Hepatitis C is alive and well thank you, IV drug use is on the rise and "Spice" ain't nice

It was the best of times, it was the worst of times. I remember fondly those days of my youth, waiting in the rain for concert tickets to Crosby, Stills, Nash & Young, Santana and Jethro Tull.

I hitchhiked everywhere, with my headband in place, and tie dyed shirt hanging over my bell-bottoms hoping to cop a ride.

At the tender age of sixteen I moved out of my parents home, into in a one bedroom apartment with six girlfriends, eating hot pizza for dinner, and scarfing down the leftovers for breakfast.

My parents had no idea the danger I was putting myself in, either did I.

The Drugs

Yes, I am a baby boomer, like most people from this generation I found that in my youth drugs were readily available. I had no idea that a one-time experiment with IV drugs some twenty years earlier would expose me to such a devastating health risk in the future.

For me, a good Catholic girl-most days, I somehow knew judgment day would one day come. I often asked myself how I escaped the consequences of my youth, I didn't  because in 1999 I was diagnosed with hepatitis C. 

Busted.

According to Dr. John Ward, hepatitis chief at the Centers for Disease Control and Prevention, one out of every 33 baby boomers are infected with hepatitis C.

Baby Boomers At Risk

Born Between 1945 and 1965
Shared needles or other drug-injection equipment.
Received a blood transfusion, blood product or organ before 1992.
Received a blood clotting product before 1987.

Baby boomers are at risk for contracting the virus through blood transfusions during the 1970s and 1980s. Effective bloodscreening for the virus wasn't developed until a first generation ELISA test was introduced in 1990. Between 1990 and 1992, there were some cases of hepatitis C transmitted through the blood supply as this screening test was not sufficiently sensitive to catch all infected blood. By 1992, a second generation HCV antibody test was introduced which significantly reduced the risk of HCV transmission via the blood supply. Patients who have had a blood transfusion prior to 1992 should be tested for HCV.

The Parents

Twenty or thirty years ago my parents, like the the majority of parents, were oblivious to the magnitude of accessibility our generation had to drugs. I was trusted.

Today parents are not that native, the days of Ward and June Cleaver are long gone. With 24 hour cable news and access to the Internet parents know the score. Awareness for HIV, hepatitis B and C has slowly made its way into the family home.  However, this loud and clear warning of chronic blood borne infections often goes unheard by our youth, just as it did generations earlier.

I have paid dearly for my small moment in time. The upside of my experience? Baby boomers make the best parents, we know how to be an effective " nark ".

The kids that are using right now are not aspiring drug addicts. Frankly, neither were we. These kids start out by experimenting, getting caught up with the feeling they get from the first injection which turns into two, then three, and ends with addiction. As parents it's up to us to stop this downward trend, before history repeats itself. Or has it already?

Hepatitis C Infection Continues In Our Children

Fast forward to March 2012, according to an article published a few days ago-

"The incidence of hepatitis C infection is increasing among adolescents and young adults in Pennsylvania, just as it has in other areas in the United States, according to surveillance data for 2003 through 2010."

During that 7-year period, the number of reports of newly recognized confirmed or probable cases of hepatitis C past or present infection among those aged 15-34 years increased from 1,384 to 2,393, representing a near doubling of the rate of cases (from 43 to 72) per 100,000 population, Dr. Sameh W. Boktor reported in a poster at the International Conference on Emerging Infectious Diseases.

 Continue Reading Here
 

The Transmission Of Hepatitis C In IV Drug Users

Hepatitis C is nearly 10 times more transmissible by a shared needle than HIV. In the United States, every year 15,000 people are newly infected with hepatitis C through sharing syringes and contaminated injection equipment. Sharing this contaminated equipment can transmit the virus - the first time - or - only time - its used.

Hepatitis C is the most common chronic blood borne infection in the United States, with 35,000 to 185,000 new cases diagnosed per year. Recently the CDC reported that hepatitis C–associated deaths are now more common in the United States than HIV-related deaths.

Why heroin use is once again increasing

One drug of choice is/was Oxycontin, the drug has become known as “Oxy” or “Hillbilly Heroin” and "White Collar" heroin. IV-oxycontin users crush up the pill and inject a diluted Oxycontin mix. To

 discourage misuse of the drug in 2010 the FDA demanded a  new formulation of Oxycontin. The drug manufacturer Purdue Pharma L.P., changed the drug by making it difficult to crush and inject. The pill no longer dissolves in water, instead it becomes a thick goopy material.

In California the prescription pain medication is becoming one of the most abused and misused drugs. On the street the drug is expensive, the price ranges from 20 to 40 dollars a pill. In Ottawa, Canada Oxycontin is the third most common used drug among addicts. The top two drugs are cocaine, including crack cocaine and marijuana.

The difficulty of injecting Oxycontin has played a roll in the increase use of heroin.  Oxycontin users can no longer inject the drug, and heroin isn't as potent when snorted, so IV use increases. In this 2011 video  Dr.Todd S. Carran discusses the rise in heroin use in Ohio, reporting that for adolescents, heroin is as easy to buy as a pack of cigarettes. Reuters reported in 2011 that in Massachusetts hepatitis C infections are increasing in the white youth population, fueled by the increase use of heroin and other injection drugs.

New synthetic drugs

Today heroin is still easily accessible, along with a new list of dangerous drugs including bath salts, spice, salvia and a new synthetic drug known as "Jewelry Cleaner" which also is called, " Eight Ballz" and " Cosmic Blast". More on the drug here.

 I am grateful that the biggest part of my job as a parent is complete. These new drugs, although often not injected have a whole new list of dangers. The only way a parent, loved one, or friend can recognize drug use or addiction, is to become knowledgeable about the drugs available on the streets.

So, we begin with an update below on the health dangers of bath salts. The video and article is from Virginia Commonwealth University. In a study from the University researchers found that "Bath salts can produce similar but stronger effects than off-the-street methamphetamine, cocaine or both." 

A few months ago we read about a woman who injected the street drug under the skin causing a flesh-eating disease, read more here at Medscape. Also, over at Medscape is a slide-show to aid clinicians in identifying, and managing this "new face of abused drugs". When I watched the slide-show I thought to myself if clinicians need help, what about the parents. I sort of borrowed the photos, and text, adding them to the blog below.

Bath Salts Update: New Research, New Evolution

 

Eric Peters
VCU Communications and Public Relations
petersem@vcu.edu

3/9/2012

In 2010, following legislation to halt a nationwide surge in the legal sale and use of synthetic marijuana, a new and far more dangerous group of legal designer drugs emerged.

The use of these new designer drugs, which are commonly referred to as bath salts and still available everywhere from the Internet to convenience stores and head shops, quickly rose to epidemic

 The New York Times reported, “Some of the recent incidents include a man in Indiana who climbed a roadside flagpole and jumped into traffic, a man in Pennsylvania who broke into a monastery and stabbed a priest, and a woman in West Virginia who scratched herself ‘to pieces’ over several days because she thought there was something under her skin.”

The active ingredients in bath salts were identified soon after use began to spread, but studies involving the effects of those chemicals on the brain, especially in tandem with one another, were never extensively explored until now.

Researchers at Virginia Commonwealth University this month presented their findings from such a study, which reveals the neurological reasons bath salts can produce similar but stronger effects than off-the-street methamphetamine, cocaine or both.

While these designer drugs are labeled as bath salts, they are anything but, and were never intended to be used as such.

The two main active ingredients in bath salts are Methylenedioxypyrovalerone (MDPV) and mephedrone, and VCU researchers found that it is the combination of these two chemicals that contributes to many of the negative effects of bath salts.

“It’s like a double punch,” says Louis J. De Felice, Ph.D., one of the researchers on the VCU study. “It’s as if a person were to take methamphetamine and cocaine at the same time.”

The mephedrone acts like methamphetamine by releasing dopamine into the brain while the MDPV acts like cocaine by preventing dopamine from being absorbed back into the brain.

“So that means the dopamine is out there, but unlike in a natural situation, it’s not able to be taken back up again,” explains De Felice.

Additionally, De Felice and colleagues discovered that the excess dopamine is likely to remain, along with the stimulating effects, long after the chemicals were removed.

The researchers at VCU only studied these long-lasting stimulating effects up to 30 minutes after removal of the chemicals, but have additional research planned that might help identify this phenomenon as the reason behind bath salts’ lingering psychotic and physical effects that sometimes last for days or weeks.

It was because of these negative effects that many bath salt variations had been outlawed throughout much of the U.S. by early 2011, but they remained easy to acquire through the Internet. According to the American Association of Poison Control Centers, there were more than 6,000 calls to poison control centers pertaining to bath salts in 2011, more than10 times the number in 2010.

Another problem, says Rutherfoord Rose, Pharm.D., director of VCU’s Virginia Poison Center, is that as soon as one ingredient or designer drug is outlawed, another takes its place.

“Substances like 2ce, 2ci and 25i have become the newest thing since bath salts were outlawed in most states,” he says. “They appear to have similar effects to the ingredients in bath salts, but in some cases we’ve seen the effect to be even more severe, producing refractory seizures, convulsions and bleeding in the brain.”

Rose says when it comes to new drugs like these, as the case once was with bath salts, his center relies on verbal reports from friends and users to identify what has been ingested because labs simply can’t test for new and emerging drugs that haven’t yet been identified and studied.

So the fight continues and researchers such as De Felice and his colleagues push forward, studying, identifying and working as quickly as possible to publish research that sheds light on how and why these chemicals are so dangerous.

Source

The New Face of Abused Drugs

Source- Medscape

Editor's Note:

Drug abuse remains a major public health problem worldwide as people continue to use or abuse "old drugs" such as alcohol, marijuana, cocaine, and opioids. Making the news lately, however, are novel substances that have attracted potential users with promises of "legal" highs and easy access via the Internet.

Clinicians need to be aware of the emerging trends in alcohol and other drug abuse, especially if they are not up to date on the new recreational drugs on the scene in their own communities.

How can clinicians identify and manage the "new face of abused drugs"? This slideshow provides healthcare providers with an at-a-glance introduction to the clinical challenges posed by patients using and abusing novel substances.

Images courtesy of WikiCommons and Getty Images/Thinkstock

 

 

Bath Salts – MDPV, Mephedrone (Rosenbaum CD, et al.^[1])

What Are They?
"Bath salts" may appear to be white powder or crystals to add to bath water, but the term actually refers to amphetamines and cathinones (synthetic derivatives of the stimulant found in the khat plant) that are sold in clandestine packaging to avoid detection by law enforcement. MDPV and mephedrone often are the active compounds, with effects similar to those of ecstasy (MDMA).

Street slang terms and product names include -
drone, bubbles, meow-meow, MCAT, Ivory Wave, Vanilla Sky, Cloud 9, Red Dove, and White Rush.

Who Is Most at Risk?
Use is most prevalent among teens and young adults who wish to avoid drug detection while enjoying what used to be a "legal high." Before the US Drug Enforcement Administration acted to make bath salts illegal in September 2011, these substances were sold at gas stations, head shops (retail drug paraphernalia outlets), and record stores. Users still can purchase the products online.
Image courtesy of New Jersey Division of Consumer Affairs

Bath Salts – cont (Rosenbaum CD, et al.[1])

Clinical Presentation

Sympathomimetic effects (eg, elevated pulse and blood pressure; diaphoresis; agitation; and, with long-term use, psychotic features) may predominate.

Drug Screen Availability

Cathinones will not appear on standard immunoassays for drugs of abuse (DOA). Amphetamines may be detected with DOA immunoassay, and both substances are detectable with gas chromatography–mass spectrometry (GC-MS) analysis.

Patient Management Summary

Management includes supportive care. Benzodiazepines are useful for agitation and psychosis. Patients who have used amphetamines such as MDMA may present with serotonergic symptoms requiring supportive care or treatment with benzodiazepines or cyproheptadine. Patients with severe agitation and vital sign abnormalities may require intensive monitoring and care.

Herbal Marijuana Alternatives and Synthetic Cannabinoids
(Rosenbaum CD, et al.^[1])

What Are They?
These "incense" products contain herbal plant matter adulterated with synthetic cannabinoids and are usually smoked. Baybean, beach bean, blue lotus, lion's ear/tail, wild dagga, Indian warrior, and dwarf skullcap are examples of the herbal ingredients. Synthetic cannabinoids include JWH-018/073/200, CP-47,497, and RCS-4. Spice, K2, Chill Zone, Sensation, Chaos, Aztec Thunder, Red Merkury, and Zen are some of the common brand names.

Who Is Most at Risk?
 Users typically range in age from 14 to 50 years. Although 5 synthetic cannabinoids are now illegal in the United States,^[2] these products are still widely available in gas stations and head shops and via the Internet, owing to reformulations to skirt the federal ban. Military personnel and others who must undergo regular drug testing (eg, for marijuana) know that these "legal highs" may be undetectable.

Herbal Marijuana Alternatives and Synthetic Cannabinoids – 
cont (Rosenbaum CD, et al.^[1])

Clinical Presentation
Clinical effects include hypertension, tachycardia, nausea, vomiting, agitation, anxiety, paranoia, seizures, and suicidal ideation.

Drug Screen Availability
Synthetic cannabinoids are undetectable using standard DOA immunoassays directed at tetrahydrocannabinol, the active ingredient in cannabis. Analysis with GC-MS can identify specific synthetic cannabinoids in a patient's urine, but only under highly restrictive circumstances.

Patient Management Summary
Management includes supportive care. Symptoms are typically short-lived (< 24 hours), but some cases have required bilevel positive airway pressure and admission to the intensive care unit for respiratory distress (Rosenbaum CD. Unpublished data).
Image courtesy of Getty Images/Thinkstock

Salvia divinorum (Rosenbaum CD, et al.^[1])

What Is It?
Salvia divinorum, a hallucinogenic herb belonging to the mint family, contains the hallucinogen salvinorin A. Traditionally, the Mazatec Indians of Oaxaca, Mexico, chewed or brewed Salvia divinorum as tea to facilitate spiritual encounters; it is now being used recreationally worldwide. Salvinorin A is inactive after ingestion; as a result, users seeking a high must chew or smoke the leaves.^[3]

 Who Is Most at Risk?
Young adults, adolescents, and anyone with access to the Internet who is interested in avoiding drug detection via this "legal high" (in some states) are considered at most risk.
Image courtesy of WikiCommons

Salvia divinorum – cont (Rosenbaum CD, et al.^[1])

Clinical Presentation
Users report potent open- and closed-eye hallucinogenic effects. Unlike other hallucinogens, salvinorin A does not have serotonergic activity. Instead, its affinity for the kappa opioid receptor may cause sedation, analgesia, gastrointestinal hypomotility, aversion, and depression.

Drug Screen Availability
Salvinorin A is not detected by standard DOA immunoassays. Salvinorin A can be detected in urine and saliva using GC-MS analysis.

Patient Management Summary
Management includes supportive care. Because salvinorin A acts solely at kappa opioid receptors, in theory it should not cause respiratory depression, although respiratory monitoring is prudent.
Image courtesy of WikiCommons

Khat (Cathinone) (Rosenbaum CD, et al.^[1])

What Is It?
Khat (Catha edulis) is a plant whose leaves and twigs are chewed for their reported amphetamine and euphoric effects. Common in Yemen, Somalia, and Ethiopia, khat abuse has now spread beyond its geographic and historic roots as a result of online information and sales. Cathinone is the main active ingredient.

Who Is Most at Risk?
Anyone with access to the Internet may obtain khat. In 2006, 10 million people were estimated to have used the drug.

Clinical Presentation
Amphetamine-like effects produce agitation, tachycardia, hypertension, and psychosis.

Drug Screen Availability
Cathinone cannot be detected by DOA immunoassay. However, GC-MS analysis can detect cathinone and synthetic cathinone derivatives.

Patient Management Summary
Management includes supportive care, benzodiazepines, and sympatholytics.
Image courtesy of WikiCommons

Insufflation of Oral Medications

What Is the Emerging Issue?
Crushing and insufflating ("snorting") an oral medication allows immediate bioavailability of far larger doses of the drug than would be available from ingesting an intact tablet. Some newer, so-called "abuse-resistant" formulations can be crushed but with difficulty.

Who Is Most at Risk?
Populations at greatest risk include young people experimenting with drugs and long-term or habitual drug users who have developed a tolerance to their typical oral medication.

Clinical Presentation
Nasopharyngeal necrosis (destruction of the nasal septum, soft or hard palate, and other facial structures) has been reported from insufflation of opioid analgesics as well as other drugs.^[4-6]
Image courtesy of Getty Images/Thinkstock

Insufflation of Oral Medications (cont)

Drug Screen Availability
Detection depends on the drug used. Opioids (eg, hydrocodone, oxycodone, oxymorphone, hydromorphone, propoxyphene, and tramadol) cannot be detected by DOA immunoassays. Methylphenidate is also uncommonly detected by DOA immunoassays. GC-MS analysis and opioid-specific immunoassays are commercially available to detect opioids but often require special ordering and testing.

Patient Management Summary
Management of drug effects should be directed at the specific xenobiotic involved. Opioid intoxication may be managed with naloxone, whereas intoxication with stimulants, such as methylphenidate, may require benzodiazepines.
Image courtesy of Photo Researchers

Energy Drinks

What Are They?
Energy drinks are flavored, typically sugar-sweetened beverages that manufacturers claim enhance energy and performance. These drinks contain as much as 360 mg/L of caffeine (roughly the equivalent of 3-4 cups of coffee), along with other ingredients that act as stimulants (eg, guarana, taurine, ginseng, and L-carnitine).

Who Is Most at Risk?
Populations most at risk are young people and others seeking to stay awake for personal, school-, or job-related reasons.
Image courtesy of WikiCommons

Energy Drinks (cont)

Clinical Presentation
Caffeine (1,3,7-trimethylxanthine) is a structural analog of adenosine and a functional adenosine receptor antagonist. Presynaptic alpha-1 antagonism causes catecholamine release and adrenergic surge. Symptoms of caffeine intoxication can range from mild nausea and palpitations to severe, protracted vomiting; cardiac dysrhythmias; and seizures.^[7,8]

Drug Screen Availability
Caffeine may be detected by specific testing with GC-MS analysis; it is not detected by DOA immunoassay.

Patient Management Summary
Supportive care should include intravenous fluid resuscitation, antiemetics, and sympatholytics.
Image courtesy of WikiCommons

Methoxetamine (Rosenbaum CD, et al.^[1])

What Is It?
Methoxetamine (MXE) is an analog of ketamine ("special K"). Both drugs share structural similarity with phencyclidine (PCP).

Who Is Most at Risk?
Methoxetamine use is popular in the United Kingdom but has the potential for wider use via Internet sales. Little is known about the users or specific patterns of abuse, other than that the drug can be injected intravenously.^[9,10]

Clinical Presentation
The clinical experience with methoxetamine is limited to self-report and advertising. Users reported abusing the drug for its euphoric and hallucinogenic effects but may experience opioid effects such as respiratory depression, vomiting, diarrhea, anxiety, and paranoia. Classically associated with ketamine, nystagmus may be observed. One case report describes a 19-year-old who injected methoxetamine intravenously and later presented with semistuporous mental status, agitation, ataxia, hypertension, and tachycardia.^[10]
Image courtesy of WikiCommons

Methoxetamine – cont (Rosenbaum CD, et al.^[1])

Drug Screen Availability
Methoxetamine may not be detectable via GC-MS analysis. The DOA immunoassay directed at PCP detection also may not identify methoxetamine.

Patient Management Summary
No specific management of methoxetamine intoxication has been described at this time. However, similar management to that for ketamine, PCP, or opioid intoxication should be used. Suggested strategies may include supportive care, intravenous fluid resuscitation, benzodiazepines for agitation, and respiratory support.
Images courtesy of Getty Images/Thinkstock and WikiCommons

Piperazine Derivative (Rosenbaum CD, et al.^[1])

What Is It?
Piperazine was initially designed as an antihelminthic but was discovered to have stimulant properties. Many different piperazines exist (eg, BZP, CPP, MBZP, MeBP, MeOPP, MeP, and TFMPP). They are often sold as pills or powders containing a mixture of multiple drugs.

 Who Is Most at Risk?
Young adults, especially those involved in club culture, may be most attracted to this designer "party pill," or "legal ecstasy" as it is sometimes known on the street.^[11] Piperazine abuse has been extensively identified in Europe and New Zealand.^[12,13] Young males, typically in their twenties (age range 13-44 years), use piperazines for their amphetamine or stimulant-like effects, especially when attending dance clubs and possibly as a means to avoid withdrawal from amphetamines.^[13,14] Given the availability of these drugs on the Internet, their popularity will likely spread to the United States to demographics beyond just the "club scene."
Image courtesy of WikiCommons

Piperazine Derivative – cont (Rosenbaum CD, et al.^[1])
Clinical Presentation
Sympathomimetic and serotonergic effects may predominate owing to the ability of piperazine to impair serotonin reuptake and directly stimulate serotonin receptors.

Drug Screen Availability
Piperazines are not detectable by typical immunoassay testing, but they may be detectable via GC-MS or liquid chromatography-MS analysis.

Patient Management Summary
Benzodiazepines for agitation and intravenous fluid resuscitation should form the foundation of supportive care, directed in a manner similar to that for other sympathomimetics.^[11] If serotonergic effects are observed, supportive care and possibly antiserotonergic medications, such as cyproheptadine, may be indicated.
Image courtesy of WikiCommons

Author
Christopher D. Rosenbaum, MD, Assistant Professor, University of Massachusetts Medical School; Attending Physician, Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical Center, Worcester, Massachusetts

Christopher D. Rosenbaum, MD, has disclosed the following relevant financial relationships:
Received income in an amount equal to or greater than $250 from: UpToDate

Reviewer
Edward W. Boyer, MD, PhD, Professor of Emergency Medicine, Director of Toxicology and the Toxicology Fellowship, Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical Center, Worcester, Massachusetts

Edward W. Boyer, MD, PhD, has disclosed no relevant financial relationships

 Source- Medscape