In response to concerns raised by communities, public health and treatment practitioners regarding the emerging trend of “Bath Salts” and Synthetic Marijuana use, in September 2012 OASAS convened a symposium of experts from a cross-section of fields to provide information, perspective and guidance on the topic. These two products are part of the ongoing evolution of licit and illicit chemical analogs that are designed to evade enforcement and control. Perhaps more importantly, they are potentially deadly and addictive. This document was developed to provide background information and to assist in initiating a response to the broader concern of synthetic drugs of abuse.
- From a clinical perspective, caregivers and responders need to be able to identify the signs and symptoms that can help to shape an appropriate response and the delivery of effective care. They must also implement policies and procedures for the protection of patients and staff from harm.
- From a social perspective, the challenges include education of the public to the risks that are to be managed, as well as legislative empowerment of enforcement in order to protect the public.
- From a technological perspective, we need to develop efficient and effective detection technology as well as compassionate and responsive treatment interventions.
“Bath Salts” often contain various amphetamine-like chemicals, such as methylenedioxypyrovalerone (MPDV), mephedrone and pyrovalerone. These drugs are typically administered orally, by inhalation, or by injection. The worst outcomes are associated with snorting or intravenous administration. Mephedrone is of particular concern because it presents a high risk for overdose. These chemicals act in the brain like stimulant drugs (i.e. cocaine, amphetamine or MDMA (Ecstasy)) and are sometimes touted as substitutes); thus they present a high abuse and addiction liability. Consistent with this notion, these products have been reported to trigger intense cravings not unlike those experienced by methamphetamine users, and clinical reports appear to corroborate their addictive potential. They can also confer a high risk for other medical adverse effects (seizure, hypertension, myocardial ischemia, and heart attack). Some of these may be linked to the fact that, beyond their known psychoactive ingredients, the contents of "bath salts" are largely unknown, which makes the practice of abusing them, by any route, that much more dangerous. "Bath Salts" - Emerging and Dangerous Products (National Institute on Drug Abuse (NIDA), Feb 2011)
Synthetic Marijuana at times referred to as “"Spice or K2" refers to a wide variety of herbal mixtures that produce experiences similar to marijuana (cannabis) and that are marketed as "safe," legal alternatives to that drug. Sold under many names, including K2, fake weed, Yucatan Fire, Skunk, Moon Rocks, and others - and labeled "not for human consumption" - these products contain dried, shredded plant material and chemical additives that are responsible for their psychoactive (mind-altering) effects. So far, there have been no scientific studies of Spice’s effects on the human brain, but we do know that the cannabinoid compounds found in Spice products act on the same receptors as THC, the primary psychoactive component of marijuana. Some of the compounds found in synthetic marijuana are stronger cannabinoid receptor agonists that may result in a much more powerful and unpredictable effect or may be shorter acting leading to more frequent dosing. Because the chemical composition of many products sold as Spice is unknown, it is likely that some varieties also contain substances that could cause dramatically different effects than the user might expect. Drug Facts: Spice (Synthetic Marijuana) (NIDA, Dec 2012)
Patients may not know what is happening to them or experience a reaction that is different than expected. Acute reactions to these substances can require critical care interventions. While a differentiation can be made between “Bath Salts” and Synthetic Marijuana, chemical adulterants in either of these may result in severe and life-threatening reactions. NIDA notes "Bath salts" have already been linked to an alarming number of ER visits across the country. Doctors and clinicians at U.S. poison centers have indicated that ingesting or snorting "Bath Salts" containing synthetic stimulants can cause chest pains, increased blood pressure, increased heart rate, agitation, hallucinations, extreme paranoia, and delusions. In 2010, a reported 11,406 US emergency room visits were linked to synthetic marijuana. Of these, 75% involved people between the ages of 12 and 29.
PSYCHOACTIVE ‘BATH SALT’ (PABS) INTOXICATION AND PYSCHOSIS: RECOGNITION AND TREATMENT:
The main active psychogenic agents in ‘Bath salts’ are methylenedioxypyrovalerone (MDPV) and 4-methylmethcathinone (mephedrone) norepinephrine - dopamine reuptake inhibitors and central nervous system stimulants (cathinones) as well as SSRIs and epinephrine - nor-epinephrine" stimulators. Patients with PABS intoxication can present with extreme sympathetic stimulation and profoundly altered mental status. The sympathetic effects may include tachycardia, hypertension, hyperthermia, and seizures. Deaths have been reported. Altered mental status presents as severe panic attacks, agitation, paranoia, hallucinations, violent and suicidal behavior. Patients who present after exposure to PABS should be observed and monitored in an intensive care setting. Treatment is largely supportive, typically with intravenous benzodiazepines (for sedation, to control seizures, or both) and intravenous fluids (particularly if there is suspicion of rhabdomyolysis). Urine drug screens may not detect PABS, thus a high level of clinical suspicion is warranted. Psychoactive "bath salts" intoxication with methylenedioxypyrovalerone (PubMed Abstract, Sept 2012)
Patients report nausea, vomiting, fatigue, flushed face, sweating and that the high is fast but the crash is heavy. In some cases they have reported using synthetic salts when coming off heroin. Patients say it is a horrible high but they are drawn back to it. As a psychoactive experience the reports are varying and can appear similar to amphetamines and/or hallucinogens with increased energy, euphoria and hallucinations or other distortions of perception.
With regard to synthetic marijuana , practitioners in behavioral health settings are reporting that patients may present with persistent depression. This may be a result of decreasing available serotonin and medication may be indicated. There may be increased depression with use of synthetics, but not as profound as with methamphetamine. It has also been reported that patients may experience problems with memory (that can last for several weeks) and blunted affect. Patients may have difficulty focusing or participating in their care until they begin to stabilize.
Users of synthetic marijuana report experiences similar to those produced by the plant marijuana - elevated mood, relaxation, and altered perception. In some cases the effects are even stronger than those of the naturally obtained THC. Some users report psychotic effects like extreme anxiety, paranoia, and hallucinations.
Synthetic marijuana users who have been taken to Poison Control Centers report symptoms that include rapid heart rate, vomiting, agitation, confusion, and hallucinations. The drug can also raise blood pressure and cause reduced blood supply to the heart (myocardial ischemia), and in a few cases has been associated with heart attacks. Regular users may experience withdrawal and addiction symptoms. We still do not know all the ways synthetic marijuana may affect human health or how toxic it may be, but one public health concern is that there may be harmful heavy metal residues in mixtures. Without further analyses, it is difficult to determine whether this concern is justified. Drug Facts: Spice (Synthetic Marijuana) (NIDA, Dec 2012)
Other synthetics that have been noted include "Smiles/2C-I" (an analog of mescaline that can last up to 12 hours that is usually used in a pill form that is insufflated) and Krokodil (desomorphine ((Dihydrodesoxymorphine)) an opiate analogue invented in 1932 that is a derivative of morphine. Desomorphine has attracted attention in Russia due to its simple production, utilizing codeine, iodine, gasoline, paint thinner, hydrochloric acid, lighter fluid and red phosphorus. Since the mix is routinely injected immediately with little or no further purification, "Krokodil" has become notorious for producing severe tissue damage including injury to the veins (phlebitis) and gangrene. Other consequences of use have included severe withdrawal, spread of HIV through the use of contaminated needles and death.
When intoxication is encountered, the taskforce recommends:
- Assess the need for emergency care.
- Establish a supportive, low-stimulus environment
- Efforts to identify agent of use through history taking from family, friends and patient
- Adequate hydration
- Drug testing can be helpful but limited
- Conservative use of anti-psychotic medication and/or benzodiazepines for severe and psychotic presentations of intoxication.
- The work group made special note that because of the commercial availability of these substances, aspects of an alcohol treatment model should be utilized.
While there is either minimal or no research specifically addressing the treatment of dependence to emerging designer drugs, extensive experience in the psychosocial treatments of substance use disorders, in general, can be quite informative. There is good reason to believe that a number of interventions that have been shown to be very helpful in the treatment of dependence to alcohol, sedatives, stimulants, and opioids, can also be applied to the treatment of these new drugs of abuse. Including:
- Individual Psychotherapy or Counseling
- Group Psychotherapy of Counseling
- Inpatient Rehabilitation
- Partial Hospitalization
- Intensive Outpatient Programs
- Half-way Houses
- Motivational Interviewing
- 12-Step Programs
- Relapse Prevention
- Contingency Management
- Treatment for Co-Occurring Psychiatric Disorders
- Treatment for Co-Occurring Medical Disorders
- Specialized Programs (e.g., Spanish speaking, LGBT, seniors, women, dual diagnosis)
- Family Therapy
Conversely, pharmacological treatments must be tailored to the specific drug of abuse. Since the only FDA-approved pharmacological treatments are for alcohol, nicotine, and opioid dependence, little can be gained by looking to medications for the treatment of dependence to these new drugs. This being said, a practitioner, would be greatly helped by knowing the “prototype” drug behind each one of these new agents. For example:
- Bath Salts: Methamphetamine
- Spice/K2: Cannabis
- Krokodil: Morphine
- Ketamine: Phencyclidine
- Gamma hydroxybutyric acid (GHB): Gamma-aminobutyric acid (GABA)
In the absence of specific research on a drug, the practitioner can make an educated guess in the management of acute intoxication and withdrawal syndromes by consulting the existing evidence that applies to the “prototype” drug.
The workgroup, to this point, is unable to identify a specific set of protocols or treatment models specific to treating synthetic drug use. However, there is acknowledgement that the standards of good clinical supervision, a researched knowledgebase and competency with a variety of interventions supports effective patient centered care. In addition to a continued review of papers, articles and presentations, we were able to identify the following downloadable training package.
Will They Turn You Into a Zombie? What Clinicians Need to Know about Synthetic Drugs; Jane C. Maxwell, Ph.D., Senior Research Scientist, Addiction Research Institute, Center for Social Work Research, The University of Texas at Austin,1717 West 6th, Suite 335 Austin, Texas 78703,512 232-0610, 512 232-0617
The purpose of this introductory training package is to provide clinicians from a variety of work and educational backgrounds (including, but not limited to physicians, dentists, nurses, other allied medical staff, therapists and social workers, counselors, specialists, and case managers working in substance use disorders, mental health, and other health-related settings) with a detailed overview of synthetic drugs, including substances known on the street as K2, Spice, and Bath Salts. The presentation seeks to raise awareness by defining key terms, describing the main classes of synthetic drugs commonly available, presenting available data on the extent of use, providing information on how to identify and assess individuals who are using synthetic drugs, and presenting clinical implications of synthetic drug use. A series of slides have been included for audiences who have little or no familiarity with psychoactive drugs and substance use disorder-related terminology. Case examples and clinical case studies have been inserted towards the conclusion of the presentation to encourage dialogue among participants, and to illustrate how the information presented can be used clinically. The duration of the presentation is approximately 1.5 - 2 hours.
Both residential and outpatient environments present different challenges in terms of establishing patient and staff safety. Residential facilities face the challenge of contraband being brought into the community and providing 24/7 oversight. Outpatient programs contend with patients who may be constantly exposed to addictive agents. In either case the possibility of a critical episode or the result of chronic use exists. The recommendations from the taskforce encourage clear policies and procedures that are shared appropriately with staff and patients. These should include.
- Warning signs and symptoms
- How a critical incident is to be managed while maintaining staff and patient safety
- Program policies when dealing with emergency personnel
- Property and personal searches
- Toxicology testing resources and limitations
- Patient education
- Facility security
- Periodic anonymous patient surveys of drug trend/ availability
Patients believe the synthetics may not show up at all and this presents additional challenges in the therapeutic relationship. Currently, there are significant issues with regard to toxicology testing for synthetics. These drugs are generally not included as part of a standard test panel and also may not be able to identify the analogs with specificity. However, there was discussion of toxicology manufacturers making a broad spectrum test available if there is sufficient demand. It was also noted that there are increased costs associated with testing and while some insurers have not objected, no new government funds have been identified for this purpose.
While there is increasing public information about the presence and use of synthetic drugs. The OASAS reporting systems showed little or no change in the type or frequency of drug use on admission to treatment.
However, in July 2012 OASAS surveyed a cross-section of our system to include outpatient (822-4 and 822-5) and residential providers regarding patient use of synthetics during the past 6 months.
- 48 programs from across the state; 100% response rate
- 5877 patients captured in this snapshot
- 1759 of the cases reported synthetic use (29.9%)
- Of the 1759 who used synthetics,
- 494 used Bath Salts (28% of total users)
- 1265 reported use of Synthetic Cannabinoids (72% of total users).
- 413 Bath Salt over 18 y.o.
- 81 Bath Salt under 18 y.o.
- 754 Synthetic Cannabinoids over 18 y.o.
- 511 Synthetic Cannabinoids under 18 y.o.
In response to the finding, OASAS will seek to use the county planning process to identify emerging trends in addition to the standard reporting processes.
Law Enforcement and Community Response
On July 15, 2011 New York State banned the sale and possession of Bath Salts. This was followed by passage in July 2012, of a federal law that was unique in that it prohibits not only the compounds currently identified as “bath salts,” but also outlaws similar compounds that may be produced in the future. In addition to the identified compounds, the law prohibits other synthetics that may have different chemical formulas but produce the same effects. This closes loopholes that have allowed manufacturers to circumvent local and state bans and ensure that you cannot simply cross state lines to find these deadly bath salts. The law enumerates 31 compounds that are explicitly banned. DEA and Homeland Security with state and local police were then able to arrest and prosecute individuals and establishments where these substances were sold under a variety of names.
While there has been significant progress made in reducing the commercial availability of synthetics, their underground presence and continued use is an ongoing problem for communities, practitioners, and users. There have always been evolving trends of substance use and misuse that require surveillance, reporting, and action. Beyond local enforcement resources, communities may reach out to two statewide points of contact established by New York State. To report synthetic drug abuse, sale, manufacturing, distribution or possession:
- Call 1-888-99-SALTS (1-888-997-2587) or
- E-mail the Bureau of Narcotic Enforcement - In the e-mail please provide the name, address (including county) of the establishment engaged in the synthetic drug activity and the type of activity noted (manufacturing, sales, distribution, or possession).
Much of the organization of the New York State substance use treatment and prevention system is built on the coordination of services and resources through county and local government. To that end, OASAS and its sister agencies will continue working with Local Mental Hygiene Directors, Prevention Councils, and treatment and recovery organizations to promote awareness and education.
OASAS wishes to extend its thanks and appreciation to the individuals and institutions who have made themselves available in the development of this guidance.
Michael Delman, MD - North Shore University Hospital
Petros Levounis, MD - Addiction Inst of NY
Ziva Cooper, Ph.D - Columbia University
Chris Urban - Huther Doyle
Stanley Long BS, CASAC - Harbor Lights
Ramon Welsh - The New York Foundling Mental Health & Chemical Dependency Services
David Tymchyn, LMSW - Conifer Park
Bill De Joy - Conifer Park
Michael North, LCSWR - Dutchess County Department of Mental Hygiene & Chemical Dependency Services
Tami Amodio - Catholic Charities of Columbia and Greene Counties
Tom Brouette, MD - SUNY Downstate Medical Center
Trisha Rue, RN - Renaissance Project
Ann Domingos - St. James Mercy Hospital, Hornell NY.
Gary S Belkin, MD, PhD, MPH - New York City Health and Hospitals Corporation
Alissa Mallow, DSW, LCSW - R ACACIA NETWORK
John Bennett - Genesee/Orleans Council on Alcoholism and Substance Abuse, Inc.
Antonio M. Valdez, CASAC, ICADC - CNPCII Main Treatment, Jamaica, Queens,
Elizabeth Berry, Ph.D. - Crouse Hospital
Gregory Miller MD - NYS OMH
Michael Lesser MD - NYS OMH
Hillary Kunins, MD MPH - NYCDOHMH
Mark Hammer - NYS DOH
Loretta Hartley-Bangs, LCSW, ACSW - Mineola Community Treatment Center
Tara Costello - Oneida County Department of Mental Health
Jennifer Faringer, MS. Ed. - DePaul's National Council on Alcoholism & Drug Dependence
Kristin McConnell - National Council on Alcoholism & Other Drug Dependencies/Putnam
Naura Slivinsky - National Council on Alcoholism & Other Drug Dependencies/Putnam
Kristin McConnell, M.S. - National Council on Alcoholism & Other Drug Dependencies
Terence J O'Leary, Director - NYSDOH Bureau of Narcotic Enforcement
Steven Kipnis, MD, FACP, FASAM, Medical Director - NYS OASAS
Charles Morgan, MD - NYS OASAS
Tamara Miller- Kammerer - NYS OASAS ATC
Rob Piculell, LMSW - NYS OASAS