Susan Pike, MD November 27, 2012

Transcription

1 Susan Pike, MD November 27, 2012

2 NIDA Quiz 1. Spice aka K2 A. Is considered to be fake marijuana B. Has put people in ER with vomiting, confusion and hallucinations C. Ingested mainly by smoking D. All of the above USHHS. NIDA. Drugs: Shatter the myth

3 NIDA Quiz 1. D. All of the above. Spice products are labeled not fit for human consumption Rapid heart rates, vomiting, agitation, and hallucinations Results in abuse and dependence K2 testing available but usually not part of UDS USDHSS. NIDA. Sara Bellum Blog.

4 NIDA Quiz 2. "Ivory Wave," "Red Dove," "Blue Silk," "Cloud Nine," "White Lightning," "Scarface," and "Hurricane Charlie" are names for A. Synthetic marijuana B. Bath salts C. Street benzodiazepines D. Victoria s Secret underwear NIDA. Messasges from the Director. Feb 2011.

5 NIDA Quiz 2. B. Bath salts: Synthetic stimulants with amphetamine-like chemicals: mephedrone, pyrovalerone, MDPV Administered orally, snorted, injected High rate of ER visits: Chest pain, increased HR/BP, agitation, hallucinations, delusions, extreme paranoia Poison Control: 2010:304; 2011:6128; 2012:>7000 Mephedrone: High risk for quick addiction and overdose USDHSS. NIDA. Messasges from the Director. Feb USA Today. April 13, 2012

6 NIDA Quiz 3. Marijuana addiction A. Does not exist B. Occurs only in connection with addiction to other drugs, such as alcohol/cocaine C. Occurs in 1 in 11 people who use it D. Has a causal relationship with psychosis USDHSS. NIDA. Drugs: Shatter the Myths

7 NIDA Quiz 3. C and D. Marijuana use: Evokes compulsive drug seeking despite known harmful effects Develops tolerance Forces increasing numbers to seek treatment because of inability to quit Presents with withdrawal symptoms including irritability, sleeplessness, decreased appetite, anxiety and drug craving Encompasses 9% of all users, 17% of adolescent users, 33-50% of daily users USDHSS. NIDA. Drugs: Shatter the Myths Budney et al. J Substance Abuse Treatment

8 NIDA Quiz 3. C and D. Multiple studies and meta-analyses within the last 10 years have established a causal effect between cannabis abuse and psychosis THC composition has increased significantly from 1-3% to 7-12% in US and up to 20-40% in Netherlands/UK Hall. Nature. 2007

9 Synthetic Products Casper, WY, 2012: Public health officials warned people to avoid the synthetic drugs after three people who smoked or swallowed "blueberry spice" went into kidney failure and at least a dozen others needed medical help. "We are viewing use of this drug as a potentially lifethreatening situation," said Tracy Murphy, state epidemiologist with the Wyoming Department of Health. USA Today. April 13, 2012.

10 Synthetic Products In Blaine, MN, 2012: 22-year-old male shared 2 C-E, a synthetic hallucinogen he purchased on the Internet, with friends at a party. One teen died. 22-year-old pleaded guilty to murder with potential prison sentence of 20 years USA Today. April 13, 2012

11 Synthetic Products Bowling Green, KY, 2011: Recent high school graduate took a hit of a synthetic marijuana known as 7H while hanging out at a hookah bar with friends Within three minutes, high school graduate became paralyzed and required immediate hospitalization USA Today. April 13, 2012

12 Synthetic Products Iowa Sen. Chuck Grassley, sponsor of a bill to outlaw synthetic marijuana, said It is poison. People are spraying chemicals on a pile of plant clippings, putting that in an envelope and selling it to kids. USA Today. Bath salt poisoning rise as legislative ban tied up. April13, 2012

13 UIHC Statistics 1JPE Statistics 25% of patients have substance abuse dx at discharge Increasing number of patients with discharge diagnosis of substance abuse/dependence Increasing number of patients with synthetic substance abuse Increasing number of patients with psychotic symptoms that appear to be substance induced

14 Local Statistics Scott Gaarde, Johnson County Drug Task Force Local substance abuse in adolescents: THC/K2 - very prevalent Legislation behind modifications on synthetic products Most significant increase in use among JHS students EtOH - fairly common Prescription Drug Abuse - emerging problem Inhalants - decreasing problem

15 2010 National Survey on Drug Use and Health (NSDUH) Illicit drug use (12-17yo) % Alcohol use 13.6% Tobacco use 10.7% Marijuana use - 7.5% Prescription drug abuse - 3.0% Inhalants - 1.1% Hallucinogens - 0.9% Ecstasy use - 0.5% Cocaine - 0.2% US Dept HHS. SAMHSA. NSDUH

16 2010 NSDUH Males higher use (11.2%) cf females (6.8%) Males more likely to use THC Females more likely to use prescription drugs (stimulants and pain relievers) Equal use of alcohol (13%) US Dept HHS. SAMHSA. NSDUH

17 National Statistics US Dept HHS. SAMHSA. NSDUH

18 2010 NSDUH Alcohol use in adolescents 10 million underage drinkers 6.5 million binge drinkers 2.0 million heavy drinkers 26.3% of yo consumed EtOH in last month 17% of yo binge drink By 12 th grade, 28.9% males By 12 th grade, 27.5% females US Dept HHS. SAMHSA. NSDUH

19 Summary of Statistics Locally and nationally, substance abuse is important problem in adolescents Recent evidence points to increased vulnerability to effects of substance abuse on adolescent brain

20 Spice Wide variety of herbal mixtures that product experiences similar to use of cannabis Sold as incense predominantly through online sales since nd most popular illicit drug used by high school seniors Marijuana 36.4 % seniors Spice 11.4 % seniors NIDA. Drug Facts. Spice (Synthetic Marijuana). April 2012.

21 Spice Names: K2, fake weed, Yucatan Fire, Sence, Genie, Skunk, Moon Rocks, Spice Silver, Spice Gold, Spice Diamond, Arctic Synergy, Tropical Synergy, Spice Egypt, ChillX, etc. Marketed as Safe, Natural and Legal alternatives to THC Contain dried plant materials BUT also have active synthetic or designed cannabinoid compounds NIDA. Drug Facts. Spice (Synthetic Marijuana). April 2012.

22 Spice Users reports: Common: Elevated mood, relaxation, altered perception Other experiences: Extreme anxiety, paranoia, hallucinations Poison Control Centers reports: Rapid heart rate, vomiting, agitation, confusion, hallucinations Elevated blood pressure, myocardial ischemia, rare myocardial infarctions NIDA. Drug Facts: Spice (Synthetic Marijuana). April 2012.

23 Spice 2011: DEA designated five active chemicals most frequently found in Spice as Schedule I controlled substances Result: Manufacturers modify chemicals to keep products legal Europol and FDA currently investigating products NIDA. Drug Facts. Spice (Synthetic Marijuana). April 2012.

24 Bath Salts Synthetic chemicals related to cathinone Abused orally, snorted or injected Contain 3,4-methylenedioxypyrovalerone (MDPV), mephedrone, methylene and/or other compounds Chemically similar to amphetamines/mdma (Ecstasy) Raise levels of dopamine in brain similar to cocaine BUT >10 times more potent NIDA. Drug Facts. Synthetic Cathinones ( Bath Salts ). November 2012.

25 Bath Salts Users Reports: Euphoria Increased sociability Increased sex drive Severe Intoxication: paranoia, agitation, psychosis NIDA. Drug Facts. Synthetic Cathinones ( Bath Salts ). November 2012.

26 Bath Salts Poison Control Centers Reports: Racing heart, elevated blood pressure, chest pain Paranoia, hallucinations Violent behavior Panic attacks Excited delirium Dehydration Breakdown of skeletal muscle tissue Kidney failure Death NIDA. Drug Facts. Synthetic Cathinones ( Bath Salts ). November 2012.

27 Bath Salts High Abuse and Addiction Potential Rats: Escalation of drug intake similar to methamphetamine addiction Bath salts users report intense cravings Frequent use: tolerance, dependence, and strong withdrawal symptoms NIDA. Drug Facts. Synthetic Cathinones ( Bath Salts ). November 2012.

28 Bath Salts Cathinone: amphetamine-like stimulant from the Khat plant Considered a divine food by ancient Egyptians who felt that using it released humanity s divinity Chewing Khat: Social custom in Horn of Africa and Arabian Penisula for thousands of years In Yemen, 40% of water supply dedicated to growing khat that required 40 x water for grapes

29 Bath Salts Cathinone: Breaks down into cathine and norephedrin Affinity for serotonin receptors Causes euphoria and hallucinatory effects Slows reuptake of epinephrine and norephinephrine Causes wakefulness and insomnia Can cause restless pacing and picking behaviors Cathine: Causes release of epinephrine and norepinephrine

30 Dissociative Drugs - Salvia Herb occurring naturally in North America, Central America, and South America Chewed, smoked as joint or in water pipe, or drunk as extracted juices Active ingredient: salvinorin A Potent activator of kappa opioid receptors NIDA. Info Facts: Salvia: December 2011.

31 Dissociative Drugs - Salvia Users Reports: 2011 Statistics: 8 th grade: 1.6% 10 th grade: 3.9 % 12 th grade: 5.9 % Intense but short-lived psychotomimetic episodes Occur <1 minute after ingestion Last < 30 minutes NIDA. Info Facts: Salvia: December 2011.

32 Dissociative Drugs - Salvia Psychedelic-like experiences Visual perceptions Mood and body sensations Emotional lability Feelings of detachment Highly modified perception of external reality and self Decreased ability to interact with environment NIDA. Info Facts: Salvia: December 2011.

33 Dissociative Drugs-Ketamine Ketalar SV, Cat Valium, Special K, Vitamin K DEA Schedule III drug Injected, snorted and smoked Acts on NMDA (glutamate) receptor Can result in tolerance and craving Epidemiology: 8 th grade: 1.0% 10 th grade: 1.3% 12 th grade: 1.7% NIDA. InfoFacts: Club Drugs (GHB, Ketamine, and Rohypnol). July 2010.

34 Dissociative Drugs-Ketamine Users Reports: Dissociation from one s body and environment dream-like state Impaired motor function Anxiety Tremors Numbness Memory Loss Nausea NIDA. InfoFacts: Club Drugs (GHB, Ketamine, and Rohypnol). July 2010.

35 Dissociative Drugs-Ketamine Poison Control Centers Reports: Analgesia Delirium Respiratory depression Respiratory arrest Death NIDA. InfoFacts: Club Drugs (GHB, Ketamine, and Rohypnol). July 2010.

36 Hookahs Single or multi-stemmed water pipes for smoking Flavored tobaccos Tobacco-free alternative products, eg, tobamel, tealeaf, stones soaked in molasses products 2011: 18.5 percent of 12th graders had smoked a hookah at some point in the past year NIDA. Drug Facts: High School and Youth Trends. July 2012.

37 Hookahs 2005 WHO Report: Regular hookah tobacco use: Serious potential health hazard Average hookah session: >40 minutes inhalations liters of smoke per inhalation In 60 minutes: consumption of x volume of smoke of cigarettes WHO Study Group on Tobacco Product Regulation. Advisory Note: Waterpipe tobacco smoking: Health effects, research needs and recommended actions by regulators. WHO

38 Club Drugs - MDMA MDMA Ecstasy, XTC,Adam, Clarity, Eve, Lover s speed, Peace, Hug,Uppers Ingested, snorted or injected 2010 Use: 8 th grade: 2.4% 10 th grade: 4.7 % 12 th grade: 4.5% Resurgence in 2011 from previous years NIDA. Drug Facts: MDMA (Ecstasy). December 2010.

39 Club Drugs - MDMA Mechanisms: Binds to serotonin transporter to prolong serotonin signal Enters serotonergic neurons to cause excessive release of serotonin Causes excessive release of norepinephrine to increased heart rate and blood pressure Minimal impact on dopamine NIDA. Info Facts: MDMA (Ecstasy). December 2010.

40 Club Drugs - MDMA Poison Control Centers Reports: Nausea, muscle cramping, teeth clenching, blurred vision Impaired ability to regulate temperature: chills, sweating, hyperthermia Confusion Insomnia Drug craving Depression, severe anxiety Rare death NIDA. Drug Facts: MDMA (Ecstasy). December 2010.

41 Club Drugs - Rohypnol Rohypnol/Flunitrazepam Aka Forget-me pill, Mexican Valium, R2, Roche, Roofies, Roofinol, Rope, Rophies BZD banned in US Odorless, colorless, tasteless Ingested (frequently combined with alcohol) or snorted Involved in date-rapes NIDA. InfoFacts: Club Drugs (GHB, Ketamine, and Rohypnol). July 2010.

42 Club Drugs - Rohypnol Mechanism Acts at GABA-A receptor Produces anterograde amnesia Chronic use produces tolerance, dependence, and addiction Epidemiology 8 th grade 0.4% 10 th grade 0.4 % 11th grade 1.0% NIDA. InfoFacts: Club Drugs (GHB, Ketamine, and Rohypnol). July 2010.

43 Club Drugs - Rohypnol Users Reports re Rohypnol: Sedation Muscle relaxation Confusion Dizziness Memory loss Impaired concentration Potentially lethal when combined with alcohol NIDA. InfoFacts: Club Drugs (GHB, Ketamine, and Rohypnol). July 2010.

44 Club Drugs GHB Gamma-hydroxybutirate, G, Georgia home boy, Grievous bodily harm, Liquid Ecstasy, Soap, Scoop, Goop, Liquid X Odorless, colorless, tasteless Ingested or swallowed (frequently placed in alcohol) Involved in date-rapes Used by bodybuilders for anabolic effects (fat reduction, stimulation of protein synthesis) Can cause seizures and coma NIDA. InfoFacts: Club Drugs (GHB, Ketamine, and Rohypnol). July 2010.

45 Club Drugs - GBH Mechanism Acts on GABA-B receptor and GHB binding site Causes sedation At high doses, results in sleep, coma or death Epidemiology 8 th grade: 0.7 % 12 th grade: 1.1% NIDA. InfoFacts: Club Drugs (GHB, Ketamine, and Rohypnol). July 2010

46 Adolescent Development Physiological Changes: Delayed sleep and awakening Pubertal Changes: Primary and secondary sex characteristics Cognitive Changes: Increased emotionality and risk taking, especially in early/middle adolescence Social Changes: Distancing from parents and increased time with peers Windle. Pediatrics

47 Adolescent Brain Development Adolescent Brain Processes: 1. Proliferation 2. Pruning 3. Myelination Processes enable functional maturation of neural pathways in cortex and subcortical areas Alcohol :15-26

48 Adolescent Brain Development Proliferation: Rapid growth of gray matter and formation of new connections Maximal Frontal/Parietal Lobe Gray Matter Volume yrs in females, 12 yrs in males Maximal Temporal Love Gray Matter Volume 16.7 yrs in females, 16.5 yrs in males Maximal Prefrontal Cortex Gray Matter Volume Occurs in late adolescence (>21yrs) Trends in Neuroscience. 2006

49 Adolescent Brain Development Pruning: Gray matter maturation in which new synaptic connections are formed and others are eliminated Inverted U-shaped developmental curve from childhood to adolescence to adulthood Decreased gray matter volume, especially in PFC Influenced by environmental experiences Trends in Neuroscience. 2006

50 Adolescent Brain Development Myelination: Progressive enclosure of axons with myelin to speed communication among neurons and stabilize connections Significantly increased cortical white matter from adolescence and into adulthood Increased connectivity of subcortical regions (hippocampus, amygdala, areas with high sex steroid receptors) Guerri. Alcohol

51 Adolescent Brain Development Brain development progresses from Lower to higher brain centers Brain stem to the cerebral cortex Caudal to rostral direction In adolescence, mismatch occurs Bottom-up thinking trumps top-down thinking Reward areas of brain trump decision-making areas Casey and Jones. JAACAP

52 Adolescent Brain Development