New Drugs of Abuse in North America

An Update on the Implications of New Psychoactive Substances in Public Health

The emergence of new psychoactive substances has earned a great deal of attention, and several reports of acute poisoning and deaths have been issued involving, for instance, synthetic opiates. In recent years, there have been profound alterations in the legislation concerning consumption, marketing, and synthesis of these compounds; rapid alert systems have also been subject to changes, and new substances and new markets, mainly through the internet, have appeared. Their effects and how they originate in consumers are still mostly unknown, primarily in what concerns chronic toxicity. This review intends to provide a detailed description of these substances from the point of view of consumption, toxicokinetics, and health consequences, including case reports on intoxications in order to help researchers and public health agents working daily in this area.

Hallucinogenic mushroom misuse reported to Texas poison centers

BACKGROUND

Hallucinogenic mushrooms are fungi that contain the substance psilocybin. When ingested, psilocybin can induce hallucinations, euphoria, and alterations in the perception of space and time. Ingestion of hallucinogenic mushrooms may result in adverse effects.

OBJECTIVE

The objective of this study was to describe hallucinogenic mushroom misuse reported to poison centers.

METHODS

Cases were exposures to hallucinogenic mushrooms reported to Texas poison centers during 2000-2018 where the exposure reason was Intentional - Misuse or Intentional - Abuse (combined into the term "misuse" in the study). The distribution of the cases was determined for various factors related to patient demographics, exposure circumstances, management, and outcome.

RESULTS

Texas poison centers managed 486 hallucinogenic mushroom misuse exposures. Eighty-five percent of the patients were male; the mean age was 20.9 years (range 12-57 years). The exposure route was ingestion alone in 91% of the cases. Seventy-two percent of the exposures occurred at the patient's own residence. Seventy-one percent of the patients were already at or en route to a healthcare facility when the poison center was contacted, 22% were referred to a healthcare facility by the poison center, and 7% of the patients were managed on-site. The most frequent clinical effects were neurological (72%), cardiovascular (25%), and gastrointestinal (23%).

CONCLUSIONS

The majority of hallucinogenic mushroom misuse exposures involved adolescents or young adults and were male. Most of the exposures tended to be managed at a healthcare facility. The most common clinical effects tended to be neurological, cardiovascular, and gastrointestinal in nature.

High Seroprevalence of Autoantibodies Typical of Autoimmune Liver Disease in Eastern Ethiopia: Is Chewing of Khat (Catha edulis) a Triggering Factor?

BACKGROUND

Recent studies have identified chewing of khat (Catha edulis) as an independent risk factor for liver injury; however, the pathogenetic mechanism remains poorly understood. Case series have found markers of autoimmune hepatitis in patients with khat-related liver disease, suggesting that khat chewing might trigger an autoimmune response. The aims of the present study were (i) to assess the prevalence of autoantibodies typical for autoimmune liver diseases in a healthy population in Ethiopia and (ii) to explore the hypothesis that khat usage triggers autoimmunity.

METHODS

Consenting adults (≥18 years) without known autoimmune disease or manifest liver disease were included. One-hundred-and-sixty-nine individuals with current khat use were compared to 104 individuals who never used khat. Seroprevalence of antinuclear (ANA), antismooth muscle (SMA), and antimitochondrial antibodies (AMA) were determined and compared between the groups using logistic regression models to adjust for age and sex.

RESULTS

Overall, 2.6% of the study subjects were positive for ANA, 15.4% for SMA, and 25.6% for AMA. When comparing khat users to nonusers, ANA was detected in 4.1% vs. 0% (p=0.047), SMA in 16.0% vs. 14.4% (p=0.730), and AMA in 24.9% vs. 26.9% (p=0.704). ANA was excluded from multivariable analysis since there was no seropositive in the reference group. After adjusting for sex and age, no significant association between khat use and SMA or AMA was found.

CONCLUSIONS

No association between khat usage and the seropresence of SMA or AMA was found, weakening the hypothesis that khat-related liver injury is mediated through autoimmune mechanisms. However, the seroprevalences of AMA and SMA were strikingly high in this Ethiopian population compared to global estimates, suggesting that diagnostic algorithms for autoimmune liver diseases developed in Europe and North America might lead to misdiagnosis of patients on the African continent.

Benzylpiperazine: "A messy drug"

Designer drugs are synthetic structural analogues/congeners of controlled substances with slightly modified chemical structures intended to mimic the pharmacological effects of known drugs of abuse so as to evade drug classification. Benzylpiperazine (BZP), a piperazine derivative, elevates synaptic dopamine and serotonin levels producing stimulatory and hallucinogenic effects, respectively, similar to the well-known drug of abuse, methylenedioxymethamphetamine (MDMA). Furthermore, BZP augments the release of norepinephrine by inhibiting presynaptic autoreceptors, therefore, BZP is a "messy drug" due to its multifaceted regulation of synaptic monoamine neurotransmitters. Initially, pharmaceutical companies used BZP as a therapeutic drug for the treatment of various disease states, but due to its contraindications and abuse potential it was withdrawn from the market. BZP imparts predominately sympathomimetic effects accompanied by serious cardiovascular implications. Addictive properties of BZP include behavioral sensitization, cross sensitization, conditioned place preference and repeated self-administration. Additional testing of piperazine derived drugs is needed due to a scarcity of toxicological data and widely abuse worldwide.

Patterns and Perceptions of Dextromethorphan Use in Adult Members of an Online Dextromethorphan Community

Dextromethorphan (DXM) is a widely available antitussive that has, at elevated dose levels, euphoric and dissociative effects. This article presents the reported patterns and preferences of DXM use, and perceptions of DXM use among adult members of an online DXM community. Analyses were conducted of quantitative and qualitative responses from nine female and 43 male individuals, aged 18-63 years old. All respondents reported illegal and DXM drug use, beginning, on average, at 15.7 and 17.1 years of age, respectively. The majority of respondents first heard about DXM online or from a friend, preferred to use DXM alone, ingested substances concurrently with DXM to modify its effects, had not been to an emergency room or arrested because of their DXM use, and used DXM for its dissociative and mind-altering effects. DXM was perceived as safe and in no need of further regulation with only 14% of respondents mentioning DXM's addictive qualities. Findings from this sample of adult DXM users reveal a sophisticated subculture in which users report using DXM specifically to induce changes to their mental state and use a variety of substances to modify or enhance DXM's effects.

Mass Spectral and Chromatographic Studies on Some Halogenatedphenyl-2-Piperazinopropanones

Gas chromatography-mass spectrometry (GC-MS) studies on the halogenatedphenyl-2-piperazinopropanones (XPPPOs): Twelve XPPPOs were subdivided into four groups of compounds and studied using GC-MS. The four studied groups include the three ring-substituted fluorophenylpiperazinopropanones, chlorophenylpiperazinopropanones, bromophenylpiperazinopropanones and trifluoromethylphenylpiperazinopropanones. The three compounds in each group have equal mass and many common mass spectral fragment ions. Perfluoroacylation of the secondary amine nitrogen of these isomeric piperazines gave mass spectra with differences in relative abundance of some fragment ions but acylation did not alter the fragmentation pathway and did not provide additional MS fragments of discrimination among these isomers. The perfluoroacyl derivatives of these piperazines were resolved on a stationary phase of 100% trifluoropropyl methyl polysiloxane (Rtx-200).

GC-MS and IR studies on the six ring regioisomeric dimethoxyphenylpiperazines (DOMePPs)

A number of N-substituted piperazines have been described as drugs of abuse in recent years. This new drug category includes several series of aromatic ring substituted phenylpiperazines. The wide variety of available precursors makes regioisomerism a significant issue in these totally synthetic compounds. In this study, a complete series of regioisomeric dimethoxyphenylpiperazines were synthesized and evaluated using GC-MS and FT-IR. The EI mass spectra show fragments characteristic of both the dimethoxyphenyl and the piperazine portions of the molecules including the dimethoxyphenylaziridinium cation (m/z 180) and dimethoxyphenyl cation (m/z 137). The ion at m/z 56 for the C3H6N(+) fragment is characteristic of the piperazine ring and was observed in all the spectra. The perfluoroacyl derivatives were resolved by GC, and their mass spectra showed some differences in relative abundance of ions. FTIR provides direct confirmatory data for differentiation between the regioisomeric dimethoxyphenylpiperazines, and GC separation was accomplished on an Rtx-200 phase.

Regioisomeric bromodimethoxy benzyl piperazines related to the designer substance 4-bromo-2,5-dimethoxybenzylpiperazine: GC-MS and FTIR analysis

A series of seven regioisomeric bromodimethoxy benzyl piperazines including the designer benzylpiperazine (4-bromo-2,5-dimethoxybenzylpiperazine) were synthesized and their analytical profiles evaluated using GC-MS and FT-IR. The mass spectra for the seven regioisomeric bromodimethoxy benzyl piperazines are almost identical with only the two 2,3-dimethoxy isomers showing one unique major fragment ion at m/z 214/216. Thus, mass spectrometry alone does not provide for the confirmation of identity of any one of the seven compounds to the exclusion of the other isomers. Perfluoroacylation of the secondary amine nitrogen for each of the seven regioisomers gave mass spectra showing some differences in the relative abundance of fragment ions without the appearance of any unique fragments for specific confirmation of structure. Attenuated total reflection infrared spectroscopy provides direct confirmatory data for differentiation between the seven regioisomeric aromatic ring substituted bromodimethoxy benzyl piperazines. Mixtures of the seven piperazine PFP derivatives were successfully resolved via capillary gas chromatography using a relatively polar stationary phase composed of 100% trifluoropropyl methyl polysiloxane.

"Not for human consumption": a review of emerging designer drugs

Synthetic, or "designer" drugs, are created by manipulating the chemical structures of other psychoactive drugs so that the resulting product is structurally similar but not identical to illegal psychoactive drugs. Originally developed in the 1960s as a way to evade existing drug laws, the use of designer drugs has increased dramatically over the past few years. These drugs are deceptively packaged as "research chemicals," "incense," "bath salts," or "plant food," among other names, with labels that may contain warnings such as "not for human consumption" or "not for sale to minors." The clinical effects of most new designer drugs can be described as either hallucinogenic, stimulant, or opioid-like. They may also have a combination of these effects due to designer side-chain substitutions. The easy accessibility and rapid emergence of new designer drugs have created challenges for health care providers when treating patients presenting with acute toxicity from these substances, many of which can produce significant and/or life-threatening adverse effects. Moreover, the health care provider has no way to verify the contents and/or potency of the agent ingested because it can vary between packages and distributors. Therefore, a thorough knowledge of the available designer drugs, common signs and symptoms of toxicity associated with these agents, and potential effective treatment modalities are essential to appropriately manage these patients.

Differentiation of the 1-(methylenedioxyphenyl)-2-piperazinopropanes and 1-(methoxyphenyl)-2-piperazinopropanones by GC-IRD and GC-MS

Two amphetamine-like piperazine-containing compounds, 1-(3,4-methylenedioxyphenyl)-2-piperazinopropane (3,4-MDPPP), its positional isomer 1-(2,3-methylenedioxyphenyl)-2-piperazinopropane (2,3-MDPPP) and three methcathinone-like piperazine-containing regioisomeric ring substituted 1-(methoxyphenyl)-2-piperazinopropanones (OMePPPOs) have identical elemental composition and no marked differences in their mass spectra. Perfluoroacylation of the secondary amine nitrogen of these isomeric piperazines gave mass spectra with differences in the relative abundance of some fragment ions but did not alter the fragmentation pathway to provide unique ions for discrimination among these isomers. Gas chromatography coupled to infrared detection (GC-IRD) provides direct confirmatory data for the identification of the carbonyl containing compounds and the differentiation of the 3,4-MDPPP from its direct (2,3-MDPPP) and indirect (OMePPPOs) regioisomers. The vapor phase infrared spectra provide for specific confirmation of each of the isomeric piperazines. The perfluoroacyl derivative forms of the five piperazines involved in this study were resolved on two stationary phases, the first is composed of 100% dimethyl polysiloxane (Rtx-1) and the second of 5% diphenyl and 95% dimethyl polysiloxane (Rtx-5).

Gas chromatography/mass spectrometry analysis of the six-ring regioisomeric dimethoxybenzyl-N-methylpiperazines (DMBMPs)

RATIONALE

Piperazine-based designer drugs represent a novel class of substances found in illicit drug samples in the US and abroad. The clandestine production of these substances often makes use of piperazine as a key commercially available precursor substance. The commercial availability of 1-methylpiperazine suggests additional designer modification based on this additional precursor material.

METHODS

This study focuses on the electron ionization mass spectrometric (EI-MS) fragmentation of the dimethoxybenzyl-N-methylpiperazines as potential designer modifications of the general benzylpiperazine drug skeleton and explores the gas chromatography (GC)/MS properties of all six of these regioisomeric substances.

RESULTS

Fragmentation of the bond between the benzylic carbon and the adjacent piperazine nitrogen provides the base peak in all six spectra. The internal fragmentation within the piperazine ring produces a number of unique ions in the mass spectra of these dimethoxybenzyl-N-methylpiperazines. The migration of methyl groups from nitrogen and oxygen were confirmed by deuterium-labeling experiments.

CONCLUSIONS

The six regioisomeric dimethoxybenzyl-N-methylpiperazines yield equivalent fragment ions and deuterium labeling confirmed the elemental composition of the characteristic fragments in their mass spectra. Mixtures of the dimethoxybenzyl-N-methylpiperazines were successfully resolved via capillary gas chromatography using a relatively polar stationary phase and temperature-programming conditions. Copyright © 2013 John Wiley & Sons, Ltd.

Study on action mechanism of 1-(4-methoxy-2-methylphenyl)piperazine (MMPP) in acquisition, formation, and consolidation of memory in mice

In the present study, the mechanism of action of MMPP (1-(4-methoxy-2-methylphenyl) piperazine) in the acquisition (pretraining administration), formation (posttraining administration), and consolidation (pretest administration) of memory was assessed in the passive avoidance test using a short- and long-term memory protocol in mice. MMPP modified avoidance in the acquisition and formation of memory protocols but not in the consolidation protocol. Scopolamine (0.1 mg/kg i.p.), dizocilpine (0.003 mg/kg i.p.), and buspirone (0.1 mg/kg i.p.) completely inhibited MMPP-induced effects on memory acquisition and partially inhibited memory formation in the short-term but not long-term paradigm. This suggested that cholinergic, N-methyl-D-aspartate (NMDA) and 5-hydroxytryptamine-1A (5-HT1A ) receptors were implicated in the MMPP-induced improvements in memory. The sedative, anxiolytic, motor impairment, myorelaxant, and anticonvulsive (pentylenetetrazole-induced seizures) properties of MMPP were also assessed with the compound only showing a nondose-dependent myorelaxation. These results suggest that MMPP can enhance acquisition and formation, but not consolidation, of memory in short-term and long-term protocol via cholinergic, NMDA-glutamatergic, and 5-HT1A receptors.

2C or not 2C: phenethylamine designer drug review

New groups of synthetic "designer drugs" have increased in popularity over the past several years. These products mimic the euphoric effects of other well-known illicit drugs but are advertised as "legal" highs and are sold over the internet, at raves and night clubs, and in head shops. The 2C series drugs are ring-substituted phenethylamines that belong to a group of designer agents similar in structure to 3,4-methylenedioxy-N-methylamphetamine (MDMA, Ecstasy). Understanding the pharmacology and toxicology of these agents is essential in order to provide the best medical care for these patients. This review focuses on the pharmacology, pharmacokinetics, clinical effects, and treatment of 2C drug intoxication based on available published literature. Multiple names under which 2C drugs are sold were identified and tabulated. Common features identified in patients intoxicated with 2Cs included hallucinations, agitation, aggression, violence, dysphoria, hypertension, tachycardia, seizures, and hyperthermia. Patients may exhibit sympathomimetic symptoms or symptoms consistent with serotonin toxicity, but an excited delirium presentation seems to be consistent amongst deaths attributed to 2C drugs; at least five deaths have been reported in the literature in patients intoxicated with 2C drugs. 2C drugs are a group of designer intoxicants, many of which are marketed as legal, but may carry risks that consumers are unaware of. These drugs may be characterized by either serotonergic toxicity or a sympathomimetic toxidrome, but a presentation consistent with excited delirium is consistent amongst the reported 2C-related deaths. Treatment of 2C intoxication is primarily supportive, but immediate action is required in the context of excited delirium, hyperthermia, and seizure activity.

High rates of midazolam injection and associated harms in Bangkok, Thailand

AIMS

To identify the prevalence and correlates of midazolam injection among injecting drug users in Thailand.

DESIGN

Serial cross-sectional mixed-methods study.

SETTING

Bangkok, Thailand.

PARTICIPANTS

  A total of 435 adults who had injected drug(s) in the past 6 months were recruited through peer outreach and word of mouth in Bangkok in 2011.

MEASUREMENTS

Multivariable logistic regression was used to analyze self-reported data collected through an interviewer-administered survey in July-October 2011 (n = 435). Additionally, qualitative data were collected in June-July 2009 (n = 10) and analyzed to explore the health problems attributable to midazolam injection.

FINDINGS

Among 435 survey participants, the prevalence of daily midazolam injection in the past 6 months was 37.0% (95% confidence interval: 32-42). While 75.8% of the daily midazolam injectors identified heroin as their drug of choice, 91.8% of these individuals reported substituting heroin with midazolam when heroin was unavailable. In multivariable analyses, daily midazolam injection was associated with femoral vein injection [adjusted odds ratio (AOR) = 4.48], polydrug use (AOR = 4.94), daily heroin injection (AOR = 3.25), binge use (AOR = 1.75) and perceived increase in policing pressure (AOR = 1.95) (all P < 0.05). Qualitative accounts indicated severe health problems associated with midazolam injection, including nerve and vascular injuries.

CONCLUSION

Midazolam misuse is increasing among injecting drug users in Bangkok and appears to be used primarily as a substitute for heroin. Midazolam injection was associated independently with various risk factors for injection-related complications. Given the many deleterious effects of midazolam injection, novel interventions for midazolam injectors are needed urgently.

Piperazine compounds as drugs of abuse

Synthetic drugs are among the most commonly abused drugs in the world. This abuse is widespread among young people, especially in the dance club and rave scenes. Over the last several years, piperazine derived drugs have appeared, mainly available via the internet, and sold as ecstasy pills or under the names of "Frenzy", "Bliss", "Charge", "Herbal ecstasy", "A2", "Legal X" and "Legal E". Although in the market piperazine designer drugs have the reputation of being safe, several experimental and epidemiological studies indicate risks for humans. Piperazine designer drugs can be divided into two classes, the benzylpiperazines such as N-benzylpiperazine (BZP) and its methylenedioxy analogue 1-(3,4-methylenedioxybenzyl)piperazine (MDBP), and the phenylpiperazines such as 1-(3-chlorophenyl)piperazine (mCPP), 1-(3-trifluoromethylphenyl)piperazine (TFMPP), and 1-(4-methoxyphenyl)piperazine (MeOPP). Toxicokinetic properties, including metabolic pathways, actions and effects in animals and humans, with some hypothesis of mechanism of action, and analytical approaches for the identification of these drugs are summarized in this review.

Differentiation of methylenedioxybenzylpiperazines and ethoxybenzylpiperazines by GC-IRD and GC-MS

The substituted benzylpiperazines, 3,4-methylenedioxybenzylpiperazine, its regioisomer 2,3-methylenedioxybenzylpiperazine and three isobaric ring substituted ethoxybenzylpiperazines have equal mass and many common mass spectral fragment ions. The mass spectra of the three ethoxybenzylpiperazines yield a unique fragment at m/z 107 that allows the discrimination of the three ring substituted ethoxybenzylpiperazines from the two methylenedioxy isomers. Perfluoroacylation of the secondary amine nitrogen of these isomeric piperazines gave mass spectra with differences in relative abundance of some fragment ions, but acylation does not alter the fragmentation pathway and did not provide additional MS fragments of discrimination among these isomers. Gas chromatography coupled with infrared detection provides direct confirmatory data for the structural differentiation between the five isomers. The mass spectra in combination with the vapor phase infrared spectra provide for specific confirmation of each of the isomeric piperazines. The perfluoroacyl derivatives of the ring substituted benzylpiperazines were resolved on a stationary phase of 50% phenyl and 50% methylpolysiloxane. Gas chromatography coupled with time-of-flight mass spectrometric detection provides an additional means of differentiating between the isobaric compounds 3,4-methylenedioxybenzylpiperazine and 4-ethoxybenzylpiperazine, which have similar nominal masses but are different in their calculated exact masses.

Field testing of collection cards for Cannabis sativa samples with a single hexanucleotide DNA marker

The validity and feasibility of using DNA collection cards in the field for preservation and analysis of Cannabis sativa genotypes were investigated using a highly specific hexanucleotide marker. Collection cards were submitted to the National Marijuana Initiative, which selectively trained and managed the collection of specific types of samples from a variety of participating agencies. Samples collected at seizure sites included fresh marijuana leaf samples, dried "dispensary" samples, U.S. border seizures, and hashish. Using a standardized PCR kit with custom-labeled oligonucleotide primers specific to marijuana, collection cards produced eight genotypes and 13 different alleles, extremely low baselines, and no cross-reactivity with control plant species. Results were produced from all sample types with the exception of hashish. Plant DNA collection cards represent an easily implementable method for the genetic identification and relatedness of C. sativa street and grow site-seized samples with applications for databasing and market disruption.

Drug abuse in plastic surgery patients: optimizing detection and minimizing complications

Drugs of abuse present numerous challenges to plastic surgeons, and detection remains difficult. With rates of drug abuse and misuse on the rise, clinicians must remain especially attentive to drug abusers' verbal and nonverbal cues, and be familiar with treating perioperative complications if they arise. Informed deductions regarding drug abuse can enable a plastic surgeon to identify drug abuse, minimize complications, and optimize patient care.

Transdermal patch medication delivery systems and pediatric poisonings, 2002-2006

Transdermal drug delivery systems are an increasingly popular method of medication delivery containing large quantities of medication and presenting new opportunities for toxicity. To provide a description of exposures to transdermal medications in a pediatric population, we studied exposures in individuals less than 12 years of age. This is a retrospective database study in which the Texas Poison Center Network database from 2002 to 2006 was reviewed. In all, 336 poison control center records of patch exposures over the 5-year period were identified. Of those, 110 cases involved children less than 12 years old. A majority of cases resulted in no significant clinical effects. One death resulted from opioid toxicity. Although a majority of patch exposures in children less than 12 years of age resulted in no significant clinical toxicity, practitioners and the public must be made aware of the available patch-based medications and their potential for toxicity in children.

Antibody-catalyzed anaerobic destruction of methamphetamine

Methamphetamine [(+)-2] abuse has emerged as a fast-rising global epidemic, with immunopharmacotherapeutic approaches being sought for its treatment. Herein, we report the generation and characterization of a monoclonal antibody, YX1-40H10, that catalyzes the photooxidation of (+)-2 into the nonpsychoactive compound benzaldehyde (14) under anaerobic conditions in the presence of riboflavin (6). Studies have revealed that the antibody facilitates the conversion of (+)-2 into 14 by binding the triplet photoexcited state of 6 in proximity to (+)-2. The antibody binds riboflavin (K(d) = 180 muM), although this was not programmed into hapten design, and the YX1-40H10-catalyzed reaction is inhibited by molecular oxygen via the presumed quenching of the photoexcited triplet state of 6. Given that this reaction is another highlight in the processing of reactive intermediates by antibodies, we speculate that this process may have future significance in vivo with programmed immunoglobulins that use flavins as cofactors to destroy selectable molecular targets under hypoxic or even anoxic conditions.