Clinical Experience of Novel Psychoactive Substances
Dr Richard Stevenson
Background
 Legal Highs -> Novel Psychoactive Substances
 41 new substances in 2010 alone
 Diverse collection of compounds
 Piperazines
 Cathinones
 Synthetic cannabinoids
 Isolated compounds
 Recreational problem identified in 2008/2009
 Varying legal status
GRI Emergency Dept Experience
 12 AMT
 22 synthetic cannabinoids
 3 cathinone
 2 methoxetamine
 1 salvia
 9 life threatening toxicities
Why are people taking them?
 Legal status
 Perception of safety
 Difficult to detect
 Point of care urine testing
 Odourless
 Availability
 Internet
 “Head shops”
 Sold as other drugs
AMT
5-IT
Common Problems
 Lack of reliable data
 “Not what is says on the tin”
 Dosage
 Inter-individual variability
 Time of onset to effect
 Polysubstance misuse
 Interactions ?
Challenges in Clinical Care
 Acute
 Identification of xenobiotic
 Lack of toxicological data



Mechanism of action
Duration
Clinical effects
 Appropriate treatment
 Chronic
 Long term psychological effects
 Long term physical effects
Cathinones
 Synthetic variations of natural cathinones in Khat
 Mephedrone, methedrone, naphyrone
 Ivory wave, meow-meow, bubbles, ocean snow, NRG
 Sympathetic Toxidrome
 ↑HR, RR, BP, temp
 Tremor, agitation, paranoia, hallucinations, seizures
 ***duration 24 – 48 hours***
 Treatments
 Benzodiazepines +/- haloperidol
Piperazines
 Developed in 1950s – anti-helminthic agents
 BZP “Benzo Fury”
 Neurotransmitter release/reuptake inhibition
 Phenylpiperazines
 Direct serotonin receptor activation
 Reversal of serotonin uptake
 Clinically
 Sympathetic toxidrome
 Serotonin toxicity?
Synthetic Cannabinoids
 Annihilation, Black Mamba, Spice, K2
 Structurally dissimilar to THC
 Herbal material sprayed with chemicals
 Clinical effects
 Nausea +++
 Collapse
 Some psychotropic effects
Methoextamine
 Structurally similar to ketamine
 NMDA receptor agonist
 Clinically (dose related)
 Excitation, tachycardia, euphoria
 Hallucinations
 Dissociation
 Prolonged neurological effects - ataxia
 Supportive management
AMT/5-IT
 AMT – Alphamethyltryptamine
 5-IT – 5-aminopropylindole
 AMT researched as antidepressant in 1960’s
 Non-specific MAOI
 Hallucinations +++
 Psychomotor agitation +++
 Serotonin toxicity
 High risk of toxicity
Serotonin Toxicity
 Exposure to a
serotonergic drug
 Clinical features
 Confusion
 Autonomic instability
 Hyperkinetic
musculoskeletal system
Treatment of Serotonin Toxcity
 Morbidity & Mortality related to hyperthermia
 Temp ≥40 oC
 Duration
 Consequences
 Rhabdomyolysis
 Acute kidney injury
 Acidosis
 Cerebral damage
Treatment of Serotonin Toxicity
 Aggressive cooling
 Antipyretics do not work!
 Control muscular activity
 High dose benzodiazepines
 Haloperidol for severe non-responders
 Appropriate fluid control
 BP control agents
 Anaesthesia with muscle paralysis
The Future?
 Market flooded with NPS
 Difficult to legislate/control
 Long term effects?