Emerging Trends in Drug Abuse
Joshua Pruitt, MD, FAAEM
February 6, 2014

What’s New
• E-Cigarettes
• “Krokodil”
• “N-bomb”
• “Syrup,” “Purple Drank,” “Sizzurp,” “Lean”
• “Molly”
• Salvia Divinorum

What’s ‘Sort-of’ New
• K-2/Synthetic Cannabinoids
• Bath Salts, MDPV, Khat
• Energy drinks

E-cigarettes
• Battery-operated devices marketed as “safer” than traditional cigarettes
• Produce flavored nicotine aerosol/steam that looks and feels like tobacco smoke
• No tar or other chemicals from burning tobacco leaves
• Still require a chemical diluent that has an unknown safety profile

E-cigarettes

“Krokodil”
• Cheap heroin substitute
• Desomorphine (Heroin is diacetylmorphine)
• Made by combining codeine tablets with toxic chemicals (i.e., lighter fluid, industrial cleaners)
• More powerful than heroin with a shorter duration
• Causes gray/green scaly flesh at site of injection, thus the name
• Injection sites often become gangrenous
• Average life-span after beginning use is 2 years

“Krokodil”

“N-bomb,” “Legal Acid,” “Smiles,” “25I,”
“25C,” “25B”
• Three closely-related synthetic hallucinogens
• Substitute for LSD or mescaline
• Serotonin stimulant, more powerful than LSD
• Can cause seizure, MI, respiratory depression/arrest, death
• 19 related deaths in US between 3/2012 and
8/2013

“N-bomb,” “Legal Acid,” “Smiles,” “25I,”
“25C,” “25B”

“Syrup,” “Purple Drank,” “Sizzurp,”
“Lean”
• Phenergan w/codeine plus soda (Actavis)
• May include hard candies
• Celebrated in rap music
• High risk of respiratory depression and CNS depression
• Deaths from prescription opioids now outnumber deaths from all other drugs

“Syrup,” “Purple Drank,” “Sizzurp,”
“Lean”
• Implicated in the deaths of DJ Screw and Pimp C

“Syrup,” “Purple Drank,” “Sizzurp,”
“Lean”
• Overdose symptoms related to promethazine and codeine
• Promethazine – CNS depression, anticholinergic
– Tachycardia, altered mental status, delirium
• Codeine – CNS depression, respiratory depression
– Miosis, bradypnea/apnea, hypoventilation
• Seizures highly unusual and usually related to hypoxia

“Syrup,” “Purple Drank,” “Sizzurp,”
“Lean”

“Molly”

“Molly”
• Slang for “molecular”
• Refers to pure crystalline powder form of MDMA
(Ecstasy)
• Sold in capsules
• Celebrated in rap/hip-hop music
• Produces energy and euphoria
• May cause hyperthermia, confusion, depression, sleep problems

“Molly”
• Symptoms often mixed toxidrome due to coingestions
CNS effects
AMS
Seizures
Restlessness
Agitation
Hyperthermia
Syncope
Ataxia
CV effects
Palpitations
Chest pain
Dental effects
Bruxism
Enamel erosion
GI effects Derm effects
Dry mouth Diaphoresis
Nausea/vomiting Piloerection
Cramping
Anorexia GU effects
Urinary retention
Sexual dysfunction

“Molly”

Salvia
• Highly selective kappa-opioid receptor agonist
• Originated with Mexican Mazatec shamanism
• Hallucinogen with psychedelic/dissociative effects
• Taken by smoking, no real effects from ingestion

Salvia
• Intoxication effects
– Uncontrollable laughter
– Vivid reliving of past memories
– Sensation of motion or being pulled by something
– Visions of membranes or other 2-D surfaces
– Merging with or becoming objects
– Overlapping realities, such as being in two places at once

Salvia

“K-2,” “Spice,” Synthetic Cannabinoids
• Very diverse class of drugs
• Bind to the cannabinoid receptor
• Similar effects to marijuana
• Often more intense effects
• Include hallucinogenic and psychedelic effects

“K-2,” “Spice,” Synthetic Cannabinoids
• Reported effects
Impaired driving incidents
Increased anxiety
Palpitations
Aggression
Altered perception
Suicide attempts
Panic attacks
Respiratory “complications”
Mood instability
Paranoia

K-2/Synthetic Cannabinoids

Bath Salts, MDPV, Khat
• Synthetic cathinones
• Function as dopamine-norepinephrine reuptake inhibitors
• Four times more potent than Ritalin or Concerta
• Duration of action 3-4 hours, with after-effects lasting as long as 6-8 hours

Bath Salts, MDPV, Khat
CNS/Psych effects
Aggression
Agitation
Confusion
Extreme anxiety
Hallucinations
Hyperthermia
Delusions
Paranoia
Suicidal ideations
CV effects
Hypertension
Vasoconstriction
Tachycardia
Chest pain
Respiratory effects Renal/GI effects
Tachypnea Transaminitis
Respiratory alkalosis Urinary incontinence
Fecal incontinence
Nausea/vomiting
Rhabdomyolysis
AKI

Bath Salts, MDPV, Khat
• Amateur chemists change the chemical composition of the “bath salt” and make it nearly impossible for regulation to keep up with production.
• Mortality rate from “excited delirium” estimated at
8-14%, most die while in police custody
• Treatment is supportive
– Benzo’s, restraints if necessary, watch for rhabdo

Bath Salts, MDPV, Khat
Elevated temperature
Respiratory arrest
Agitated delirium
DEATH

Bath Salts, MDPV, Khat

Energy Drinks
• Drinks like Red Bull, Rock Star, Monster
• Contain caffeine and other legal stimulants
(guarana, ginseng)
• Can contain 75 to >200 mg of caffeine per serving
– 34 mg per serving in Coke
– 55 mg per serving in Mt. Dew
• If it says “no caffeine,” then it uses guarana, which is the same as caffeine

Energy Drinks
• 5-hour energy advertises “no crash,” but that relates to the sugar crash
– Contains artificial sweeteners
• Short term problems
– Increased heart rate, palpitations
– Hypertension
– Dehydration
– Sleep problems

Energy Drinks
• Some may have 2 servings per can
• When used occasionally, not necessarily dangerous
• Think of them as highly caffeinated drinks
• Combination with alcohol
– The stimulant effect of the energy drink can mask how intoxicated someone is
– Can give the drinker the impression they are not impaired
– Research shows that people drink more and have higher BALs when they combine alcohol and caffeine

Energy Drinks
• ER visits related to energy drink consumption
– 10,068 in 2007; 20,783 in 2011
– 60% of patients drank energy drink alone
– 27% of patients combined with prescription drugs
– 13% combined with alcohol
– 10% combined with illegal drugs
– 9% combined with prescription stimulants

Questions