Synthetic Drugs: Dangers, Detection, & Trends Presented by Problems & Challenges Posed by Spice/K2, Bath Salts, Heroin, Painkillers, Oxy, Bup, etc. Vinnie Happ Redwood Toxicology Laboratory October, 2014 Drug Testing: Synthetic THC / K2 n n n n n n Rapid, onsite instant test Laboratory-based screening test (becoming more widespread) Most Laboratories are employing LC/MS/MS technology Primarily via urine, however some labs can test via oral fluid and or blood $$$ varies greatly Onsite vs Laboratory testing is very different On-site vs Laboratory testing for K2 On-site K2 test JWH-018 & JWH-073 primary strucuture Cut-off at 25 or 50ngs/ml Higher threshold to trigger + Greater chance for false +/Screening technology Laboratory K2 test JWH-018, 073, plus *28 other synthetic cannabinoid structures: JWH-019, 081, 122, 200, 203, 210, 250, 398, AM2201, MAM2201, RCS4, RCS8, AM-694, AM-1248, AKB48, UR-144, XLR-11, 5-Fluro AB-PINACA,5-Fluoro ADB-PINACA5-Fluoro ADBICA,5-Fluoro AKB-48, 5-Fluoro PB-22, AB-PINACA, AB-FUBINACA, ADB-PINACA, ADBICA, PB-22, BB-22 Cut-off 1ng/ml or less Detecting presence Confirmatory technology *Redwood Toxicology Laboratory FAX CESAR September 8, 2014 Vol. 23, Issue 13 A Publication from the Center for Substance Abuse Research University of Maryland, College Park Study of Patients in a Midwestern Residential Treatment Program Finds 71% of Those Reporting Synthetic Cannabinoid Use Report Using to Avoid Positive Drug Test Self-Reported Reasons for Using Synthetic Cannabinoids (N=150 Adult Residential Substance Use Disorder Treatment Patients Reporting Lifetime Synthetic Cannabinoid Use) 91% Cur iosity 89% To Fe e l G ood or G e t High 71% To Re lax or Re lie ve Te nsion 71% To G e t High Without Having a Positive Dr ug Te st 63% Like d the Effe c ts 59% B or e dom To Have a G ood Time with Fr ie nds or to Fit In 59% Ange r or Fr ustr ation; To G e t Away fr om Pr oble ms or Tr ouble s 48% To He lp De al with Pain 39% To Inc r e ase or De c r e ase t he Effe c ts of Some Othe r Dr ugs 32% B e c ause It Is Safe r Than Othe r Dr ugs 30% 0% 20% 40% 60% 80% 100% SOURCE: Adapted by CESAR from Bonar, E.E., Ashrafioun, L., and Ilgen, M.A, “Synthetic Cannabinoid Use Among Patients in Residential Substance Use Disorder Treatment: Prevalence, Motives, and Correlates,” Drug and Alcohol Dependence, In Press, 2014. For more information, contact Erin Bonar at erinbona@med.umich.edu. 301-405-9770 (voice) 301-403-8342 (fax) CESAR@umd.edu www.cesar.umd.edu The CESAR FAX is independently funded by CESAR and may be copied without permission. Please cite CESAR as the source. MDPV (Methylenedioxypyrovalerone) a psychoactive drug with powerful stimulant properties which acts as both a norepinephrine & dopamine reuptake inhibitor (NDRI). “A two for” usually snorted like cocaine duration of effect 2-3 hours /adverse effect 6-8 hrs MDPV - no history of FDA approved medical use adverse medical or psychiatric ramifications Mephedrone (Methylmethcathinone) amphetamine-like properties, powerful stimulant “rediscovered” by synthetic chemists in 2003 reformulation of cathinone, a chemical found in the khat plant of Eastern Africa khat existence traced to 15th C. Ethiopia khat is banned in the U.S. Methylone (3,4-methylenedioxy-N-methylcathinone) very similar to MDMA stimulant phenethylamine, amphetamine, and cathinone properties euphoria and increased sociability insomnia and restlessness hallucinations and psychosis MDMA – Ecstasy / Molly • MDMA, was patented by Merck pharmaceuticals in 1912 • Used in the 70/80’s as a psychotheraputic tool • Became popular “club drug” in 90’s then fell out of favor, too may additives. Come back in last couple of years • capsules sell for $8 to $40. • the most common Molly additives are bath salts, including methylone and mephedrone. • DEA's New York division highlighted the results of 143 lab tests over the past four years of substances suspected of being Molly. Only 13% of the drugs were MDMA, while 41% were 4-MEC, and 20% were methylone (bath salt materials). Pharmacological Effects of “Bath Salts” increase heart rate & blood pressure pupil dilation, rapid speech hyperactivity, arousal, & over stimulation increased energy & motivation euphoria - agitation dizziness, nausea hallucinations, seizures, convulsions breathing difficulties!!! diminished perception of the requirement for food and sleep Testing for Bath Salts?? Yes! However: No on-site, rapid, instant tests No laboratory-based screening tests Laboratories employing GC/MS and LC/MS/MS technologies Detection times remain unknown Bath Salts and beyond!!! Expanded Synthetic Stimulant Panel α-PVP BZP Butylon Buphedrone Cathinone Ethylone Flephedrone MBDB mCPP MDA MDEA MDMA MDPV Mephedrone Methcathinone 4-Methylethcathinone- (4MEC) Methylone Pentedrone Pentylone Pyrrolidinopentiophenone TFMPP FAX CESAR August 12, 2013 Vol. 22, Issue 32 A Weekly FAX from the Center for Substance Abuse Research University of Maryland, College Park Number of Calls to U.S. Poison Control Centers About Exposure to Synthetic Marijuana and Synthetic Cathinones Stable at Lower Levels Than Recent Years 800 700 Synthetic Marijuana Number of 600 Exposure 500 Calls 400 300 200 Synthetic Cathinones 100 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 0 2010 2011 2012 . 2013 Narcotics / Opiate Family Opiates and Opioids: Heroin Morphine Codeine Hydrocodone - (Vicodin, Loratab, ZohydroER, TarginiqER) Hyrdomorphone - (Dilaudid) Oxycodone – (OxyContin, Percocet, Roxicodone) Oxymorphone – (Opana, OpanaER) Fentanyl Methadone Buprenorphine – (Suboxone) Tramadol – (Ultram) - Philip Seymour Hoffman's heroin overdose exposes 100 percent RISE in 'epidemic' across US since 2007 - More than 660,000 Americans used heroin in 2012 - Resurgence attributed to crackdown on illegal 'pill mills' producing prescription drugs like OxyContin, which gives same high as heroin - Pill addicts have turned to heroin because its cheaper and available - Popular in rural and suburban areas, not just inner city - Users buying single hits of heroin for as little as $4 - Drug cartels pushing ever-larger amounts across the Southwest border New York hospital pharmacist charged in theft of 200,000 pills JULY 9, 2014 Tuesday, June 8, 2014 photo shows Anthony D'Alessandro. The former pharmacy chief for Mount Sinai Beth Israel hospital in Manhattan allegedly stole nearly 200,000 oxycodone pills from the medical center over more than five years. Prosecutors are still investigating what became of the drugs but believe the medications ended up on the thriving black market for prescription narcotics, where the more than 193,000 missing pills could fetch a total of about $5.6 million. Ex-sheriff's wife released from prison early Jul 08, 2014 WAUSAU (WI) – A one-time state probation agent and wife of a former Marathon County sheriff has been released from prison about seven months early, according to the state Department of Corrections. Last August, Kim Hoenisch, now 42, was sentenced to 18 months in prison and six years probation after she was convicted of three felonies -burglary, misconduct in office and possession of narcotic drugs - and two misdemeanors. Hoenisch was fired from her job after a state investigation concluded she had stolen prescription drugs, including Vicodin and oxycodone, from one of her clients. One in Four Americans Admits Abusing Prescription Drugs, Says FindLaw.com Survey One in four Americans admits that they have abused prescription drugs, according to a new national survey by FindLaw.com, the most popular legal information website. EAGAN, Minn., Aug. 5, 2014 - Prescription drug abuse involves taking a drug for reasons other than the drug's intended usage or use of a drug by someone other than the person listed on the prescription. The drug abuse can either be an attempt to self-medicate a medical condition, or for purposes such as getting high. How bad is the painkiller prescription problem?? CESAR FAX June 3, 2013 Vol. 22, Issue 22 A Weekly FAX from the Center for Substance Abuse Research U n i v e r s i t y o f M a r y l a n d , C o l l e g e Pa r k Lab Test Results Suggest Majority of Patients Do Not Take Prescription Drugs as Prescribed A large percentage of patients do not take their prescription drugs as prescribed, according to data from Quest Diagnostics prescription drug monitoring service. Of 151,405 urine test results from patients referred by their physicians for drug testing in 2012, 40% tested positive only for the drugs that were prescribed for them. The remaining 60% of specimens had inconsistent results, suggesting that the patient misused their medication in one of three ways: 1) by not using the prescribed drug (those testing negative for any drug, 25%); 2) by using other drugs instead (those testing negative for prescribed drugs and positive for other drugs, 15%); or 3) by combining the prescribed drug with other drugs (those testing positive for both prescribed and other drugs, 20%). According to the authors, “each of the three patterns of misuse has the potential to put a patient’s health at risk. A patient who does not take a prescribed drug will not receive potentially efficacious treatment for a medical condition and contributes to healthcare waste. A patient who uses non-prescribed dugs does so without a clinician’s supervision. And a patient who combines drugs without a physician's guidance increases the potential for dangerous drug combinations” (p. 4). Percentage of Patients Referred to Quest Diagnostics Laboratories for Drug Testing by Their Physicians Testing Positive and Negative for Drugs Prescribed for Them, 2012 Negative for Any Drug (Including Prescribed Drug) Positive for Prescribed Drug and Negative for Other Drug 25% 40% Negative for Prescribed Drug and Positive for Other Drug 15% 20% Positive for Prescribed Drug and Positive for Other Drug NOTE: The Quest Diagnostics prescription drug monitoring service tests for up to 26 commonly prescribed and abused drugs, including pain medications, central nervous system medications and amphetamines, as well as certain illicit drugs, such as marijuana and cocaine. Data presented here include results of 1) testing services ordered by physicians (such as family practitioners and internists) serving patients in a primary care setting; 2) testing services ordered by specialists that may be expected to use Quest’s prescription drug monitoring services (such as psychiatrists and neurologists); and 3) patients under care at pain management clinics and hospitals. Data do not include results of patients tested by drug rehabilitation clinics or those receiving treatment from clinicians focused on drug addiction, given the unusually high rates of drug inconsistency expected within this clinical segment. SOURCE: Adapted by CESAR from data from Quest Diagnostics, Prescription Drug Misuse in America: A Report on Marijuana and Prescription Drugs, 2013. Available online at www.questdiagnostics.com/home/physicians/health- FDA Toughens Warning on Pain Drugs Agency Cites Serious Risks Associated With Pills Such as OxyContin USA TODAY - September 10, 2013 The FDA said that long-acting forms of "opioid" painkillers, such as OxyContin, should be used only when there is no alternative. The new drug label drops the word "moderate" and says it should be used only to manage "pain severe enough to require daily, around-the clock, long-term treatment.” The new warnings only relate to extended-release forms of the drugs, which are often prescribed for months or years to treat chronic pain. They don't affect immediate-release forms, which include Vicodin or Percocet and are often used to treat acute pain, such as after surgery. The FDA is also considering whether to tighten restrictions on hydrocodone products like Vicodin. Doctors urge FDA to reverse approval of Zohydro, controversial new pain drug The potent drug has drawn widespread concern from addiction experts and state attorneys general, who fear it will fuel opioid abuse and overdose. FEBRUARY 28, 2014 REUTERS ZohydroER contains a higher dosage of pure hydrocodone than Vicodin. Unlike Vicodin, the drug does not contain aspirin or acetaminophen. Acetaminophen was removed because of liver-damage concerns. Zohydro's labeling will feature warnings about abuse, addiction and misuse. Zogenix is working on an abuse-deterrent version of Zohydro that should become available in three years March/April, 2014 Purdue Pharma announces & then submits NDA to FDA for its abuse-resistant, extended-release hydrocodone product. July 2, 2014 -- Zogenix, Inc. (ZGNX) today announced an update on its development programs focused on the introduction of abuse deterrent formulations of Zohydro(R) ER Application for Next Generation of Zohydro(R) ER to be filed by October 2014 Extended-Release Opioid Receives FDA Approval July 24, 2014 The Food and Drug Administration (FDA) announced its approval of Targiniq ER, an extended-release opioid combining the effects of oxycodone and a drug commonly used to reverse the effects of opioid overdose, known as naloxone. Purdue Pharma L.P., which originally marketed a harder to crush version of their opioid OxyContin in 2010, created Targiniq ER. When Targiniq ER is crushed and snorted, or dissolved and injected, the typical euphoric effects of oxycodone are blocked by naloxone. Mexico Trades Marijuana for Heroin April 2014 -The Washington Post has printed a grim exposé on the shift from Mexican marijuana to Mexican heroin. Mexican marijuana has dropped from $100 per kilogram to just $25 per kilogram. Said Rodrigo Silla, 50, a lifelong cannabis farmer. “I wish the Americans would stop with this legalization.” The DEA paints a picture of shrewd Mexican cartels reacting to their cut in marijuana business by sowing more heroin addicts. DEA claims cartels send their heroin pushers to work in the cities with the worst prescription pill epidemics and have them “set up right outside the methadone clinics.” Heroin-fentanyl mix plaguing many states January 31, 2014 Pittsburgh Post-Gazette Police: 2 dead after chewing on pain patches to get high July 2014 - Authorities in Athens, Tenn., say two of three men who died Friday of apparent drug overdoses had misused the pain medication Fentanyl. Harold “Marty” Coleman, 48, of 1004 South Jackson Street, Athens, was found lying in the driveway at his mobile home. He had a pain patch in his mouth. Coleman had a prescription for the patches and other narcotics found inside the residence. While emergency medical officials were preparing to transport Coleman's body, authorities found 46-year-old Donald Sturdivant in the laundry room of the home unconscious but breathing, the detective said. Sturdivant died a short time later after he was taken to the hospital. Screening vs Confirmation testing of Opiates Typical Screening test Primarily targets: Morphine/Codeine Confirmation Testing (GC/MS) Morphine Codeine Hydrocodone Hydromorphone 6-MAM (heroin marker) Oxycodone Drugs not detected Buprenorphine Methadone Fentanyl Tramadol - Ultram Soma Opiate vs Oxycodone Screen why you should consider splitting them out when testing Opiate Screen @ 300ng Primarily targets morphine and codeine Oxycodone – 30,000ng Needed to trigger a positive Miss the chippers, O.O.U. Opana – Oxymorphone 100,000ng needed to trigger positive on onsite Opiate test Oxycodone Screen @ 100ng Oxycodone – 100ng Needed to trigger a positive Detect the chippers Will detect oxymorphone and hydrocodone if 1562ngs Oxymorphone – Opana / ER Oxycodone lab EIA screen has 100% cross reactivity to Oxymorphone From: Tracy, Carrie Sent: Tuesday, August 05, 2014 11:31 AM To: Happ, Vinnie Subject: false positive question Hi VinnieWondering if someone that is prescribed Vicodin and taking it regularly would all of the sudden test positive for Oxycodone on 3 occasions and then miraculously test negative for Oxycodone when confronted about possible use. ThanksCarrie Carrie L. Tracy Senior Probation Officer Take away comments If positive on an Opiate screening test – an Opiate family member most likely detected Confirmation testing will specifically identify the member If 6-AM (6-Acetylmorphine) detected at the Lab: heroin use If confirmed positive just for Morphine metabolized heroine to morphine and or morphine use i.e. from a prescription medication, poppy seed use Sharp rise in ER visits tied to abuse of sedative May 22, 2014 (HealthDay News) -- There's been a steep increase in the number of Americans being treated at emergency departments for abuse of the sedative alprazolam, best known as Xanax. The number of emergency department visits related to abuse of climbed from more than 57,000 in 2005 to nearly 124,000 in 2011, according to the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). Xanax abuse "is especially concerning in light of the dramatic rise in nonmedical use of opioid painkillers like oxycodone [OxyContin] and Vicodin, because these increases in nonmedical use parallel the rapid rise in accidental overdose deaths in our country," Collins said. Suboxone-Buprenorphine FDA approved in 2002 used to treat opiate addiction alternative to methadone partial agonist (ceiling) in pill, film, patch 2mg & 8mg doses will not test positive on an opiate test significant diversion contains naloxone- guard against misuse subutex – no naloxone individuals will get high on this stuff What’s the attraction to Bup? user’s experience euphoria effect if taken in conjunction with other sedative drugs like alcohol, sleeping pill (ambien) or a benzodiazepine (klonopin)- extreme sedation, drowsiness, unconscious, or even death may occur method of ingestion – typically sublingual (under tongue), pill format going away, reports of snorting & injecting self medication and or currency in W/R or C/R setting only test positive if specifically testing for buprenorphine incredibly easy to smuggle Endo and BioDelivery Sciences announce positive top-line results from the Phase III clinical trial of BEMA® buprenorphine in opioid-experienced patients with chronic pain July 7, 2014 /PRNewswire/ -- Endo Pharmaceuticals Inc. and BioDelivery Sciences International, Inc. announced today positive top-line results from its pivotal Phase III efficacy study of BEMA buprenorphine in opioid-experienced patients. BEMA buprenorphine is being developed for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate in both patients who are opioid naive and opioid experienced. Top 17 Abused Prescription Drugs of 2013 Below is a list of 17 abused prescription drugs as listed by CDC, FDA, the U.S. Drug Enforcement Agency (DEA), and non-government nonprofit sources on public websites. OxyContin- oxycodone Suboxone - buprenorphine Ambien - sedative Ritalin - stimulant Zoloft – antidepressant Lunesta -sedative Adderall -amphetamine Opana - oxymorphone Xanax - benzodiazepine Klonopin – benzodiazepine Fentora - fentanyl Percocet - oxycodone Ativan - benzodiazepine Soma - sedative Valium - benzodiazepine Vicodin -hydrocodone July 2, 2014 SUMMARY With the issuance of this final rule, the Deputy Administrator of the Drug Enforcement Administration places the substance 2[(dimethylamino)methyl]-1-(3-methoxyphenyl)cyclohexanol (tramadol), including its salts, isomers, and salts of isomers, into schedule IV of the Controlled Substances Act. Corrective measures in other States Emerging Drugs or Media Hype?? Smiles, NBOMe, Krokodil, and Kratom (2C-I) Nicknamed Smiles popular among teens, responsible for dozens of overdoses and deaths. white crystalline powder, typically snorted or ingested. high and effects can last a few hours to a few days a combination of MDMA and LSD, only more intense. 2C-I is being made by dealers and “hobbyists,” chemicals can be obtained over the internet 2C-I overdoses can cause seizures, kidney failure, and fatally high blood pressure. NBOMe – Synthetic LSD BRAND NAMES 2C-C-NBOMe = (25C-NBOMe; NBOMe-2C-C); 2C-I-NBOMEe = (25I-NBOMe; NBOMe-2C-I); EFFECTS CLASSIFICATION Psychedelic; Stimulant; Euphoriant DESCRIPTION The NBOMe series of chemicals are primarily N-o-methoxybenzyl analogs of the 2CX family of phenethylamines, and are (serotonin 2A) receptor agonists. This group are active at very low sub-milligram doses. These chemicals have nearly no history of human use prior to 2010 when they first became available online. DEA declared three N-bomb variants—25I-NBOMe, 25C-NBOMe and 25B-NBOMe to be illegal Schedule I drugs under the Controlled Substances Act. Pharmacological Effects Dilated pupils Sweating Dry mouth Rapid speech Rapid/frequent mood swings Hyperactivity/ Elevated BP Hair standing on end Nasal passage irritation Behind the Krokodil Panic Nov 7, 2013- The Daily Beast Relax! The home-brewed Russian drug isn’t invading America. Cases popped up in at least six states and the media went wild. But here’s the catch: not one of the dozens of suspected cases tested positive for desomorphine, the drug's official name. In fact, according to public-health experts and federal officials, the great Krokodil scare of 2013 is really just the latest symptom of a true epidemic long in the making: American’s growing dependence on heroin and prescription painkillers. The drug, a morphine analogue that acts similarly to heroin but with a shorter high, is made by combining codeine, paint thinner, and lighter fluid (among other things) in small batches. An April 2013 article from the International Journal of Drug Policy titled “Breaking Worse” explains the dangers of the homemade drug. “Desomorphine may be the opioid that the cooks intend to produce, but it is not what they necessarily end up with,” the article reads. The “bootleg chemistry” results in a drug that is notoriously impure and often contains a lethal mix of toxins. But for American’s who can buy heroin much more easily than they can codeine, Krokodil use just doesn’t make sense. OP/ED 1/10/2014 Forbes Krokodil Crock: How Rumors Of A 'Flesh-Eating Zombie Drug' Swept The Nation “A lot of people want to call it a trend, but we’re not seeing it,” says Joseph Moses, a spokesman for the Drug Enforcement Administration (DEA). In fact, Moses says, “I’m not aware of any forensic laboratory that has come up with a desomorphine sample. A report by two St. Louis doctors who claimed to have treated a man with krokodil-related symptoms, published online by The American Journal of Medicine in November 2013, was removed from the journal’s website a week later after the paper received strong scientific criticism NMS Labs has had approximately forty toxicology cases of suspected Krokodil from around the US submitted in the last six months. All have been negative. “To our knowledge there is not a single confirmed Krokodil death through either toxicological testing or through testing of associated paraphernalia, in the US.” KRATOM not a synthetic but a plant derived drug main alkaloids responsible for the effect are mitragynine and 7-hydroxymitragynine. at low doses causes a stimulating effect at high concentrations causes an opiate like sedative effect From the website: buykratom.us Your Price: $14.99 This is our newest addition and we are very excited about offering another Bali'esque type strain. This strain is harvested from the Kalimantan Region, using only mature leaves and then finely ground. You must be 18 years of age to purchase any products on the website. All products on the website are sold not for human consumption, and are for incense or ethnobotanical research purposes only. Kratom Products: The Best Option to Wean Off Opiate and Heroin Addiction June 11, 2014 Livermore, CA – To clarify the majority’s misconceptions on kratom (Mitragyna Speciosa), it is not an opiate. It is not a drug, and it does not give that high that one is getting from heroin. Kratom soothes the “needy” receptors, easing through natural stimulation back into a more balanced state. The use of kratom for opiate withdrawal began to appear in 1987, when Henry Nicholas Ridley published the book “Malay Plant Names” and stated that the plant can be used to wean opium addicts. Nowadays, kratom is often used in methadone detox programs. Hospitals like the National Institute of Thai Traditional Medicine in Bangkok are endorsing kratom as a course of action against drug addiction withdrawal. Recent research points to the plant’s alkaloids, 7-hydroxymitragynine as possibly the major agonist accountable for soothing withdrawing receptors. Erowid.org “Documenting the complex relationships between humans and psychoactives” Great resource for information Take with a grain of salt Your clients are probably aware of this site as well Thank you for your time. Vinnie Happ vhapp@redwoodtoxicology.com