Emerging illicit drugs of abuse

1. The legal highs
Dr Ioana Vlad

2. Synthetic / emerging drugs
• What are they?
• How do patients present?
• How do we treat?
• What is all the fuss about?

3. Issues
- readily available in retail stores and online
- cheap
- highly attractive packaging
- perceived as safe drugs
- party pills / herbal highs / legal highs /
nutritional supplements
- not easily detectable in urine or blood samples

4. Synthetic / emerging drugs
• Synthetic cannabinoids
• Synthetic cathinones
• Novel psychedelics / synthetic LSD

5. Synthetic cannabinoids

6. Synthetic cannabinoids
• Usually marketed as incense sticks
• Smoked or ingested “with a carrier high in
fat content”
• Labeled “not for human consumption”

7. Synthetic cannabinoids
•
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•
•
•
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Spice
K2
Happy Tiger Incense
Blueberry spice
Purple rush
Banana cream nuke
Kronic

8. Synthetic cannabinoids ( ~ 460)
Naphthoylindoles
JWH-018
JWH-081
JWH-250
AM-2201
JWH-073
JWH -200
Cyclohexylphenoles
CP-47497
CP 47
CP 497
• structurally different from THC but same effect
on cannabinoid receptors

9. Synthetic cannabinoids
• 1984 John Huffman
University of Clemson
(USA)
• 2004 “Spice” appeared
in London - The Psyche
Deli company

10. Advertised effects
• Euphoria / relaxation / laughter / feelings of joy

11. Clinical presentations
• Agitation / paranoid psychosis
• Seizures
• Nausea, vomiting
• Acute kidney injury
• Hypokalaemia / hyperglycaemia
• Hyperthermia
• SVT / cardiomyopathy / acute LVF / AMI
• Hypertension

12. Synthetic cathinones

13. Synthetic cathinones
- chemically similar to
cathinone found
in the khat plant of
eastern Africa
- manufactured in China
- tablets or powder / swallowed, snorted or injected
- most common - 3,4 methylenedioxypyrovalerone
(MDPV), mephedrone, methylone

14. 3, 4-Methylenedioxypyrovalerone
(MDPV) & other synthetic cathinones
 effects similar to cocaine /
amphetamines / MDMA
- sometimes labeled as legal
cocaine or legal
amphetamines

15. MDPV timeline
 Developed in the 1960s for the
treatment of chronic fatigue, but
abandoned due to abuse and dependence
 1969: Boehringer Ingelheim files a patent application for
MDPV
 2005: MDPV on recreational drugs markets and mentioned
on Drugs forum

17. MDPV timeline
 2007: first seizure of MDPV as a recreational drug, by
customs officials in Germany (shipped from China)
 2009: MDPV made illegal in Denmark
2010: UK
2011: USA, Australia

18.  Sold as bath salts / insect repellant / research
chemical / plant food
 Sold mostly on the internet,
but can also be found in adult
or herbal shops
 Labeled “not for human consumption.”

19.  Red Dove
 Blue Silk
 Cloud Nine
 Ocean Snow
 Lunar Wave
 Vanilla Sky
 Ivory Wave
 White Lightning
 Scarface
 Purple Wave
 Star Dust
 Hurricane Charlie

20. Advertised effects
 Euphoric
 Anorectic
 Aphrodisiac
 Anxiogenic
 Increases alertness
 Inhibits sleep

21. Advertised effects
“ Swim says he finds MDPV a wonderful compund for getting things
done, like cleaning the flat, getting long boring e-mails written and
sent and working through shitloads of Uni-grade maths at hyperspeed.
The lack of euphoria is almost concieved as positive by SWIM as it
doesn't distract him from the task at hand."
"...lower doses of MDPV produces a clarity of thought far superior
to just about every other stimulant I've ever tried."

22. Clinical presentation
dopamine-noadrenaline reuptake inhibitors (NDRI)
- Agitation / aggression / paranoid delusions with violent
behaviour / increased alertness/awareness / insomnia
- Headache, confusion, seizures
- Movement disorders - bruxism / muscle spasms
- Abdominal pain
- Rhabdomyolysis, renal failure; hyponatraemia
- Tachycardia, hypertension, vasoconstriction – STEMI
- Tachyarrhythmias
- Hyperthermia

23. MDPV
 quick onset
 peak effects for 3 - 4 hours
 tachycardia, hypertension, and mild stimulation
last 6 - 8 hours

24. MDPV’s chemical ‘cousins’
 α-pyrrolidinopropiophenone (α-PPP)
- detected in Germany in seized "ecstasy" tablets
 4'-methyl-α-pyrrolidinopropiophenone (MPPP)
- Germany late 1990s / early 2000s
 3',4'-methylenedioxy-α-pyrrolidinopropiophenone (MDPPP)
- Germany late 1990s / early 2000s - imitation ecstasy

25. Gen 2, 3 etc. of “bath salts”
• Naphyrone / O-2482 / naphthylpyrovalerone
– “Cosmic Blast” - marketed as a jewelry
cleaner
– triple reuptake inhibitor (serotonin / noradr /
dopamine)
– anecdotal reports of prolonged toxicity and severe
hyperthermia
• Pentedrone, Alpha-PVP, 3,4-DMMC

26. What are the issues with MDPV?

27. What are the issues with MDPV?
"MDPV is the most compulsive drug swim has ever done, he
just can't stop hitting that pipe, it's worse than fucking
crack! He's been at it since 11am, 16 hours ago, and in that
time he's done 150mg so far, solely via the pipe, far too
much!! He's still got over 300mg left, aargh!!! ...He's not
even sure if he's still enjoying it, don't think he is, but still
he can't stop hitting that pipe for some reason (though he
does know why really, dopamine = reward innit). Bloody
strange substance! Any swimer fancy coming round and
freeing
swim
of
this
bloody
pipe?"

28. What are the issues with MDPV?
"MDPV is like the bastard with a whip you've got to obey
or you get hurt. Then you obey and get hurt even worse.
Finally, it's "Thank you sir may I have another... thank you
sir, may I have another... thank you sir, may I have
another..." and you wonder why you've come to enjoy
feeling like shit nearly every waking moment. You vow
never to touch MDPV again, then an hour or two after it
wears off you find yourself eagerly using MDPV."

31. Novel psychedelics / NBOMe
Alexander Shulgin
Albert Hofmann

32. Novel psychedelics / NBOMe

34. Novel psychedelics or synthetic LSD
 25B-NBOMe / 25I-NBOMe
 derivatives of the 2C family of phenethylamine
psychedelics
 very potent partial agonists 5HT – 2A receptor
 snorted or dissolved into a liquid and placed on blotter
paper under the tongue

36. Advertised effects
 90s – replacement for ecstasy
 Colourful hallucinations
 Feelings of empathy
 Feelings of closeness with
others

37. Effects
• Aggitation / extreme behaviours
• Tahycardia, hypertension
• Hyperthermia
• Seizures
• Metabolic acidosis
• Multiorgan failure

38. Effects
- onset ~15 min
- may last 6-10 hours
- active at very low doses

40. Treatment
- Supportive care - benzodiazepines for agitation,
seizures, tachycardia, and hypertension
- Significant hyperthemia may require passive or active
cooling
- Consider checking electrolytes, renal and liver function
tests, cardiac markers, CK
- Observe until resolution of abnormal vital signs,
vomiting, and psychiatric symptoms

41. Legislation issues
- June 2011 – synthetic cannabinoids banned in WA /
QLD / VIC and then federal
- October 2011 – MDPV banned in USA and most European
countries
- February 2012 – WA bans MDPV
The problem: drugs could only be added to the
list once identified

42. DMEC
Methedrone
Ethedrone
3-MOMC
2-FMC
2-FEC
3-FMC
3-FEC
3-CMC
3-BMC
Flephedrone
4-FEC
Brephedrone
FMMC
2,5-DMOMC
bk-MDA
2,3-MDMC
Methylone
Ethylone
O-2384
α-PVP (O-2387)
4-MeMABP
4-Me-NEB
4-Methoxybuphedrone
Butylone
Eutylone
BMDB
bk-DMBDB
5-Methylmethylone
5-Methylethylone
2-Methylbutylone
5-Methylbutylone
Pentylone
MMP
MEP
bk-Methiopropamine
αPhthalimidopropiophen
one
α-PPP
α-PBP
EDMC
3,4-DMMC

43. • Urine drug screens will not pick them up
• Blood tests available
– Expensive
– Only for identified structures

44. Legislation issues
- Sept 2013 – NSW law banning “manufacture, supply
and advertising of psychoactive substances (schedule 9)”

45. Take home messages
- drugs of abuse are forever changing
- manipulation of basic chemical structures to
avoid legal ramifications
- the classes of drugs more important than names
- effects: psychoactive and sympathomimetic
- symptomatic management
-BZDs are a useful adjunct