screens and can not be detected by drug dogs. There are now drug tests that do test for Bath Salts. Ammon labs, Redwood Toxicology, and Dominion Diagnostic offer these drug screens.
  34. 34. TREATMENTAntipsychotics to treat psychosisBenzodiazepines to decrease agitationTen to twenty times the normal dose of sedatives have been used.Try to avoid using restraints, but speak reassuringly to people who are agitated and paranoidMove to a quiet room with low light to help calm patient.Avoid loud noises and try medications prior to restraint.
  35. 35. TREATMENTMonitor the person for suicidal ideation even after they have stopped using the drug. Address both mental health and addiction issues.Psychotic symptoms often persist after treatmentEnhance coping skills to assist the person in dealing with anger and other emotions.No standard treatment protocol for MD’s or others so treat symptoms of the individual.Train staff to deal with specialized issues and incorporate questions into intake and assessment.
  36. 36. Movie MadnessBATH SALT ZOMBIESAvailable on DVD February 19Bath Salt Zombies is a new horror film directed and co-written by Dustin Wayde Mills (Puppet Monster Massacre, Zombie A-Hole, Ballad of Skinless Pete) and produced and co-written by Clint Weiler of Aggronautix. The movie sensationalizes the recent bath salt epidemic and the attacks surrounding them
  37. 37. “Zombie Apocalypse”The shocking wave of attacks associated with Bath Salts has sparked fears of a real-life zombie outbreak in the south. This led to The Center for Disease Control and Prevention releasing a statement saying it is not aware of any virus that can cause zombie-like behavior.
  38. 38. What next?Partnerships and networks between the community and law enforcement have made an impact in the sale and distribution of this drug.Education regarding the dangers of Bath Salts.
  39. 39. Spice / K2
  40. 40. What is Spice and K2?Spice and K2 refer to commercially available products sprayed with chemicals called synthetic cannabinoids. These products claim to be a mixture of herbs but often do not have herbs in them. They include other ingredients that are unknown and not listed.Many have warning labels as not intended for human consumption, but are solely intended for human consumption. Marketed as incense. Resembles potpourri.
  41. 41. Synthetic CannabinoidsSynthetic Cannabinoid products are manufactured in Asia and sold in US in many different arenas (gas stations, liquor stores, smoke shops and internet)Sold under different brand names: “K2, Spice, Spice Gold, Spice Black, Mr. Nice Guy, Yucutan Fire and many others”Since the national ban on five synthetic cannabinoids, new brand names have developed, such as K2 Sky, K3, and K4
  42. 42. What is a Synthetic Cannabinoid?A class of synthetic substances that bind to the cannabinoid receptors(CB1 and CB2) in the body. When used they create a high similar to THC. Bind more strongly than THC. There are hundreds of synthetic cannabinoids.Used in an attempt to avoid laws that make marijuana illegal. National Ban on five cannabinoids began in March 2011.
  43. 43. History of Spice and K2? The cannabinoid-like chemicals were first developed in research laboratories to study receptors in the body and brain and for other research purposes. The five banned cannabinoids are JWH-018, 073, 200, CP 47, and 497.JWH-018 was first made in 1995 by Dr. John Walter Huffman at Clemson University. Manufacturers read research and copied it to produce this cannabinoid and marketed it for commercial distribution.Brand “Spice” was released in 2004 and gained popularity in 2006.
  44. 44. Spice and K2The company that started the “Spice” line went from assets of 65,000 Euros in 2006 to 899,000 Euros in 2007. Spice was the dominant brand until 2008. Then competing brands like “K2” hit the market. Now there are many distributors of these products.Rick Broider with North America Herbal Incense Trade Association estimates profits at 5 billion per year.In 2011, Redwood Toxicology Lab developed testing for six synthetic cannabinoid chemicals. 72 hours for urine and 24 – 48 for saliva.
  45. 45. Spice ProductsSpiceSpice GoldSpice DiamondSpice Tropical SynergySpice Arctic SynergySpice Gold SpiritPEP Spice
  46. 46. Many Faces of Spice
  47. 47. K-2/SPICE
  48. 48. Other Herbal Incense ProductsGenie Spike 99Yucatan Fire BlazeDream SparkEx-ses FusionBlaze MANY others!
  49. 49. Spice IngredientsOne or more synthetic cannabinoid compounds. Can be different mix each time.  JWH-018, CP 47, 497, C8, JWH-073, and JWH-250 have been found most often in spice products.Other legal substances such as Pink Lotus,Dwarf Skullcap, Indian Warrior, and Lion’s Tail  Potentiate or add to effects  Create different effects between products  Many have psychoactive effects on their own  Some used as marijuana substitutes in the past.  Cost $30 - $40 per 3 gram bag.
  50. 50. Other Synthetic CannabinoidsHU named after Hebrew University where they were created. HU-210  Various studies show it is anywhere from 66-800 times more potent than ∆9 THC1  Schedule I under CSA: Illegal in U.S. HU-211  Studies tentatively show no ∆9 THC-like effects  Used to research treatment of brain damage related to stroke, brain trauma, glaucoma, and multiple sclerosis HU-311  Has potent antineoplastic and antiproliferative activity (cancer fighting drug) 1 J. Med. Chem.35 (11): 2065–9.
  51. 51. Synthetic CannabinoidsCP 47,497 and analogues (CP Created by Pfizer)  3 to 28 times more potent than ∆9 THCCP 55,940  45 times more potent than ∆9 THCJWH-015JWH-018 4-5 x more potent than THC and same chemical structure shared with known cancer causing agents.JWH-073WIN 55,212-2 (WIN is for Sterling Winthrop)  Used to research treatment for Alzheimers  Effects milder and don’t last as long as ∆9 THC
  52. 52. Other Herbal Incense Ingredients (Not all inclusive) Baybean Pink Lotus Blue Lotus Marsh Mallow Lions Tail Red Clover Lousewort Rose Indian Warrior Vanilla and Honey Dwarf Scullcap Fly Agaric Maconha Brava Siberian Motherwort Indian Pennyworth Damiana Clove Stevia Leaf Hops Lemon Grass Tribulus Terrestris Turnera diffusaMany other legal herbs and herbal extracts are used to enhance aroma, potency
  53. 53. Why Do People Use It?Herbal incense products are smoked or snorted for marijuana-like effectsLegal substitute to marijuanaOther reasons: increase creativity, reduce stress, experience euphoria, increase personal insight, and increase appreciation for the artsThere are numerous blogs and websites the provide users the opportunity to share experiences.
  54. 54. EffectsMarijuana-like effects: euphoria, giddiness, silliness, bloodshot eyes, impaired short-term memory and concentration, and “munchies.”Other common effects: cotton mouth, light sensitivity, a warm sensation in the limbs, dry eyes, paranoia, light headedness, auditory and visual hallucinations, painless head pressure, time distortion, panic attacks, delirium, impaired coordination, and sleeplessnessOnset/duration: 5-10 minutes, and effects vary from 2 hours for JWH and 5-6 for CP. Can get high off a hit or two.
  55. 55. EffectsA number of users experience hangover-like effects the morning after use including dry mouth, intense headachesDepending on the product, inhaled smoke is as harsh as marijuana smoke Taste can vary from a very bad to sickly sweet.
  56. 56. EffectsOne hospital reported a patient with a 1-3 gram a day habit and severe withdrawal symptoms (tremors, headache, nausea, vomiting and depression).One person reported spending $2000 in the last month on Spice and Bath Salts.
  57. 57. DangersA Boston University School of Medicine study suggests that use may cause increase in paranoia, hearing voices, disorganized behavior, and panic symptoms.Psychotic symptoms may last for a few days to months.Another study found these products may create psychosis in patients with no history of psychiatric disorder.Overdose potential from unknown amounts and ingredients in products.
  58. 58. Ppp BppPoison Control Centers Data
  59. 59. Dangers Poison Control Centers had 112 calls in 2009, 2906 in2010, 6,959 in 2011, and 4,161 by September 10, 2012.Users are experimenting with combining differentproducts, which can dramatically change or increase theeffects. These cannabinoids were created forexperimental use. Not tested on people. No one knowslong term effects of these products.Public health concern over possible metal residue inthese products.
  60. 60. DangersJWH-018 and others, have a shared chemical structure with cancer causing agents, according to NIDA.A hospital in Kansas reported 8-10 people hospitalized in past month after smoking the products with hallucinations, seizures and bleeding from the nose and mouth.Three teens ages 16 and 18, showed up in ER with anxiety, agitation, excessive sweating, and inability to speak.
  61. 61. DangersKids’ brains are still developing.Across the US, people are showing up in emergency rooms with aggressive and unusual behavior. Suicides have been reported.A NIDA study stated 11% of school seniors have used Spice/K-2 in 2011. Second most frequently used drug after THC.Medical personnel often don’t know what they are dealing with unless the person self-reports.
  62. 62. DANGERS
  63. 63. AppearanceMost herbal incenses appear as an olive green leafy material very similar in appearance to marijuana, oregano
  64. 64. ParaphenaliaHerbal incense smokers will use the same or similar products used by marijuana smokers Pipes, bongs, hookahs Rolling papers Blunts (hollowed out cigars packed with product)Herbal incense specific paraphernalia Vapor Genie Grinders (to further grind into a finer mixture)
  65. 65. Hookah
  66. 66. Grinders
  67. 67. Controlled Substances ActIn Nov. 2010, the USDEA moved to ban 5 synthetic cannabinoids, placing them in Schedule I status due to high potential for abuse, and no known medical benefits. The ban would be in effect for one year.The ban was delayed due to companies stating the ban was unconstitutional.On March 1, 2011 the National Ban was enacted.This means that is illegal to possess and sell products containing these.Before the ban, 15 states had already taken action to control one or more of these five chemicals.
  68. 68. Challenges - ManufacturingManufacturing occurs in countries where synthetic cannabinoids are legal.As detection catches up with manufacturing, makers will alter ingredients. They are using new ingredients which are not illegal at this time.Federal bans target larger distributors. States will need to go after smaller distributors.
  69. 69. Challenges - MarketingProduct will not cause positive drug test“Theres never been a case reported by our clients that any of our Herbal Smoke Blends caused them to fail a test”“YOULL NEVER FAIL A DRUG TEST”Why would this be an issue for a product marketed as incense and not for human consumption?
  70. 70. Challenges - Marketing Ingredients1 Synthetic cannabinoids not listed Listed ingredients are not necessarily in the product Consumers don’t know what they are actually getting Raises questions of consumer protection and product misrepresentation1 Understanding the ‘Spice’ Phenomenon Thematic Paper, European Monitoring Centre for Drugsand Drug Addiction, 2009, Portugal
  72. 72. ENERGY DRINKSAmerican Association of Poison Control Centers – ( urges the public to use caution using these products.Highly concentrated amounts of sugar, caffeine, and other ingredients. Was mixed with alcohol in the past and sold next to bath salts.Caution for children and adolescents. Children should not have it and adolescents should not have more than 100 mg of caffeine per day = one cup of coffee**Journal of Pediatrics
  73. 73. Energy DrinksDue to labels, it is often hard to know how much caffeine is in the drink.Drinks contain natural caffeine-containing ingredients that are not separately listed, such as, yerba mate, cacao, and guarana.These drinks are considered dietary supplements and not regulated by the FDA so there is no limit to amount of caffeine that can be in them.Drinking too many at one time or too fast ……..
  74. 74. EFFECTSNausea and vomiting SeizuresInsomnia Kidney ProblemsDelirium Mood ChangesHeadache Increased BPAltered and increased heart rhythmWithdrawalChest PainsDehydrationSweating
  75. 75. BATH SALTS & ENERGY DRINKSA 28 year old man was found passed out in a random person’s driveway, and was taken to the hospital. It was discovered that the man had overdosed on energy drinks and bath salts.According to a report by the Caledonia Police, officers found the man lying on the floor of his van.An individual said he found the van in his own driveway. The individual stated the the engine was off and that no keys were found in the ignition. The victim was found slouched over the steering wheel. There was a cell phone in the man’s possession, and the last dialed contact was that of his mother.
  76. 76. POISON CONTROL CENTER2607 calls to Poison Control Centers related to the use of Energy Drinks through October 31, 2012
  77. 77. ResourcesLife Center of Galax is equipped to treat persons using these substances. Our confidential referral and assessment number is 1-800-345-6998. We are available 24/7 to speak with anyone.
  78. 78. Thank You