WCSAD | Synthetic Drugs an Elusive, Evolving Threat

With synthetic drugs being developed at a rapid rate, more than 300 new drugs have been identified in the US over the past 10 years, Andrew Kurtz, LMFT, clinical specialist, UCLA Integrated Substance Abuse Programs, told West Coast Symposium on Addictive Disorders attendees in a session presented Saturday.

But the availability of reference materials on synthetics has increased, there are continual evaluations of new drugs and drug classes, and there is early and frequent communication at the federal level regarding emerging drug threats and trends.

“While it’s difficult to narrow these down, stay up to date on them as much as you can,” Kurtz recommended. “Talk to your clients about them. They are often a great resource. And when in doubt, try to keep that person in treatment and engaged, and provide support as best you can.”

Kurtz discussed types of synthetic drugs available, as well as trends around the use of synthetics in the US. Synthetics are intended to mimic naturally occurring substances and circumvent laws and regulations around distribution of those substances or create a more pronounced effect of substance, Kurtz explained. The first generation of synthetic cannabinoids and cathinones emerged in 2008, and in the ensuing years, other synthetic drugs such as fentanyl, designer benzodiazepines and novel opioids followed, as did later generations of synthetic cannabinoids.

“You start to see this evolution rapidly where we move from one type of substance to the next evolution of that substance within a few years, if not a few months,” Kurtz said. “It happens fairly rapidly. As chemists and facilities become more proficient in how they produce these substances, we’ll start to see more of these generations.”

There are misconceptions about where synthetic opioids are being developed and produced. While some come from illicit markets and facilities, others are developed in legitimate manufacturing centers that are producing pharmaceuticals and academic settings for the purposes of research.

“It’s not somebody in a meth lab in their kitchen in the woods putting together this leap from one generation to the next,” Kurtz said. “Oftentimes, it’s done in a more professional, controlled setting, but it doesn’t always stay in that setting.”

Many synthetic drugs are known by colloquial terms, such as “spice,” “bath salts,” or “plant food,” but they do not have the same chemical properties as the household products of the same names.

“Even though they are referred to similarly, the bath salts we’re talking about that are synthetic cathinones are not going to do a whole lot if you put them in your bathtub,” Kurtz clarified.

Bath salts can refer to synthetic cathinones (most common), 2C-phenethylamines, tryptamines, and piperazines. They are designed to mimic amphetamines and other stimulants, or psychedelics.

Now on their eighth generation, synthetic cannabinoids are different from their natural counterpart. The cannabinoid-like effect produced by synthetic marijuana, for example, comes from a chemical additive sprayed onto a dried plant product, not the plant itself. The chemical spray, Kurtz noted, can be purchased wholesale online. Synthetic marijuana is mainly consumed by smoking and many of its active chemicals have been classified by DEA as Schedule I controlled substances. Packaging of these products often appeals to younger individuals.

Synthetic cannabinoids induce psychoactive effects, and because they are readily available in retail stores and online, many users mistakenly consider them safe. Another appealing aspect of synthetic cannabinoids for their users is that they are not as easily detected in urine and blood samples because such tests aren’t designed to detect synthetics’ chemical compounds.

Use of synthetic cannabinoids leads to dangerous symptoms in pregnant women, similar to those caused by preeclampsia and eclampsia. Preeclampsia is marked by high blood pressure and elevated levels of protein in urine. Preeclampsia can lead to eclampsia, which can cause a pregnant woman to develop seizures or coma.

Many symptoms of synthetic cannabinoid use are similar to cannabis intoxication, such as:

• Tachycardia
• Red eyes
• Anxiousness
• Mild sedation
• Hallucinations
• Acute psychosis
• Memory deficits

Synthetic cannabinoid use symptoms not seen after cannabis intoxication, however, include:

• Seizures
• Hypokalemia
• Hypertension
• Nausea/vomiting
• Agitation
• Violent behavior
• Coma

Synthetic cathinones, meanwhile, are sold online with little information on ingredients or dosage. They are marketed as products such as glass cleaner or carpet cleaner that are not for human consumption, thus evading laws prohibiting sales or possession, Kurtz said. Synthetic cathinones can be taken orally or by inhaling. Their serious side effects include tachycardia, hypertension, confusion or psychosis, nausea, and convulsions.

Methamphetamine Trends

Reported use of methamphetamine has increased nationally every year since 2008, and methamphetamine use overtook cocaine use during the early months of the pandemic, Kurtz said. There are issues specifically related to methamphetamine and opioid co-ingestion, as the 2 substances taken together create a synergistic effect that increases the risk of overdose.

Kurtz recommended combining medication-assisted treatment for heroin addiction and contingency management for the treatment of meth addiction. Buprenorphine is preferred over methadone for such patients because meth and methadone have potent interactions in patients who relapse during treatment, Kurtz explained.

As methamphetamine use increases, the dramatic rise in synthetic opioid use since 2015 is alarming, Kurtz said. The percentage of opioid-related deaths involving stimulants is climbing, as is the number of stimulant-related deaths that involve opioids, particularly stimulant-involved deaths that also involve synthetic opioids.

Treatment Protocols

Users of synthetic cannabinoids should be directed to an emergency room via ambulance, and a poison control center should be contacted. Acute management of symptoms includes supportive care with the use of benzodiazepines to control agitation and anxiety. Patients should be observed until the resolution of abnormal vitals, vomiting, and psychiatric symptoms.

Patients using synthetic cathinones may present a profoundly altered mental status, including severe panic attacks, agitation, paranoia, hallucinations, and suicidal behavior. Such patients require supportive care, which includes aggressive sedation with benzodiazepines. Significant hyperthermia may require active or passive cooling. Lab studies including electrolytes, renal and liver function tests, cardiac markers, and creatine kinase also should be considered.

“There aren’t a ton of treatments available for these novel substances,” Kurtz said. “We know we can generalize some medications to manage symptoms and talk about behavioral interventions, but not a lot of that has been studied or validated. So, triaging, stabilizing the person, and engaging them in care are some of the best recommendations we have at this time. A little education could be important, too.”

Reference

Kurtz A. What providers need to know about synthetic drugs. Presented at: West Coast Symposium on Addictive Disorders; September 29-October 3, 2021; Virtual.