Children’s Hospital of Michigan Regional Poison Control Center

Children’s Hospital of Michigan

Regional Poison Control Center

The principal pre-hospital concerns with these agents are:

1. 
   Airway- anticipate vomiting before and during transport
   
2. 
   Respiratory depression/coma
   
3. 
   Hyperthermia/heatstroke- initiate cooling as soon as possible
   
4. 
   Dehydration/electrolyte abnormalities
   
5. 
   Behavioral changes leading to trauma, sexual assault, etc.
   

Transport to the hospital should be considered in those with:

1. 
   Tachycardia
   
2. 
   Hypotension or hypertension
   
3. 
   Hyperthermia
   
4. 
   CNS depression
   
5. 
   Delirium, agitation or seizures
   
6. 
   Persistent hallucinations
   
7. 
   Vomiting
   

Herbal blends containing cannabinoid receptor agonists are becoming popular. They are sold over the Internet and in community “head shops”. Trade names include “Spice silver”, “Spice Gold”, “Spice Diamond”, “Spice Arctic Synergy”, “Spice Tropical Synergy”, “Spice Egypt”, “Smoke”, “Sence”, “Skunk”, “Yucatan Fire”, “Genie”, “ChillX”, “Highdi’s Almdrohner”, “Earth Impact”, “Gorillaz”, “Galaxy Gold”, “Space Truckin”, “Solar Flare”, “Moon Rocks”, “Blue Lotus”, “Aroma”, “Scope”, and “Serenity Now”. Labeled ingredients include blends of herbs designed to cause relaxation, such as Leonotis leonurus (Wild dagga), Pedicularis densiflor (Indian warrior), or Nymphaea nouchali var caerulea (Blue Lotus).

• 
  Some or all of these homologs are also sold as pure powders to sprinkle on tobacco or other plants, such as parsley.
  
• 
  Presentation: after smoking 300 mg of an herbal blend, clinical effects include red conjunctiva, tachycardia, dry mouth, and altered mood and perception. The effects persisted for six hours, with mild after-effects the following day.
  
• 
  Toxicity: symptoms included agitation, confusion, hallucinations, dizziness, severe tachycardia, hypertonia, dyspnea, vomiting, panic, and ECG changes.
  
• 
  Withdrawal: symptoms include diaphoresis, tremor, palpitations, insomnia, headache, diarrhea, nausea, and vomiting
  
• 
  Laboratory: an advantage to the user is the complete lack of cross-reactivity between these entirely synthetic compounds and urine immunoassays for THC (marijuana metabolites). This is true of all of these designer cannabinoids.
  
• 
  Treatment
  

-Anticipate vomiting

-Benzodiazepines for panic reactions or severe agitation

II. Herbal Products Containing Other Research Chemicals

Beyond cannabinoids, some herbal mixtures can contain other "research chemicals". A recent tact is to sell them as fertilizer powders. None of these chemicals are listed in the controlled substance act in the United States. These chemicals usually increase the brain neurotransmitter serotonin, but can also affect dopamine or norephinephrine.

• 
  Slang terms include:
  
  • 
    "meow-meow", "bounce", "bubble", "bubble love", "plant food", "drone", "MCAT", "miaow miaow", and "Neo Doves" = [mephedrone (4-methylmethcathinone)]
    
  • 
    “sonic” = [methylenedioxypyrovalerone (MDPV)]
    
  • 
    (MPBP)[40394]
    
  • 
    “woof-woof” = 5,6-Methylenedioxy-2-aminoindane (MDAI)
    
  • 
    “rave”, “NRG-1” = [naphyrone (Naphthylpyrovalerone)]
    

• 
  Presentation: after smoking, signs and symptoms suggest serotonin excess (hyperreflexia/clonus) or norepinephrine excess (seizures) and should prompt consideration of one of these substances rather than the cannabinoids.
  
• 
  Some, like sonic have a prolonged duration of 3-8 hours
  
• 
  Treatment
  

-Anticipate vomiting

-Benzodiazepines for agitation/seizures/rigidity

-Monitor for hyperthermia/rhabodmyolysis

-Consider intracranial bleed or electrolyte disturbance if mental status if seizures occur or mental status is depressed
III. Fentanyl: Schedule II and clandestine manufacture

Fentanyl, an analgesic with a potency of about 80 times that of morphine available under the trade names of Sublimaze®, Duragesic® (transdermal patch), and Actiq® (a lollipop). Related drugs include alfentanil (Alfenta®), an ultra-short acting analgesic, and sufentanil (Sufenta®), an exceptionally potent analgesic, 5 to 10 times more potent than fentanyl. Carfentanil (Wildnil®) is an analogue of fentanyl with an analgesic potency 10,000 times that of morphine and is used in veterinary practice to immobilize certain large animals. Over 12 different analogues of fentanyl have been produced in clandestine laboratories in the US.

• 
  The presentation of fentanyl overdose is indistinguishable from that of heroin overdose except for much greater potency
  
• 
  The classic triad of CNS depression, respiratory depression and miosis is typical
  
• 
  The onset of action is 5-15 minutes chewed; duration 1-2 hours
  

• 
  Laboratory:
  

• 
  Treatment:
  

-may require larger than usual doses of naloxone; up to 10 mg

• 
  Slang: GHB, GBH, Grievous Bodily Harm, Easy Lay, Georgia Home Boy, Liquid Ecstasy, Liquid X, Liquid E, Soap, Scoop, Salty water, G-Riffick, Cherry Meth, Organic Quaalude, Natural Sleep-500, Oxy-Sleep, Somatomax, Somsanit, Gamma OH, Gamma hydrate, 4-hydroxybutyrate, Alcover, Anetamin, and Zonked, GHB+ketamine+alcohol = Special K-lude
  

• 
  Likely to be sold as a clear solution in small shampoo/hand lotion/mouth wash bottles (typically one ounce) or carried in mineral water bottles
  

• 
  Taste is described as salty or soapy
  

• 
  Very short half life
  

• 
  Symptoms begin within 15 minutes of ingestion
  

-Dizziness, lightheadedness, “high feeling”, hallucinations, confusion, ataxia, loss of peripheral vision

-Nausea & vomiting, possibly excessive salivation

-Abrupt unconsciousness with intermittent respiratory depression and apnea

-Random clonic movements of face and extremities

-Pupils may be constricted or dilated, hypothermia or bradycardia are seen with severe cases

• 
  Laboratory: GHB levels will not be useful in OD setting. Drug screens may reveal co-ingestants. Contact the Poison Center for laboratories that will analyze GHB in cases of date rape or sexual assault.
  

• 
  Treatment:
  

-Anticipate vomiting

-Naloxone, thiamine, glucose

-Flumazenil does not effectively reverse effects from GHB

-No need for GI decontamination

-Atropine for bradycardia, only if hemodynamically significant

-Very cautious administration of benzodiazepines for severe agitation or seizure-like activity (be prepared to intubate if benzodiazepines are given)

-Current evidence does not support the use of physostigmine

• 
  GBL (gammabutyrolactone). Slang and trade names: Renewtrient, Regenerize, Invigorate, Revivarant G, Blue Nitro, Blue Nitro Vitality, GH Revitalizer, Gamma G, Remforce, Firewater, ReActive, Rest-Eze, Beta-Tech, Thunder, Jolt, Verve.
  
• 
  Recently being sold as CleanStar 24” Wheel Cleaner
  
• 
  BD (1,4-butanediol). Slang terms and trade names: Pine Needle Oil, Natural Borametz Extract, Biocopia, Zen, Serenity, SomatoPro, Inner G, NRG3, Enliven, Growth Hormone Release Extract, Thunder Nectar, Weight Belt Cleaner, Rest-Q, X-12, Dormir, Amino Flex, Orange fX, Rush, Lemon fX Drop, Cherry fX Bomb, Promusol, BVM.
  

Clinically, the presentation and management are identical to GHB.

1. 
   MDMA (methylenedioxymethamphetamine):
   

combined with LSD= "rolling and trolling"

combined with heroin = "rolling"

combined with Viagra = "hammerhead"

combined with Methamphetamine = “MethX”

2. 
   PMA (paramethoxyamphetamine):
   

possibly more potent than MDMA

delayed onset of action relative to MDMA (90 minutes)

3. 
   Methamphetamine:
   

D. “Smurfing” = going to various pharmacies to gather pseudoephedrine

E. Others: MDEA, MDA, PMMA

• 
  These agents are both stimulants (enables users to dance for extended periods) and entactogens (promotes empathy, removes fear)
  
• 
  MDMA is generally taken orally as a white/off-white/tan tablet, debossed with one of many possible logos (four-leaf clover, the Mitsubishi logo, TNT, omega, bird, butterfly symbol to name only a few; numbers are generally absent from the tablets)
  
• 
  The typical dose is 75- 100 mg
  
• 
  Onset of action is 30 minutes; duration 3-6 hours
  
• 
  As the dose is escalated, dilated pupils, tachycardia, hypertension hallucinations, and hyperalertness develop
  
• 
  MDMA users may have uncontrollable bruxism and therefore place objects in their mouths such as glo-sticks or candy pacifiers
  
• 
  Stroking/caressing neighbors is common
  
• 
  The stimulant effect enable users to dance for long periods of time, rendering them susceptible to heat stroke and dehydration which may in turn lead to rhabdomyolysis, DIC and secondary liver and renal failure
  
• 
  Severe hyponatremia is not uncommon
  
• 
  Cardiovascular collapse, serotonin syndrome, seizures and intracranial bleed may occur
  

• 
  Laboratory:
  

• 
  Treatment:
  

-Aggressive cooling best performed with misting and evaporation (fans)

-Charcoal may be administered for recent ingestions (< 60 minutes)

-Control of agitation/seizures with benzodiazepines

-Rule out intracranial bleed in those with altered MS

-Anticipate rhabdomyolysis and treat accordingly

-Address fluid/electrolyte abnormalities (hyponatremia)
VII. Ketamine: Schedule III

This is an anesthetic agent (Ketalar® and other products) that is diverted from legitimate human or veterinary use. It is available as clear liquid that is usually dried and then sold in small ziploc bags, paper folds, foils, vials or capsules. The powder is then snorted, put into drinks, injected or smoked. (Slang: K, Special K, Green, Jet, Kay, Mauve, Purple, Special LA Coke, Super acid, Super C, Cat Valiums)

• 
  The onset of symptoms is 1-10 minutes after use. The effects last 2 to 3 hours.
  

• 
  Symptoms include
  

-Dose dependent respiratory depression

-Nystagmus

-Cataleptic state

-Hypertonicity, vocalizations, dystonic reactions

-Increased secretions/salivation

-State of dissociation: loss of awareness of environment

-Mellow, colorful hallucinations, sense of immobility and being transported through space = “K-land”

-Near-death experience, paralysis = “K-hole”

-Seizures, respiratory arrest, cardiac arrest following high doses

-Amnesia for 1-2 hours after use

• 
  Laboratory:
  

• 
  Treatment:
  

-Anticipate vomiting

-Benzodiazepines for panic reactions or severe agitation

-Diphenhydramine has reversed dystonia

-No role for GI decontamination

VIII. Dextromethorphan: non-scheduled

Coricidin HBP Cough & Cold™, skittles, blue velvet (combined with nitrous)]

• 
  Dosing: 300 mg to 900 mg (8 to 24 Coricidin tablets); half-life 2- 4 hours
  

• 
  Effects: LSD-like high, dissociation, hallucinations, vivid dreams, tachycardia, hypertension, vomiting, choreoathetosis
  

• 
  ? Synergistic with MDMA
  

• 
  Note: Coricidin HBP Cold & Flu™ contains acetaminophen and laboratory evaluation is required in the dosages used for abuse. In addition to DXM, both Coricidin formulations also contain chlorpheniramine and present with anticholinergic signs (agitation; tachycardia; hypertension; hyperthermia; dilated pupils; dry mouth, dry, warm, flushed skin; diminished bowel sounds; urinary retention)
  

• 
  Laboratory: DXM cross-reacts with phencyclidine (PCP) on some urine screens
  
• 
  Treatment:
  

Naloxone reversal of DXM effect is variable

Cooling and benzodiazepines for agitation related to chlorpheniramine
IX. Inhalants

1. 
   Nitrous Oxide:
   

• 
  Slang: Laughing gas, buzz bomb, shoot the breeze, N20, N0X
  

• 
  Nitrous oxide abuse poses unique hazard based on its ability sensitize the heart to the effects of catecholamines (adrenaline-like substances). Even first-time users may have sudden cardiac death.
  
• 
  Typically sold as balloons or as whippets
  

2. 
   Other Inhalants:
   
   1. 
      Dust Off and Axe Deodorant
      

• 
  Rapid CNS effects occur with use: initial disinhibition followed by inebriation, dizziness, vertigo, drowsiness or in severe cases, coma
  
• 
  Hypoxemia may result in uncontrolled twitching while unconscious, coined by users as “going fishing”
  
• 
  Ventricular dysrhythmias (classically while running) and respiratory depression may be seen
  
• 
  Treatment:
  

-100% oxygen

-Cardiac monitoring is important

-Keep victim calm

-Anticipate coma, seizures, dysrhythmias

-Avoid epinephrine or other sympathomimetics if possible, unless cardiac arrest

-Consider esmolol for tachydysrhythmias

X. Other Hallucinogens

1. 
   Tryptamines: Schedule I or non-scheduled
   

These are purchased on the Internet as “research chemicals”, with the exception of Foxy, which is Schedule I. The most common form is powder or homemade capsules, but tablets have been found. Slang terms are: Foxy, 5-MEO DIPT (5-methoxy diisopropyl tryptamine), AMT (alpha methyl tryptamine), and 5-MEO DMT (5-methoxy dimethyltryptamine).

• 
  These agents are stimulants with hallucinogenic properties
  
• 
  Foxy is generally taken orally as a powder-filled capsule or yellow, blue or tan round tablet debossed with one of many possible logos (alien, pacman, spider), typically containing 4 mg
  
• 
  Other tryptamines are generally in powder form
  
• 
  The typical dose is 10-20 mg
  
• 
  Onset of action is 30 minutes; duration 3-6 hours
  
• 
  As the dose is escalated, dilated pupils, tachycardia, hypertension hallucinations, and hyper-alertness develop
  
• 
  Foxy users may demonstrate catalepsy (limbs moved by the evaluator will stay in place) with temporary inability for voluntary movement
  
• 
  Stroking/caressing neighbors is common
  

• 
  Laboratory:
  

• 
  Treatment:
  

-Aggressive cooling best performed with misting and evaporation (fans)

-Charcoal may be administered for recent ingestions (< 60 minutes)

-Control of agitation/seizures with benzodiazepines

-Rule out intracranial bleed in those with altered MS

-Anticipate rhabdomyolysis and treat accordingly

• 
  These agents are stimulants with hallucinogenic properties
  
• 
  They may be used in combination with MDMA to prolong effects
  
• 
  Generally taken orally as a powder-filled capsule, but can be smoked or snorted. 2CI has been sold as a white 16 mg pill with imprint “I”
  
• 
  The typical dose is 10-60 mg
  
• 
  Onset of action is 30-60 minutes; duration 3-6 hours; can be > 16 hours
  
• 
  As the dose is escalated, dilated pupils, tachycardia, hypertension hallucinations, and hyper-alertness develop
  

• 
  Laboratory:
  

• 
  Treatment:
  

-Aggressive cooling best performed with misting and evaporation (fans)

-Charcoal may be administered for recent ingestions (< 60 minutes)

-Control of agitation/seizures with benzodiazepines

-Rule out intracranial bleed in those with altered MS

-Anticipate rhabdomyolysis and treat accordingly

• 
  Amphetamine-like stimulant
  
• 
  Combined with TMFPP (see below) as MDMA substitute
  

• 
  Recent DEA testing of over 1400 “ecstasy” tablets purchased in Detroit revealed no MDMA, but instead, BZP and TMFPP with caffeine
  

• 
  Most commonly, abusers present with hallucinations and signs of catecholamine excess (tachycardia, hypertension, dilated pupils, sweating)
  
• 
  Treatment is supportive (calm environment, reassurance)
  
• 
  Benzodiazepines may be used in the severely agitated patient
  
• 
  There is no role for GI decontamination with LSD (minute quantities are typically involved)
  
• 
  Charcoal may be administered for recent mescaline or mushroom ingestions
  

• 
  Often biphasic in presentation, with initial hallucinations, excitability, myoclonus, followed by CNS depression. May not have respiratory depression. Can be bradycardic with large doses.
  
• 
  Usually ingested as a cold tea
  
• 
  Onset of action is 30-90 minutes; peak 2-3 hours; duration 12 hours
  

• 
  Laboratory:
  

• 
  Treatment:
  

-benzodiazepines may be useful to control agitation and myoclonus

Slang:

• 
  2-mg white rectangle-shaped tablets: Xanax Bars, Coffins, French Fries, Totem Poles, Candy Bars, Yellow Ladders
  
• 
  1-mg lavender-colored tablets: Footballs or Blues
  
• 
  Xanax Blotter Paper (“xanax” inside a tablet shape repeatedly printed on the paper)
  

• 
  Abuse of Xanax (alprazolam) is on the rise in children and young adults, often in combination with alcohol or other depressants. Older adults use it as a “downer” after binging on cocaine or other stimulants. "Trinity" is the combination of Xanax (alprazolam), Vicodin (hydrocodone), and Soma (carisoprodol).
  
• 
  Xanax is ingested or crushed and snorted
  
• 
  Symptom onset is rapid. The half-life is approximately 12 hours.
  
• 
  Urine drug screens may not be positive for benzodiazepines given the low concentrations of the metabolite typically found in the urine
  
• 
  Treatment:
  

-Anticipate vomiting

-Naloxone, thiamine, glucose

-Avoid flumazenil given the potential for use in combination with other drugs