The Designer Drug – What You Always Wanted to Know

Steven Kipnis MD, FACP, FASAM

Medical Director, NYS OASAS

Thanks to:

Paul L. Cary

Toxicology Laboratory

University of Missouri

Steve Hanson

Acting Associate Commissioner - NYSOASAS

CASE

A healthy 48-year-old man has a generalized convulsion after ingesting a powder he purchased through the Internet. The powder was sold with the wording “not for human consumption” listed on the packaging.

The seizures continue in the pre-hospital setting, as well as in the ED, for approximately

15 minutes in total before ceasing after administration of lorazepam 4 mg IV.

Initial vital signs after cessation of his seizures include a blood pressure of 140/88 mm Hg; pulse, 106 beats/min; respiratory rate, 22 breaths/min; temperature, 37.7°C. Physical examination is notable for mydriasis and diaphoresis with 5 beats of myoclonus in the bilateral lower extremities. Shortly after arrival in the ED, the patient is intubated for airway control.

Finding on noncontrast CT of the brain are unremarkable, and EEG results are normal.

Initial pertinent laboratory values include normal electrolyte, creatinine, and glucose

levels. His creatine phosphokinase level is elevated, at 2,500 U/L. Toxicology screening does not detect acetaminophen, ethanol, or salicylates

CASE

A healthy 48-year-old man has a generalized convulsion after ingesting a powder he purchased through the Internet. The powder was sold as “research grade JWH-018 – synthetic cannabinoid,” with the wording “not for human consumption” listed on the packaging.

The seizures continue in the prehospital setting, as well as in the ED, for approximately

15 minutes in total before ceasing after administration of lorazepam 4 mg IV.

Initial vital signs after cessation of his seizures include a blood pressure of 140/88 mm Hg; pulse, 106 beats/min; respiratory rate, 22 breaths/min; temperature, 37.7°C. Physical examination is notable for mydriasis and diaphoresis with 5 beats of myoclonus in the bilateral lower extremities. Shortly after arrival in the ED, the patient is intubated for airway control.

Finding on noncontrast CT of the brain are unremarkable, and EEG results are normal.

Initial pertinent laboratory values include normal electrolyte, creatinine, and glucose

levels. His creatine phosphokinase level is elevated, at 2,500 U/L. Toxicology screening does not detect acetaminophen, ethanol, or salicylates

• A 36-year-old male in the Netherlands became acutely agitated and enraged after ingesting mephedrone along with cocaine, and subsequently lost consciousness and died despite resuscitation efforts.

• A 29-year-old male found unresponsive at a nightclub died of cerebral edema and brainstem herniation. Serum sodium was

• noted to be 125 mmol/L, later suggested by laboratory data to have resulted from water intoxication.

• The first synthetic cathinone-related death in the United States, described in the scientific literature, involved a 22-year-old male who was found unresponsive and subsequently died at the receiving hospital.

• One case of mephedrone-related myocarditis has also been reported in the literature. A 19-year-old male presented with crushing chest pain after ingesting mephedrone sold as ‘‘not for-human-consumption’’ plant food.

Drive to Get High

• People will seek any means to alter their state of consciousness

THE STORY OF DESIGNER DRUGS

Designer Drugs:

Created (or reformulated, if the drug already existed) to get around existing drug laws (Controlled Substance Act), usually by modifying the molecular structures of existing drugs to varying degrees.

Designer Drugs:• Second International Opium Convention in 1925 which

specifically banned alternative esters of morphine• 1960s - 1970s, new synthetic hallucinogens (modifications of

LSD & PCP)• “Designer drug” was first coined by law enforcement in the

1980s• 1980s - 1990s, design of MDMA (ecstasy) & methcathinone• 2000 - 2005, derivatives of psilocybin & mescaline, anabolic

steroids• European authorities have identified 41 new psychoactive

drugs in 2010 alone

What Drives the Production Designer Drugs ?

• Consumer preferences

• Law enforcement control

An agonist is a chemical that binds An agonist is a chemical that binds to a receptor and triggers a to a receptor and triggers a

response – often mimicking the response – often mimicking the action of a naturally occurring action of a naturally occurring

substance.substance.Receptor

Drug (agonist)

Why Change the Key?

• Prolong the effect of the drug• Increase the potency of the drug• “Select” the desired effect• Make the drug more difficult to

detect• Avoid patent infringement• Make an illegal drug “legal”

Drug

SPICE/K2 AND SYNTHETIC CANNABINOIDS

(HMA – HERBAL MARIJUANA ALTERNATIVES)

No! We’re not talking about this!

We’re talking about this! There are hundreds of synthetic cannabinoids.

Brand Names of Common HMA’s

• Spice• K2• Tai Fun (Blackberry, Vanilla, Orange)• Exclusive (Original, Mint, Cherry)• Chill Zone (Berry, Mint, Original)• Chill Out (Cherry, Mint, Original)• Sensation (Vanilla, Orange, Bkberry)• Chaos (Mint, Original, Cherry)• Zen• Zen Ultra

WHAT’S IN THESE “INCENSE” PRODUCTS?

“Listed” Ingredients in Spice•Canavalia rosea: beach bean or bay bean•Nymphaea caerulea: Blue Egyptian water lily•Scutellaria nana: Dwarf skullcap•Pedicularis densiflora: Indian warrior•Leonotis leonurus: Lion's Tail and Wild Dagga

•Cannabis – like effect •Zornia latifolia: is a perennial herb•Nelumbo nucifera: Lotus•Leonurus sibiricus: Honeyweed or Siberian motherwort•Vanilla•Honey

Preparation of the “incense”:• Botanicals (vegetable matter) are

sprayed with liquid preparations of:o HU-210o HU-211o CP 47,497o JWH-018o JWH-073

Origins of Synthetic Cannabinoids• CP 47,497 - developed by Pfizer in 1980 as an analgesic• HU-210 & HU-211 - synthesized at Hebrew University,

Israel in 1988. HU-210 is an anti-inflammatory; HU-211 as an anesthetic

• JWH-018 & JWH-073 - synthesize by a researcher at Clemson (1995) for use in THC receptor research - John W. Huffman

• more than 100 different synthetic cannabinoids have been created

Usage

• Very little known about the extent of use

• 2009 Survey in Frankfurto Surveyed 1463 students aged between 15 and 18 at schools providing

general and vocational training.o Prevalence of use was 6% of respondents reported using Spice at least

once

• National Poison Data System in 2010 (Aurora, CO)o During the 9 month study period, there were 1898 exposures reported

with a mean age of 22.5 years oldo Most cases reported were in men.

• Community Epidemiologic Work Group (CEWG) noted K2 epidemic in Midwest US in 2010

• Appears to be shifting from marijuana to synthetics

Usage

• Mode of use:o Smokedo Drink as an infusion/herbal tea

Availability

• Sold in metal-foil sachetso Typically contain 3 g of smoking mixture sufficient for 8 jointso Typical cost is 20 – 60 dollars per pack

• Sold in:o Internet siteso Tobacco storeso Head shopso Some gas stations

• Often sold as “incense” labeled with disclaimer: not for human consumption

Smoking Cannabinoids

• Basal Ganglia: motor control, learning

• Hippocampus: memory, spatial navigation

• Cerebrum: cognitive functions - attention, language, emotions

*CB2 found in blood cells, immune tissue and spleen. ? in CNS

What does CBWhat does CB11 receptor receptor

control?control?

• Dual effects:o Herbs (very little medical literature of effects)o Synthetic cannabinoid

Pharmacological Effects of Synthetic Cannabinoids are Similar to THC

• Mental (these affects predominate):o Altered state of consciousness o Mild euphoria and relaxation o Perceptual alterations (time distortion)o Intensification of sensory experienceso Pronounced cognitive effectso Impaired short-term memory o Anxietyo Paranoiao Avoidant eye contacto Agitationo Delusions (paranoid, grandiose)o Psychosis

Pharmacological Effects of Synthetic Cannabinoids are Similar to THC

• Physical:o Increase heart rate & blood pressureo Dry eyeso Diaphoresiso Mild decrease in potassiumo Seizures o Reduction in motor skill acuityo Increase in reaction times

DependenceSyndrome Similar to Marijuana

Withdrawal:•“Inner unrest”•Drug craving•Nightmares•Profuse sweating•Nausea•Tremor•Headache•Hypertension•Increased HR

Reported Effects of Synthetic Cannabinoids are Different Than THC

• Production inconsistencies

• Herbal incense blends are harsher to inhale

• Effect on appetite is non-existent

• Increased restlessness & aggressive behavior

• Herbal incense produces a shorter “high” (perceptual alterations & sensory effects are limited)

• Doesn’t mix well with alcohol (hangovers)

• Incense costs more than marijuana

Synthetic Cannabinoid Data

Percentage of U.S. 12th Grade Students Reporting Past Year Use of Drugs*

Other Than Alcohol and Tobacco, 2011(N=approximately 14,900)

• Marijuana and synthetic marijuana are the most prevalent illicit drugs used by 12th graders, according to recent data from the 2011 Monitoring the Future (MTF) survey. Slightly more than one-third (36.4%) of high school seniors reported using marijuana in the past year, including 11.4% who reported using synthetic marijuana, compared with less than 10% for all other illicit drugs.

0% 10% 20% 30% 40%

Percentage of U.S. 12th Grade Students

Synthetic Marijuana

Amphetamines

Tranquilizers

OTC Cough/Cold

Hallucinogens

Sedatives

Inhalants

Cocaine

36.4%

11.4%

8.7%

8.2%

5.6%

5.3%

5.2%

4.3%

3.2%

2.9%

Other Narcotics (e.g., Vicodin®, Oxycontin®)

Marijuana(including Synthetic Marijuana)

Legal Status of Synthetic Cannabinoids (DEA)

• March 1, 2011, the DEA, issued final notice to temporarily place five synthetic cannabinoids into the Controlled Substances Act (CSA) for at least one year

• Synthetic cannabinoids treated as Schedule 1 drugso A drug that has a high potential for abuse

o A drug that has no currently accepted medical use in treatment in the United States

o There is a lack of accepted safety for use of the drug under medical supervision

Legal Status of Synthetic Cannabinoids (DEA)

• DEA took action - imminent hazard to the public safety

• Imposes criminal sanctions and regulatory controls of Schedule I substances under the CSA

• Covers the manufacture, distribution, possession, importation, and exportation

• US Senate considering a bill permanently banning these drugs

State Laws

• Some states have passed their own laws banning the substance

• New York has pending legislation

Synthetic Cannabinoids “Banned” by the (DEA)

• Synthetic cannabinoids covered under the DEA’s new rule includes the following:

o JWH-018 *o JWH-073 *o JWH-200o CP-47,497o CP-47,497 (C-8 homologue)

CAN SYNTHETIC THC CHEMICALS BE DETECTED BY DRUG TESTING?

Drug Testing:• New on-site, rapid, instant tests• Numerous laboratories employing LC/MS/MS

technology• $$$ per sample• Many unknowns regarding this testing

• While parent drugs are detectable, metabolites of synthetic cannabinoids may be the only detectable compounds found

• Can use blood and urine as sample

Unresolved Issues of Concern:• What synthetic compounds (or metabolites) are

being tested by these laboratories?• No standardized urine cutoff levels• No standardized methods (LC/MS/MS)• Tests detect metabolites• No independent quality control materials• No proficiency testing• Detection window unknown

o May be 48 – 72 hours

What to test for ? ? ?

More dangerous than we first thought?

Management

• No pharmacolgically specific antidote

• Supportive care• Benzodiazepines for

agitation and anxiety• Intubation in one case

for decreased respiratory rate

• Duration of effects???

BATH SALTS

Bath Salts:

• Ivory Wave• Ivory Pure• Ivory Coast• Purple Wave• Vanilla Sky

Appealing Product?

Not talking about this:

What’s in Bath Salts

• Cathinoneo Known for centurieso Active metabolite is cathineo Found in leaves and twigs

of Khat plant (Catha edulis)o Original synthetic

cathinone is methcathinoneo Produced in 1928o Public Health hazard as

per League of Nations in 1933

o Schedule I drug in 1993

• Reformulation of cathinone is a chemical found in the khat plant of Eastern Africa

• Khat existence traced to 15th C. Ethiopia• Grown in Somalia, Yemen, Kenya, Ethiopia• Khat is banned in the U.S.

Mephedrone

• Designer drug chemically similar to cathinone

• First synthesized in 1929

• Amphetamine-like properties

• Powerful synthetic stimulant

• “Rediscovered” by synthetic chemists

in 2003

• Widespread in Europe, Australia, US

Methylmethcathinone (Mephedrone)

What’s in Bath Salts:

• Methylenedioxypyrovalerone (MDPV) is a psychoactive drug with stimulant properties which acts as both a norepinephrine-dopamine reuptake inhibitor (NDRI).

• MDPV has four times the potency of Ritalin• MDPV - no history of FDA approved medical use• Sold since 2007 as a research chemical• September 2011 – DEA Schedule I (mephedrone,

methylone and MDPV)

MDPV:• Currently popular in Europe, UK & Australia• Is usually snorted - similar to cocaine • Considered extremely addictive• MDPV was “legal” – now Schedule I • Adverse medical/psychiatric ramifications• No on-site or screening drug tests

4-methylethcathinine (4-MEC)

• Found commonly used as the active ingredient in "Ecstasy" pills in some countries such as New Zealand

• Referred to as “Molly”

Usage

• UK online study of club-goers reported:o 41% tried methedroneo 10% tried methyloneo 33% used in the last montho 14% used it weekly

• Blood samples from Finland were taken from 3000 drivers suspected to be under the influence

o 286 (8.6%) had positive for bath salts

Administration – white/brown powder; capsules and tablets also available

• Oral (mouth, “bombing”)• Intranasal (snorting, “keying”)• Intramuscular• Intravenous• Rectal• Gingival• Inhalation via smoking

Onset and Duration of Action

• Onset:o Mephedrone 30-45 mino Methylone 30 – 45 mino MDPV 15 – 30 min

• Durationo Mephedrone 2 – 5 hrso Methylone 2 – 5 hrso MDPV 2 – 7 hrs

1. Inhibitor of reuptake of dopamine, serotonin and NE

2. Increased presynaptic release of same monoamines though less effect than number 1

Pharmacological Effects of “Bath Salts”:

• Physical:o Increase heart rate & blood

pressureo Pupil dilation o Dizzinesso Nauseao Breathing difficultieso Headacheo Chest paino Bruxismo Tremorso Insomniao Myocardial infarction

Pharmacological Effects of “Bath Salts”:

• Mental:o Hyperactivity, arousal & over stimulationo Increased energy & motivationo Euphoria - agitation o Diminished perception of the requirement for food

and sleepo Talkativenesso Increases sexual arousalo Crave to redose frequently

Health Hazard?

Health Hazard?

• Bizarre behavior• Phenomenal physical

strength• Self mutilation• Suicide• Persistent paranoid

psychosis• Persistent symptoms of

paresthesias and mood changes for days to weeks after using

?

Dependence

• Like amphetamines – induce tolerance and dependency in at least 30 percent of users with craving and impaired control

Long Term Effects

• Little is know as relatively recent use• Potential neurotoxicity with decrease dopamine

transporter activity in the basal ganglia leading to a parkinson’s like disorder

Detection

• Not detected in routine urine Elisa testing• May cause false positive methamphetamine screen• GC-MS test available for mephedrone, MDPV,

methylone

Management• No specific antidote exists

• Supportive care

• Aggressive sedation with benzodiazepines for increased heart rate, seizures, agitation and hypertension

o Avoid beta blockade due to potential exacerbation of hypertension due to unopposed alpha-adrenergic stimulation

• Hyperthermia may require cooling

• If severe (persistent vital sign elevation, neuro and psychiatric abnormalities), all patients should be admitted and have:

o EKGo Serial temperature checkso CPKo Lyteso Renal/liver functions

On September 8, 2011, the Drug Enforcement Administration (DEA) published a Notice of

Intent to place three synthetic cathinones into Schedule I of the Controlled Substances Act

(CSA)

• mephedrone, • 3,4 methylenedioxypyrovalerone (MDPV)• methylone

New York

Bath Salt Data

The Next Wave (or a repeat of an

old wave repackaged)?

Kratom• Legal plant product –

Mitragyna speciosa Kortho South Eastern Asia

tree• Used to treat opioid

withdrawal• Access via internet

without prescription• Dual properties of

stimulation and analgesia

M. Speciosa Korth

• Plant with greater than 25 alkaloids• Mitragynine responsible for opioid effect• Works at the mu and delta supraspinal opioid receptors,

serotonin and noradrenergic pathways in spinal cord

Mitragynine

• 13 times more potent than morphine• Powder, leaves, gum• Smoked or tea

Reported Benefits

• Analgesic• Anti-inflammatory• Anti-pyretic• Anti-tussive• Antihypertensive• Local anesthetic• Hypoglycemia• Antidiarrheal• Anti-malarial

Clinical Effects

• 5 – 10 minutes after consumption effects start• Last about one hour• Low dose – stimulant effect• High dose – opioid effect• Seizures can be seen

Detection

• Liquid chromatography/MS

Management

• Supportive• Airway management

The New “Designer Drugs”

• Hallucinogens - This class has many different compounds that can be used for this purpose. These include:

o Salvinorin A (Salvia divinorum)o Lysergic Acid Amideo Leunorine (Lion’s Ear)o Tropane Alkaloids (atropine, scopolamine)

• Datura stramonium

• Atropa Belladonnao Psilocybino Muscarineo N,N-Dimethyltryptamine

The New “Designer Drugs”

• Hallucinogens o Salvinorin A:

• Street names include: Magic Mint, Seer’s Sage, Lady SD, and Sally D.

• used for centuries by the Mazatec shamans in Oaxaca Mexico for spiritual healing

• used by chewing the fresh leaves, ingesting a tincture or juice from the leaf, or smoking dried leaves

• The psychoactive component is neoclerodane diterpene Salvinorin A.

• It is the most potent of all naturally occurring hallucinogens and is equal to LSD.

• Unlike LSD which acts on the serotonin receptors, this works at the Kappa Opioid receptor as an agonist.

• There is rapid onset when smoking (one minute) to ten minutes seen with buccal (oral) absorption.

• It has a short half-life as the effect usually lasts 20 minutes

The New “Designer Drugs”

• Hallucinogens o Salvinorin A:

• Users state that they “enter another reality”, have improved mood, are calm, have increased insight and have a floating feeling. There are visual and auditory hallucinations that occur with use.

• Adverse effects have included:o Sweatso mind racingo Yawningo anxietyo irritabilityo insomniao dizzinesso fatigueo loss of coordinationo mental slowness

Detection

• High performance liquid chromatography• MS

Management

• Supportive• No antidote• ?? if naloxone can reverse effects

The New “Designer Drugs”

• Hallucinogens o Lysergic Acid Amide (LSA):

• ergot and fungi infected plants and produce

• ten times less potent than LSD (Lysergic Acid Diethylamide)

• Seeds are crushed and eaten or soaked in water or alcohol and eaten.

• The effects last four to eight hours and can include: auditory and visual hallucinations; elevated blood pressure and heart rate; memory loss; anxiety; panic attacks; acute psychosis; and suicidal thoughts.

DESIGNER DRUGS

• MDMA (ECSTASY)

PMA (CARDIO AND NEUROTOXIC)

PMMA(NEUROTOXIC)

• PCP

PCC(DEATH)

Molly

• Hallucinogenic amphetamine

• Similar effects to MDMA and methamphetamines

• $50 - $100 per gram

2C-E Nicknamed "Europa"• synthesized in 1970’s -1980’s• psychedelic phenethylamine• taken orally• powerful hallucinogenic effects• high can last 6- 12 hours• sold through European sources• one death reported in MN on March 11, 2011

2C-E Nicknamed "Europa"

• synthesized by Alexander Shulgin

• popularized MDMA (Ecstasy)

• 2C-I another phenethylamine available

• 2C-E is chemically related to other 2C phenethylamines

• exact legal status is unclear - 2C-B banned under CSA

Methoxetamine

• Access via the internet• “Legal ketamine” – ketamine analog• Discovered in 2010

Piperazine Derivatives

• Amphetamine like – originally developed as an antihelminthic

• BZP, TMFPP – “legal ecstasy”• Schedule I in 2004

BZP

• Antidepressant• Inhibits serotonin transporter• Pills/powder• Effect lasts 6 – 8 hours• Takes 2 hours to get first effect• Management:

o Benzodiazepineso Fluidso Coolingo EKG

“Krokodil”

•Desomorphine (Dihydrodesoxymorphine) is an opiate analogue invented in 1932 in the United States that is a derivative of morphine•Desomorphine has attracted attention in Russia due to its simple production, utilizing codeine, iodine, gasoline, paint thinner, hydrochloric acid, lighter fluid and red phosphorus. •The street name in Russia for home-made Desomorphine made in this way is "krokodil" (crocodile), reportedly due to the scale-like appearance of skin of its users•Since the mix is routinely injected immediately with little or no further purification, "Krokodil" has become notorious for producing severe tissue damage including injury to the veins (phlebitis) and gangrene. Other consequences of use have included severe withdrawal, spread of HIV through the use of contaminated needles and death.

Pump-it! Powder:• Methylhexanamine• Source - found naturally in the geranium

plant• It is not scheduled by the DEA - legal• Banned in athletics• Stimulant• Not widely studied

Wet Marijuana

• Embalming Fluid-Soaked Marijuana: o The trend of smoking marijuana soaked in embalming fluid is

gaining popularity throughout the United States.  The syndrome of intoxication looks nearly identical to that seen following phencyclidine (PCP) use, with agitation, disorganized speech and thoughts, and diminished attention.   The authors believe that this new trend in drug use involving marijuana also presents a resurgence in PCP use.

• Soaked in water – uneven burn

• Mixed with THC: wet, fry, crystal joint, supergrass

“Jenkem”:• Fermentation of human

waste • Feces and urine stored in

tight container for several days

• Reaction produces methane gas

• Methane major component of natural gas

• “Huffed” by users producing anoxia

Growth of Designer Drugs

What’s different today then in the 1970’s when the drug Ecstasy (MDMA) was popularized?

What has changed to fuel the rapid development and distribution of designer drugs?

Internet!

over 100 million

over 2 billion

over 800 million users

What does the Internet offer?

• Improved accessibility

• Increased affordability

• Enhanced anonymity

Unfortunate Truisms:

• Legal controls that prohibit designer drugs will always lag behind their production

• Drug detection methods for the identification of designer drugs may also not be available when these compounds become popular

Erowid

Designer Drugs:• Designer drugs are here to stay

• Rapid evolving landscape

• Testing will nearly always lag behind

• Legal controls with be challenging and delayed

• Growing evidence of adverse effects

• Some become fads, others stay around (MDMA)

A Final Note

• New legislation

Legislation 2012

• The Synthetic Drug Control Act of 2012 (US Senate .3189) amends the Control Substance Act to add two classes of substances to schedule 1 – most addictive and most restrictive use with the highest legal implications if found to be using or selling:

o Cannabimimetic substances and analogs- all analogs of cannabinoid receptor agonists (CB1). This is the class of THC which stimulates the cannabinoid type 1 receptors in the brain

o Stimulants (bath salts are in this class) and all the isomers and analogs:• Methedrone• MDPV• Methylone• Naphyrone• Flephedrone• Methedrone• Ethcathinone• Butylone• Alpha-PPP• MOPPP• MDPPP• Alpha-PVP• MDAI• MPBP

Legislation 2012

• FDA Safety and Innovation Act (Reauthorization Bill)will change emergency scheduling of drugs from one year with a possible 6 month extension to 2 years with a possible 1 year extension.

• All future analogs of synthetic drugs (structure and/or function) will be schedule 1 if the bill is signed by the President.

• ONDCP will be unveiling a Synthetic Drug Prevention Toolkit, which we hope will serve as a resource for communities dealing with this issue. 

• Governor Cuomo Announces State Makes it Illegal to Sell or Possess Bath Salts or Synthetic Drugs (August 7, 2012)

o Governor Andrew M. Cuomo today announced that the New York State Department of Health (DOH) has issued new regulations to crack down on the increasingly widespread use of bath salts and other synthetic drugs.

o The new regulations, issued today by DOH and approved by the Public Health and Health Planning Council, will expand the existing list of prohibited drugs and chemicals to include dozens more substances that are now used to make synthetic drugs, better ensuring that distributors can no longer skirt the law by simply modifying the drug's ingredients. In addition, the regulations will allow for the first time an owner of an establishment and/or an employee selling synthetic drugs to be charged with possession of an illicit substance. Further, to support enforcement, the regulations will increase the criminal penalties for those who violate the rules. Violators will face fines up to $500 and potentially up to 15 days in jail.

• The Governor also announced a new toll-free hotline 1-888-99SALTS (1-888-997-2587). Individuals with information about illegal distribution of bath salts or synthetic drugs are encouraged to call this hotline.

Resources

• Synthetic Cannabinoids• 1. http://www.redwoodtoxicology.com/resources/

drug_info/synthetic_cannabinoids.html• 2. http://www.ncsl.org/issues-research/justice/synthetic-

cannabinoids-enactments.aspx• 3. http://www.justice.gov/dea/pubs/abuse/

drug_data_sheets/K2_Spice.pdf• 4. http://www.drugfreeinfo.org/PDFs/Synthetic

%20Marijuana%20Fact%20Sheet.pdf• 5. http://www.drugfreeinfo.org•  

Resources

• Bath Salts:• 1. http://www.webmd.com/mental-health/features/bath-

salts-drug-dangers• 2. http://www.drugabuse.gov/about-nida/directors-

page/messages-director/2011/02/bath-salts-emerging-dangerous-products

• 3. http://www.iowa.gov/odcp/docs/BathSaltsAlert.pdf• 4. http://www.iowa.gov/odcp/docs/

IAPoisonhotlineBathSalts.pdf• 5. http://www.drugfreeinfo.org•  

stevenkipnis@oasas.ny.gov

www.oasas.ny.gov/admed/

www.askdoctorsteve.com