The New Face of Abused Drugs

Editor's Note:

Drug abuse remains a major public health problem worldwide as people continue to use or abuse "old drugs" such as alcohol, marijuana, cocaine, and opioids. Making the news lately, however, are novel substances that have attracted potential users with promises of "legal" highs and easy access via the Internet.

Clinicians need to be aware of the emerging trends in alcohol and other drug abuse, especially if they are not up to date on the new recreational drugs on the scene in their own communities.

How can clinicians identify and manage the "new face of abused drugs"? This slideshow provides healthcare providers with an at-a-glance introduction to the clinical challenges posed by patients using and abusing novel substances.

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Bath Salts – MDPV, Mephedrone (Rosenbaum CD, et al.^[1])

What Are They?

"Bath salts" may appear to be white powder or crystals to add to bath water, but the term actually refers to amphetamines and cathinones (synthetic derivatives of the stimulant found in the khat plant) that are sold in clandestine packaging to avoid detection by law enforcement. MDPV and mephedrone often are the active compounds, with effects similar to those of ecstasy (MDMA). Street slang terms and product names include drone, bubbles, meow-meow, MCAT, Ivory Wave, Vanilla Sky, Cloud 9, Red Dove, and White Rush.

Who Is Most at Risk?

Use is most prevalent among teens and young adults who wish to avoid drug detection while enjoying what used to be a "legal high." Before the US Drug Enforcement Administration acted to make bath salts illegal in September 2011, these substances were sold at gas stations, head shops (retail drug paraphernalia outlets), and record stores. Users still can purchase the products online.

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Bath Salts – cont (Rosenbaum CD, et al.^[1])

Clinical Presentation

Sympathomimetic effects (eg, elevated pulse and blood pressure; diaphoresis; agitation; and, with long-term use, psychotic features) may predominate.

Drug Screen Availability

Cathinones will not appear on standard immunoassays for drugs of abuse (DOA). Amphetamines may be detected with DOA immunoassay, and both substances are detectable with gas chromatography–mass spectrometry (GC-MS) analysis.

Patient Management Summary

Management includes supportive care. Benzodiazepines are useful for agitation and psychosis. Patients who have used amphetamines such as MDMA may present with serotonergic symptoms requiring supportive care or treatment with benzodiazepines or cyproheptadine. Patients with severe agitation and vital sign abnormalities may require intensive monitoring and care.

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Herbal Marijuana Alternatives and Synthetic Cannabinoids (Rosenbaum CD, et al.^[1])

What Are They?

These "incense" products contain herbal plant matter adulterated with synthetic cannabinoids and are usually smoked. Baybean, beach bean, blue lotus, lion's ear/tail, wild dagga, Indian warrior, and dwarf skullcap are examples of the herbal ingredients. Synthetic cannabinoids include JWH-018/073/200, CP-47,497, and RCS-4. Spice, K2, Chill Zone, Sensation, Chaos, Aztec Thunder, Red Merkury, and Zen are some of the common brand names.

Who Is Most at Risk?

Users typically range in age from 14 to 50 years. Although 5 synthetic cannabinoids are now illegal in the United States,^[2] these products are still widely available in gas stations and head shops and via the Internet, owing to reformulations to skirt the federal ban. Military personnel and others who must undergo regular drug testing (eg, for marijuana) know that these "legal highs" may be undetectable.

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Herbal Marijuana Alternatives and Synthetic Cannabinoids – cont (Rosenbaum CD, et al.^[1])

Clinical Presentation

Clinical effects include hypertension, tachycardia, nausea, vomiting, agitation, anxiety, paranoia, seizures, and suicidal ideation.

Drug Screen Availability

Synthetic cannabinoids are undetectable using standard DOA immunoassays directed at tetrahydrocannabinol, the active ingredient in cannabis. Analysis with GC-MS can identify specific synthetic cannabinoids in a patient's urine, but only under highly restrictive circumstances.

Patient Management Summary

Management includes supportive care. Symptoms are typically short-lived (< 24 hours), but some cases have required bilevel positive airway pressure and admission to the intensive care unit for respiratory distress (Rosenbaum CD. Unpublished data).

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Salvia divinorum (Rosenbaum CD, et al.^[1])

What Is It?

Salvia divinorum, a hallucinogenic herb belonging to the mint family, contains the hallucinogen salvinorin A. Traditionally, the Mazatec Indians of Oaxaca, Mexico, chewed or brewed Salvia divinorum as tea to facilitate spiritual encounters; it is now being used recreationally worldwide. Salvinorin A is inactive after ingestion; as a result, users seeking a high must chew or smoke the leaves.^[3]

Who Is Most at Risk?

Young adults, adolescents, and anyone with access to the Internet who is interested in avoiding drug detection via this "legal high" (in some states) are considered at most risk.

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Salvia divinorum – cont (Rosenbaum CD, et al.^[1])

Clinical Presentation

Users report potent open- and closed-eye hallucinogenic effects. Unlike other hallucinogens, salvinorin A does not have serotonergic activity. Instead, its affinity for the kappa opioid receptor may cause sedation, analgesia, gastrointestinal hypomotility, aversion, and depression.

Drug Screen Availability

Salvinorin A is not detected by standard DOA immunoassays. Salvinorin A can be detected in urine and saliva using GC-MS analysis.

Patient Management Summary

Management includes supportive care. Because salvinorin A acts solely at kappa opioid receptors, in theory it should not cause respiratory depression, although respiratory monitoring is prudent.

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Khat (Cathinone) (Rosenbaum CD, et al.^[1])

What Is It?

Khat (Catha edulis) is a plant whose leaves and twigs are chewed for their reported amphetamine and euphoric effects. Common in Yemen, Somalia, and Ethiopia, khat abuse has now spread beyond its geographic and historic roots as a result of online information and sales. Cathinone is the main active ingredient.

Who Is Most at Risk?

Anyone with access to the Internet may obtain khat. In 2006, 10 million people were estimated to have used the drug.

Clinical Presentation

Amphetamine-like effects produce agitation, tachycardia, hypertension, and psychosis.

Drug Screen Availability

Cathinone cannot be detected by DOA immunoassay. However, GC-MS analysis can detect cathinone and synthetic cathinone derivatives.

Patient Management Summary

Management includes supportive care, benzodiazepines, and sympatholytics.

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Insufflation of Oral Medications

What Is the Emerging Issue?

Crushing and insufflating ("snorting") an oral medication allows immediate bioavailability of far larger doses of the drug than would be available from ingesting an intact tablet. Some newer, so-called "abuse-resistant" formulations can be crushed but with difficulty.

Who Is Most at Risk?

Populations at greatest risk include young people experimenting with drugs and long-term or habitual drug users who have developed a tolerance to their typical oral medication.

Clinical Presentation

Nasopharyngeal necrosis (destruction of the nasal septum, soft or hard palate, and other facial structures) has been reported from insufflation of opioid analgesics as well as other drugs.^[4-6]

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Insufflation of Oral Medications (cont)

Drug Screen Availability

Detection depends on the drug used. Opioids (eg, hydrocodone, oxycodone, oxymorphone, hydromorphone, propoxyphene, and tramadol) cannot be detected by DOA immunoassays. Methylphenidate is also uncommonly detected by DOA immunoassays. GC-MS analysis and opioid-specific immunoassays are commercially available to detect opioids but often require special ordering and testing.

Patient Management Summary

Management of drug effects should be directed at the specific xenobiotic involved. Opioid intoxication may be managed with naloxone, whereas intoxication with stimulants, such as methylphenidate, may require benzodiazepines.

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Energy Drinks

What Are They?

Energy drinks are flavored, typically sugar-sweetened beverages that manufacturers claim enhance energy and performance. These drinks contain as much as 360 mg/L of caffeine (roughly the equivalent of 3-4 cups of coffee), along with other ingredients that act as stimulants (eg, guarana, taurine, ginseng, and L-carnitine).

Who Is Most at Risk?

Populations most at risk are young people and others seeking to stay awake for personal, school-, or job-related reasons.

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Energy Drinks (cont)

Clinical Presentation

Caffeine (1,3,7-trimethylxanthine) is a structural analog of adenosine and a functional adenosine receptor antagonist. Presynaptic alpha-1 antagonism causes catecholamine release and adrenergic surge. Symptoms of caffeine intoxication can range from mild nausea and palpitations to severe, protracted vomiting; cardiac dysrhythmias; and seizures.^[7,8]

Drug Screen Availability

Caffeine may be detected by specific testing with GC-MS analysis; it is not detected by DOA immunoassay.

Patient Management Summary

Supportive care should include intravenous fluid resuscitation, antiemetics, and sympatholytics.

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Methoxetamine (Rosenbaum CD, et al.^[1])

What Is It?

Methoxetamine (MXE) is an analog of ketamine ("special K"). Both drugs share structural similarity with phencyclidine (PCP).

Who Is Most at Risk?

Methoxetamine use is popular in the United Kingdom but has the potential for wider use via Internet sales. Little is known about the users or specific patterns of abuse, other than that the drug can be injected intravenously.^[9,10]

Clinical Presentation

The clinical experience with methoxetamine is limited to self-report and advertising. Users reported abusing the drug for its euphoric and hallucinogenic effects but may experience opioid effects such as respiratory depression, vomiting, diarrhea, anxiety, and paranoia. Classically associated with ketamine, nystagmus may be observed. One case report describes a 19-year-old who injected methoxetamine intravenously and later presented with semistuporous mental status, agitation, ataxia, hypertension, and tachycardia.^[10]

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Methoxetamine – cont (Rosenbaum CD, et al.^[1])

Drug Screen Availability

Methoxetamine may not be detectable via GC-MS analysis. The DOA immunoassay directed at PCP detection also may not identify methoxetamine.

Patient Management Summary

No specific management of methoxetamine intoxication has been described at this time. However, similar management to that for ketamine, PCP, or opioid intoxication should be used. Suggested strategies may include supportive care, intravenous fluid resuscitation, benzodiazepines for agitation, and respiratory support.

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Piperazine Derivative (Rosenbaum CD, et al.^[1])

What Is It?

Piperazine was initially designed as an antihelminthic but was discovered to have stimulant properties. Many different piperazines exist (eg, BZP, CPP, MBZP, MeBP, MeOPP, MeP, and TFMPP). They are often sold as pills or powders containing a mixture of multiple drugs.

Who Is Most at Risk?

Young adults, especially those involved in club culture, may be most attracted to this designer "party pill," or "legal ecstasy" as it is sometimes known on the street.^[11] Piperazine abuse has been extensively identified in Europe and New Zealand.^[12,13] Young males, typically in their twenties (age range 13-44 years), use piperazines for their amphetamine or stimulant-like effects, especially when attending dance clubs and possibly as a means to avoid withdrawal from amphetamines.^[13,14] Given the availability of these drugs on the Internet, their popularity will likely spread to the United States to demographics beyond just the "club scene."

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Piperazine Derivative – cont (Rosenbaum CD, et al.^[1])

Clinical Presentation

Sympathomimetic and serotonergic effects may predominate owing to the ability of piperazine to impair serotonin reuptake and directly stimulate serotonin receptors.

Drug Screen Availability

Piperazines are not detectable by typical immunoassay testing, but they may be detectable via GC-MS or liquid chromatography-MS analysis.

Patient Management Summary

Benzodiazepines for agitation and intravenous fluid resuscitation should form the foundation of supportive care, directed in a manner similar to that for other sympathomimetics.^[11] If serotonergic effects are observed, supportive care and possibly antiserotonergic medications, such as cyproheptadine, may be indicated.

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Author
Christopher D. Rosenbaum, MD, Assistant Professor, University of Massachusetts Medical School; Attending Physician, Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical Center, Worcester, Massachusetts

Christopher D. Rosenbaum, MD, has disclosed the following relevant financial relationships:
Received income in an amount equal to or greater than $250 from: UpToDate

Reviewer
Edward W. Boyer, MD, PhD, Professor of Emergency Medicine, Director of Toxicology and the Toxicology Fellowship, Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical Center, Worcester, Massachusetts

Edward W. Boyer, MD, PhD, has disclosed no relevant financial relationships.