DESIGNER & CLUB DRUGS IN OUR COMMUNITY Patricia Junquera, MD Daniel Castellanos, MD Assistant Professor, Department of Psychiatry & Behavioral Health Herbert Wertheim College of Medicine, Florida International University Founding Residency Program Director Department of Psychiatry, Citrus Health Network in affiliation with FIU Herbert Wertheim College of Medicine Professor and Founding Chair, Department of Psychiatry & Behavioral Health Herbert Wertheim College of Medicine, Florida International University Student Services Mini-Conference Miami Dade County Public Schools February 7, 2014 Designer & Club Drugs Objectives:  Participants will identify the names of the most commonly used designer and club drugs  Participants will recognize the psychoactive and physical effects of the most commonly used designer and club drugs  Participants will identify the signs and symptoms of persons using designer and club drugs Junquera & Castellanos, 2014 Overview of the Problem  Designer and club drug use has increased in popularity over the past few years  Serious medical consequences can result  We have seen an increase in ED visits associated with use of these drugs Junquera & Castellanos, 2014 High School Students Who Reported Current Alcohol Use, 2011 * Had at least one drink of alcohol on at least 1 day during the 30 days before the survey. Source: National Youth Risk Behavior Survey, 2011 Junquera & Castellanos, 2014 High School Students Who Reported Current Marijuana Use, 2011 * Used marijuana one or more times during the 30 days before the survey. Source: National Youth Risk Behavior Survey, 2011 Junquera & Castellanos, 2014 Nonmedical use of prescription drugs  The 2011 National Youth Risk Behavior Survey (YRBS) (www.cdc.gov/yrbss) found that 1 in 5 high school students in the US have ever taken a prescription drug, such as OxyContin, Percocet, Vicodin, Adderall, Ritalin, or Xanax, without a doctor’s prescription. Junquera & Castellanos, 2014 Percentage of High School Students Who Ever Took Prescription Drugs Without a Doctor's Prescription,* by Type of Grades Earned , 2009 Source: United States, Youth Risk Behavior Survey, 2009 Junquera & Castellanos, 2014 Percentage of High School Students Who Ever Used Ecstasy, 2011 * Used ecstasy/MDMA one or more times during their life. Source: National Youth Risk Behavior Survey, 2011 Junquera & Castellanos, 2014 Annual Prevalence of Designer Drug Use by US 8th, 10th & 12th Graders, 2013 8 7.9 7.4 7 6 5 8th 10th % 4 4 12th 4 3.6 3 2 1.4 1.1 1 1 0 Synthetic Marijuana MDMA GHB Ketamine Source: Johnson LD et al, Monitoring the Future National Survey on Drug Use, 2014 Junquera & Castellanos, 2014 % of Florida High School Students who used Club Drugs* & Synthetic Marijuana, 2013 16 14.8 14 12 10 8th 10th 8 % 12th 6 5.3 4.6 4 2 2.1 1.1 1.8 0.3 0 Lifetime Past 30 Days Club Drugs* 1.8 unk unk Lifetime unk unk Past 30 Days Synthetic Marijuana *Ecstasy, Rohypnol, GHB, Ketamine Source: 2013 Florida Youth Substance Abuse Survey Junquera & Castellanos, 2014 Emergency Room Visits, Miami-Dade County Source: DAWN Report, 2012; http://www.samhsa.gov/data/2k12/DAWN096/SR096EDHighlights2010.htm Junquera & Castellanos, 2014 Emergency Room Visits, Miami-Dade County  398 MDMA -involved ED visits for Miami-Dade County during 2011  Represents 2 percent of all ED visits among 6 categories of substances (cocaine, cannabinoids, illicit stimulants, MDMA, nonmedical use of prescription opioids & BZs  The 2011 total represented a 91 percent increase over the 209 MDMA reports in 2004 Junquera & Castellanos, 2014 Designer & Club Drugs           Synthetic Marijuana GHB MDMA Ketamine N-Bomb Bath Salts Kratom Dextromethorphan DMT Sizzurp Junquera & Castellanos, 2014 Synthetic Cannabinoids Junquera & Castellanos, 2014 Introduction  Product line marketed as incense, herbal or aromatic incense or potpourri  “Not for human consumption”  All ingredients don’t have to be listed  Not “intended” for smoking but most of the products are smoked in hand-held pipes, water pipes or rolled in cigarette paper  Synthetic cannabinoid is sprayed on the product  Manufacturers are substituting more potent synthetic cannabinoid products every day Junquera & Castellanos, 2014 Source for syn cann chart: Data extracted from NMS Labs Laboratory Information Management System. Synthetic Cannabinoid confirmed positive blood samples. Oct 2010-Jan 2013. (n=155)http://www.nmslabs.com/uploads/PDF/Designer%20Drug%20Testing%20March%202013.pdf Introduction II  After marijuana, synthetic canniboids are the most frequently used illicit drugs by 12th graders  One of 9 US high school students reported having used an SCP in 2012.  Sold in Europe since 2006, possibly as early as 2004  Can be purchased:  Online  Head shops  Convenience stores  Gas stations Junquera & Castellanos, 2014 2/11/2014 Draft Synthetic Cannabinoids Physical Effects  Gastrointestinal: Nausea, vomiting  Appetite changes  Conjunctival injection / Red eyes  Tremors  Numbness  Dry mouth  Paleness of skin  Listlessness / Lack of interest  Sweating  Tachycardia  Increased blood pressure Junquera & Castellanos, 2014 Synthetic Cannabinoids Psychoactive Effects  Mood changes:     Euphoria Anxiety Irritability Depression  Cognitive changes:     Impaired short term memory Confusion Cognitive dulling Impairment of linear thinking Junquera & Castellanos, 2014 Synthetic Cannabinoids Psychoactive Effects II  Changes in activity:  Sedation  Excitability  Agitation  Sleep Changes  Psychosis:  Disorganized thinking  Paranoid delusions  Auditory and visual hallucinations Junquera & Castellanos, 2014 Dangers of Synthetic Cannabinoids  Psychosis  New onset  Exacerbation of previously stable psychotic disorders  Extreme mood changes  Effects persist beyond acute intoxication  Tolerance, withdrawal & dependence may be associated with long term use. Junquera & Castellanos, 2014 GHB Junquera & Castellanos, 2014 Overview of GHB  Hypnotic (non analgesic) anesthetic  Epileptogenic agent in animals  Increases growth hormone  Promotes slow wave sleep  Trials for the treatment of opiate and alcohol withdrawal  Treatment of narcolepsy/cataplexy Junquera & Castellanos, 2014 History of GHB  1960: induce a sleeplike state with cardiovascular      stability 1960’s anesthetic was abandoned because of poor analgesic effects 1970’s: first studied for treatment of narcolepsy/cataplexy 1980’s: marketed as a “fat burner and muscle developer” 1990: FDA ordered it to be removed from store’s shelves 2000: Federally classified as a 'Schedule I' drug Source: am, PC, & Yoong, FF. (1998). Gamm a-hydroxybutyric acid: an emerging recreational drug. Anaesthesia, 53(12), 1195-8 Junquera & Castellanos, 2014 Reasons for use  Sense of improved sleep  Sense of improved dancing  Antidepressant (mood lifting)  Anxiolytic  Socialization increases (disinhibiting) Junquera & Castellanos, 2014 GHB Street Names  Blue Nitro  Revivarant  Blue Nitro Vitality  Serenity  G3  Solar Water  Gamma G  SomatoPro  GHRE  Thunder Nectar  Invigorate  Verve  Jolt  Weight Belt Cleaner  Remforce  ZEN  Renewtrient  Revitalize Plus  www.ashesonthesea.com/  GHB/analogs.htm#trinka2 Junquera & Castellanos, 2014 GHB  Often sold as clear salty liquid, taken in capsules or in drinks (Often carried in Visine containers)  Capsule concentration varies 500mg-5g  Rapidly absorbed, peak concentration 20-60 min  Half life is 20 min.  Almost completely oxidized to carbon dioxide  Readily crosses the blood brain barrier and placenta Junquera & Castellanos, 2014 Psychoactive and Physical effects of GHB  Euphoria  Optimism  Increased sexuality  Increased energy  Wellbeing  Giddiness  Relaxation  Talkative  Increased sensitivity to sound  Tranquility  Silliness  Drowsy  Sweaty  Loss of consciousness Junquera & Castellanos, 2014 Dangers of GHB GHB has an incredibly small therapeutic index:  Difficult for enforcement officials to detect as it may be smuggled in vessels like Visine containers  Overdose may result in:  Decreased respiration  Death due to carbon dioxide poisoning Junquera & Castellanos, 2014 Ecstasy - MDMA Junquera & Castellanos, 2014 Overview of Ecstasy  MDMA 3,4 methylenedioxymethamphetamine  Hallucinogenic amphetamine  Historical use in research and psychotherapy  DEA ban on MDMA in 1985 Junquera & Castellanos, 2014 History of MDMA/Ecstasy  1914: E. Merck Pharmaceutical company developed MDMA in Germany  1950's: briefly evaluated as an adjunct to psychotherapy based on a reported ability to produce a state of consciousness that promotes willingness towards emotional self-disclosure  1970's: and early 1980's: again investigated as an adjunct to psychotherapy  1985: Drug Enforcement Agency in US placed MDMA on Schedule I of controlled substances, citing increasing recreational use and concern over potential neurological damage Junquera & Castellanos, 2014 Psychoactive and physical effects of MDMA  Altered time perception  Increased ability to interact with others  Decreased defensiveness  Changes in visual perceptions  Increased awareness of emotions  Decreased aggression  Decreased restlessness  Less impulsive Leister M et al, J of Nerv Ment Dis, 1992; 180 345-352 and McDowell & Kleber, Psychiatric Annals 1994; 24 127-130 Junquera & Castellanos, 2014 Adverse Effects of the Use of MDMA  Decreased desire to     perform mental or physical task Bruxism Decreased libido Increased restlessness Increased anxiety  Depressed mood  Nystagmus  Motor tics  Headaches  Anhedonia  Lethargy  Anorexia  Decreased motivation Leister M et al, J of Nerv Ment Dis, 1992; 180 345-352 and McDowell & Kleber, Psychiatric Annals 1994; 24 127-130 Junquera & Castellanos, 2014 Ecstasy- MDMA  Dose concentration 50 to 300 mg  Cost $25 per tablet  Onset 20 to 40 minutes  Effects less than 24 hours  Street names: e, Adam, X, XTC, purest form MOLLY( Usually white pill or powder) Junquera & Castellanos, 2014 Dangers of MDMA / Ecstasy  Memory problems for at least 2 weeks after use  Functional consequences  Reduction in number of serotonin transporters - PET Studies (can leads to depression)  Damage of serotonin nerve endings  Hyperthermic Syndrome:  elevated temperature  tachyarrhythmia's  hypertension  muscle rigidity, rhabdomyolysis  Hepatotoxicity  Neurotoxicity Bolla, McCann & Ricaurte Neurology 51, 1998 Junquera & Castellanos, 2014 “Molly”  Hundreds of “Molly” capsules tested in two South Florida crime labs in 2012, for example, contained:  methylone, a dangerous stimulant commonly found in “bath salts” News reports elsewhere have reported “Molly” capsules containing:  cocaine  Heroin  and other substances. Junquera & Castellanos, 2014 Ketamine Take a little ‘K’ and Meet the “K-Monster” Junquera & Castellanos, 2014 Overview of Ketamine  Central nervous system depressant  Usually snorted or insufflated  Rapid acting-acting dissociative anesthetic  Sedative-hypnotic, analgesic and hallucinogenic properties  Structurally similar to PCP  N-methyl-D-Aspartate (NMDA) antagonist Junquera & Castellanos, 2014 History of Ketamine  1962: developed and initially promoted as a fast acting general anesthetic  1970’s: approved for human use by federal government, and as a result became  late 1970’s and early 1980’s: abuse began to increase across the country  1999: classified as a Schedule III controlled substance in August 1999, creating more stringent controls of the drug  2012: Being studied for adjunct treatment in patients with Major depressive disorder University of Maryland, http://www.cesar.umd.edu/cesar/drugs/ketamine.asp Junquera & Castellanos, 2014 Subjective Psychoactive and physical effects of Ketamine  Muscle spasm  Blurred vision  Dizziness  Slurred speech  Visual “flashbacks”  Psychological effects  Tolerance  Agitation  Increased temperature Junquera & Castellanos, 2014 Ketamine – “Special K”  Snorted or insufflated  Dissociative effects called a “K-hole” – your brain is active but your body isn’t, “like you’re in a tunnel, your hear echoes, you’re in a semiconscious state”  Used at rave/dance club scene, not as popular as in past “like living inside a big cotton ball,” “everything is in slow motion” Junquera & Castellanos, 2014 Ketamine  Administration: injected, intranasal, oral  10 ml vials provide 5 illicit doses  Sell for $20 a dosage unit  Rapid onset of effects  Duration of effects 4-6 hours  Street names: Special K, Vitamin K, KitKat, Blind squid, Super acid Junquera & Castellanos, 2014 Dangers of Ketamine  Paralyzing agent  Flammable  Confusion  Loss of Consciousness  With Chronic use:  Brain damage in the form of vacuoles  Personality changes Junquera & Castellanos, 2014 N-Bomb Junquera & Castellanos, 2014 Overview of N-Bomb  It affects the serotonin receptors in the brain  It is considered a powerful synthetic hallucinogen  They are being sold as LEGAL substitutes for LSD and mescaline. Junquera & Castellanos, 2014 History of N-Bomb  Discovered in 2003 by a chemist in Berlin  It was further investigated by a team of researchers in 2007 by a research team in Perdue University  The compound was labeled as 25I-NBOMEe  It was classified as a radiotracer used in PET scans  2013 this compound is being sold in the internet as a designer drug. Junquera & Castellanos, 2014 Psychoactive and Physiological effect of N-Bomb  Agitation  Visual & Auditory hallucinations  Seizures  Increased body temperature  Muscle breakdown  Aggression  Acute kidney injury Junquera & Castellanos, 2014 N-Bomb  25I-NBOMe usually taken sublingually or by mouth  The effects usually last 4-6 hours could be up to 12 hours  Liquid more potent faster acting  Stamps with caricatures usually laced with the substance Junquera & Castellanos, 2014 N-Bomb Street names  25I  Smiles  Legal acid Junquera & Castellanos, 2014 Dangers of N-Bomb  Confusion  Seizure  Cardiac arrest  Respiratory arrest  Death  At least 19 young people are reported to have died after taking 25I- 25C- or 25B-NBOMe between March 2012 and August 2013. Junquera & Castellanos, 2014 Bath Salts Junquera & Castellanos, 2014 Overview of Bath Salt Abuse  Patients report: “It’s like a poor man’s cocaine that’s legal”  Poison Control Center has received over 4,000 call last year  MDPV (methylenedioxypyrovalerone)  Mephedrone  Increased Blood Pressure, Heart Rate,  Agitation, Hallucinations, Paranoia,  Delusions Junquera & Castellanos, 2014 History of Bath Salts  First synthesized in the 1920s  In 2009-2010: they became popular in the underground market  2010: started to be marketed as “ not for human consumption”  2011:New York was one of the first states to ban the sale of Bath salts  2012: President Obama signed a bill that amended the Federal drug policy of the United States to ban “bath salts” Junquera & Castellanos, 2014 Psychoactive and Physiological effects of Bath Salts  Agitation  Hypertension  Increased temperature  Muscle breakdown  Impulsivity  Lack of Judgment and Insight  Bruxism  Muscle spasm  Increased body strength Junquera & Castellanos, 2014 Bath Salts  Powder packets of 50 mg  $20-$40 Latest Designer Drug  Used as synthetic stimulant; snort/insufflate, smoke, inject  Illegal in 41 states and pending legislation in the others  Deaths reported  Some call it a Mini Crack Junquera & Castellanos, 2014 Bath Salts Street Names  Ivory Wave  Bliss  White Lightning  Vanilla Sky  Cloud 9  Hurricane Charlie (most popular)  Zoom  Purple wave Junquera & Castellanos, 2014 Dangers of Bath Salts  Overstimulation of the central nervous system  Body temperature dysregulation  Seizures due to temperature  Supernatural aggression  Death Junquera & Castellanos, 2014 Kratom Junquera & Castellanos, 2014 Overview of Kratom  Opiate like sedation  Coca like stimulation  Stimulating at low dose levels  Higher doses more opiate like Junquera & Castellanos, 2014 Psychoactive and Physiological effects of Kratom  Sedation at higher doses  Stimulation at low doses  Low acting anesthetic  Depression after use or in withdrawal  Nausea, vomiting Junquera & Castellanos, 2014 Kratom  Effects noticeable in 20-30 minutes  Effects can last 2-6 hours.  Physical dependency can occur  Withdrawal symptoms: irritability, yawning, diarrhea, pain  Street names: Kakaum, Ithang, Thom Junquera & Castellanos, 2014 Dangers of Kratom  Same as those of Heroin and Cocaine  Low doses much like Cocaine (upper)  Higher doses much like Heroin (downer) Junquera & Castellanos, 2014 Dextromethorphan Junquera & Castellanos, 2014 Dextromethorphan  Over the counter cough and cold remedies  Street names:  “DXM”  “Triple-C” “Skittles”  “Robo-tripping”  PCP or ketamine-like Junquera & Castellanos, 2014 Psychoactive and Physiological effects of Dextromethorphan  Hallucinations  Delirium  Hypertension  Tachycardia  Ataxia  Agitation  Seizures Junquera & Castellanos, 2014 DMT (Dimethyltryptamine) Junquera & Castellanos, 2014 Overview of DMT  A psychoactive chemical in the tryptamine family  Present in thousands of species of plants  Used traditionally in South America  Intense visuals and strong psychedelic  Mental effects when smoked, injected, snorted or when swallowed orally (usually with an MAOI)  Standard Dose (15-60mg) Hit ($10-30) Junquera & Castellanos, 2014 Psychoactive and physiological effects of DMT  Hallucinations  Delirium  Agitation  Confusion  Palpitations Junquera & Castellanos, 2014 Sizzurp Junquera & Castellanos, 2014 Overview of Sizzurp  It’s a concoction which includes:  Cough syrup with codeine  Promethazine  Jolly Rancher candy or Skittles  Soda pop  Usually served in Styrofoam cup but also drank out of the soda bottle Junquera & Castellanos, 2014 History of Sizzurp  Originated in Houston, Texas  1960: It was first used by Blues singers in the in order to perform and continue to work.  They used Robitussin with beer and then when wine coolers became popular they replaced it.  1980-1990: The recipe was changed to use it with codeine promethazine cough syrup with a lemon lime soda and Jolly Ranchers  1990s: Made popular by a DJ in Houston and his music being played in a slow tempo as if they were on codeine and promethazine  This concoction caused his early death and it was then that is caught the attention of law enforcement  2012: It became popular in the hip hop community Junquera & Castellanos, 2014 Psychoactive and physiological effects of Sizzurp  Slow reaction time  Sedation  Relaxation  Decreased respiratory rate  Weight gain  Tooth decay  Dizziness  Lethargy  Dissociative feeling  Motor skill impairment Junquera & Castellanos, 2014 Sizzurp Street Names  Purple drank  Purple lean  Purple jelly  Texas Tea  Syrup Junquera & Castellanos, 2014 Dangers of Sizzurp  Seizures when mixed with alcohol or if person prone to seizures  Shut-off of the respiratory center in the brain Junquera & Castellanos, 2014 What can we do?  Education to:  Young Adults  Parents  Educators  Community at large  Decrease stigma about substance used disorders in order to increase the users from seeking help.  Arm ourselves with a “First Aid Kit” to recognize intoxication with these substances and get them help. Junquera & Castellanos, 2014 Edible Cannabis Junquera & Castellanos, 2014 Closing Remarks Designer drug use will not go away  New drugs will continue to emerge  No matter how designer drugs evolve, we need to be ready Junquera & Castellanos, 2014 References  Galloway, GP, Frederick Osborne, SL, Seymour, R, et al. (2000). Abuse and therapeutic potential of gammahydroxybutyric acid. Alcohol, 20(3), 263-9.  Kam, PC, & Yoong, FF. (1998). Gamma-hydroxybutyric acid: an emerging recreational drug. Anaesthesia, 53(12), 1195-8.  Koesters, SC, Rogers, PD, & Rajasingham, CR. (2002). MDMA ('ecstasy') and other 'club drugs'. The new epidemic. The Pediatric clinics of North America, 49(2), 415-33.  Rochester, JA, & Kirchner, JT. (1999). Ecstasy (3,4- methylenedioxymethamphetamine): history, Neurochemistry, and toxicology. The journal of the American Board of Family Practice, 12(2), 137-42.  www.clubdrugs.org  NIDA’s “Initiative to Combat Club Drugs Junquera & Castellanos, 2014