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November 29, 2010 (simone)
1. 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
2. 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
3. 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
4. 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
5. 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
7. 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
8. 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
9. 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
10. 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
11. 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
12. Suicide Attempts
Children under 19 years
N=336 substances
Other
Sedatives/hypnotics 9%
13%
Antihistam ines
6%
Cough and cold
5%
Alcohols
Antidepressants
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
13. 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
14. 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
15. 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
16. What do all of these products have in
common?
16
20. 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
21. 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
22. 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
23. 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
25. 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 sugars
Caloric intake (16 – 18 yrs): 1800 – 2400 (females), 2400 – 3200 (males)25
26. 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
27. 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
29. 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
30. 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
32. Kratom – per label
Stimulant and Depressant?
Amazing legal high / herbal high!
Low dose: stimulating and euphoric
High dose: sedative at higher doses
Plant: mitragyna
Active ingredient: mitragynine
Mechanism: stimulates delta opioid receptors
Effects:
Calms the mind, lowers anxiety
Causes to feel: happy, strong, and active, with a
strong desire to do work
Onset: 5 - 10 minutes after use
Duration: several hours (longest with highest dose),
positive afterglow effect possible 1 day after use
High dose effect: a state of blissful euphoria with the 32
possibility of mild visuals
33. 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