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Include ‘Legal Highs,’ Designer Drugs in Screening

August 24, 2012

Dr. Leslie Gee walked into a local smoke shop near Stanford in May 2012 and bought a packet of synthetic cannabinoids 7 months after California banned similar versions.

That’s just one of many designer drugs that adolescents are using and abusing, with effects that may mimic illicit substances but also can cause unpredictable and sometimes serious adverse effects.

Courtesy Dr. Leslie Gee
Dr. Gee bought this packet of synthetic cannabinoids months after her state banned similar products.
If you don’t ask about it, teenagers probably won’t tell.

Ask adolescent patients, “Are you using anything to get high?” Dr. Gee said at a pediatric update sponsored by Stanford (Calif.) University. Send acutely intoxicated teens to the emergency room or pediatric intensive care unit if needed, or provide supportive care and monitor them.

Call the American Association of Poison Control Centers help line at 800-222-1222 if you’re confused about what’s happening, and give the phone number to parents and families before they might need it, added Dr. Gee, a pediatrician at the university whose clinical focus is adolescent medicine.

A July 2012 federal law placed many synthetic cannabinoid ingredients into schedule I of the Controlled Substances Act, but manufacturers keep changing the ingredients, so they still can be bought legally.

Synthetic cannabinoids are available in shops and on the Internet, and adolescents are using them. In 2011, 11% of 12th graders reported using synthetic cannabinoids and 36% reported using marijuana, according to an annual survey of 50,000 teenagers by researchers at the University of Michigan.

Dr. Seth D. Ammerman

The survey found that 7% of eighth graders and 3% of 12th graders abused inhalants in 2011. Prescription medications were abused by 15% percent of 12th graders. A total of 6% of 10th graders and 5% of 12th graders tried to get high from dextromethorphan, an ingredient in many over-the-counter cold medications that’s also sold as a powder online. About 6% of 12th graders tried chewing or smoking salvia, an herb in the mint family sold in smoke shops and on the Internet. There are no data yet on abuse of some of the newer designer drugs, such as so-called “bath salts,” said Dr. Gee, who also is a postdoctoral research fellow in psychiatry and behavioral science.

Some of these substances can’t be detected by urine drug screens. But a laboratory screen for substance abuse generally is fairly useless in adolescents anyway, whether you’re concerned about legal or illegal drugs, Dr. Seth D. Ammerman said in a separate presentation at the meeting.

“Kids are a step ahead,” said Dr. Ammerman, an adolescent medicine expert and medical director of the Teen Health Van at the university. “You can get a lot more out of a history than a drug screen.”

Mnemonics such as HEADSSS, SBIRT, and CRAFT can help remind physicians about questions to ask when screening for substance abuse, but make sure any particular tool has been tested in teenagers before adopting it, he advised.

Most important, make substance abuse screening part of your routine, he urged. Screen for tobacco use at all adolescent encounters. Screen all adolescents for substance use at visits for preventive services. And screen for substance use in higher-risk patients, including teens brought in by parents because of behavioral issues or school problems, adolescents with acute medical problems such as GI disturbances or trauma, teens seen in emergency departments for any reason but especially for trauma, and residents of group homes, juvenile hall, foster homes, or shelters.

“We still have a ways to go to figure out the best way to screen adolescents for substance use. There’s much active research and some useful tools, but none include every question” that you may want to ask, Dr. Ammerman said.

A common way to start is the HEADSSS assessment, with questions about home; education or work; activities; drugs, alcohol and tobacco; sexuality; sadness; depression or suicidal ideation; and safety.

The SBIRT – Screening, Brief Intervention, and Referral for Treatment – doesn’t address tobacco use, but if you routinely screen for tobacco as a vital sign, you’ll have that covered, Dr. Ammerman said. Under SBIRT, ask if the patient has drunk alcohol, smoked marijuana, or used any other substance to get high including illicit drugs, over-the-counter preparations, prescription medications, inhalants, herbs, or plants.

If the patient says, “No” to all three questions, praise the patient and continue to encourage abstinence, he said. If there’s a “Yes” response, perform the CRAFFT screen for alcohol and drug use, Dr. Ammerman suggested. The acronym stands for Car, Relax, Alone, Forget, Friends/family, and Trouble. Have you driven or ridden in a Car in which anyone was high? Have you used substances to Relax or feel better about yourself? Have you used substances Alone? Ever done anything under the influence of substances that you Forgot? Have Friends or family commented on your use? Have you had any Trouble with parents, school, police, etc., related to substance use?

Adolescents who give at least two positive responses are increased risk of addiction and deserve further attention.

Dr. Leslie Gee

Many physicians received a screening tool in the mail last year from the National Institute on Alcohol Abuse and Alcoholism with specific questions for different age groups entitled “Alcohol Screening and Brief Intervention for Youth: A Practitioner’ Guide,” but “I personally prefer the SBIRT,” Dr. Ammerman said. “It’s validated and easy to use.”

Dr. Gee described some of the common “legal highs” and designer drugs, and what to do besides taking a good history if you suspect adolescents are using them.

• Inhalants. The average U.S. household contains 30-50 products that can be used for inhalant abuse through sniffing, “bagging” (spraying or placing in a bag and then inhaling from the bag), or “huffing” (placing a rag soaked in chemicals on one’s face). Some contain hydrocarbons that depress the central nervous system. Others contain nitrite that cause vasodilation.

Inhalant abuse can cause asphyxia, suffocation, or “sudden sniffing death” from sensitization of the myocardium to catecholamines (especially Freon) and a catecholamine rush after exercise or masturbation, resulting in cardiovascular collapse, she said.

Clues to inhalant abuse include a “glue sniffer’s rash” on the face, cheeks, and nose. The family may notice empty containers around the house or a chemical smell on the teen’s breath, skin, or clothes.

Most inhalants won’t be detected by standard urine drug screens. Evaluate using pulse oximetry, an ECG, and cardiac monitoring for arrhythmias, complete blood count, complete metabolic panel, and urinalysis, she suggested. Depending on the substance being abused, consider checking methemoglobin and lead levels. Treat with supportive care.

• Prescription drugs. Prescribed narcotics, benzodiazepines, or medications for attention-deficit/hyperactivity disorder are found in many households. They may cause respiratory depression or organ failure. Evaluate with urine drug screening and manage with supportive care appropriate to the ingested substance.

• Dextromethorphan. It goes by at least 10 aliases: Robo; Skittles; Dex; and more. A typical dose for cold therapy is 15-30 mg four times a day. Higher doses produce side effects at different dose plateaus: mild inebriation or stimulation from 100-200 mg, and euphoria, mild hallucinations, slurred speech, and short-term memory loss after 200-400 mg. A dose of 300-600 mg can alter consciousness and impair vision and motor control. At 500-1,500 mg, the mind and body dissociate.

Abuse can produce life-threatening effects including serotonin syndrome, high fever, rhabdomyolysis, arrhythmias, loss of consciousness, and brain damage.

Treatment is supportive care. When you suspect dextromethorphan abuse, also screen and treat for coingestion of other substances, especially acetaminophen and selective serotonin reuptake inhibitors.

• Salvia. A perennial herb native to Mexico, salvia is not a controlled substance, but California prohibits its sale to minors. Effects kick in within 5-10 minutes of chewing or within 30 seconds of smoking 200-500 mcg, and include hallucinations, bright lights, vivid colors and shapes, body or object distortions, uncontrolled laughter, or a sense of body loss. Provide supportive care.

• Synthetic cannabinoids. Added to blends of herbs and sold legally in the United States as alternatives to marijuana from 2009 until the recent regulations, synthetic cannabinoids produce psychoactive and sedative effects similar to marijuana, although possibly less potent. They also may produce more adverse effects, including withdrawal symptoms, cardiac problems, or psychoses. “I’ve seen reports of acute MIs and arrhythmias” from these products, Dr. Gee said.

Standard urine drug screens won’t detect them, but newer screening tests are in development. Consider coingestion of other substances and contaminants and provide supportive care.

• Bath salts. These synthetic cathinones entered the United States from Europe around 2010. They contain methylenedioxypyrovalerone, methylone, 4-methylmethcathinone – all three of which became schedule I substances in 2011 – or an ever-new roster of similar drugs. “They’re just marketed as bath salts or plant food as a way to get around regulations,” Dr. Gee said. “They’re not something you’d want to put in your bath or plants.”

Snorting or consuming orally induce empathy, stimulation, alertness, and euphoria within 3-4 hours that last 6-8 hours – similar to the effects of cocaine, cathinone (khat), amphetamines, or 3,4-methylenedioxymethamphetamine (MDMA, or Ecstasy). But they also can cause intense, prolonged panic attacks, violent behavior, and psychosis. Some “dramatic, scary” news reports have linked bath salts with violent behavior, she said.

Standard drug screens won’t detect synthetic cathinones, but tests are being developed. Consider coingestion of other substances and contaminants if you suspect bath salts use, and provide supportive care for agitation and psychoses.

Some possible references to help with substance abuse screening follow:

• The U.S. Drug Enforcement Administration offers handouts, links, and information on legal issues surrounding drugs and chemicals of concern.

• The Partnership at drugfree.org produced a toolkit for parents about synthetic drugs.

• The U.S. Office of National Drug Control Policy soon will release a Synthetic Drug Prevention Toolkit, Dr. Gee said.

• A sort of wiki for drug use, the website Erowid.org posts accounts of personal experiences – what happened when someone tried a drug, how much they tried, etc. It’s a window for clinicians looking to understand more about drug use and abuse, she added.

• One physician in the audience recommended Millennium Laboratories of San Diego to test patient samples for any synthetic drug, with a 24-hour turnaround.

Dr. Gee and Dr. Ammerman reported having no relevant financial disclosures.




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