Can conventional treatment handle Flakka?

Flakka roared into national consciousness three years ago when a man ate the face off of a homeless person on the street in Miami. After the man was shot by police, his behavior was blamed on bath salts. This created a media buzz at the time, but more recently, increasing Flakka use and its effects have led to even more of these bizarre reports.

Flakka is the latest incarnation of bath salts, which are cheap, easily obtained synthetic stimulants or “designer drugs.” Headlines are now declaring things like: “Naked Sniper Blames Flakka,” “Wild Man Kicks In Police Door,” or “Designer Drug Creates Zombies!” Some have stated that media reports about Flakka are exaggerated and hyped, but something must be going on that harkens to the days of acid trippers flying out of windows. What is Flakka, what are its real effects and dangers, and how do we treat addiction to it?

Jim Hall, an epidemiologist at Nova Southeastern University in Florida, says, “Flakka is a Spanish term referring to an elegant beautiful woman who charms all she meets,” but it does anything but charm. Flakka’s effects have led to nicknames such as “White Lightning of Magic” because its high lasts longer than crack, and it has a stimulant effect more potent than methamphetamine. These same effects at times can also lead to a frenzied delirium and psychotic paranoia; fantastical media reports have highlighted behavior by those intoxicated with it, who in fact resemble zombies.

Thousands of people are using Flakka, though, and they do not as a rule kick in the doors at police stations or get reported as committing other notorious acts. Still, on an individual basis, there is a characteristic “crazy” description of these users, and the rapid spread of its use is alarming. One treatment clinic in South Florida reports having seen about one Flakka patient per month in 2014, but about 40 to 50 per month this year. Flakka is also becoming increasingly prevalent in rural communities already hard hit by drugs in Kentucky, Tennessee and Ohio, and its use is spreading at an alarming rate throughout drug-using populations.

At their presentation, patients on Flakka can be more difficult to manage than the opiate-, alcohol- or cocaine-dependent person seen more commonly in the ER or at a treatment center. Intoxication with Flakka can lead to a “fight or flight” fueled aggression fed by scary delusions that are difficult for law enforcement and treatment centers alike. It can take anywhere from 3 to 30 days to detox from this substance, and there is no treatment known to speed up this process.

Flakka is the street name for alpha-pyrrolidinopentiophenone (alpha-PVP), a compound related to other cathinones or bath salts that can be taken orally, snorted, smoked, vaped or injected. It is a potent stimulus for the release of dopamine in the brain, even more so than cocaine and methamphetamine. This leads to its extremely addictive nature. A testament to its addictive nature is the fact that former users have reported effects so profound that they became afraid of the drug’s effects, yet they would still continue to use it. Some say they have sold their heroin or cocaine in order to buy Flakka.

Flakka also stimulates the release of serotonin similar to MDMA (Ecstasy) or LSD, resulting in its hallucinogenic effects. Norepinephrine release also occurs under the influence of Flakka, which results in a hyperdynamic state of arousal with increased blood pressure and heart rate. Hyperactivity of the cardiovascular and muscular systems can lead to elevated temperatures, toxin buildup (rhabdomyolysis) and kidney failure. Contributing to the systemwide deleterious effects of this drug is the fact that it is often seen alongside use of other substances. Use may be unintentional as drug dealers use cheaper Flakka to cut heroin, cocaine or marijuana. The drug can have the effect of amplifying any depression tendencies or conditions in a user, leading to dangerous acts or suicide.

Flakka users' medical presentation at treatment venues can vary depending on how long it has been used, the amount used, use with other substances, or time since last use. Acutely, a hyper-state of arousal with elevated vital signs is present. In the most severe situations, a medical emergency can present with extremely high body temperatures and other physiologic insults. This is not a common finding at presentation, but neither is it rare. More commonly, usual supportive treatment that is available in a treatment center setting will be sufficient. At times, the level of arousal combined with scary delusions will require sedation in a facility providing a level of care that supports this. Cognitive processes that may be described as schizoid can persist for several days, or longer in severe cases.

The overstimulation of several neurotransmitters during use of Flakka eventually leads to their depletion and withdrawal characterized by profound fatigue, anhedonia, lack of motivation and depression. Dopamine and serotonin depletion can persist for some time in the post-acute withdrawal period, requiring the proper treatment level and medical/medication support for persistent fatigue and depression. Stimulants should be avoided—they may provide apparent short-term benefit, but at a cost to long-term physiologic and addiction recovery. From a medical and a clinical perspective, these patients are different in some ways, but their needs in a treatment setting can be considered similar to those of a long-term methamphetamine addict.

Flakka costs just $5 per dose and can be purchased at gas stations and head shops. The Justice Department added Flakka to the list of illegal drugs in the U.S. last year, but it still can be ordered on the Internet in large quantities from China, Pakistan or India, and it shows up at the front door via mail-order delivery. It is sold on the Internet packaged as items such as jewelry cleaner, phone screen cleaner, or aquarium gravel. It often looks like a granular candy. This, combined with price and availability, makes youth particularly susceptible. The dance between the Drug Enforcement Administration (DEA) and these drug manufacturers and dealers continues to evolve, with the ever-vigilant manufacturers continually tweaking compounds and packaging just enough to stay a step ahead of authorities.

Flakka provides just what the health of our patients and this industry does not need: a cheap, highly addictive, risky drug that is easy to obtain. Despite the sensationalism of a few media cases, this addiction is usually treatable in any treatment facility following evidence-based standards with close medical support. But treatment of these patients can tax resources of a center, because of the “crazy” behavior that media outlets love to report.