Legal (and not so legal) Highs
Tom Heaps
Consultant Acute Physician
Legal Highs
Herbal Highs
Research Chemicals
Party Pills
BubbleLuv
Bath Salts
Plant Foods
Novel Psychoactive Substances (NPS)
Incense
Designer Drugs
Legal Highs: the basics
 Often manufactured in laboratories in China
 Readily available on the internet or in ‘headshops’
 Often marketed as ‘research chemicals / powders’, ‘bath salts’, ‘herbal
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incense’ or ‘plant foods’
Disclaimers ‘for research purposes only’ or ‘strictly not for human
consumption’
No quality control or guarantee of purity
Often adulterated with illegal substances and / or cut with other (toxic)
substances e.g. caffeine, benzocaine, detergents
Actual constituents often differ markedly to ingredients listed on packet
‘Same’ product / brand name may contain completely different chemicals
Black Mamba
2011
- AM-2201
2014
- 5F-PB-22
- 5F-AKB48
Green Rolex ‘legal’ ecstasy tablets
PMA
PMMA
5-MeO-DALT
MDMA
caffeine
caffeine
Legal Highs: a growing problem?
INCB Annual Report 2013
 UK has 5th largest market for legal highs in the world
 56% increase in UK hospital admissions from 2009-2012
 20% of all websites selling legal highs are hosted on servers in the UK
EMCDDA European Drugs Report 2015
 10% of 15-24 year-olds in the UK have used legal highs
 ROI has highest prevalence (22% of 15-24 yo) of legal high use in Europe
Toxbase Statistics
Novel NPS detected by EMCDDA
120
100
80
60
40
20
0
2010
2011
2012
2013
2014
Deaths from NPS in the UK
120
100
80
60
40
20
0
2007
2008
2009
2010
2011
2012
2013
2014
Drugs and their ‘families’
Stimulant
Gogaine (ethylphenidate)
Depressant
Geeb (GBL, gamma butyrolactone)
Hallucinogen
Green Beans (AMT)
Empathogen
Benzo Fury (5-APB)
Synthetic Cannabinoid (SCRA)
Blue Cheese (SCRA)
Dissociative
Mexxie (MXE, methoxetamine)
Opioid
Krokodil (desomorphine)
Ethnobotanical
Salvia divinorum
The Drugs Wheel
www.thedrugswheel.com
Stimulants
 Bath salts, research powders / pills, plant foods
 Cathinones, MPA, PMA/PMMA, MDPV, ethylphenidate, 2-AI, BZP, khat
 Gogaine, Ching, Chang, Charly Sheen, Charles, China White
 Insufflated (powders), swallowed (tablets or ‘bombs’) or injected
 Elevate levels of adrenaline, noradrenaline and dopamine
 PMA/PMMA have strong serotonergic properties
 Similar chemical structure and toxicity to amphetamines
Chemical Structures
Mephedrone
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4-methylmethcathinone, 4-MMC, MCAT
Bubbles, Meow Meow, Drone
Cathinone which occurs naturally in ‘khat’ (Catha Edulis)
First synthesized in 1929 (from pseudoephedrine) but recreational use
prominent since 2007
Usually taken by nasal insufflation (‘snorting’) or swallowed (‘bombing’)
Increasingly injected (high rates of soft tissue and vascular complications)
Stimulant and entactogenic/empathogenic properties
Anxiety/agitation, seizures, cardiovascular and serotonergic toxicity
Heavy use associated with significant ‘comedowns’, psychosis and
dependency
Class B under MDA in April 2010 (responsible for 29 deaths)
Synthetic Cannabinoid Receptor Agonists (SCRAs)
 incense, pot pourri, herbal blend, spice
 AKB48, 5F-AKB48, PB-22, 5F-PB22, JWH-018 etc.
 Spice, K2, Black Mamba, Blue Cheese, Psyclone, Exodus Damnation,
Clockwork Orange, Pandora’s Box
 Usually smoked (sprayed onto herbal blends or put into e-liquids)
 Many times more potent than THC (higher affinity for CB-1 receptor)
 Do not give a positive urine test result for cannabis
 Anxiety, hallucinations, delirium, seizures, agitation / aggression,
hypokalaemia and AKI
Clinical Case
 24-year-old male with no relevant past medical history
 Admitted to AMU with severe anxiety / agitation, vomiting and sweating
 ED clerking states that he had been given a ‘legal high’ at a party the
previous night
 BP 162/97, HR 121 (sinus tachycardia on ECG)
 No obvious confusion / delirium
 Pupils symmetrically dilated
 Mild metabolic acidosis on VBG
HOW SHOULD YOU PROCEED?
Difficulties in Management
 Multiple drugs may be co-ingested (often with alcohol)
 Patients often do not know exactly what they have taken
 Even if they can provide you with the name / packaging of the legal high….
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Impossible to ascertain dosing
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Ingredients listed on packet may not be representative of actual contents
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Same ‘brand’ may contain completely different chemicals in differing quantities
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Unknown toxins often present
 Toxicological databases and clinical experience of managing toxicity cannot
keep pace with the development of novel compounds
DOES THIS MATTER?
So What Can You Do?
 Attempt to identify chemical compound / group responsible for toxicity
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Collateral history / packaging
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Formulation / route of administration
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Toxbase
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WEDINOS
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Google and other websites
 Determine the predominant toxidrome and manage accordingly
Toxidromes associated with legal highs
Stimulant
SCRA
Depressant
Hallucinogen
Dissociative
Depressant
tachycardia, hypertension, dilated pupils, sweating, seizures,
agitation +/- signs of serotonin syndrome
history of smoking a ‘herbal’ product, mild stimulant /
hallucinogenic features, seizures
reduced conscious level and hypoventilation +/bradycardia and constricted pupils
visual, auditory or tactile hallucinations, agitation, confusion.
+/- mild-moderate stimulant features
primarily neuropsychiatric features including ‘out of body’
experiences, agitation, analgesia, drowsiness, nystagmus,
ataxia, coma, seizures
Dissociative
SCRA
Stimulant
Hallucinogen
General Management Principles
 ABCDE approach
 ECG, bloods (including clotting and CK) and VBG
 Monitoring (observations, GCS, CBG, cardiac monitoring)
Agitation / anxiety / delirium: benzodiazepines
Hyperthermia: benzodiazepines, active cooling, dantrolene, paralysis
Hypotension: IV fluids, vasopressors
Hypertension: benzodiazepines, IV GTN, labetalol
Metabolic acidosis: oxygen, IV fluids, IV sodium bicarbonate
Seizures: benzodiazepines, (phenytoin), thiopental
QRS / QTc prolongation: IV bicarbonate / IV magnesium
Respiratory depression: naloxone, (flumazenil), airway and respiratory support
Refer to www.toxbase.org for more specific management
Legal Highs: summary
 Rapidly growing public health problem in the UK
 Legal highs are not necessarily legal and may not give you a high!
 Legal does not mean safe (legislation just hasn’t caught up yet)
 Systems of classification (e.g. the drug wheel) can be informative
 Often very difficult to know exactly what compounds have been taken….
 …..manage according to toxidrome
 Psychoactive Substances Bill 2015 currently going through House of
Commons but refer to experience in ROI…..