Lạm dụng các loại ma túy mới: ý nghĩa lâm sàng

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<b>Emerging Drugs of Abuse: </b>

<b>Clinical Implications </b>

<b>Scott Phillips, MD, FACP, FACMT, FAACT</b>
<b>Associate Medical Director</b>

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“Synthetic” Drugs

 Drugs like Molly, MDMA, 2C-E, bath salts, tend

to be a small segment of drug use

 Present a problem because they rapidly change

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History

 1990s: surge in use of

3,4-methylenedioxy-N-methylamphetamine (MDMA), rave drugs

 Many new derivatives available now

 Most contain little MDMA

 Amphetamine, DXM, BZP, etc.

 Next generation includes:

 Tryptamines

 Phenylethylamines

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Tryptamines

 Re-emerged on drug scene

 Include DMT, 5-MeO-DIPT, 5-MeO-DMT,

and more

 Yakee plant, Foxy methoxy, alpha-O, O-DMS,

alpha and bufo toad secretions

 Similar to psilocybin, psilocin, and bufotenine

 Derivatives of tryptamine contain stimulant

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Tryptamine Pharmacology

 Mechanism of action not fully elucidated
 Similar to classical hallucinogens like LSD

 Direct agonists at 5-HT_2A and 5-HT_1C

 Presentation includes

 Empathy

 Euphoria

 Visual/auditory hallucinations
 Tachycardia/HTN

 Confusion
 Seizures

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Dimethyltryptamine (DMT)

 DMT discovered in

1960s

 “Businessman’s

lunch”

 DMT used in South

America for spiritual
and medicinal

purposes

 Available in various

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Management of Tryptamine Toxicity

 Treatment

 Supportive care
 No antidotes

 Nice, quiet dark room

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Phenylethylamines

 Newer designer analogues designated “2C”

series

 DOM: STP (Serenity, Tranquility, & Peace)
 Mescaline: Mesc, Buttons, Cactus

 2C-B: Nexus, Bromo, Bees, Venus
 2C-T-2: Triptasy or Beautiful

 2C-E: Europa, Eternity

 2C-T-7: Blue Mystic and 7th Heaven

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Phenylethylamines

 Pharmacology similar to bath salts

 Affect dopamine, norepinephrine and serotonin

 Increase release of catecholamines and inhibit the

reuptake of them

 Ring substitutions increase affinity for 5-HT₂

receptors

 Agonist properties at other 5-HT substypes

and α₁-adrenergic receptor

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Phenylethylamines

 Hallucinations

 Visual and auditory

 Euphoria
 Entactogen
 Tachycardia
 Paranoia
 Delirium
 Bruxism

 Violent behavior

 Refractory seizures

and serotonin toxicity
with 2C-I reported

 Recently in Seattle

 Death in 15 yo by

25i-NBOMe

 Fatal cardiac arrest

after 2C-E

 No literature on

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Molly

 Highly purified form of MDMA

 Methylene-dioxy-methamphetamine

 Oftentimes contains very little MDMA

 Other drugs sold as Molly

 MDMA is neurotoxic even with a single dose

 Destroys 5-HT receptors and serotonergic neurons
 Long terms effects result in neuroendocrine

impairments to deficits in verbal memory and
reasoning

 Chronic psychosis responds poorly to traditional

therapy

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Management

 In the ED

 Management largely supportive

 Benzodiazepines as indicated for sympathomimetic

symptoms

 Hyperthermia is what kills these patients
 Body temps of 111 degrees F

 Rapid cooling with ice and chilled saline fluids

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“NMUO”

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Opiate Prescribing

 Steady increase in opioid prescribing from 2006,

 Total # of Rx’s peaked in 2012 at >255 million and a rate of 81.3 Rx per 100
 The overall national opioid prescribing rate declined from 2012 to

2016

 In 2016, the Rx rate had fallen to the lowest in 10 years at 66.5 Rx per 100

 over 214 million total opioid prescriptions).

 However, in 2016, prescribing rates continue to remain very high in

areas across the country.

 In ¼ of U.S. counties, opioid Rx’s were dispensed for every

person.

 Opioid prescribing rate in 2016 was 66.5 prescriptions per 100

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Fentanyl

 50-100 times > potent than Morphine

 50 times > than heroin

 1 kg can make 1 million tablets

 20-80 USD per tablet

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Methamphetamine History

 Developed in late 1800s and used during

WWII to keep troops awake

 Given to pilots to enhance “performance”

 Used previously as diet aid, antidepressant,

stimulant, and drug of abuse

 Street names

 Speed, Krystal meth, Tina, Ice, Crank,

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Management

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Where did it come from?

 1960s: research into THC-like compounds

 Analgesic and anti-inflammatory minus

psychotropic effects

 Recognized as drugs of abuse in early 2000’s

in Europe

 Dr. JW Huffman researched THC analogues

for use in cancer and AIDS patients
 Developer of JWH compounds

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What are they?

 Synthetic cannabinoids which work on the

CB1 and CB2 receptor like THC

 Marketed as herbal incense, herbal smoking

blends, potpourri, etc.

 Spice, K2, Mr. Nice Guy, Legal Funk, Tai Fun
 Misleading packaging

 Not for human consumption

 Commonly smoked

 New chemicals like PINACA and

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Pharmacology

 Effects likely from mixture of herbs and actual

synthetic compounds

 Baybean, Beach bean, Dwarf skullcap, red clover,

vanilla, honey, wild dagga and more

 Affects CB1 and CB2 receptors found in

CNS/PNS

 Responsible for elevating mood, anxiety, cognition
 Responsible for reducing inflammation induced pain

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Clinical Manifestation

 Most information from case reports and case

series

 Psychiatric effects predominate

 Anxiety, paranoia, agitation, delusions, and

psychosis

 Physical manifestations

 Tachycardia, HTN, diaphoresis, seizures, muscle

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Management

 Agitated Delirium

 Like bath salts, unpredictable

 ABCs

 GI decontamination

 No antidote

 Supportive care

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What are bath salts?

 Synthetic cathinone derivatives

 Synthesized as early as 1928 and studied for

medical use

 Methcathinone (1928)
 Mephedrone (1929)

 Used as antidepressant in 1930s in Soviet

Union

 Bupropion only cathinone with medical

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Common Synthetic Cathinones and

Names

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α-

<b>PVP</b>

 α-Pyrrolidinopentiophenone (also known as

α-pyrrolidinovalerophenone, α-PVP, O-2387,
β-keto-prolintane, prolintanone, or

desmethylpyrovalerone) “Flakka”

 Substituted cathinone & pyrrolidine

 Developed in the 1960s

 Heightened tactile enhancement

 Norepinephrine-dopamine reuptake inhibitor

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Pharmacology

 β-ketonated amphetamines

 Ketone on β carbon leads to decreased CNS

penetration  increased doses  increased
effects

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Clinical Manifestations

 Agitation (53.3%)

 Tachycardia (40%)
 Hypertension (20%)
 Seizures (20%)

 Palpitations (13.3%)

 Hallucinations/delusions
 Paranoia

 Renal failure

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Management

 Protect yourself!

 Difficult to manage patients and unpredictable

behavior

 ABCs

 No antidote

 GI decontamination

 Benzodiazepines, barbiturates for agitation,

hallucinations and seizures

 Caution against using haloperidol

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Loperamide & Diphenoxylate Abuse

 Inexpensive OTC anti-diarrheal with peripheral mu opioid

receptor activity

 200 - 400 tablets of Loperamide 2 mg daily
 Produces cardiac conduction abnormality

 QTc > 600 msec

 Normal up to 460

 High risk for TdP

 Mechanism of toxicity unknown

 Watch for patients purchasing MASSIVE quantities of

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Other Common Drugs of Abuse

 Diphenhydramine

 Anticholinergic toxicity
 Lilliputian

hallucinations

 Physostigmine?

 DXM

 “Robotripping” or

“Triple C’s”

 Hallucinations and

euphoria

 Serotonin syndrome

 Nutmeg

 Contains myristicin
 Causes LSD-like

hallucinations

 Ingest grams

 Morning Glory Seeds

 Contains LSD-like

alkaloid

 Hallucinations
 N/V

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