aka Toxicology Conundrum 040
Reviewed and revised 25 June 2012
For the 40th Toxicology Conundrum (!), LITFL have recruited Leon Gussow F.UCEM, the force behind The Poison Review, to bring you this post on the toxicity of new recreational drugs. Leon recently authored this must-read article:
Gussow L. . Emergency Medicine News 2010;32(7)20-21. [free fulltext]
There has been an avalanche of new recreational drugs hitting the streets recently. It is almost impossible to keep up with the ever-changing drug scene and reliable information is scanty. Apart from a few anecdotal reports, most of the information available to clinicians comes from those involved in drug culture. Given these limitations, treatment of toxicity from these new recreational drugs should be guided by the clinical manifestations and the known pharmacology of these agents. Meticulous supportive care is paramount and some soothing benzodiazepines are probably helpful in most cases.
Are you ready to test your knowledge of these new agents?… You’d better be, after all, they will be coming to an ED near you soon.
Q1. How is Bromo-DragonFLY typically purchased?
BDF is usually sold as a “plant food” or “research chemical” and is often purchased over the Internet. It has no known medical or industrial use.
Q2. How did bromo-DragonFLY get its name?
It is a phenethylamine derivative that resembles a dragonfly:
Q3. What is known about the pharmacological action of Bromo-DragonFLY?
BDF has a high affinity for 5-HT2A serotonin receptors (typical of phenylethylamines) and is an alpha-1 agonist.
Q4. What are the clinical effects of Bromo-DragonFLY?
- potent hallucinogen
- intense peripheral vasoconstriction and hypertension
- limb ischemia
- probably can cause coronary vasospasm
- other ischemic multi-organ effects (e.g. ischemic hepatopathy)
Tachycardia, agitation and seizures may occur
BDF toxicity can be devastating and fatal.
Q5. What is the time course of the clinical effects of Bromo-DragonFLY?
The clinical manifestations of BDF generally have:
- a delayed onset to peak effect (up to six hours)
- prolonged duration (up to several days)
“It was like being dragged to hell and back again. Many times. It is the most evil [thing] I’ve ever tried. It lasted an eternity”
— quote from from a Danish user of Bromo-DragonFLY (source: Wikipedia)
Q1. What are some of the street names of mephedrone?
This drug has only been on the scene in the UK (where it is already banned) and the States over the past 3 or so years. Street names include Meow, Drone, Bubble, M-Cat, and Milton Keynes (when combined with ketamine).
Q2. What is known about the clinical pharmacology of mephedrone?
Mephedrone , or 4-methylmethcathinone, has a structure similar to cathinone (Khat) and appears to be a potent sympathomimetic agent. Mephedrone has a short half life ( 30-90 min) with effects typically lasting 2-4 hours.
Q3. How is mephedrone usually administered?
Mephedrone usually comes as a clear white powder hence the incorporation into ‘bath salts’. It is also found as crystals, capsules and pills. The powder form is usually mixed with water and swallowed (bombed) but can be sniffed/snorted or taken intravenously.
Q4. What are the clinical effects of mephedrone?
- intense peripheral vasoconstriction
- palpitations, diaphoresis, tachycardia, hypertension, pupillary dilatation
- anxiety, panic attacks, and paranoia
- severe hallucinations with heavy use
The expected complications and management of mephredrone toxicity are similar to that of amphetamine toxicity, as described here.
Q1. What are the street names for Nexus/ 2C-B?
Nexus also goes by the names of Bees, Venus, Erox, Performax, Toonies, and Bromo mescaline to name a few.
Q2. How is Nexus/ 2C-B usually administered?
It is typically supplied as a white powder or a tablet, and is usually ingested or snorted.
Q3. What is known about the pharmacological action of Nexus/ 2C-B?
Like BDF, Nexus is a synthetic phenylethylamine. It is an agonist at alpha-1 adrenergic receptors and 5-HT2 serotonergic receptors.
Q4. What are the clinical features of Nexus/ 2C-B intoxication?
- intense nasal pain (<30 min duration) following snorting
- CNS effects (probably predominantly due to 5HT2 agonism):
euphoria, increased visual and tactile sensations, relaxation, synesthesia, and hallucinations
- potential for alpha-1 mediated vascoconstriction and ischemia
(persistent neurological deficits attributed to cerebral ischemia have been reported)
Q5. What is the time course of the clinical effects of Nexus/ 2C-B?
Time course of the clinical effects of Nexus:
- Onset 30 to 90 min after ingestion
- Duration of effect 4-8 hours
Q1. How was K2/Spice created?
K2/Spice is a cannabinoid analogue originally used in research to investigate different types of cannabinoid receptors (CB1R in the CNS mediates psychotrpoic effects and CB2R modulates immune cell function). The agent was subsequently synthesised by ‘street chemists’ and added to herbal mixtures and tobacco.
Q2. What are the clinical effects of K2/Spice?
Little is known, though it may have stronger psychotropic effects than marijuana.
Q1. What is Salvia?
Salvia divinorum is a perennial plant in the mint family. Historically it was used by the Mazatec Indians of Mexico in shamanistic rituals for its hallucinogenic properties.
Q2. What is Salvia’s active ingredient and what is its mechanism of action?
The active ingredient is salvinorin A.
Salvinorin A selectively stimulates kappa opioid receptors in the brain and spinal cord, and can be blocked by naloxone. Thus Salvinorin A is has a mechanism of action unlike most hallucinogens, which are typically 5HT2A receptor agonists.
Q3. What are the clinical effects of Salvia?
- Vivid hallucinations that may last ~10 minutes when Salvia is smoked.
- Salvinorin A can also cause spinal anesthesia.
Thus far there have been no reports of significant toxicity.
Q1. What is naphyrone?
Naphyrone is a synthetic chemical derived from pyrovalerone. it’s arrival in the wake of the banning of mephredrone in the UK highlights the the growing public health problem of rapidly emerging legal highs in an age of internet marketing. Naphyrone is also known as NRG-1, however batch analysis of some NRG-1 samples highlights another problem with the the influx of new recreational agents: they may or may not contain the supposed active ingredient.
Q2. Describe the clinical pharmacology of naphyrone.
Naphyrone is a ‘triple uptake inhibitor’, it potently inhibits the reuptake of noradrenaline, dopamine and serotonin. The clinical effects are yet to be well characterized.
Q1. What is methoxetamine?
Methoxetamine is an analogue of ketamine and phenylcyclidine (PCP) that is typically sold as a ‘research chemical’.
It’s street names include: M-ket, Kmax, Mexxy and Special K (note: ketamine also appears under this street name)
Q2. Describe the clinical pharmacology of methoxetamine.
This isn’t well understood — the first laboratory confirmed case was published in January 2012 — but it likely has similar pharmodynamics to ketamine and PCP.
Compared to ketamine, methoxetamine appears to have a more delayed onset (up to 90 min) and longer duration of action (5-7 hours).
Q3. What are the clinical effects of methoxetamine?
The effects described are typical of the adverse effects of ketamine:
- tachycardia, hypertension, confusion, agitation, mydriasis
- an acute cerebellar syndrome, characterised by dysarthria, nystagmus, and ataxia, that can be severe and may even last days
- Withdrawal symptoms have also been described.
Methoxetamine is purported not to cause cystitis and bladder fibrosis, two well-known effects of chronic ketamine abuse.
References and Links
Social media and other web resources
Leon Gussow’s Emergency Medicine News articles (for all of Leon’s EMN toxicology articles click here)
Joe Lex’s Free Emergency Medicine Talks
The Poison Review
- Bath Salts
Bath salts: calls to poison centers in Louisiana and Kentucky
New England Journal of Medicine on “Bath Salts” New York Times on Bath Salts
NBC’s Dateline goes undercover to investigate the “bath salt” industry
“Bath salts” in Michigan Were “bath salts” involved in a double murder/suicide in Washington State?
Dr. Oz on bath salts (MDPV)
NBC’s Today Show reports on bath salts (MDPV)
Death in Britain: “Ivory Wave” (MDPV) or diabetic ketoacidosis
“Ivory Wave” identified as MDPV
It’s not your mom’s bath salts
Bromo-Dragonfly — not your father’s hallucinogen
Mephedrone (meow-meow): first confirmed case report
Mephedrone after the ban Woof-woof: the new meow-meow?
Confirmed mephedrone-associated fatality
How does the body handle mephedrone and other designer drugs?
Methoxetamine: a designer ketamine analogue
Acute cerebellar syndrome? Think methoxetamine
The chemistry of naphyrone
NRG-1? Buphedrone? Flephedrone? — What will follow meow-meow and where will it come from?
- New Recreational Drugs
Comprehensive review of new designer drugs
The science of designer drugs: essential review
“Party pills”: review of BZP and TFMPP
- Nexus/ 2-CB
Nexus (2C-B) associated with Significant Cerebral Vasospasm
Johns Hopkins team investigates effects of Salvia divinorum
Salvia divinorum and YouTube