ADOLESCENT INGESTION OF ILLICIT OR LICIT DRUGS

Teri Moser Woo PhD, CNL, CPNP, ARNP, FAANP

DISCLOSURE

• Teri Moser Woo, PhD, RN, CNL, CPNP, ARNP, FAANP has no relevant financial relationships to disclose.

• James Hanley MD, FAAP contributed to the content of this presentation

OBJECTIVES

• Review current patterns of illicit and licit substance use and abuse among adolescents and young adults.

• Discuss common substances adolescents and college students are ingesting and using to become intoxicated.

• Review symptoms of and treatment for overdose or toxicity of common ingestions.

NATIONAL SURVEYS

• High School Youth Risk Behavior Survey - 2015• Grades 9 to 12 • 50 states and the District of Columbia • http://www.cdc.gov/healthyyouth/yrbs/overall.htm

• Monitoring the Future 2016• 8th, 10th, 12th graders• College students and young adults • www.monitoringthefuture.org

ADOLESCENT SUBSTANCE ABUSE

• Alcohol and tobacco use• Current alcohol use (used in past 30 days) among adolescents has decreased

over the past 20+ years• YRBS 50% in the 1991 to 1999 report to 32.8% in 2015• MTF survey

• 12th grade: decrease from 54% in 1991 to 33% in 2016• Tobacco use decreasing

• YRBS reported frequent use prevalence decrease from 12.7%-16.8% in 1991-1999 to 3.4% in 2015

• MTF reports 30-day use among 12th grader decreased from 28.3% in 1997 to 5.9% in 2013

INCREASE IN ILLICIT DRUG USE • The use of illicit (unlawful) and licit (legal) drugs among adolescents has

seen an upswing over the past 20 years• MTF: 48 to 50% have tried illicit drugs in their lifetime by Grade 12

• Marijuana use: • YRBS 38.6% have ever used(2015)• MTF last 30 days: 12th grade 22.7% (6% daily)

• Synthetic marijuana (K2, Spice)• 3.5% of 12th graders used in past year (MTF, 2016)

• Ecstasy (MDMA)• YRBS survey: 5.8% in 2007, increase to 6.6% in 2013; 2015 8% in 12th grade males • MTF survey (2016):

• Ever tried: 12th 3.1% • Last 30 days: 12th 0.6%

MONITORING THE FUTURE (2016)

INCREASE IN LICIT DRUG USE

• Easily accessible over-the-counter and prescription drugs

• Dextromethorphan: 2016 MTF 3.2% abused cough syrup in the past year • Increase in 8th graders to 2.6% in 2016

• Nonmedical use of prescription drugs: • MTF survey: 21.5%• YRBS 2015 report: 16.8% (Oxycontin, Percocet, Vicodin, codeine, Adderall, Ritalin,

or Xanax)• Hand sanitizers• Caffeine

LEGALIZATION OF MARIJUANA

• 26 states and DC have legalized marijuana

• Range in 1 to 24 oz usable • 4 to 24 plants

• Recreational use• Washington, Oregon, Maine,

California, Massachusetts, Colorado, District of Columbia, Nevada, Alaska

• Medical marijuana laws have been passed in North Dakota, Arkansas and Florida

http://www.governing.com/gov-data/state-marijuana-laws-map-medical-recreational.html

CANNABIS BOTANICALS

• “Medical” marijuana• Cannabis sativa

• uplifting and energetic• best suited for day use

• Cannabis indica• relaxing and calming• best suited for night use

• Cannabis ruderalis• Low in THC• High in cannabidiol

Used with Permission of Chilly’s Garden

CANNABIS ADVERSE EFFECTS

• Decreased cerebral blood flow in adolescents heavy users (Jacobus et al, 2012)

• Batalla et al (2013) Systematic review of functional studies in adolescents and adults

• Structural and functional changes found in adolescents who use cannabis

• Marijuana users (mean age 21.2 yrs) had increased depressive symptoms over controls (Wright, Scerpella & Lisdahl, 2016)

• Female users had increased anxiety scores

ADOLESCENT USE AND PSYCHOSIS

• Increased incidence of psychosis in heavy cannabis users• Longitudinal studies -> increased schizophrenia

• ? Self medicating• Endocannabinoid system plays an important role in

fundamental brain developmental processes • Use during adolescence can affect brain functions and behavior

Malone et al, 2010

SPICE/K2

• Synthetic cannabinoid • mixture of dry, shredded plant material that is sprayed with

synthetic cannabinoid receptor agonists• bind to one of the cannabinoid receptors (i.e. CB1, CB2)• CB1 is found in the CNS; responsible for the physiological

and psychotropic effects of cannabis or tetrahydrocannabinol (THC)

• Currently identified synthetic cannabinoid groups• JWH, CP, HU, benzoylindoles• DEA has made JWH-018, JWH-073, HU-210 and CP 47, 497 Schedule 1• Newest: AB-CHMINACA, AB-PINACA and THJ-2001

SPICE/K2• Spice is usually smoked via joint or water pipe

• Onset of action occurring within minutes • Causes elevated mood, relaxation, altered perception • Other symptoms: scleral injection, tachycardia, xerostomia,

increased appetite, nausea and vomiting may occur• Overdose and death reported with: AB-CHMINACA and AB-PINACA• Symptoms last up to six hours • Synthetic cannabinoids may not be detected on a routine urine drug

test

SPICE/K2: ADVERSE EFFECTS • Poison Center reports: severe agitation and anxiety,

muscle spasms, seizures and tremors, intense hallucinations and psychotic episodes, suicidal thoughts and actions

• 11/13/14 NIDA alert: “Cloud” and “Mojo” causing hallucinations, aggressive behavior, vomiting, suicidal thoughts

• 8/14/14 New Hampshire governor declares State of Emergency due to 41 overdoses from use of “Smacked”

• 2015: 7,779 reports of exposures to Poison Centers, 1345 in 2017(through 8/31/17) (www.aapcc.org)

• Severe tachycardia and hypertension have been reported

• Also fever, hyperglycemia, hypokalemia, chest pain and acidosis

• Kidney failure

SPICE/K2: TREATMENT

• Psychosis

• Treatment – Emergency Department • Seizure medications• Antipsychotics • Monitoring of heart and liver function

SALVIA • Salvia (Salvia divinorum) is an herb and member of the

mint family• MTF survey: 2016 1.2% of 12th graders reporting use in the

past 12 months (1% of college students)• Salvia is abused for its hallucinogenic effects• Salvia divinorum’s active ingredient, Salvinorin A,

selectively activates the kappa opioid receptors in the brain leading to hallucinations and dysphoria

SALVIA: ADVERSE EFFECTS & TREATMENT

• Short-term hallucinations or “psychomimetic” experiences similar to psychosis

• Dysphoria or mood swings• Incoordination, dizziness and slurred speech• Treatment

• Quiet environment if they are hallucinating • ED care: Monitor VS and neurological status

ECSTASY, MOLLY (MDMA)

• Synthetic drug 3,4-Methylenedioxymethamphetamine (MDMA)• Structurally similar to the stimulant methamphetamine and the hallucinogen

mescaline • MDMA causes release of neurotransmitters from storage

• Serotonin • Tolerance occurs

ECSTASY (MDMA)

• Onset 30 to 60 minutes; peak at 90 minutes • The effects of MDMA last 3 to 6 hours• Metabolized by CYP 2D6

• Poor metabolism may increased risk of fatality • MDMA inhibits its own metabolism

• May contain other drugs

ECSTASY (MDMA)

• Acute effects of MDMA begin 30 minutes after oral intake • adverse effects include anxiety, tachycardia and elevated blood pressure

• An hour after intake user experiences relaxation and euphoria• increased sensitivity to touch, increased energy, increased sensual arousal,

emotional warmth, and need to be touched• Post-use period of lethargy, anorexia and dysphoria for 24 to 48 hours

ECSTASY: ADVERSE EFFECTS• Serotonin syndrome

• hyperthermia, changes in level of consciousness, autonomic instability and altered muscle tone

• Sympathetic effects• tachycardia, hypertension and hyperthermia

• Dehydration, hyperthermia and hyponatremia• Liver toxicity• Syndrome of Inappropriate Antidiuretic Hormone (SAIDH) • Stroke• Long-term adverse effects on the brain

• May damage serotonin receptors • Poor performance on cognitive and memory tasks • Depression for weeks and months after use

ECSTASY (MDMA): TREATMENT

• If stable, treatment is symptomatic • Moderate-to-severe toxicity requires prompt treatment to decrease

mortality • O2, IV fluids, serial neuro checks

• Monitor for dysrhythmias, seizures, hyperthermia and hyponatremia/SAIDH

• Hyperthermia may be life-threatening • Monitor urine output• Seizures or muscle spasms are treated with benzodiazepines• Long term care: depression

BATH SALTS

• Synthetic stimulants that contain mephedrone and/or MDPV • Synthetic cathinones are structurally similar to amphetamine• Mephedrone increases dopamine, norepinephrine and serotonin levels in

the synapse • Stimulant effect and euphoria

• MDVP acts as a dopamine and norepinephrine inhibitor• stimulation and euphoria

BATH SALTS

• Synthetic stimulants or bath salts are usually snorted, but may be injected or used rectally

• Mephedrone: onset of action 10 to 20 minutes after snorting or ingestion, peak in 45 minutes to one hour

• duration of action of 60 to 120 minutes • MDPV onset of action one hour after ingestion, peak at 90 minutes

• duration of stimulant action lasting 2.5 to 3.5 hours • Standard urine drugs screens do not detect synthetic cathinones

BATH SALTS: TREATMENT

• ED care required: • Treatment of synthetic stimulant toxicity is based on the presenting symptoms • Agitation and seizures are treated with benzodiazepines (lorazepam) • Heart and kidney function need to be monitored

DEXTROMETHORPHAN

• 2016 MTF survey: 2.6% of 8th graders used in the past 12 months • Dextromethorphan (d-3-methoxy-N-methyl-morphine) the D-isomer of the

codeine analogue levorphanol• acts centrally in the cough center in the medulla to elevate the threshold for

coughing• gives a dissociative experience similar to PCP and ketamine • inhibits the reuptake of serotonin

ABUSERS OF DXM DESCRIBE FOUR DOSE-DEPENDENT “PLATEAU”

Plateau Dose (mg) Behavioral Effects1st 100–200 Mild stimulation

2nd 200–400 Euphoria and hallucinations

3rd 300–600 Distorted visual perceptionsLoss of motor coordination

4th 500-1500 Dissociative sedationDEA, 2010

DEXTROMETHORPHAN

• OTC dextromethorphan is often found in a combination cough and cold medication

• analgesic (acetaminophen)• decongestant (phenylephrine or pseudoephedrine)• antihistamine (chlorpheniramine or diphenhydramine)• Alcohol

• Toxic effects of other ingredients• Acetaminophen level• Anticholinergic toxicity

DEXTROMETHORPHAN

• Onset of CNS effects within 20 minutes• Extensively metabolized in the liver by CYP 2D6

• Poor metabolizers unable to convert dextromethorphan to dextrophan, leading to toxicity

• Extensive 2D6 metabolizers may experience more euphoria

DEXTROMETHORPHAN: ADRS

• Symptoms of intoxication are dependent on dose • Adverse effects include:

• nystagmus, dilated pupils, body itching, rash, ataxia, sweating, hot/cold flashes, fever, hypertension, shallow respiration, urinary retention, diarrhea, opisthotonostachycardia, hyperthermia, toxic psychosis and coma

• Chronic ingestion may cause a withdrawal syndrome • Interactions with other drugs

• SSRIs inhibit CYP2D6, so may cause serotonin syndrome• MDMA may cause serotonin syndrome

DEXTROMETHORPHAN: TREATMENT

• American Association of Poison Control Centers guidelines for treatment • If more than 5 to 7.5 mg/kg DMX ingested refer to ED for evaluation • If > 7.5 mg per kg has been ingested emergency department care is mandated

to evaluate and treat adverse effects• Naloxone (Narcan) used if sedated or in coma

https://www.cdc.gov/drugoverdose/data/statedeaths.html

OPIOIDS

OPIOIDS

• MTF 2016: 12th graders annual prevalence: 2.9% Vicodin; 3.4% Oxycontin• Nonmedical use of prescription opioids (NUPO) is highly correlated with

prescribed medical use over time (McCabe et al., 2017)• “the majority of adolescents indicating NUPO also had a history of medical use

of prescription opioids” (p. 5)• Males more likely to use opioids to get high • Recommendations

• Use prescription drug monitoring programs with adolescents• Educate patients and parents about storage, monitoring and disposal• Screen for NUPO• Prescribe lowest effective dose and minimum quantity, combining with

acetaminophen or ibuprofen to reduce opioid requirement

TOBACCO AND NICOTINE PRODUCTS

• Hookah 21.4% of 12th graders (2013 MTF)• Decline to 13% in 2016

• Bidis 1.4% (2010 MTF)

• Kreteks 1.6% (2014 MTF)

ELECTRONIC CIGARETTES • In 2015 e-cigarettes were the most commonly use tobacco product among

US middle and high school students (Singh et al, 2016)• Battery-powered devices that provide doses of nicotine and other additives

CAFFEINE/ENERGY DRINKS

• The Drug Abuse Warning Network (DAWN) has reported a large increase in ED visits associated with ingesting energy drinks

• July 2014: NIDA Alert regarding caffeine powder • Energy drinks have 80mg to 500 mg caffeine per serving

• Also contain supplements: B vitamins, taurine, ginsing, ginko biloba, guarana• Caffeine is a methylxanthine• CNS stimulant

CAFFEINE

• Rapidly absorbed, with peak in 30 to 60 minutes • Intoxication: seizures, fast/irregular heart rate and death• Combining alcohol and energy drinks masks intoxicating effects of alcohol • Treatment

• Supportive care• Charcoal if within 1 hr of ingestion• Benzodiazepines for seizures or CNS excitation • Hemodialysis

HAND SANITIZER

• ER reports of adolescents presenting with alcohol poisoning from ingesting hand sanitizers

• > 10,000 calls to US Poison Centers in 2017 for hand sanitizer exposure (http://www.aapcc.org/alerts/hand-sanitizer/)

• 60% ethyl alcohol “Purell Shots” • Alcohol poisoning may be fatal due to high concentration of alcohol

• Whiskey 80 proof = 40% alcohol

TAKE AWAYS

• Kids are creative!• Think outside the box when evaluating an adolescent or young adult with

cognitive or behavior changes• Prescribe opioids judiciously and monitor use • Urine drug screens may not give you an accurate picture of what is

happening

QUESTIONS?

• wootm@plu.edu

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