1. Jay Lance Kovar, MD, FACEP
Tomball Regional Medical Center
EMS WEEK
2012

3. • Review new synthetic substances of abuse
• Discuss pharmacology and clinical
presentations
• Identify emergency treatment options for care

5. Just when you were
getting used to
drunks and junkies…

7. • synthetic product
• contains hallucinogenic, mind-
altering chemicals
• similar in structure to those
also found in cocaine and
ecstasy
• depending on which brand or
form is purchased.

8. • Sold as:
• a bath salt,
• or plant food
• Labeled:
• “for novelty use only”
• “not for human consumption”
• to by- pass FDA regulations-not being sold as food or drug
product.
• Sold in:
• either 250 or 500 mg packets depending on brand or form
purchased.

9. Ivory Wave is the most popular brand of this product
• Vanilla Sky • Ocean Burst
• Fly • Lunar Wave
• Snow
• Ivory • Lady Bubbles
• Charge • Arctic Blast
• Ivory Coast • Sextacy
• Purple Wave • Disco
• Cristalius
• Magic • Snow Leopard
• Ocean Blue • Natural NRG
• Columbian Salts • Tranquility
• Bolivian Salts

10. • MDPV (methylene-dioxy-pyro-valerone)
usually referred to as pyro-valerone, (Super
Coke)
• powerful psychoactive chemical similar to Ritalin
• acts as a stimulant that inhibits re-uptake of
dopamine & norepinephrine
• minimal effects on serotonin levels.
• most versions of these products as containing Lidocaine
• may also contain similar components to 2-DPMP or MDMA
(aka ecstasy).

11. • Purposely designed in a way that will mimic the
effects of:
• Cocaine
• Crack
• Ecstasy
• Most often used by snorting.
• i.e. perfect for high school promotion

12. • It is sold most frequently
• on-line
• tobacco/smoke shops
• as a novelty item “not for human consumption”
• $30 for a small package
• in bulk (50-100 packets) for a discount rate.
Bath salts have increased in “club scene” use
as ecstasy availability and use have declined

13. • Poison Control calls 2009 0
• Poison Control calls 2010 303
• Poison Control calls 2011 4,100
Samples seized from different regions
reveal a great deal of variance despite
the same labels and producers

14. • Multiple manufactures sources
• Vary in purity, concentration, and fillers
• Sold in
• packages 50mg to 200mg
• vials 500mg
• Consumed
• orally, rectal, insufflated, injected, or smoked

15. Effects
• Onset, peak, and duration depends upon route
Major source seems to be China, routed through
New Orleans and out I-10 corridor
• Houston #1
• Montgomery County Top 10

16. • Effects of amphetamines, cocaine, and ecstacy without
hangover, comedown, or depression commonly following
the use of those drugs
• Elevates mood, decreases hostility, raises energy levels,
improves sense of well-being, improves attentions span
and attention to detail, euphoria, empathy, and sexual
stimulation.

17. • Appears to be extremely addictive with many
users reporting an “almost uncontrollable urge
for another hit” immediately, stating that its
effects are several times stronger than cocaine
when snorted.

18. • Acute psychosis
• Severe anxiety, paranoia, agitation, bizzarre behavior, tremors,
persecutory hallucinations
• Sympathetic overdrive
• Palpitations, shortness of breath, diaphoresis, hot flashes,
headaches, hyperthermia, overwhelming thirst
• Bruxism

19. • muscular pain/spasms
• emotional fragility
• acute paranoid psychosis
• sore jaw
• kidney failure
• loss of bowel control
• intense high followed by painful hangover
• suppressed appetite

20. • West Virginia woman scratched herself “to pieces”
over several days because she thought there was
something under her skin.
• August 2010 - UK man died after he experienced
severe hallucinations and jumped off a cliff top.

21.  November 2010 - Louisiana man sliced his throat
and said, "I can't handle what this drug has done to
me. I'm never going to touch anything again."
Hours later he shot and killed himself when he had
visions of army men swarming his house.
 December 2010 - Mississippi man shot and killed
Tippah County Deputy Sheriff DeWayne Crenshaw
at a disturbance call. It took six men more than
half an hour to wrestle the man into an ambulance.
He ripped through gurney straps and heavy
medical tape.

22. • January 2011 - Florida woman attacked and
attempted to behead her 71 year-old mother with a
machete.
• March 2011 - Pennsylvania man broke into a
monastery and stabbed a priest.
• March 2011 - Pennsylvania couple almost slashed
their 5 year-old daughter with knives as they
attacked “voices in the walls”.

23. • May 2011 - West Virginia man killed his neighbor's
goat. Man was found semi-dressed in women's
clothing in his bedroom with blood everywhere. The
goat was dead on the floor next to a pornographic
photo.
• June 2011 - Indiana man climbed a roadside
flagpole and jumped into traffic.
• July 2011 - Arizona man seriously burned his child’s
hands because the child had touched his Bible. The
man stated that voices told him the child was
possessed.

25. • K2

26. • K2/Spice products are a mixture of herbal/spice plant
products sprayed with potent psychotropic drugs
• often contaminated with unidentified toxic substances which
contribute to various adverse health effects
• cause hallucinogenic effects similar to effects of PCP.
• Marketed under variety of names
• K2, Spice, Pep Spice, Spice Silver, Spice Gold, Spice
Diamond, Smoke, Sence, Skunk, Yucatan Fire, Genie & Zohai
• sold in variety of colors/flavors- usually sold in foil
packaging

27. • Symptoms/Side-Effects may include:
• mimics marijuana “high” (often induced more quickly/more intense
than “real” marijuana)
• hallucinations
• seizures/tremors
• coma/unconsciousness
• vomiting
• numbness/tingling
• Paranoia amplified 4-10x

28. • Symptoms/Side-Effects may include:
• increased respiration rate
• elevated blood pressure (reported up to 200/100)
• elevated heart rate (reported up to rate of 150)
• increased level of anxiety/agitation leading to panic attacks
(possible suicide attempts)

29. • Depending on synthetic compound in specific
commercial brand, can be anywhere from 4
times to over 100 times more potent than
marijuana (THC)
• Sold in tobacco shops, head shops, and
convenience stores
• Sold as “incense” marked “not for human
consumption”
• Internet source from China

30. Price averages $45 for 3 grams (about equal to 3
sugar packets)-higher than good grade
marijuana
• Most often smoked but can be mixed in with
food or drink
• Most likely users:
• 14-27 yr. olds
• Prisoners/probationers
• Military (use now banned by all military branches)
• 50% of 2010 users were from mid-west US

31. • Developed by Dr. John W. Huffman, a Clemson University professor,
as part of research for National Institute for Drug Abuse (NIDA) on
endogenous cannabinoid receptors-but never tested on humans nor
approved by FDA
• “It is like Russian roulette to use these drugs. We don’t know a
darn thing about them for real.” “It shouldn’t be out there.”
• JWH-018 & many of its “cousins” such as HU-210/211, JWH-073 &
CP 47/497 found in these drugs have a chemical structure shared
with known cancer-causing agents.
• All effects of K2/Spice drugs may not be known for very long time
because of long time period that body stores them.

32. • Majority of the compounds were identified
as JWH related varieties
• JWH-018 (63%)
• JWH-250 (14%)
• JWH-073 (9%)
• JWH-081 (5%)
• JWH-200 (2%)
• JWH-019, JWH-210, JWH-251, RCS-4, AM-
2201, AM-694, CP-47, CP-497, AM-356

33. • Nothing is known about metabolism of the
chemical compounds in K2/Spice drugs
• some may be toxic
• pharmacologically active-differing from batch to batch in
kind/amount applied
• higher risk of accidental overdosing which has already been seen
• increase numbers of ER incidents reported

34.  There are hundreds more of these chemical
compounds containing strong, active
cannabinoid receptors agonists
 Increasing challenges for toxicology testing, law
enforcement and medical professionals.
 Causing difficulties for law enforcement
agencies, probation & parole, as well as drug
courts due to difficulties in testing for presence
 one lab test now known to detect it in system but at
cost of $50 & will probably not test positive for all the
known variations

35. “hijacking the part of the brain important for many
major functions: temperature control, food
intake, perception, memory and problem
solving. Many people taking these high-potency
drugs are affecting important functions
throughout their bodies-hormone functions for
example.”
Drugs may involve acute toxicity levels, possibly
long term, as well as impacting cannabinoid
receptors that regulate body’s immune system.

36. • Source primarily Mid-West US
• Recent increase in sales from app. $1000 daily
up to $10, 000 daily.
• Rapid and powerful addiction on a level not
usually found among smokers of “real”
marijuana.
• Recently linked to over 352 nationwide
emergency room incidents
• suicide attempts, extremely elevated heart rate/blood
pressure, comas, seizures, and anxiety attacks.

37. • The NEW Pot
• Ancient drug (natural product)
• Psychoactive, dissociative, hallucinogenic
• Non alkaloyd drug with similar effects to LSD
• Most potent natural hallucinogen, low toxicity
• 2006-2007 saw use grow from 750,000 to > 1,000,000
US persons
• Chewed, tinctured, or smoked

38. • Uncontrollable laughter
• Past memories, such as revisiting places from childhood
memory
• Sensations of motion, or being pulled or twisted by forces
• Visions of membranes, films and various two-dimensional
surfaces
• Merging with or becoming objects
• Overlapping realities, such as the
perception of being in several
locations at once
• Youtube effect has mobilized
• Communities to ban.

39. • Controlled Substances Act amendment for Schedule I
status in 2002 did not pass
• Texas banned 2011, Class A misdemeanor $4,000 fine
• Banned by various branches of the U.S. military and
some military bases

42. • An imminently life threatening medical emergency…
• Massive release of epinephrine, norepinephrine,
dopamine, serotonin in the body and brain.
• Severe delirium and agitation
42

43. • Agitation or Excitement = Increased activity and intensity
• Aggressive, threatening or combative – gets worse when
challenged or injured
• Amazing feats of strength
• Pressured loud incoherent speech
• Sweating (or loss of sweating late)
• Dilated pupils/less reactive to light
• Rapid breathing
43

44. • Delirium = Confusion
• Disoriented
• Person, place, time, purpose
• Rapid onset over a short period of recent time
• “He just started acting strange”
• Easily distracted/lack of focus
• Decreased awareness and perception
• Rapid changes in emotions (laughter, anger, sadness)
44

45. • Psychotic = bizarre behavior
• Thought content inappropriate for circumstances
• Hallucinations (visual or auditory)
• Delusions (grandeur, paranoia or reference)
• Flight of ideas/tangential thinking
• Makes you feel uncomfortable
45

46. • Alcohol intoxication or withdrawal
• Other drug use problems
• Example: Cocaine psychosis
• Pure psychiatric disease
• Head injury
• Dementia (Alzheimer’s Disease)
• Hypoglycemia
• Hyperthyroidism
46

47. • Combative
• Self destructive
• Homicidal/suicidal
• Agitation followed by severe depression

48. • Differential
• PCP
• LSD
• Cocaine
• Methamphetamines
• Alcohol
• Hypoglycemia
• Hypoxia
• Head trauma
• CNS infection

49. • Urine Tox
• r/o routine street drugs + “polypharmacy”
• BMP
• Hypoglycemia, metabolic acidosis
• CBC
• Infection and anemia
• CT Head
• Intracranial hemorrhage, hydrocephalus
• 12 lead EKG
• Biomarkers, myoglobin, lactic acid
• Temperature monitoring

50. No Antidote
Supportive therapies
• Sympathetic Overdrive
• Alpha and beta receptor stimulation
• Sustained endogenous norepinephrine release
• Beta blocker caution?
• Metabolic dysfunction
• Hepatic metabolism of bath salts
• Hyperthermia

51. No Antidote
Supportive therapies
• Psychosis
• Benzodiazepines
• Versed, Valium, Ativan
• Antipsychotics
• Haldol, Inapsine
• Geodon
• Ketamine

52. • Unpredictable dose and duration
• Psychiatric evaluation when clear
• Home
• Jail
• Psychiatric facility

53. • Many European countries ban sale and use
• Kansas was first state to ban use
• 15 states so far to officially ban the sale & use of
these products statewide.
• October 2011 DEA made it illeagal to possess or
sell the chemicals or products containing the
chemicals found in bath salts in the US for 1 year
pending a review of permanently banning them
• Bath Salts are a Schedule 1 substance

54.  The Texas House passed a bill banning K2 or spice, a
synthetic marijuana
 The Texas Department of State Health Services
outlawed the fake pot last month after the Drug
Enforcement Agency issued an emergency ban for a
year.
 The possession of K2 a misdemeanor, but
manufacturers and sellers would be charged with a
felony effective September 2011

55. Certain synthetic compounds deceptively labeled as “bath
salts” and synthetic marijuana products (K2 or spice)
have been added to Penalty Group 2 of the Texas
Controlled Substances Act.

56. JWH-004; JWH-193; JWH-196; JWH-203; I, II, III, IV,
JWH-007; JWH-198; JWH-197; JWH-204; IX, X, XI,
JWH-009; JWH-200; JWH-199; JWH-205; XII, XIII,
JWH-015; JWH-210; JWH-030; JWH-206; XV, and
JWH-016; JWH-211; JWH-145; JWH-207; XVI;
JWH-018; JWH-212; JWH-146; JWH-208; delta-9-
JWH-019; JWH-213; JWH-147; JWH-209; THC;
JWH-020; JWH-234; JWH-150; JWH-237; delta-8-
JWH-046; JWH-235; JWH-156; JWH-248; THC;
JWH-047; JWH-236; JWH-243; JWH-249; Nabilone;
JWH-048; JWH-239; JWH-244; JWH-250; HU-210;
JWH-049; JWH-240; JWH-245; JWH-251; HU-211;
JWH-050; JWH-241; JWH-246; JWH-252; and
JWH-070; JWH-242; JWH-292; JWH-253; WIN-
JWH-071; JWH-262; JWH-293; JWH-302; 55,212-2.
JWH-072; JWH-386; JWH-307; JWH-303;
JWH-073; JWH-387; JWH-308; JWH-304;
JWH-076; JWH-394; JWH-346; JWH-305;
JWH-079; JWH-395; JWH-348; JWH-306;
JWH-080; JWH-397; JWH-363; JWH-311;
JWH-081; JWH-398; JWH-364; JWH-312;
JWH-082; JWH-399; JWH-365; JWH-313;
JWH-094; JWH-400; JWH-367; JWH-314;
JWH-096; JWH-412; JWH-368; JWH-315;
JWH-098; JWH-413; JWH-369; JWH-316;
JWH-116; JWH-414; JWH-370; CP-55,940;
JWH-120; JWH-415; JWH-371; CP-47,497;
JWH-122; JWH-175; JWH-373; and
JWH-148; JWH-184; JWH-392; analogues
JWH-149; JWH-185; JWH-176; of CP-
JWH-180; JWH-192; 47,497,
JWH-181; JWH-167;
JWH-194; JWH-201; including
JWH-182; JWH-195; VII, V, VIII,
JWH-189; JWH-202;

57. • If the patient has illegal substances, is using substances
illegally, or is under the influence of these substances,
are we required to report that to the police?
• No
• Are we violating patient rights (HIPAA) if we report it?
• No, commission of a
crime invalidates HIPAA
in Texas

60. 1. They are harmless
2. They are neither food or drug
3. They have been marked “not for human consumption”
4. There is a popular demand

61. 1. Cocaine
2. Ecstasy
3. Methamphetamine
4. Mr. Bubble

62. 1. Alcohol intoxication or withdrawal or Cocaine
psychosis
2. Pure psychiatric disease
3. Head injury or Dementia (Alzheimer’s Disease)
4. Hypoglycemia or Hyperthyroidism
5. All of the above
6/21/2012

63. 1. Developing a differential of causes and addressing
appropriately
2. Administering the Bath Salt antidote
3. Incomplete without 5 large policemen to restrain the
patient
4. A contraindicated condition for Ketamine use.

64. 1. Bath salts are legal for purchase
2. Bath salts are legal to sell
3. Bath salts are legal to possess
4. Bath salts sale, purchase, and possession
are a felony

65. 1. 3
2. 4
3. 5
4. 1
5. 4