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November 29, 2010 (simone)
1. Northern New England Poison Center
Teen Poisonings
from RX Drugs to K2, Salvia and Monster
Karen E. Simone, PharmD, DABAT
simonk@mmc.org
1
207-662-7221
2. Contents
⢠Overview of poisoning (abuse, suicide, other)
⢠Types of teen substance abuse poisonings
⢠Most commonly abuse substances (by teens)
⢠Substances used in teen suicide attempts
⢠Information about the substances abused
2
3. Northern New England Poison Center
Staff
⢠Physicians board-certified in Toxicology
⢠PharmD board-certified in Toxicology
⢠Nurses nationally-certified in Poison Information
⢠Nurses in Training
⢠Nurse Educators, some with Public Health Masters
⢠EMTs and other providers (under supervision)
⢠Administrative, including toxicsurveillance specialist
3
4. Northern New England Hotline Calls
N = 107,533
Human Poisonings
30%
Animal Poisonings
2%
Confirmed Non-
Exposures
<1%
Questions ME, NH, VT; 2009
68% 4
5. Types of Poisonings
Hotline Call Reasons
⢠Unintentional
â General, environmental, misuse, therapeutic error,
occupational, food poisoning, bite/sting
⢠Intentional
â Abuse, misuse, suicide attempt
⢠Other
â Malicious, tampering/contamination, withdrawal
⢠Adverse effect
â Drug, chemical, other
⢠Unknown
5
â Drug, chemical, other
7. Poisonings in Teens 13 - 18 years
N=926
Suicide Attem pt
24%
Unintentional:
26% therapeutic error
29% misuse
Substance Abuse/Withdraw al
12%
Other Intentional
11%
Adverse /reaction
3%
Unintentional Malicious/tam pering
47% 2%
Unknow n
1%
ME from July 2009 - June 2010
7
8. Substance Abuse/Withdrawal
Children under 19 years
N=156 substances
Alcohol: Mostly
unknown beverage,
Other
some vodka and
9% tequila, Listerine spray
Dextrom ethorphan
Plants/m ushroom s and hand sanitizer
4% 21%
Antidepressants
5%
Inhalants: Keyboard
cleaner, disc cleaner,
Antihistam ines spray paint, markers,
6% helium, nail polish
remover, fire
extinguisher
Inhalants
6% Stim ulants/street drugs
18%
Sedatives/hypnotics
Plants: Nutmeg (3),
9% kratom (1)
Alcohol Analgesics (opioid m ostly)
10% 12%
Substance Abuse 8
ME from July 2009 - June 2010
9. Stimulants and Street Drugs
Children under 19 years
N=28
Cocaine
K2 4%
7%
Ecstasy and related
11% Marijuana
35%
Caffeine (pills/drinks)
14%
ADHD Medications Substance Abuse
29% 9
ME from July 2009 - June 2010
10. Analgesics
Children under 19 years
N=18
Unknow n opioid
6%
Hydrocodone (Vicodin, Lortab) Buprenorphine (Suboxone)
6% 21%
Tram adol (Ultram )
11%
Ibuprofen (Motrin)
11%
Acetam inophen (Tylenol)
17%
Codeine
11%
Oxycodone (OxyContin,
Percocet)
Substance Abuse
17% 10
ME from July 2009 - June 2010
11. Sedatives/Hypnotics
Children under 19 years
N=14
Antipsychotic
21%
Benzodiazepine (Xanax,
Ativan, Valium , Klonopin)
43%
Zolpidem (Am bien)
36%
Substance Abuse
11
ME from July 2009 - June 2010
12. Suicide Attempts
Children under 19 years
N=336 substances
Other
Sedatives/hypnotics 9%
13%
Antihistam ines
6%
Cough and cold
5%
Alcohols
Antidepressants
4%
19%
Stim ulants/street drugs
4%
Anticonvulsants
3%
Vitam ins
2%
Antibiotics
2%
Cardiovascular
Analgesics 2%
31%
Suicide Attempts
ME from July 2009 - June 2010 12
13. Analgesics
Children under 19 years
N=106 substances
Aspirin
10%
Acetam inophen (Tylenol) Opioids
30% 9%
Acetam inophen w ith
(diphenhydram ine, caffeine,
m enstrual)
9%
Acetam inophen and Aspirin
6%
Other (phenazopyridine)
1%
NSAIAs (ibuprofen, naproxen)
35% Suicide Attempts
ME from July 2009 - June 2010
13
14. PCP (Phenycyclidine)-like
⢠Dextromethorphan (DXM) +/- antihistamine
â Slang: DXM, RoboTrip or Triple C
â Products: Robitussin DM, Coricidin HBP for Cough and
Cold, others
⢠Dissociative analgesic/anesthetic in overdose
â Caused by metabolite â dextrorphan
â Dissociation of thalamoneocortical from limbic systems
⢠Drowsiness or agitation
â Coma or seizures possible but not common
⢠Vertical or rotary nystagmus may be present
⢠Large or small pupils possible 14
15. Amphetamines
⢠Amphetamine brand names: Adderall,
Dexedrine, Vyvanse
⢠Amphetamine-like brand names: Ritalin,
Concerta, Methylin, Focalin
⢠Medical concerns:
â Increased heart rate and blood pressure (irregular
heart rhythm, heart attack, stroke)
â Increased body temperature
â Seizures
â Psychosis Similar to cocaine
â Addiction 15
16. What do all of these products have in
common?
16
20. What effects can occur?
⢠Stomach: upset stomach and vomiting,
sometimes abdominal pain and diarrhea
⢠Nervous System: anxiety, agitation,
irritability, tremor, headache, dizziness,
hallucinations (not common) and seizures
⢠Heart: rapid heartbeat, increased blood
pressure, chest pain and irregular rhythms
20
21. Energy Drinks - Teenage
Problem?
⢠Large amounts are available in forms
marketed to teens and young adults.
⢠Teens and young adults often lack the
good judgment to limit dosing.
⢠Some ingest up to 5 cans of energy
drink (equivalent to 8 cups of coffee) in
one sitting.
21
22. What about caffeine
with alcohol?
⢠More risky behaviors (possibly)
⢠Not safer to drive: performance not
significantly better, in some ways worse
⢠May not realize unsafe to drive: may
have false sense of ability to drive safely
22
23. What about carbs and calories?
⢠Sobe Adrenaline Rush 16 oz (2 servings):
â Calories: 260
â Carbs: 68 g (22%) with 66 g as sugars
⢠Red Bull 8.3 oz (1 serving) â double if 16.9 oz:
â Calories: 110
â Carbs: 28 g (9%) with 27 g as sugars
23
25. Winner â Most Carbs
⢠Sobe Adrenaline Rush 16 oz (2 servings):
â Calories: 260
â Carbs: 68 g (22%) with 66 g as sugars Coke and Pepsi
have ~ 40 g carbs
⢠Starbuckâs Grande Latte 16 oz: per 12 oz
â Calories: 280 (150 calories)
â Carbs: 36 (12%) with 34 g as sugars
⢠Krispy Kreme Donut â Chocolate Iced Kreme Filled:
â Calories: 350
â Carbs: 39 g (13%) with 23 g as sugars
⢠McDonaldâs Big Mac:
â Calories: 540
â Carbs: 45 g (15%) with 9 g as sugars
Caloric intake (16 â 18 yrs): 1800 â 2400 (females), 2400 â 3200 (males)25
26. Mushrooms (Shrooms)
⢠Timing:
â Onset: 10 â 30 minutes
â Duration: 4 â 5 hours
â Back to normal: 6 â 12 hours
⢠Effects:
â Fast heart rate, increased blood pressure, large
pupils, dry mouth, nausea/vomiting
â Uncontrollable laughter, vivid hallucinations (bright
colors and shapes)
â Loss of sense of time, meditative
26
27. Salvia divinorum
⢠Names:
â Divinerâs sage, magic mint, Maria Pastoria
⢠Use:
â Ceremonial healing
â Divination rituals
â An entheogen (âthat which causes god to be within a
personâ)
⢠Component: salvinorin A
â Type: ?dissociative hallucinogen?
⢠Similar to: PCP, ketamine and DXM
â Mechanism: Opioid kappa agonist
⢠Similar to: butorphanol (StadolŽ) and pentazocine (TalwinŽ)
â Dose: 100 â 200 mcg 27
29. Salvia divinorum
⢠Hallucinogenic effects:
â Type: out of body experience, entering another
reality, time and space displacement
â Effects: altered perceptions, hallucinations, ataxia,
depersonalization, hysterical laughter, incoherent
speech, unconsciousness
â Onset/duration: rapid/an hour or so
â Dose relationship (inhalation):
⢠Hallucinations: 0.2 â 0.5 mg
⢠Out-of-body experience: > 1 mg
29
30. K2 (Spice, Spice Gold)
⢠Synthetic cannabinoid (JWH-
018 and JWH-073)
⢠Anticipate similar effects to
marijuana
⢠Probably not illegal yet
⢠Not anticipated to cross with
marijuana screens
30
32. Kratom â per label
Stimulant and Depressant?
Amazing legal high / herbal high!
Low dose: stimulating and euphoric
High dose: sedative at higher doses
Plant: mitragyna
Active ingredient: mitragynine
Mechanism: stimulates delta opioid receptors
Effects:
Calms the mind, lowers anxiety
Causes to feel: happy, strong, and active, with a
strong desire to do work
Onset: 5 - 10 minutes after use
Duration: several hours (longest with highest dose),
positive afterglow effect possible 1 day after use
High dose effect: a state of blissful euphoria with the 32
possibility of mild visuals
33. Kratum (mambog) â per science
⢠Mitragyna with mitragynine
⢠Psychoactive, opioid substitute
⢠Use: increase productivity and heat tolerance
⢠âTherapeuticâ effects:
â Onset 5 â 10 minutes after chewing leaves
â Type: mild euphoria and stimulation
⢠Overdose:
â Effects: nausea, vomiting, flushing, stupor, vertigo, giddiness, tremors of
face, extremities and tongue, rombergism (loss of positional sense â
unable to balance standing with feet together and eyes closed)
⢠Chronic toxicity:
â Effects: anorexia, weight loss, abdominal distension and constipation,
skin discoloration (dry, unhealthy, tan without sun OR pallor), (numbness
and twitching)
⢠Withdrawal:
â Effects: aggression, tearfulness, runny nose, muscle aches, âjerkyâ
motions 33