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Bath salts, spice, and nutmeg are more than common household items; they are also designer drugs that can send people to the emergency department.
While emergency department visits resulting from use of older drugs of abuse such as LSD and cocaine have gone up 29%-48% over the past decade, ED visits resulting from the use of nontraditional, emerging, and Web-based (NEW) drugs have increased by estimates ranging from 187%-5,846%, Dr. Mark B. Mycyk said at the annual meeting of the American College of Emergency Physicians.
The Internet has been a "huge source of information and a powerful influence on this rapidly evolving and changing epidemic," said Dr. Mycyk of Cook County Hospital in Chicago. Designer drugs are easily available from websites such as Silk Road, "the Amazon.com of some of these NEW drugs," he said, and anyone with access to a computer "can pretty much get almost anything delivered to their homes or dorm rooms or a post office box." According to one study, websites touting recreational drugs were a factor in 27% of new drug use in college-age students (Pediatrics 2002;109:e96).
"Cases we see in the ED are extreme ... cases where people end up with complications," Dr. Mycyk said. Emergency physicians may see patients who have used the following NEW drugs:
• Bath salts (methylenedioxypyrovalerone, MDPV). "Brand names" include Ivory Wave, Bliss, and White Lightning; also called Plant Food. Popularized in Australia, these are not the kind of bath salts you would buy at a home goods store, which cause only severe rhinitis if snorted. The type sold online and in "head shops" is a stimulant and hallucinogen that causes cardiovascular and psychiatric adverse effects. "Self-harm has become a common complication. ... People get so psychotic, they are actually getting aggressive and harming others," Dr. Mycyk said. MDPV also has "lots of other profound effects on human neurotransmitters that we still do not understand," and the drug is "so addictive that users say it provokes an almost-uncontrollable urge for another hit." The chemicals used to make "bath salts" were classified as schedule 1 substances in late October by the Drug Enforcement Agency.
• Spice. Also known as K2. This synthetic cannabinoid, developed for animal research, "has resulted in a number of ED visits, and some of these visits can be pretty prolonged, and we’ve seen some unanticipated complications," Dr. Mycyk said. K2 is "much more potent and powerful than natural marijuana, so the effects that we see are much more extreme." Symptoms include agitation, cardiovascular effects, and inappropriate affect (Clin. Toxicol. [Phila.] 2011;49:431-3). Several varieties are now illegal in the United States, but chemists can create "newer synthetic analogs, which look different from Spice and K2, and that way, they evade the legal authorities," he said.
• Meow-Meow (mephedrone, 4-methylmethcathinone). Other street names include Drone, Bubble, and MCAT. This synthetic cathinone, derived from an African shrub, is a stimulant and sympathomimetic agent. Its effects and structure are similar to those of ephedra and amphetamine. Symptoms of Meow-Meow use include seizures, agitation, tachycardia, hypertension, and hyperthermia (Toxicol. Lett. 2011;201:191-5).
• Bromo-DragonFLY (bromo-benzodifuranyl-isopropylamine). Adverse effects of this designer drug include hallucinations, seizures, vomiting, and intense vasoconstriction with resulting ischemia in fingers and toes. The drug has "hallucinogenic, Ecstasy-like properties" and is a serotoninergic receptor agonist. The name derives from the resemblance its chemical structure has to a dragonfly.
• Nutmeg. At doses as high as 50 g, the common spice nutmeg has hallucinogenic properties. "When we see nutmeg users in the ED, we’re seeing a small proportion who took an extremely large dose or have an unanticipated complication from it," Dr. Mycyk said. In one case series of 119 patients, the most common symptoms were tachycardia, palpitations, and agitation. The researchers found that "clinical effects from ingestion can be significant and can require medical intervention" (Clin. Toxicol. [Phila.] 2011;49:177-80).
• Salvia. Street names of the salvia divinorum plant include Diviner’s Sage, Shepherdess, and Sally D. Related to mint, salvia has hallucinogenic and psychotomimetic properties. Symptoms include agitation and neurologic, cardiovascular, and gastrointestinal effects. The herb can be made into a tea; fresh leaves can be chewed; or leaves can be dried and then smoked, snorted, or injected. The drug has not been well studied, but one group of researchers analyzed YouTube videos of salvia users to study its effects (Drug Alcohol Depend. 2010;108:138-40).
• Snakebite. The venom of the naja naja snake, or Indian cobra, contains neurotoxins that can have opiate-like effects on the central nervous system. The venom can cause blackouts and feelings of well-being and lethargy in people who deliberately have themselves bitten by a cobra (Subst. Abus. 2011;32:43-6). "It boggles my mind what people will do to get high," Dr. Mycyk said.
• Buprenorphine (Suboxone). Clinically used for opioid dependence, this drug is smuggled into prisons by being crushed into a paste that is applied to a drawing or card, or hidden under stamps. A recent study found that 12% of drug contraband in Massachusetts prisons is buprenorphine (Curr. Drug Abuse Rev. 2011;4:28-41). Buprenorphine intoxication causes mild euphoria, somnolence, and possible respiratory depression; laboratory and toxicology screens for illicit drugs would be negative.
Diagnosis
Hospital-based drug screens don’t detect most of the new and evolving designer drugs that result in emergency department visits. "A lot of hospitals have invested in expanded drug-screening panels, but these hospital machines cannot keep up with the creative chemists and users out there," Dr. Mycyk said. So "tox testing is not that helpful for some of these NEW drugs. In fact, it might falsely reassure you."
So, to make the diagnosis, "if the patient is conscious, ask them. Know their language, know the slang. They will tell you. ... They are frightened, and they don’t want to die."
If the patient is delirious or has altered mental status, examine his or her belongings carefully. "Completely examine your patient’s belongings, and you will probably find your answer." Check the small pocket in jeans, Dr. Mycyk suggested. "I’ve been surprised how often I find drug contraband in that small pocket."
Accessing one of the "drug partisan sites" – such as erowid.org, lycaeum.org, shroomery.org, and talktofrank.com – also can be useful if you want to figure out what your patient has taken. However, while it might be helpful to know the agent, focus on symptoms and "treat the patient; don’t treat the product," he said.
Treatment
Deaths from NEW drug abuse most commonly occur due to dysrhythmias, hyperthermia, or metabolic complications. There are no antidotes for any of these NEW drugs, but "symptom-based, goal-directed, supportive therapy will save most of these patients’ lives."
Use common sense, and trust your instincts, Dr. Mycyk said. Get an electrolyte panel if the patient is persistently symptomatic. If a patient is tachycardic and having palpitations, getting an ECG may be appropriate. If they’re overly agitated, it is safe to use benzodiazepines. If they’re dehydrated, give them IV fluids, he said.
It is important to get complete vital signs on these patients, and the most important vital sign is temperature, as elevated body temperature is the best predictor of death in the ED. Degree of tachycardia or tachypnea is not as concerning, he said.
For most of these patients, brief ED observation is fine. However, some of the NEW drugs have long duration of activity; for example, the effects of buprenorphine can last 24-37 hours, so admission might be considered.
All patients with an ED visit for drug use should have counseling before discharge. Simple ED counseling can help, Dr. Mycyk said. "They think a lot of this stuff is safe, and we just need to remind them that it is not safe."
Dr. Mycyk had no significant financial relationships to disclose.
Bath salts, spice, and nutmeg are more than common household items; they are also designer drugs that can send people to the emergency department.
While emergency department visits resulting from use of older drugs of abuse such as LSD and cocaine have gone up 29%-48% over the past decade, ED visits resulting from the use of nontraditional, emerging, and Web-based (NEW) drugs have increased by estimates ranging from 187%-5,846%, Dr. Mark B. Mycyk said at the annual meeting of the American College of Emergency Physicians.
The Internet has been a "huge source of information and a powerful influence on this rapidly evolving and changing epidemic," said Dr. Mycyk of Cook County Hospital in Chicago. Designer drugs are easily available from websites such as Silk Road, "the Amazon.com of some of these NEW drugs," he said, and anyone with access to a computer "can pretty much get almost anything delivered to their homes or dorm rooms or a post office box." According to one study, websites touting recreational drugs were a factor in 27% of new drug use in college-age students (Pediatrics 2002;109:e96).
"Cases we see in the ED are extreme ... cases where people end up with complications," Dr. Mycyk said. Emergency physicians may see patients who have used the following NEW drugs:
• Bath salts (methylenedioxypyrovalerone, MDPV). "Brand names" include Ivory Wave, Bliss, and White Lightning; also called Plant Food. Popularized in Australia, these are not the kind of bath salts you would buy at a home goods store, which cause only severe rhinitis if snorted. The type sold online and in "head shops" is a stimulant and hallucinogen that causes cardiovascular and psychiatric adverse effects. "Self-harm has become a common complication. ... People get so psychotic, they are actually getting aggressive and harming others," Dr. Mycyk said. MDPV also has "lots of other profound effects on human neurotransmitters that we still do not understand," and the drug is "so addictive that users say it provokes an almost-uncontrollable urge for another hit." The chemicals used to make "bath salts" were classified as schedule 1 substances in late October by the Drug Enforcement Agency.
• Spice. Also known as K2. This synthetic cannabinoid, developed for animal research, "has resulted in a number of ED visits, and some of these visits can be pretty prolonged, and we’ve seen some unanticipated complications," Dr. Mycyk said. K2 is "much more potent and powerful than natural marijuana, so the effects that we see are much more extreme." Symptoms include agitation, cardiovascular effects, and inappropriate affect (Clin. Toxicol. [Phila.] 2011;49:431-3). Several varieties are now illegal in the United States, but chemists can create "newer synthetic analogs, which look different from Spice and K2, and that way, they evade the legal authorities," he said.
• Meow-Meow (mephedrone, 4-methylmethcathinone). Other street names include Drone, Bubble, and MCAT. This synthetic cathinone, derived from an African shrub, is a stimulant and sympathomimetic agent. Its effects and structure are similar to those of ephedra and amphetamine. Symptoms of Meow-Meow use include seizures, agitation, tachycardia, hypertension, and hyperthermia (Toxicol. Lett. 2011;201:191-5).
• Bromo-DragonFLY (bromo-benzodifuranyl-isopropylamine). Adverse effects of this designer drug include hallucinations, seizures, vomiting, and intense vasoconstriction with resulting ischemia in fingers and toes. The drug has "hallucinogenic, Ecstasy-like properties" and is a serotoninergic receptor agonist. The name derives from the resemblance its chemical structure has to a dragonfly.
• Nutmeg. At doses as high as 50 g, the common spice nutmeg has hallucinogenic properties. "When we see nutmeg users in the ED, we’re seeing a small proportion who took an extremely large dose or have an unanticipated complication from it," Dr. Mycyk said. In one case series of 119 patients, the most common symptoms were tachycardia, palpitations, and agitation. The researchers found that "clinical effects from ingestion can be significant and can require medical intervention" (Clin. Toxicol. [Phila.] 2011;49:177-80).
• Salvia. Street names of the salvia divinorum plant include Diviner’s Sage, Shepherdess, and Sally D. Related to mint, salvia has hallucinogenic and psychotomimetic properties. Symptoms include agitation and neurologic, cardiovascular, and gastrointestinal effects. The herb can be made into a tea; fresh leaves can be chewed; or leaves can be dried and then smoked, snorted, or injected. The drug has not been well studied, but one group of researchers analyzed YouTube videos of salvia users to study its effects (Drug Alcohol Depend. 2010;108:138-40).
• Snakebite. The venom of the naja naja snake, or Indian cobra, contains neurotoxins that can have opiate-like effects on the central nervous system. The venom can cause blackouts and feelings of well-being and lethargy in people who deliberately have themselves bitten by a cobra (Subst. Abus. 2011;32:43-6). "It boggles my mind what people will do to get high," Dr. Mycyk said.
• Buprenorphine (Suboxone). Clinically used for opioid dependence, this drug is smuggled into prisons by being crushed into a paste that is applied to a drawing or card, or hidden under stamps. A recent study found that 12% of drug contraband in Massachusetts prisons is buprenorphine (Curr. Drug Abuse Rev. 2011;4:28-41). Buprenorphine intoxication causes mild euphoria, somnolence, and possible respiratory depression; laboratory and toxicology screens for illicit drugs would be negative.
Diagnosis
Hospital-based drug screens don’t detect most of the new and evolving designer drugs that result in emergency department visits. "A lot of hospitals have invested in expanded drug-screening panels, but these hospital machines cannot keep up with the creative chemists and users out there," Dr. Mycyk said. So "tox testing is not that helpful for some of these NEW drugs. In fact, it might falsely reassure you."
So, to make the diagnosis, "if the patient is conscious, ask them. Know their language, know the slang. They will tell you. ... They are frightened, and they don’t want to die."
If the patient is delirious or has altered mental status, examine his or her belongings carefully. "Completely examine your patient’s belongings, and you will probably find your answer." Check the small pocket in jeans, Dr. Mycyk suggested. "I’ve been surprised how often I find drug contraband in that small pocket."
Accessing one of the "drug partisan sites" – such as erowid.org, lycaeum.org, shroomery.org, and talktofrank.com – also can be useful if you want to figure out what your patient has taken. However, while it might be helpful to know the agent, focus on symptoms and "treat the patient; don’t treat the product," he said.
Treatment
Deaths from NEW drug abuse most commonly occur due to dysrhythmias, hyperthermia, or metabolic complications. There are no antidotes for any of these NEW drugs, but "symptom-based, goal-directed, supportive therapy will save most of these patients’ lives."
Use common sense, and trust your instincts, Dr. Mycyk said. Get an electrolyte panel if the patient is persistently symptomatic. If a patient is tachycardic and having palpitations, getting an ECG may be appropriate. If they’re overly agitated, it is safe to use benzodiazepines. If they’re dehydrated, give them IV fluids, he said.
It is important to get complete vital signs on these patients, and the most important vital sign is temperature, as elevated body temperature is the best predictor of death in the ED. Degree of tachycardia or tachypnea is not as concerning, he said.
For most of these patients, brief ED observation is fine. However, some of the NEW drugs have long duration of activity; for example, the effects of buprenorphine can last 24-37 hours, so admission might be considered.
All patients with an ED visit for drug use should have counseling before discharge. Simple ED counseling can help, Dr. Mycyk said. "They think a lot of this stuff is safe, and we just need to remind them that it is not safe."
Dr. Mycyk had no significant financial relationships to disclose.
Bath salts, spice, and nutmeg are more than common household items; they are also designer drugs that can send people to the emergency department.
While emergency department visits resulting from use of older drugs of abuse such as LSD and cocaine have gone up 29%-48% over the past decade, ED visits resulting from the use of nontraditional, emerging, and Web-based (NEW) drugs have increased by estimates ranging from 187%-5,846%, Dr. Mark B. Mycyk said at the annual meeting of the American College of Emergency Physicians.
The Internet has been a "huge source of information and a powerful influence on this rapidly evolving and changing epidemic," said Dr. Mycyk of Cook County Hospital in Chicago. Designer drugs are easily available from websites such as Silk Road, "the Amazon.com of some of these NEW drugs," he said, and anyone with access to a computer "can pretty much get almost anything delivered to their homes or dorm rooms or a post office box." According to one study, websites touting recreational drugs were a factor in 27% of new drug use in college-age students (Pediatrics 2002;109:e96).
"Cases we see in the ED are extreme ... cases where people end up with complications," Dr. Mycyk said. Emergency physicians may see patients who have used the following NEW drugs:
• Bath salts (methylenedioxypyrovalerone, MDPV). "Brand names" include Ivory Wave, Bliss, and White Lightning; also called Plant Food. Popularized in Australia, these are not the kind of bath salts you would buy at a home goods store, which cause only severe rhinitis if snorted. The type sold online and in "head shops" is a stimulant and hallucinogen that causes cardiovascular and psychiatric adverse effects. "Self-harm has become a common complication. ... People get so psychotic, they are actually getting aggressive and harming others," Dr. Mycyk said. MDPV also has "lots of other profound effects on human neurotransmitters that we still do not understand," and the drug is "so addictive that users say it provokes an almost-uncontrollable urge for another hit." The chemicals used to make "bath salts" were classified as schedule 1 substances in late October by the Drug Enforcement Agency.
• Spice. Also known as K2. This synthetic cannabinoid, developed for animal research, "has resulted in a number of ED visits, and some of these visits can be pretty prolonged, and we’ve seen some unanticipated complications," Dr. Mycyk said. K2 is "much more potent and powerful than natural marijuana, so the effects that we see are much more extreme." Symptoms include agitation, cardiovascular effects, and inappropriate affect (Clin. Toxicol. [Phila.] 2011;49:431-3). Several varieties are now illegal in the United States, but chemists can create "newer synthetic analogs, which look different from Spice and K2, and that way, they evade the legal authorities," he said.
• Meow-Meow (mephedrone, 4-methylmethcathinone). Other street names include Drone, Bubble, and MCAT. This synthetic cathinone, derived from an African shrub, is a stimulant and sympathomimetic agent. Its effects and structure are similar to those of ephedra and amphetamine. Symptoms of Meow-Meow use include seizures, agitation, tachycardia, hypertension, and hyperthermia (Toxicol. Lett. 2011;201:191-5).
• Bromo-DragonFLY (bromo-benzodifuranyl-isopropylamine). Adverse effects of this designer drug include hallucinations, seizures, vomiting, and intense vasoconstriction with resulting ischemia in fingers and toes. The drug has "hallucinogenic, Ecstasy-like properties" and is a serotoninergic receptor agonist. The name derives from the resemblance its chemical structure has to a dragonfly.
• Nutmeg. At doses as high as 50 g, the common spice nutmeg has hallucinogenic properties. "When we see nutmeg users in the ED, we’re seeing a small proportion who took an extremely large dose or have an unanticipated complication from it," Dr. Mycyk said. In one case series of 119 patients, the most common symptoms were tachycardia, palpitations, and agitation. The researchers found that "clinical effects from ingestion can be significant and can require medical intervention" (Clin. Toxicol. [Phila.] 2011;49:177-80).
• Salvia. Street names of the salvia divinorum plant include Diviner’s Sage, Shepherdess, and Sally D. Related to mint, salvia has hallucinogenic and psychotomimetic properties. Symptoms include agitation and neurologic, cardiovascular, and gastrointestinal effects. The herb can be made into a tea; fresh leaves can be chewed; or leaves can be dried and then smoked, snorted, or injected. The drug has not been well studied, but one group of researchers analyzed YouTube videos of salvia users to study its effects (Drug Alcohol Depend. 2010;108:138-40).
• Snakebite. The venom of the naja naja snake, or Indian cobra, contains neurotoxins that can have opiate-like effects on the central nervous system. The venom can cause blackouts and feelings of well-being and lethargy in people who deliberately have themselves bitten by a cobra (Subst. Abus. 2011;32:43-6). "It boggles my mind what people will do to get high," Dr. Mycyk said.
• Buprenorphine (Suboxone). Clinically used for opioid dependence, this drug is smuggled into prisons by being crushed into a paste that is applied to a drawing or card, or hidden under stamps. A recent study found that 12% of drug contraband in Massachusetts prisons is buprenorphine (Curr. Drug Abuse Rev. 2011;4:28-41). Buprenorphine intoxication causes mild euphoria, somnolence, and possible respiratory depression; laboratory and toxicology screens for illicit drugs would be negative.
Diagnosis
Hospital-based drug screens don’t detect most of the new and evolving designer drugs that result in emergency department visits. "A lot of hospitals have invested in expanded drug-screening panels, but these hospital machines cannot keep up with the creative chemists and users out there," Dr. Mycyk said. So "tox testing is not that helpful for some of these NEW drugs. In fact, it might falsely reassure you."
So, to make the diagnosis, "if the patient is conscious, ask them. Know their language, know the slang. They will tell you. ... They are frightened, and they don’t want to die."
If the patient is delirious or has altered mental status, examine his or her belongings carefully. "Completely examine your patient’s belongings, and you will probably find your answer." Check the small pocket in jeans, Dr. Mycyk suggested. "I’ve been surprised how often I find drug contraband in that small pocket."
Accessing one of the "drug partisan sites" – such as erowid.org, lycaeum.org, shroomery.org, and talktofrank.com – also can be useful if you want to figure out what your patient has taken. However, while it might be helpful to know the agent, focus on symptoms and "treat the patient; don’t treat the product," he said.
Treatment
Deaths from NEW drug abuse most commonly occur due to dysrhythmias, hyperthermia, or metabolic complications. There are no antidotes for any of these NEW drugs, but "symptom-based, goal-directed, supportive therapy will save most of these patients’ lives."
Use common sense, and trust your instincts, Dr. Mycyk said. Get an electrolyte panel if the patient is persistently symptomatic. If a patient is tachycardic and having palpitations, getting an ECG may be appropriate. If they’re overly agitated, it is safe to use benzodiazepines. If they’re dehydrated, give them IV fluids, he said.
It is important to get complete vital signs on these patients, and the most important vital sign is temperature, as elevated body temperature is the best predictor of death in the ED. Degree of tachycardia or tachypnea is not as concerning, he said.
For most of these patients, brief ED observation is fine. However, some of the NEW drugs have long duration of activity; for example, the effects of buprenorphine can last 24-37 hours, so admission might be considered.
All patients with an ED visit for drug use should have counseling before discharge. Simple ED counseling can help, Dr. Mycyk said. "They think a lot of this stuff is safe, and we just need to remind them that it is not safe."
Dr. Mycyk had no significant financial relationships to disclose.