Herbal Incense and Bath Salts An Awareness Presentation

Herbal Incense and Bath Salts An Awareness Presentation Kristine Nutt, LCSW, LCAS, CSI

Disclaimer �This presentation is meant to provide basic awareness information on herbal incense products and bath salts. �There are hundreds of products being smoked for cannabis-like effects �Manufacturers constantly change product ingredients and market products under new names to circumvent the law. �Constantly moving target �Product names and lists, as well as the list of synthetic cannabinoids, in this presentation are not all inclusive.

“SMILES”

“SMILES” • • • 2 C-1 Hallucinogen synthetic drug Part of the 2 C family of drugs Powder or Pill form Often mixed with chocolate and candy Schedule 1 class of drug in July 2012 • According to LAPD, there has been an increase of overdose deaths from this drug recently. Popular with teens and college students. • Formulas were published in book “Pi. HKAL: A chemical Love Story” (Transform Press, 1991)

“Smiles” • Dessa Bergen-Cisco, a Professor of Public Health at Syracuse University stated, “Basically, it’s a pure and potent form of estacy or MDMA”. • Effects are compared to a potent combination of MDMA and LSD with terrifying hallucinations and superhuman strength. • Overdoses have been reported in California, Ohio, and other states.

“Smiles”

“SMILES” • Recently in the news due to Johnny Lewis, 28, who was known for his role in the television show, “Sons of Anarchy” killed 81 year old landlady and her cat before jumping to his death. No evidence of drugs were found in his system. • One guy began beating his head into the ground. • One 17 year old in North Dakota overdosed and was observed shaking, growling, and foaming at the mouth. Another teen died the night before from the drug. • Does not show up on drug screens

Effects • Anxiety leading to panic attacks, seizures, distortions of time. Hyperventilation • Nausea and Vomiting • Terrifying auditory and visual hallucinations and feelings of fear and panic. Last hours to days. • Increased heart rate. Can cause strokes • Can cause seizures and kidney failure • Causes muscles to contract • Elevated body temperatures up to 107 degrees. • Giddiness and relaxed state

Bath Salts Video Clip

BATH SALTS • Refers to products containing synthetic cathinones, that are chemically similar to cathinone, an organic stimulant, that occurs naturally in the Khat plant. • Highly pure white or brown powder or crystal form. Mostly seen in powder form.

BATH SALTS • First developed in research labs and became a popular party drug in Europe and UK • Spread overseas around 2010 and began to show up mostly in states like Louisiana, Kentucky, and Tennessee. Some had regional names like “Hurricane Charlie” and “Bayou”. • Other product names include Bliss, Blizzard, Blue Silk, Ivory Snow, Vanilla Sky and Ivory Wave. • Became highly publicized with the cannibalistic attack in Miami.

BATH SALTS

BATH SALTS

BATH SALTS

Marketing �Sold commercially as bath salts, plant fertilizer, toy cleaner, pond cleaner, cell phone cleaner, jewelry cleaner, insect repellant, glass cleaner, and toilet cleaner. Newest is ladybug attractant. �Chemicals imported mainly from China and India �Sold mainly on the internet buy also in “head shops”, convenience stores, and gas stations. Some people have bought on e-bay. � It is not the stuff you find at Bath and Body Works!!!

Video of Bath Salts Sale

Chemical Makeup • There are several synthetic cathinones. The most common found in “Bath Salts” are MDPV (methylenendioxypyrovalerone), mephedrone(4 MMC), or methylone. The primary ingredient in most bath salts is MDPV. • MDPV – at least 4 x potency of ritalin or concerta. • 15 -30 minutes to onset, peak effects around one hour and last around 2 – 7 hours when used orally.

Bath Salts �Costs anywhere from $40 - $100 per gram. One gram contains 8 – 40 doses. �Taken orally, IV, nasal inhalation, or rectally. Snorting and swallowing are the most common methods of use. �High risk for overdose due to packages containing as much as 500 mg. Each packet contains varying amounts of the chemical.

BATH SALTS Marketed as legal alternative to LSD, cocaine, ecstacy, and methamphetamine. Labeled not for human consumption but the sole purpose is for human consumption.

Bath Salts – Generation 2 • New type of bath salt called Amped has been reported by users in Virginia. • Six people recently reported to hospitals in Virginia that they ingested this drug. • It is being marketed as ladybug attractant.

Naphyrone • Referred to as “Cosmic Blast” and marketed as jewelry cleaner. Contains MDPV and Naphydrone. Reuptake inhibitor of serotonin. • Stays in system for long periods. Body temperatures of up to 107 degrees have been reported.

BATH SALTS Users do not know how much or what they are getting. Very inexpensive and readily available high.

Video Effects

WHY DO PEOPLE USE IT? • • Experience euphoria Increased energy and alertness Increased arousal, energy, and motivation Sexual stimulation/aphrodesiac Feel as if they don’t need to sleep or eat Increases sociability Mental stimulation

WHAT DO THEY DO? • “MDP V increases the body’s concentration of adrenaline-like hormones that prepare the heart and muscle tissue for “flight or fight” response”, explained Thomas Penders an associate professor at ECU. • "One system of circuits in our brains are wired to detect and respond to threats. Overstimulation of this circuit leads to overestimation of actions by others as threatening. When the system becomes overwhelmed, as it does [from an overdose of] 'bath salts, ' a condition develops known as 'excited delirium, '" he said • This is characterized by a pattern of paranoia, agitation, and violent behavior.

WHAT DO THEY DO? • Overdoses of crack cocaine, methamphetamine, ecstasy and PCP can also induce "excited delirium. " It's a state of paranoid fearfulness and rage mixed with seemingly superhuman strength, as more oxygen is delivered to muscles, increasing their power. "This, to some extent, explains the bizarre aggressive behaviors we have seen during the recent rash of 'bath salt' cases, " Penders said * • “Science” on nbcnews. com 6/4/2012

Bath salts vs. Cocaine/Meth • Like Amphetamines, Mephedrone releases dopamine from cells, while MDPV, like cocaine blocks the reuptake of dopamine into the cell. • MDPV is ten times stronger than cocaine. • Taking Bath Salts is like taking Cocaine and Meth together • Time delay – Mephedrone releases dopamine before the reuptake is blocked. • Pbs. org – September 2012

Bath Salts and The Brain •

EFFECTS • Increased dopamine and serotonin and affects mood and perception. • Cold fingers and an intolerance to pain • Body temperatures of up to 107 degrees have been reported. Often people take their clothes off. • Jerking eye movements and foaming at the mouth have been reported. Vomiting. • Restlessness and inability to sit still. • Insomnia – sleep deprivation * - Some people take Xanex and other drugs to try to sleep.

EFFECTS • Increased heart rate and blood pressure. • Panic attacks and chest pains are often why people show up in ER’s. • Auditory and Visual Hallucinations with common themes of monsters, demons, aliens, and God. • Irritability, suicidal thoughts, and self-harm behaviors. • Diminished thirst • Can relapse into hallucinations and paranoia weeks after last use.

BATH SALTS: Dangers and dependency

Concerns �A Marquette County, Michigan ER reported 35 admissions from November 2010 to March 2011. This prompted Law Enforcement to seize all bath salts from a local convenience store. The products tested all contained MDPV. � 17 out of 35 were hospitalized. Median age was 28 years (range 20 -55 years). One death reported. � 54% were Men, 69% self-reported a history of drug abuse, 46% or 16 patients had a history of mental illness, and 17% reported suicidal thoughts/attempts related to use of bath salts. � “Morbidity and Mortality Weekly Report, Vol 60, May 20, 2011, 624 - 627

Concerns • US Army Medic, David Stewart, killed his wife and 5 year old son in April 2011 after he and his wife were using bath salts. He shot his wife and suffocated his son the day before. Toxicology reports confirm they were using “Lady Bubbles” bath salts. • According to the Bangor Daily News, domestic violence calls have increased in Maine due to use of Bath Salts. • Cookeville Regional Medical Center in TN has treated 160 people since 2010.

Dangers and Dependency �A research study led by UNC professor CJ Malanga, MD found that mephedrone, like cocaine, has a high potential for abuse and addiction. �“The effects on the brain’s reward circuit are comparable to similar doses of cocaine” • The rodents in the study worked harder to get less reward. The drug activated the brain’s reward circuit involved in positive reinforcement. NIDA. org 2012

Legality �The Synthetic Drug Prevention Act signed by President Obama on July 9, 2012. This act bans the synthetic compounds found in synthetic THC and 29 compounds found in Bath Salts, and makes them Schedule I. �States will have to incorporate these into their drug scheduling list and update the list as new substances are discovered.

Operation “Logjam”

Operation logjam • July 26, Operation “Logjam” seized 5 million packets of synthetics and arrested 90 people in a nationwide effort to crackdown on these drugs. • Tested products contained anywhere from 17 milligrams to 2000 milligrams of chemicals.

Poison Control Center Data CALLS TO POISON CONTROL: 304 in 2010, 6, 138 in 2011, and 2654 as of December 2012. e 3 31, 2012. Ages <6 to over 59. Most ages 20 – 29. January – 228/301 July – 361/680 February – 230/487 August – 173/602 March – 264/639 September – 119/512 April – 285/600 October – 98/401 May – 295/720 November – 86(2012) June – 415/743 December – 78(2012) www. aapnc. org 1 -800 -222 -1222

B

TREAMENT • Often eat up Emergency Room resources as it takes multiple nurses and doctors to treat users. • Difficult to know what someone has taken unless they self-report or someone else reports. • Does not show up on typical toxicology screens and can not be detected by drug dogs. There are now drug tests that do test for Bath Salts. Ammon labs, Redwood Toxicology, and Dominion Diagnostic offer these drug screens.

TREATMENT • Antipsychotics to treat psychosis • Benzodiazepines to decrease agitation • Ten to twenty times the normal dose of sedatives have been used. • Try to avoid using restraints, but speak reassuringly to people who are agitated and paranoid • Move to a quiet room with low light to help calm patient. • Avoid loud noises and try medications prior to restraint.

TREATMENT • Monitor the person for suicidal ideation even after they have stopped using the drug. Address both mental health and addiction issues. • Psychotic symptoms often persist after treatment • Enhance coping skills to assist the person in dealing with anger and other emotions. • Glass may exacerbate psychotic symptoms. • Train staff to deal with specialized issues and incorporate questions into intake and assessment.

Movie Madness • BATH SALT ZOMBIES • Available on DVD February 19 • is a new horror film directed and co-written by Dustin Wayde Mills (Puppet Monster Massacre, Zombie A-Hole, Ballad of Skinless Pete) and produced and co-written by Clint Weiler of Aggronautix. The movie sensationalizes the recent bath salt epidemic and the attacks surrounding them

“Zombie Apocalypse” • The shocking wave of attacks associated with Bath Salts has sparked fears of a real-life zombie outbreak in the south. This led to The Center for Disease Control and Prevention releasing a statement saying it is not aware of any virus that can cause zombie-like behavior.

What next? • Partnerships and networks between the community and law enforcement have made an impact in the sale and distribution of this drug. • Education regarding the dangers of Bath Salts.

Spice / K 2

What is Spice and K 2? • Spice and K 2 refer to commercially available products sprayed with chemicals called synthetic cannabinoids. These products claim to be a mixture of herbs but often do not have herbs in them. They include other ingredients that are unknown and not listed. • Many have warning labels as not intended for human consumption, but are solely intended for human consumption. Marketed as incense. Resembles potpourri.

Synthetic Cannabinoids • Synthetic Cannabinoid products are manufactured in Asia and sold in US in many different arenas (gas stations, liquor stores, smoke shops and internet) • Sold under different brand names: “K 2, Spice, Spice Gold, Spice Black, Mr. Nice Guy, Yucutan Fire and many others” • Since the national ban on five synthetic cannabinoids, new brand names have developed, such as K 2 Sky, K 3, and K 4

What is a Synthetic Cannabinoid? • A class of synthetic substances that bind to the cannabinoid receptors(CB 1 and CB 2) in the body. When used they create a high similar to THC. Bind more strongly than THC. There are hundreds of synthetic cannabinoids. • Used in an attempt to avoid laws that make marijuana illegal. National Ban on five cannabinoids began in March 2011.

History of Spice and K 2? � The cannabinoid-like chemicals were first developed in research laboratories to study receptors in the body and brain and for other research purposes. The five banned cannabinoids are JWH 018, 073, 200, CP 47, and 497. �JWH-018 was first made in 1995 by Dr. John Walter Huffman at Clemson University. Manufacturers read research and copied it to produce this cannabinoid and marketed it for commercial distribution. �Brand “Spice” was released in 2004 and gained popularity in 2006.

Spice and K 2 �The company that started the “Spice” line went from assets of 65, 000 Euros in 2006 to 899, 000 Euros in 2007. Spice was the dominant brand until 2008. Then competing brands like “K 2” hit the market. Now there are many distributors of these products. �Rick Broider with North America Herbal Incense Trade Association estimates profits at 5 billion per year. �In 2011, Redwood Toxicology Lab developed testing for six synthetic cannabinoid chemicals. 72 hours for urine and 24 – 48 for saliva.

Spice Products • • Spice Gold Spice Diamond Spice Tropical Synergy Spice Arctic Synergy Spice Gold Spirit PEP Spice

Many Faces of Spice

K-2/SPICE

Other Herbal Incense Products �Genie �Yucatan Fire �Dream �Ex-ses �Blaze �Spike 99 �Blaze �Spark �Fusion �MANY others!

Spice Ingredients �One or more synthetic cannabinoid compounds. Can be different mix each time. �JWH-018, CP 47, 497, C 8, JWH-073, and JWH 250 have been found most often in spice products. �Other legal substances such as Pink Lotus, Dwarf Skullcap, Indian Warrior, and Lion’s Tail �Potentiate or add to effects �Create different effects between products �Many have psychoactive effects on their own �Some used as marijuana substitutes in the past. �Cost $30 - $40 per 3 gram bag.

Other Synthetic Cannabinoids HU named after Hebrew University where they were created. • HU-210 – Various studies show it is anywhere from 66 -800 times more potent than ∆9 THC 1 – Schedule I under CSA: Illegal in U. S. • HU-211 – Studies tentatively show no ∆9 THC-like effects – Used to research treatment of brain damage related to stroke, brain trauma, glaucoma, and multiple sclerosis • HU-311 – Has potent antineoplastic and antiproliferative activity (cancer fighting drug) 1 J. Med. Chem. 35 (11): 2065– 9.

BIZARRO - ZENCENSE

BIZARRO

Bizarro • Personal Experience and Effects: • My personal experience with Bizarro has been very enjoyable. The high itself is very distinct and very powerful. When you take a hit, you almost immediately start to feel the spice high creep into your mind and body. To some extent, the effects of Bizarro are similar to the effects of other herbal incense brands but it also very unique. The high is extremely intense. It gives a real “downer” effect; that very relaxing and euphoric feeling that you get when you smoke weed. It might make you pass out for an hour or it might just make you a little sleepy, but it will definitely relax your mind and body. You will find that the level of drowsiness decreases as your tolerance builds up. Bizarro is also a very trippy brand of herbal potpourri as well. Imagine that classic high effect that you see in movies. Things feel weird as fuck, and appropriately; bizarre. You see shimmering things in the trees and you realize that the cat you were just talking to is actually the shirt that you don’t remember taking off. Again, It is VERY trippy; almost a hallucinogenic experience. The effects from Bizarro usually lasts for about 45 minutes to 90 minutes, depending on tolerance levels. You can easily get high from a single hit, as it is very potent. There also negative effects that you can experience from Bizarro. Burning too much in a short amount of time can lead to unconsciousness, vomiting, thinking you are dead, and other afflictions. I have seen these effects on people many times and it is usually caused when someone takes a very large hit or several hits in quick succession. They basically get so high that they can’t move, they vomit on themselves, and they do not respond to outside stimuli. This happened to me before so I know that even for someone who thinks they are prepared for the full blast that Is Bizarro, they should use caution because I thought so as well. The good part is that these disturbing effects usually only last for about 5 or 10 minutes. By that time, mind starts to accept that It is tripping that fucking hard and the ill effects start to go away to be replaced by a nice high. You still might have to clean the vomit off yourself though. Another thing about this type of experience is that it usually only happens once. That one time is all you need to teach you the moderation that you lacked when you smoked more than you could handle

Bizarro • At a glance: • Out of all the varieties of incense that I have burned, a fairly large number, Bizarro is my personal favorite. That being said, I wouldn’t recommend Bizarro to just anyone. It is for experienced users and is not to be underestimated. As with other brands of herbal potpourri, the psychoactive effects from Bizarro should not be set alongside cannabis. They are much more intense and harder to control. Bizarro is a great brand of incense if used correctly, but it can also render terrifying experiences to those who dive in too fast.

Synthetic Cannabinoids �CP 47, 497 and analogues (CP Created by Pfizer) � 3 to 28 times more potent than ∆9 THC �CP 55, 940 � 45 times more potent than ∆9 THC �JWH-015 �JWH-018 4 -5 x more potent than THC and same chemical structure shared with known cancer causing agents. �JWH-073 �WIN 55, 212 -2 (WIN is for Sterling Winthrop) �Used to research treatment for Alzheimer's �Effects milder and don’t last as long as ∆9 THC

Other Herbal Incense Ingredients (Not all inclusive) �Baybean �Blue Lotus �Lion's Tail �Lousewort �Indian Warrior �Dwarf Scullcap �Maconha Brava �Indian Pennyworth �Clove �Hops �Tribulus Terrestris �Pink Lotus �Marsh Mallow �Red Clover �Rose �Vanilla and Honey �Fly Agaric �Siberian Motherwort �Damiana �Stevia Leaf �Lemon Grass �Turnera diffusa Many other legal herbs and herbal extracts are used to enhance aroma, potency

Dangers of K-2/Spice Video

Why Do People Use It? • Legal substitute to marijuana • Herbal incense products are smoked or snorted for marijuana-like effects • Other reasons: increase creativity, reduce stress, experience euphoria, increase personal insight, and increase appreciation for the arts • There are numerous blogs and websites the provide users the opportunity to share experiences.

Effects • Marijuana-like effects: euphoria, giddiness, silliness, bloodshot eyes, impaired short-term memory and concentration, and “munchies. ” • Other common effects: cotton mouth, light sensitivity, a warm sensation in the limbs, dry eyes, paranoia, light headedness, auditory and visual hallucinations, painless head pressure, time distortion, panic attacks, delirium, impaired coordination, and sleeplessness • Onset/duration: 5 -10 minutes, and effects vary from 2 hours for JWH and 5 -6 for CP. Can get high off a hit or two.

Effects • A number of users experience hangover-like effects the morning after use including dry mouth, intense headaches • Depending on the product, inhaled smoke is as harsh as marijuana smoke – Taste can vary from a very bad to sickly sweet.

Effects • One hospital reported a patient with a 1 -3 gram a day habit and severe withdrawal symptoms (tremors, headache, nausea, vomiting and depression). • One person reported spending $2000 in the last month on Spice and Bath Salts.

Dangers �A Boston University School of Medicine study suggests that use may cause increase in paranoia, hearing voices, disorganized behavior, and panic symptoms. �Psychotic symptoms may last for a few days to months. �Another study found these products may create psychosis in patients with no history of psychiatric disorder. �Overdose potential from unknown amounts and ingredients in products.

Ppp Bpp Poison Control Centers Data

Dangers Poison Control Centers had 112 calls in 2009, 2906 in 2010, 6, 959 in 2011, and 5200 by December 31, 2012. �Users are experimenting with combining different products, which can dramatically change or increase the effects. These cannabinoids were created for experimental use. Not tested on people. No one knows long term effects of these products. �Public health concern over possible metal residue in these products.

Dangers • JWH-018 and others, have a shared chemical structure with cancer causing agents, according to NIDA. • A hospital in Kansas reported 8 -10 people hospitalized in past month after smoking the products with hallucinations, seizures and bleeding from the nose and mouth. • Three teens ages 16 and 18, showed up in ER with anxiety, agitation, excessive sweating, and inability to speak.

Dangers • Kids’ brains are still developing. • Across the US, people are showing up in emergency rooms with aggressive and unusual behavior. Suicides have been reported. • A NIDA study stated 11% of school seniors have used Spice/K-2 in 2011. Second most frequently used drug after THC. • Medical personnel often don’t know what they are dealing with unless the person self-reports.

DANGERS

Appearance • Most herbal incenses appear as an olive green leafy material very similar in appearance to marijuana, oregano

Paraphenalia • Herbal incense smokers will use the same or similar products used by marijuana smokers – Pipes, bongs, hookahs – Rolling papers – Blunts (hollowed out cigars packed with product) • Herbal incense specific paraphernalia – Vapor Genie – Grinders (to further grind into a finer mixture)

Hookah

Vapor Genie Grinders

Controlled Substances Act �In Nov. 2010, the USDEA moved to ban 5 synthetic cannabinoids, placing them in Schedule I status due to high potential for abuse, and no known medical benefits. The ban would be in effect for one year. �The ban was delayed due to companies stating the ban was unconstitutional. �On March 1, 2011 the National Ban was enacted. �This means that is illegal to possess and sell products containing these. �Before the ban, 15 states had already taken action to control one or more of these five chemicals.

Challenges - Manufacturing • Manufacturing occurs in countries where synthetic cannabinoids are legal. • As detection catches up with manufacturing, makers will alter ingredients. They are using new ingredients which are not illegal at this time. • Federal bans target larger distributors. States will need to go after smaller distributors.

Challenges - Marketing • Product will not cause positive drug test • “There's never been a case reported by our clients that any of our Herbal Smoke Blends caused them to fail a test” • “YOU'LL NEVER FAIL A DRUG TEST” • Why would this be an issue for a product marketed as incense and not for human consumption?

Challenges - Marketing • Ingredients 1 – Synthetic cannabinoids not listed – Listed ingredients are not necessarily in the product – Consumers don’t know what they are actually getting – Raises questions of consumer protection and product misrepresentation 1 Understanding the ‘Spice’ Phenomenon Thematic Paper, European Monitoring Centre for Drugs and Drug Addiction, 2009, Portugal

ENERGY DRINKS

ENERGY DRINKS • American Association of Poison Control Centers – (www. aapnc. org) urges the public to use caution using these products. • Highly concentrated amounts of sugar, caffeine, and other ingredients. Was mixed with alcohol in the past and sold next to bath salts. • Caution for children and adolescents. Children should not have it and adolescents should not have more than 100 mg of caffeine per day = one cup of coffee* *Journal of Pediatrics

Energy Drinks • Due to labels, it is often hard to know how much caffeine is in the drink. • Drinks contain natural caffeine-containing ingredients that are not separately listed, such as, yerba mate, cacao, and guarana. • These drinks are considered dietary supplements and not regulated by the FDA so there is no limit to amount of caffeine that can be in them. • Drinking too many at one time or too fast ……. .

EFFECTS • • • Nausea and vomiting Seizures Insomnia Kidney Problems Delirium Mood Changes Headache Increased BP Altered and increased heart rhythm Withdrawal Chest Pains Dehydration Sweating

BATH SALTS & ENERGY DRINKS • A 28 year old man was found passed out in a random person’s driveway, and was taken to the hospital. It was discovered that the man had overdosed on energy drinks and bath salts. • According to a report by the Caledonia Police, officers found the man lying on the floor of his van. • An individual said he found the van in his own driveway. The individual stated the engine was off and that no keys were found in the ignition. The victim was found slouched over the steering wheel. There was a cell phone in the man’s possession, and the last dialed contact was that of his mother.

POISON CONTROL CENTER • 2607 calls to Poison Control Centers related to the use of Energy Drinks through October 31, 2012

Resources • Life Center of Galax is equipped to treat persons using these substances. Our confidential referral and assessment number is 1 -800 -3456998. We are available 24/7 to speak with anyone.

Thank You