Street drugs guide Fall 2022 (PHRM 48600)

Street drugs guide Fall 2022

Created by students enrolled in PHPR 48600 Beyond ecstasy

Compiled by Cynthia Koh-Knox Sharp, PharmD, RPh

Purdue University College of Pharmacy

First day ABCs

Last day ABCs

OTC Analgesics: Acetaminophen

History of Use and Abuse

KristenMouser

Acetaminophen was approved as an over-the-counter (OTC) analgesicby the FDA in 1955.1 It is currently the most common drug ingredient, being incorporated into over 600 different medications.2 With it being used in so many patients at an uncontrolled rate, comes a high amount of overdose A study done in 2021 reveals that around 56000 emergency room visits and 26000 hospitalizationsare due to acetaminophenoverdoses each year.3

The use of the medication continues to grow, and overuse tends to occur due to self-treating and the addition of OTC acetaminophen to an already prescribed medication with acetaminophen in it.4 A research article evaluating the use of nonprescription analgesics, reveals that in a study of 39767 people 38.3% reported havingused acetaminophen more than once a week for the past month.4 Then even more specifically, 10.6% of participants reported utilizing it at least once daily in the past month.4 These results reveal the frequency of acetaminophenuse in the population.

The majority of patients who reported usinghigh amounts of acetaminophen, also reported having intermittent opioid use and chronicpain (71.5%)

4Chronicpain is defined as pain that lasts more than 3 months.5 Patients experiencingthis use analgesics to make themselves more comfortable, but the problem is developingtolerance and dependence, which ultimately can lead to an increased risk of overdose. Tolerance is establishedfrom the frequent exposure to a medication where they begin developinga resistance to it, meaningthey will need a higher dose to elicit the same response.6 Then dependence is also due to the frequent use of a medication where they grow accustomed to it being in the body.6 This can create an environment where the body wont function without the medication and even if the pain resolves, the patient will feel the need to continue utilizingit.

An acetaminophen addictionis not usually due to the

same reasons as many other drugs. Unlike opioids or illicit substances there is no “high” or sense of euphoria. However, a few studies show that it may reduce emotional response.7 This indicates that those who use acetaminophen at a higher than recommended level may have reduced neural responses and has shown a decrease in both positive and negative emotions.7

Other Names for Acetaminophen

- Pain meds

- Liver killers

- Painkillers

Pharmacology/ Drug Effects

https://www.flaticon.com/free-icon/pain_387630

Acetaminophen is used as an analgesicand antipyretic, but unlike NSAIDs it does not show peripheral anti inflammatory effects. The mechanism of action is still unknown;however, it is thought to work by inhibiting the COX pathway which blocks prostaglandinsecretion in the central nervous system.8 By acting on the hypothalamus the medicationis able to play a role on temperature and reduce fever. Then there is thought to be an antinociceptive effect that occurs by activating the descendingserotonergicpathways.9 This is the response mechanism of sensory neurons to toxicities, injuries, or pain.9 With this occurring in the central nervous system it is possible this is also the cause of the reduced emotional response.

Drug interactions/ toxicology

Acetaminophendoesn’t have any severe interactions with other medications. However, it does have drug disease interactions with alcoholism and liver disease.10 Elevated and sometimes prescribed amount of acetaminophencan cause hepatotoxicity indicated by elevated serum aminotransferase.11 When there is an overdose, it can result in jaundice, confusion, acute liver injury and failure that can lead to death or need for a liver transplant. 11

Professional opinion

I would recommend Acetaminophen as a short term, as needed therapy for pain and fever management. I would consider it to be safe and have a low chance of addiction. The main concern is it is easy to overdose, patients need to be properly educated on maximum dosingand the large incorporation of acetaminophen into combinationproducts. ~ K. Mouser

References

1. Leichty J. Selection of AcetaminophenforConsiderationfor Listing . US FDA. https://oehha.ca.gov/media/dockets/19653/19710u.s._food_and_drug_administration_fda/fda_comments_notice_of_avai lability_of_hazard_identification_materials_for_acetaminophen_11420 19.pdf.Published 2019.Accessed October 10, 2022.

2. Acetaminophen.ConsumerHealthcareProductsAssociation. https://www.chpa.org/our-issues/otcmedicines/acetaminophen#:~:text=Acetaminophen%20is%20the%20m ost%20common,%2C%20cold%2C%20and%20allergy%20medicines. Published 2022.Accessed October 13, 2022.

https://www.shutterstock.com/image-illustration/conceptual-image-druginducedhepatotoxicity-3d-illustration-774287005

Laws

Currently there are no laws concerning OTC acetaminophen. In the past there have been actions made to limit the amount of drug to 325mg per unit in combinationproducts.12 This is to make the product safer for patients by reducingrisk of accidental overdose. 12

Monitoring/ drug screens

Patients frequently usingacetaminophen should first be informed of the maximum daily dosage of 4 grams a day in patients with normal liver function. It is also important to monitor for signs and symptoms of hepatictoxicity.13 These include dark colored urine, light colored bowel movements, jaundice, and loss of appetite.13 If there is an overdose the serum or blood acetaminophenlevel should be obtainedafter 4 hours of ingestion.13 If the level is at or above 150 mcg/mL then begin on acetylcysteine, the medication used to manage an acute overdose.13 If the acetaminophen level remains elevated an ALT or AST will be obtained after the acetylcysteine infusion.13 Then the infusion will continue until an ALT of less than 50% and an acetaminophenvalue of 10 mcg/mL.13

3. WhatHappensif youTakeToo MuchAcetaminophen?Piedmont Healthcare.https://www.piedmont.org/living-better/what-happens-ifyou-take-too-muchacetaminophen#:~:text=%E2%80%9CAcetaminophen%20overdose%2 0is%20one%20of,patients%20aged%2015%20to%2024.%E2%80%9D. Accessed October 13, 2022.

4. Dale, O., Borchgrevink, P.C., Fredheim, O.M.S. et al. Prevalence of use of non-prescription analgesics in theNorwegian HUNT3 population: Impactof gender, age, exercise andprescription of opioids. BMC Public Health15, 461 (2015). https://doi.org/10.1186/s12889-0151774-6

5. Commonlyusedterms. Centers for Disease ControlandPrevention. https://www.cdc.gov/opioids/basics/terms.html.Published 2021. Accessed October 13, 2022.

6. Acetaminophen -over-the-counter painmedicationabuse.New Beginnings Drug Rehab. https://www.newbeginningsdrugrehab.org/acetaminophen.Published 2019.Accessed October 13, 2022.

7. Grey H. Tylenol relief from emotionaldistress. Healthline. https://www.healthline.com/health-news/tylenol-relieve-hurtfeelings#May-blunt-positive-emotions,-too. Published 2017. Accessed October 13, 2022.

8. Gerriets V, Anderson J, NappeT. Acetaminophen.StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK482369/.Published 2022. Accessed October 14, 2022.

9. Dogrul A, Seyrek M, Akgul EO, CayciT, KahramanS,Bolay H. Systemic paracetamol-inducedanalgesicandantihyperalgesiceffects through activationof descendingserotonergic pathwaysinvolving spinal5-HT₇ receptors. Eur J Pharmacol.2012;677(1-3):93-101. doi:10.1016/j.ejphar.2011.12.016

10. Acetaminopheninteractionschecker.Drugs.com. https://www.drugs.com/drug-interactions/acetaminophen.html. Accessed October 13, 2022.

11. Toxic hepatitis. MayoClinic. https://www.mayoclinic.org/diseasesconditions/toxic-hepatitis/symptoms-causes/syc-20352202.Published 2022.Accessed October 13, 2022.

12. Prescription acetaminophenproductstobe limited to325 mgper dosage. U.S. FoodandDrug Administration. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drugsafety-communication-prescription-acetaminophen-products-belimited-325-mg-dosage-unit. Published 2018.Accessed October 13, 2022.

13. Tylenol® Products &ProfessionalResources. TYLENOL® Professional. https://www.tylenolprofessional.com/.Accessed October 13, 2022.

Pharmacology of alcohol

Alcohol binds directly to acetylcholine (ACh), serotonin, GABA, and the NMDA receptors for glutamate. GABA and glycine receptors mediate the sedative effects of alcohol. Alcohol is a dehydrating agent and disrupts the osmotic homeostasis across cell membranes.There are two main pathways for alcohol metabolism: alcohol dehydrogenase (ADH) pathway and microsomal ethanol-oxidizing system (MEOS).

https://www.harryschocolateshop.com

Street names

3,000 - 2,000 B.C.

Beer was made in Ancient Mesopotamia. Alcohol was used in sacrificial settings.

16th & 17th Century

Intoxication and drunkenness became a crime in the 1600s. Britain began taxing alcohol in 1643.

2,000 B.C.

The earliest vineyards were established by the Ancient Greeks and the Greek god of wine – Dionysus Alcohol was used as currency, medicine, and religious offering to the gods.

2016

488,000 adolescents (12-17) have had an alcohol use disorder. 10.9 million adults (> 26) have had an alcohol use disorder.

17th - 20th Centuries

Banning alcohol as payment resulted in extreme labor strike. By 1830, Americans consumed an average of 7.1 gallons per person each year. This equates to ~55 handles of alcohol. In 1860, the U.S. produced ~88 million gallons of liquor per year. In 1952, the American Medical Association first defined alcoholism.

Drug Interactions:

Aspirin and acetaminophen

Can cause liver damage

Antihistamines, such as diphenhydramine

Increased drowsiness, sedation, and decreased motor skills

Anticoagulants: warfarin

Acute alcohol consumption may increase anticoagulation by decreasing warfarin metabolism

Chronic alcohol consumption decreases anticoagulation by increasing warfarin metabolism

Benzodiazepines, such as alprazolam, lorazepam

Increased drowsiness, sedation, and decreased motor skills

NSAIDs: ibuprofen, naproxen

Increased risk of GI bleeding

MANY OTHERS!!

Alcohol Laws:

Minimum Legal Drinking Age (MDLA) of 21 years old in the United States.

National Highway System Designation Act of 1995 requires a zero-tolerance law prohibiting drivers < 21 from operating a motor vehicle with 0.02% BAC.

Public intoxication is a class B misdemeanor in Indiana.

References:

Monitoring/Testing

Blood alcohol concentration test: Blood test that shows blood alcohol levels up to 12 hours after drinking

Breathalyzer: Estimates blood alcohol content in deep lung air

Professional Opinion:

I believe that alcohol is okay in moderation. However, it is extremely important to be educated on its effects and interactions with other substances and medications. Alcohol is a drug and does need to be treated as such, although it is legally and socially acceptable. ~ A. Dollinger

1. Street names and nicknames for alcohol. Drug Rehab Options. Published September 28, 2022. Accessed October 13, 2022. https://rehabs.com/blog/street-names-and-nicknames-for-alcohol/.

2. The history of alcohol throughout the world. Recovery.org. Published July 18, 2022. Accessed October 13, 2022. https://recovery.org/alcohol-addiction/history/.

3. Ethanol. Uses, Interactions, Mechanism of Action. DrugBank Online. https://go.drugbank.com/drugs/DB00898. Accessed October 13, 2022.

4. Chapter 23: The alcohols. AccessMedicine. Accessed October 13, 2022. https://accessmedicine.mhmedical.com/content.aspx?bookid=2249§ionid=175218881#1148435877.

5. Weathermon R, Crabb DW. Alcohol and medications interactions. Alcohol Res Health. 1999;23(1):40-54. PMID: 10890797; PMCID: PMC6761694.

6. Minimum legal drinking age of 21 saves lives. Centers for Disease Control and Prevention. Published April 19, 2022. Accessed October 14, 2022. https://www.cdc.gov/alcohol/fact-sheets/minimum-legal-drinkingage.htm#:~:text=Minimum%20Legal%20Drinking%20Age%20(MLDA)%20laws%20specify%20the%20legal%20age,varied%2 0from%20state%20to%20state.

7. Blood alcohol level: Medlineplus medical test. MedlinePlus. Accessed October 14, 2022. https://medlineplus.gov/lab-tests/bloodalcohol-level/#:~:text=A%20blood%20alcohol%20concentration%20(BAC,of%20alcohol%20that%20you%20drank.

Alpha-Methyltryptamine

Fall 2022

History and Background

Alpha-methyltryptamine, also known as AMT, is a tryptamine derivative. AMT was first studied in the 1960s by a couple of pharmaceutical companies as a possible antidepressant due to its MAOI properties. AMT was studied by the Upjohn Company, but it was concluded that AMT was a toxic substance and produces psychosis. AMT was an available prescription in the 1960s in the Soviet Union, under the name of Indopan in 5 mg and 10 mg tablets. As of today, there is not much known due to little to no formal research on the drug. There are no currently accepted medical uses in the United States. Recently, AMT has been emerging in club and rave scenes for recreational use for its hallucinogenic effects and is used as a substitute for MDMA. The abuse of AMT has led to two emergency department admissions and one death.

Slang Terms: Amtrak, Amthrax, Spirals

https://www.erowid.org/archive/rhodium/chemistry/it-290.html.

Pharmacology and Drug Effects

AMT’s molecular formula is C11H14N2 and the molecular weight is 174.74 g/mol. The class of the drug is tryptamines and all are composed of a substituted monoamine group. The drug works by inhibiting MAOs which causes an impact on the brain's chemicals. It can be taken in crystal powder, capsule, or tablet form. AMT is usually taken by ingestion, smoking, or insufflation, although oral ingestion is the most common route. Common dosages include 20-40 mg for oral dosage and 6-10 mg for smoked dosage. The duration of action for AMT is 12-16 hours and the stimulant activity is due to the presence of an alpha carbon methyl group. There are many ways of synthesis for AMT from different compounds: indole, tryptophan, indole-3-carboxaldehyde gramine, and 2-nitropropene. The pyrrole of the indole ring appears to be essential for hallucinogenic activity.

AMT is considered a synthetic hallucinogen that can alter the user’s perception, thought, and mood. Effects of this substance include an increase in energy, hallucinogens with both visual and auditory distortions, euphoria, empathy, and emotional distress. Some also report nervous tension, irritability, restlessness, inability to sleep, blurry vision, and dilated pupils.

Drug Interactions and Toxicology

Drug toxicology can be separated into mild to moderate poisoning and severe poisoning. For mild to moderate, tryptamines have the potential to cause pleasant or frightening hallucinations and unpredictable behavior. Some adverse effects include nausea, vomiting, anorexia, dizziness, paresthesias, anxiety, mood alterations, time distortion, and confusion. For severe poisoning, the signs are severe anxiety, possible agitation, hypertension, sinus tachycardia, rhabdomyolysis, and hyperthermia. To show a range of toxicity based on doses; 5-10 mg is reported to be mood-lifting, 20 mg causes euphoria, and 30 mg can induce hallucinations.

Drug interactions can occur with any other MAO inhibitors, SSRIs, cold preparations, cough medications with decongestants, dextromethorphan, Demerol, sinus medications, and nose drops or nasal sprays. AMTs also interact with amphetamines, MDMA, MDA or “MD” compounds, and cocaine.

Laws

AMT is a Schedule I substance under the Controlled Substances Act in the United States. It was regulated on April 4, 2003. In Germany, it is supposedly illegal to sell or possess AMT.

Monitoring and Drug Screens

To monitor patients on AMT, check the core temperature and mental status. Hospitals can monitor serum electrolytes, liver enzymes, renal function, and urinalysis. Check the patient's ECG and conduct continuous cardiac monitoring. If patients have prolonged agitation, monitor creatine kinase. Assess for myoglobinuria and hemoglobinuria following significant exposure.

Recent research has yielded how AMT can be detected but there are no available screens now. AMT is not tested in standard and extended drug tests. The detection period in urine for AMT is unknown.

Professional Opinion

Due to the current potential of psychedelic-assisted therapies like MDMA and psilocybin for PTSD and depression, AMT can be a potential treatment with more research on efficacy and safety.

References

1.Dialtonez. AMT FAQ. Erowid AMT Vault.

https://www.erowid.org/chemicals/amt/amt_faq1.shtml. March 12, 2003.

Accessed October 13, 2022.

2.Rhodium. Synthesis of Alpha-Methyltryptamine (IT-290; AMT).

https://www.erowid.org/archive/rhodium/chemistry/it-290.html. August 2004.

Accessed October 13, 2022.

3.Hallucinogenic Tryptamines. Micromedex (electronic version). IBM Watson Health; 2019.

Accessed October 13, 2022. https://www.micromedexsolution.com

4.Vorce SP, Sklerov JH. A general screening and confirmation approach to the analysis of designer tryptamines and phenethylamines in blood and urine using GC-EI-MS and HPLC-electrospray-MS. J Anal Toxicol. 2004;28(6):407-410. doi:10.1093/jat/28.6.407

5.Drug Enforcement Administration. Alpha-Methyltryptamine. February 2020. Accessed October 13, 2022. https://www.deadiversion.usdoj.gov/drug_chem_info/amt.pdf

Amanita Muscaria

History and Background

Amanita is a native mushroom to forests in the northern hemisphere and has spread to all parts of the world. A common use for amanita is as an insecticide on certain organic farms. They also were used in religious gatherings by Siberian Shamans to reach spiritual growth and enter a “trance-like state”. Across history, Amanita usage is relatively low, but it does have some relevance between 500 BCE and 1700 AD where it was known as a mushroom for immortality and before battle.

Slang Terms

Fly Agaric

Magic Mushrooms / Shrooms

Fairy Tale mushroom

Death cap

Pharmacology & Drug Effects

A compound found in amanita is muscimol (bottom right), which is a psychoactive ingredient, and inhibits neuronal function. The precursor to muscimol is ibotenic acid (top right), a neurotoxin. Some common effects that users may experience after 2-3 hours include dizziness, changes in visual and audio perception, lack of time awareness, space distortion, and increased energy.

https://en.wikipedia.org/wiki/Amanita_muscari

a https://www.inaturalist.org/taxa/48715-Amanita-muscaria

https://edu.rsc.org/feature/the-drink-of-the-gods/2020250.article

https://www.hipsandhaws.com/7th-nov-2021-foraging-wildcraftingseries-fly-agaric-folklor e-mystique-magic-toadstool/

https://psychonautwiki.org/wiki/Ibotenic_acid, https://www.caymanchem.com/product/13667/muscimol

https://www.pinterest.com/pin/fungi 623467142171881365/

Laws

Amanita is legal to possess, sell, cultivate, and transport in the United States except in Louisiana. It is legal to do the same in other countries although illegal in Australia, Romania, Thailand, and the Netherlands.

https://ww w.tecan.com /blog/consid ering-massspec-fortherapeuticdrugmonitoring

Interactions and Toxicology

There are no known drug interactions. Sometimes known as the death cap, amanita is very poisonous and dangerous. It does irreversible damage to the liver and kidney and causes RNA polymerase inhibition, leading to cell death. This process ultimately leads to a coma and death. Eating these orally is strongly recommended against. Amanitas are less toxic when dried and crushed up in tea. Never consume Amanita with a white cap.

https://www .dhs.gov/laws -regulations

References

Psychoactive Amanitas. EROWID. Available at: https://www.erowid.org/plants/amanitas

Accessed November 6, 2022.

Amanita Muscarina: The Fascinating History of The Fairy Tale Fungus. Natura Mushrooms. Available at: https://naturamushrooms.com/blogs/news/amanita -muscaria-the-fascinating-history-of-the-fairy-talefungus. Accessed November 6, 2022.

Garcia J, Costa VM, Carvalho A, et al. Amanita phalloides poisoning: Mechanisms of toxicity and treatment. Food Chem Toxicol. 2015;86:41-55. doi:10.1016/j.fct.2015.09.008

The Ultimate Guide to Amanita Muscarina. The Third Wave. Available at: https://thethirdwave.co/psychedelics/amanit a-muscaria/. Accessed November 6, 2022.

Monitoring

Although there is controversy on what to monitor to determine amanita poisoning, the most reliable signs to test for are prothrombin time and coagulation factor V, which are early signs of liver failure.

Professional Opinion

Amanita is a very dangerous yet legal hallucinogen. Consuming this mushroom orally is not recommended unless thoroughly dried. Once dried, it can be taken orally or crushed and added to tea and still provide hallucinogenic activity to users. If used with caution it is not as dangerous. Although it is best to avoid usage, make sure to be in a safe space with people you know and trust while using this in case adverse effects occur or you need medical help. ~ A.

Fall 2022 Anthony Jewett Student pharmacist

Anabolic Steroids

History Slang

The first anabolic steroids were synthesized in Germany 1935 to treat hypogonadism. They were later discovered to be used in Soviet powerlifting competitions, and were subsequently banned by the International Olympic Committee in 1975. The Anabolic Steroids Control Act of 1990 placed anabolic steroids as a schedule III drug.

Pharmacology

• Arnolds

• Gym Candy

• Juice

• Pumpers

• Roids

• Stackers

• Weight Trainers

Anabolic steroids are drugs which mimic naturally occurring male sex hormones testosterone and dihydrotestosterone.

These drugs bind to and activate androgen receptors in the body. Anabolic steroid use results in increased protein synthesis and buildup of cellular tissue, especially within muscles.

Drug Interactions and Toxicology

Long-term use and misuse of anabolic steroids causes hepatoxicity, cardiovascular complications, and endocrine system damage.

Anabolic steroids interact with warfarin and increases the risk of bleeding when used in combination. Also, steroid use in addition to cyclosporine is not recommended due to increased risk of hepatotoxicity.

Anabolic Steroids Monitoring

Common tests to obtain when monitoring patients using anabolic steroids:

• Liver function tests

• Lipids (especially low density lipoprotein (LDL)

• Complete blood count

• Electrocardiogram

A urinalysis is the most common test used to detect anabolic steroids.

Laws

Anabolic steroids are currently listed as schedule III drugs under the Controlled Substances Act.

Anabolic steroid use is banned in most professional sports organizations.

Professional Opinion

bleacherreport.com/articles/1648362

In my professional opinion, anabolic steroids should remain a schedule III drug. I believe that they do have medicinal value, however steroids can easily be misused. Long-term use of anabolic steroids can lead to lifethreatening conditions and those using steroids must be monitored properly. ~

References

1. Albano GD, Amico F, Cocimano G, et al. Adverse Effects of Anabolic-Androgenic Steroids: A Literature Review. Healthcare (Basel). 2021;9(1):97. Published 2021 Jan 19. doi:10.3390/healthcare9010097

2. Anabolic Steroids. Alcohol and Drug Foundation Published 8 Dec. 2021. Accessed November 9, 2022. https://adf.org.au/drug-facts/steroids/. Kicman AT. Pharmacology of anabolic steroids. Br J Pharmacol. 2008;154(3):502-521. doi:10.1038/bjp.2008.165

3. What are the side effects of anabolic steroid misuse? National Institute Drug Abuse. Updated April 12, 2021. Accessed November 9, 2022. https://nida.nih.gov/publications/ researchreports/steroids-other-appearance-performance-enhancing-drugs-apeds/what-areside-effects-anabolic-steroid-misuse.

Anorectics

History & Background

Drugs that reduce appetite with the goal of weight loss

Approval in 1940s for treatment of obesity

Abuse due to perceived effects of amphetamines

Common Anorectic Drugs: benzphetamine (Didrex), diethylproprion (Tenuate, Tepanil, Amfepramone), fenfluramine (Pondimin), mazindol (Sanorex, Mazanor), phendimetrazine (Bontril)

Typically intended for use on a short-term basis due to abuse potential

Slang Term

Diet Pills

Pharmacology & Drug Effects

diethylpropion

Anorectics have a structure closely related to amphetamines

amphetamine

Act on hypothalamus, the satiety center- producing anorexic effect and decreased appetite

https://www.webmd.com/dr

ugs/2/drug7858/diethylpropionoral/details

Metabolize fat and carbohydrates

Euphoria occurs with dexamfetamine, phenmetrazine and benzfetamine

https://www.webmd.com/d rugs/2/drug7858/diethylpropionoral/details

Therapeutic effect seens after several weeks

Drug Interactions & Toxicology

Moderate to high interaction with monoamine oxidase inhibitors

Low interaction with antihypertensive drugs

Toxic effects of anorectics may occur and include hypertension, tachycardia or psychosis

Laws

Anorectic drugs are FDA approved for weight loss: WegovyTM, Saxenda®, Contrave® , Qsymia®

Qsymia® is a C-IV drug due to phentermine

In order to qualify for a Qsymia® Rx, patients must have a BMI >30 kg/m2

References

Colman E. Anorectics on trial: a half century of federal regulation of prescription appetite suppressants. Ann Intern Med. 2005;143(5):380-385. doi:10.7326/00034819-143-5-200509060-00013

Craddock D. Anorectic drugs: use in general practice. Drugs. 1976;11(5):378-393. doi:10.2165/00003495-

197611050-00002

Ehud Grossman, Franz H. Messerli: Chapter 71 - DrugInduced Hypertension. Mosby. 2007,Pages 883-893, 9780323039611, Karam, Nardine. A Review of FDA-Approved Medications for Chronic Weight Management. Drug Topics; 2021.

Monitoring & Drug Screens

WegovyTM: monitor heart rate

Saxenda®: for patients with T2D, monitor blood glucose, monitor depression for mental health disorders

Contrave®: monitor blood pressure, heart rate, and mood

Qsymia®: monitor for hypokalemia; REMS safety required from FDA due to risks of teratogenicity

Anorectics are not normally monitored in standard drug tests; however, phenteramine can cause a false positive for amphetamine

Professional Opinion

If a patient meets the criteria for anorectic drugs, I feel that it can be helpful short-term for appetite suppression. I would stress the importance of a discussed upon diet and exercise regimen as medication is not stand alone treatment.

Ayahuasca

HISTORY/BACKGROUND OF USE

Ayahuasca originates from the Banisteriosis caapi vine and is typically consumed as a brew. It produces a hallucinogenic effect upon its users and is sometimes combined with other hallucinogens to extend its properties. Ayahuasca has been used in religious ceremonies and is believed to have healing properties.

The first record of Ayahuasca use for psychoactive effects was recorded in 1852 in the Brazilian Amazon. The drug was most likely used for these effects many years before this; however, it was not recorded. Ayahuasca became popular in Western culture during the late 1900s through writing and other recordings of its effect. Most uses of the drug are reported in South America, as people desire to experience it in a “traditional setting.”

PHARMACOLOGY & DRUG EFFECTS

Ayahuasca exhibits its acute effects at about 15-30 minutes after ingestion, then reaches its peak level at about 1.5-2 hours after ingestion. Its duration is approximately 2-6 hours.

Ayahuasca is traditionally used for its neurologic and CNS effects. It has been used for the treatment of depression and anxiety and has been shown to decrease blood perfusion in areas of the brain associated with these disorders. However, it is also thought that the treatment of depression or anxiety from ayahuasca is simply placebo effect.

There has been research on using ayahuasca for patients experiencing addiction It was shown in a small trial that taking ayahuasca twice during a 4-day period improved feelings of hopefulness and empowerment.

https://www.floridarehab.com/drugs/ ayahuasca/

SLANG TERMS

Appane, Caapi, Chacrona, Cacruna, Chaliponga, Daime, Hoasca, Jagube, Jurema, Kawa, Mariri, Mihi, Natem, Ooasca, Orhoasca, Queen, Rainha, Soulvine, Yagé, Yajé

https://en.wikipedia.org/wiki/Ayahuasca

Drug Interactions and Toxicology

There is not much evidence regarding the use of ayahuasca with OTC or prescription drugs. The one known interaction is between ayahuasca and MDMA or ayahuasca and antidepressants. Ayahuasca contains MAOIs, so combining it with other drugs that alter serotonin levels could be dangerous and should be avoided.

Laws

Ayahuasca and the other plants that make up the brew are not specifically defined as illegal in the United States. However, DMT is Schedule I in the US, and ayahuasca does contain DMT, so it can be treated as an illegal substance.

Monitoring and Drug Screens

There are not typical drug monitoring screens for ayahuasca use. In one study, researchers were able to use a participant’s sweat to detect the main components of ayahuasca and this did show to be effective.

Professional Opinion

Ayahuasca is a strong psychedelic that is traditionally used for religious ceremonies. It is becoming more popular in media, so I can see that more people will want to try this drug. I think it is important for people to consider the effects this could have on their mental status and consider the fact that there is not much clinical data regarding the after effects of using the drug. A. Clarke

https://www.enigmaperu.com/blog/what-is-ayahuasca/

https://www.tikvahlake.com/blog/understanding-ayahuasca/

References

1. Ayahuasca. The Vaults of Erowid. Accessed October 12, 2022.

https://www.erowid.org/chemicals/ayahuasca/

2. Ayahuasca. Natural Medicines. Accessed October 12, 2022. https://naturalmedicinestherapeuticresearchcom.ezproxy.lib.purdue.edu/databases/food,herbssupplements/professional.aspx?productid=1550

3. Ayahuasca. Alcohol and Drug Foundation. Accessed October 12, 2022. https://adf.org.au/drug-facts/ayahuasca/

4.) Tavares L, Monedeiro F, Bordin DM, De Martinis BS. Investigation of Ayahuasca βCarboline Alkaloids and Tryptamine in Sweat Samples from Religious Community Participants by GC-MS. J Anal Toxicol. 2020;44(6):601-609. doi:10.1093/jat/bkz116

Benzodiazepines

https://en.wikipedia.org/wiki/Benzodiazepine#/media/File:Benzodiazepine.svg

Slang terms:

Alprazolam: Xannies, Bars, Brick, Planks, Upjohn Clonazepam: K, K-pin

Diazepam: Yellow V’s, Blue V’s, Tranqs, Old joes, Howard, Downers

History/Background

The history of benzodiazepines started in 1955 when a German chemist with the name of Hoffman-La Roche. He accidentally identified the first benzodiazepine and entitled it to chlordiazepoxide (Librium). The history of benzodiazepine started in 1955 when a German chemist with the name of Hoffman-La Roche. He accidentally identified the first benzodiazepine and entitled it to chlordiazepoxide (Librium). The problem of abuse was pointed out long ago by many Scientifics, but the problem became important when in 1982 a British scientist named Malcolm directed a study of these drugs to create a change in the brain that led people to become more dependent on the drug. For some unknown reason, the documentary was sealed secret in the UK and was revealed in 2014.

Pharmacology

1,4 benzodiazepines exert effect for the acute treatment of generalized anxiety disorder and panic disorder through binding to the benzodiazepine site of gamma-aminobutyric acid-A (GABA) receptors in the brain and enhances GABA-mediated synaptic inhibition.

Pharmacokinetics

Plasma levels of alprazolam increase proportionally to the dose over the range of 0.5 to 3.0 mg.

Absorption

Following oral administration, the peak plasma concentration of alprazolam (Cmax) occurs in 1 to 2 hours post-dose.

Distribution

Alprazolam is 80% bound to human serum protein, and albumin accounts for the majority of the binding.

Elimination

The mean plasma elimination half-life (T1/2) of alprazolam is approximately 11.2 hours (range: 6.3 to 26.9 hours) in healthy adults.

Metabolism

Alprazolam is extensively metabolized in humans, primarily by cytochrome P450 3A4 (CYP3A4), to 2 major active metabolites in the plasma: 4-hydroxyalprazolam and α-hydroxyalprazolam. The plasma circulation levels of the two active metabolites are less than 4% of the parent. The reported relative potencies in benzodiazepine receptor binding experiments and animal models of induced seizure inhibition are 0.20 and 0.66, respectively, for 4-hydroxyalprazolam and α-hydroxyalprazolam. The low concentrations and low potencies of 4-hydroxyalprazolam and α-hydroxyalprazolam indicate that they are unlikely to contribute much to the effects of alprazolam. Benzophenone derived from alprazolam is also found in humans. Its half-life appears to be similar to that of alprazolam.

Excretion: Alprazolam and its metabolites are excreted primarily in the urine.

Drug Interactions

Since benzodiazepines are primarily metabolized by the enzyme CYP3A4 drugs that will inhibit or increase the activity of the enzyme will impact the efficacy of a drug, such as ketoconazole, itraconazole, nefazodone, fluvoxamine, erythromycin, cimetidine, fluoxetine, carbamazepine, oral contraceptives, sertraline, warfarin, ritonavir, imipramine. There could be interactions with some natural products and drinks such as St John’s wort and grapefruit juice.

Toxicology

https://hemaware.org/ sites/default/files/images

Common signs and symptoms of overdose are primarily sedative-hypnotic effects and are a result of CNS and respiratory depression and may include sedation, dizziness, amnesia, ataxia, slurred speech, lethargy, problems with coordination, and respiratory difficulties. Acute, single-drug ingestions are typically mild and exhibit reversible symptomatology. Severe toxicity, albeit uncommon and more often associated with co-ingestions, may result in coma, hypotension, hypothermia, and respiratory depression and failure.

Laws

All benzodiazepines are currently categorized as schedule IV drugs in the United States. This means that a form of legal identification is required when picking up the medication. Contrary to other typical drugs, for which the length of the prescription is one year, a prescription for a benzodiazepine is only valid for six months. All prescriptions must include: date prescription was issued, prescriber’s signature, patient’s full name, medication name, strength, dosage form, quantity prescribed, direction of use, prescriber’s name, address, and registration number.

Monitoring and/or Drug Screening

There are no major monitoring parameters when taking a benzodiazepine. A toxicology screen might be performed in cases of an overdose to see how much drug and presence of metabolites are in the bloodstream.

Personal opinion

There are numerous medications available on the market or even on the black market that have therapeutic effects, but some people abuse the drugs to the point where they become dependent on them. This often leads to the development of legislation to halt the abuse. This is highlighted in the benzodiazepine class of pharmaceuticals. These drugs have a wide range of therapeutic applications, including the treatment of seizures, migraines, depression, and other medical disorders. If people could only use drugs when necessary and not just because there is access to them, I believe the phenomena of drug abuse would shrink and the regulations governing its availability would change. I believe benzodiazepines are great medicines for treating a wide range of medical ailments. Users should exercise greater caution when using them, and manufacturers and healthcare professionals should do more to educate the public about the dangers of these medications and their potential for addiction.

A Brief History of Benzodiazepines. Benzodiazepine Information Coalition. https://www.benzoinfo.com/a-brief-historyof-benzodiazepines/

A Brief History of Benzodiazepines. Benzodiazepine Information Coalition. Accessed October 11, 2022. https://www.benzoinfo.com/a-brief-history-of-benzodiazepines/

Popular Street Names for Benzodiazepines (Benzos). Published October 8, 2020. Accessed October 11, 2022. https://floridarecoverygroup.com/street-names-for-benzodiazepine/

DailyMed - XANAX- alprazolam tablet. Nih.gov. Published 2018. Accessed October 11, 2022. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=388e249d-b9b6-44c3-9f8f-880eced0239f

Purdue Web Authentication. Purdue.edu. Published 2015. Accessed October 14, 2022. https://online-lexi-com.ezproxy.lib.purdue.edu/lco/action/doc/retrieve/docid/310/1253640.

Alprazolam: MedlinePlus Drug Information. medlineplus.gov. Published May 15, 2021. Accessed October 13, 2022. https://medlineplus.gov/druginfo/meds/a684001.html

Bromo-Dragonfly

Slang Terms

https://drughealtheffects.wordpress. com/2015/04/29/bromo-dragonfly/

Pharmacology

• The mechanism of action of Bromo-dragonfly is on the serotonin system in the body.

• The serotonin receptors in the central nervous system are the main target and the drug is an agonist for those receptors.

• This drug has similar effects to 5-HT-2A hallucinogens.

• It is similar to LSD in potency, but has a longer duration of action. The onset will occur in 20-90 minutes, peaking over those next few hours.

• The plateau effect lasts for 6-12 hours and after this period the effects will start to wear off.

• The total amount of time the drug will act on the body can last up to 36 hours, but it is usually 12-24 hours.

https://prevenco.co/fenetilaminas/

History

• Bromo-dragonfly is named after the shape of the molecule because it has a bromine atom on it and the shape of the structure resembles a dragonfly.

• The way this drug is used is by oral ingestion using blotter paper, powder or liquid.

• The drug was first developed in 1998 by Matthew Parker as a research chemical for looking at the structure and activity of the brain’s serotonin receptors in animal studies.

• The main active ingredient of this drug is 1-(8-bromobenzo (1,2 – b; 4,5- b) difuran-4-yl)- 2-aminopropane

• The class of drug that this is listed under is a synthetic hallucinogen.

Drug Effects

• Mood lift

• Visual changes

• Increase in energy

• Decrease in appetite

• Visual distortion

• Short term memory scramble

• Muscle tension

• Confusion

• Severe, vivid, frightening hallucinations

• Agitation

• Vasoconstriction

• Ego softening

• Tissue necrosis in limbs

Drug Interactions

• Lithium à when taking with psychedelics it increases the risk of psychosis and seizures

• Cannabis à increase risk of anxiety, paranoia, panic attacks, psychosis because of synergy effect

• Stimulants àincrease risk of anxiety, paranoia, panic attacks, and thought loops

• Tramadol à lowers the seizure threshold and this drug increases seizure risk

Laws

• Bromo-dragonfly is not a scheduled drug in the United States

• It is not regulated

• It is not approved for human consumption

• Possible analog of DOB or 2C-B, which could allow for prosecution under the Federal Analogue Act if it is sold for human consumption or possession.

References

Toxicology

• There have been reported cases of overdoses and deaths from this drug.

• There is not extensive knowledge on this drug, which makes it difficult to treat overdoses.

• This drug is also often dosed in micrograms, while many other hallucinogens are dosed in milligrams, which makes the likelihood of overdose even higher. Some of the toxic side effects from this drug include:

• Death

• Seizure

• Vomiting blood

• Stopped heart or increased heart rate

• Nausea, diarrhea, stomach cramps

• Muscle spasms

• Terror inducing hallucinations

Professional Opinion

1.Bromo-Dragonfly. Erowid Bromo-Dragonfly Vault. https://www.erowid.org/chemicals/ bromo_dragonfly/. Accessed October 13, 2022.

2.Bromo-Dragonfly. Rosecrance. https://rosecrance.org/wpcontent/uploads/2018/11/USbromo_dragongfly.pdf.

Accessed October 14, 2022.

3.Bromo-dragonfly. Addictionlink.fi. https://paihdelinkki.fi/en/info-bank/articles/ drugs-and-other-intoxicants/bromo-dragonfly.

Published March 19, 2020.

Accessed October 13, 2022.

4.What you should know about bromo-dragonfly. TestCountry. https://testcountry.com/pages/allyou-need-to-know-about-lsd-acid. Accessed October 13, 2022.

5.Bromo-dragonfly. PsychonautWiki. https://psychonautwiki.org/wiki/BromoDragonFLY#Toxicity_and_harm_potential.

Published October 7, 2022.

Accessed October 14, 2022.

Overall, bromo-dragonfly is a very dangerous drug and has many toxic side effects that come with it. One thing that has been seen frequently is people assuming they are buying LSD and then end up taking BDF, and end up overdosing because it was not known what they are taking. There is not a lot of research on this drug, which makes many of the outcomes very unpredictable and dangerous.

~ Camryn Cardinal, Pharmacy Student

Monitoring and Drug Screens

• There is a urine test for Bromodragonfly that is a conditional confirmation, meaning that there will be a secondary procedure confirming the presence again.

• There is also another test that uses liquid chromatography-tandem mass spectrometry technique. This is a quantitative procedure that can detect with a limit of 1 ng/mL.

BUPRENORPHINE

Mackenzie Carr, Student pharmacist

Fall 2022

The opioid epidemic is a public health emergency that has killed over 750,000 americans since 1999. Since then, several medications have been manufactured to help patients manage symptoms of withdrawal.

STREETNAMES

BigWhites

Buse

Oranges

SmallWhites

CLINICALEFFECTS

• constipation

• nausea

• vomiting

• headache

• increasedsweating

• insomnia

• increasedpain

Buprenorphine, sold under the brand name Subutex®, is a partial opioid agonist used to treat opioid addiction. Buprenorphine therapeutics research began back in the 1920s, and provides pain relief, which is seen as a benefittomany.

DRUGINTERACTIONS

• alcohol: may enhance CNS depressant effect of buprenorphine

• amphetamines: may enhance analgesic effect

• anticholinergic agents (benadryl, meclizine, oxybutynin): may enhance risk of urinary retention and constipation

• cannabinoid-containing products: may enhance CNS effects

• diuretics: buprenorphine may diminish therapeutic effect of diuretic

TOXICOLOGY

• The rate of death from prescription opioid overdose has quadrupled in the last decade

• signs of toxicity: respiratory depression, miosis, decreased bowel motility, CNS depression

PROFESSIONALOPINION

Comparedtoothermedicationsthat helpwithsymptomsofopioid withdrawallikemethadone, buprenorphineislessaddictive,safer touseduringpregnancy,andismore convenientfor patients to use, makingitanoptimaltherapyof choice.

INDIANALAWS

• C-III: moderate to low potential forabuse/dependence

• manufacturing, dealing, or financing: level 6 felony

• 1-5g: level 5 felony

• 5-10g: level 4 felony

• 10-28g: level 3 felony

• >28g: level 2 felony

MONITORINGPARAMETERS

• Risk for dependence: monitor patients

• BP: monitor for hypotension during initiation and titration

• LFTs: measure liver function before initiation and throughout therapy for 300mg maintenance treatment with extended release injection

REFERENCES

• Bezrutczyk D, Parisi T. Drug street names. Addiction Center. Published September 14, 2022. Accessed October 12, 2022. https://www.addictioncenter.com/drugs/drug-street-names/.

• Buprenorphine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 13, 2022. http://online.lexi.com

• Indiana drug laws, penalties, & defenses. Avnet Law. Published March 21, 2021. Accessed October 13, 2022. https://avnetlaw.com/2018/09/17/indiana-drug-laws/.

• NIDA. Study highlights effectiveness of methadone and buprenorphine. National Institute on Drug Abuse website. February 28, 2020 Accessed October 13, 2022. https://nida.nih.gov/news-events/science-highlight/studyhighlights-effectiveness-methadone-buprenorphine.

• Thornton P. Buprenorphine sublingual uses, dosage, side effects. Drugs.com. Published August 30, 2022. Accessed October 13, 2022. https://www.drugs.com/buprenorphine.html.

Cannabinol/Cannabigerol (CBN/CBG)

Hojun Chang (John) Fall 2022

SLANG NAMES

Hash oil, Hemp oil, gummies, oil tincture, sleep oil

CBG vs. CBN: What are the differences. Area 52. Accessed October 12, 2022. https://area52.com/CBG-VS-CBN/

HISTORY

Cannabigerol (CBG) was first discovered by Raphael Mechoulam and Yehiel Gaoni in 1964, while cannabinol (CBN) was discovered by Robert Cahn in early 1930s.

BACKGROUND

CBG is federally legal in most states since it is young hemp derived. However, CBN is legal as long as it is derived from hemp, instead of marijuana. CBN is currently out in the market for use of sedative, anticonvulsant, and anti-inflammatory properties. CBG is not psychoactive unlike CBN, but it has an anti-inflammatory property. In addition, CBG does not have any potential of addiction.

CBN is an oxidized form of tetrahydrocannabinol (THC).

CBG vs. CBN: What are the differences. Area 52. Accessed October 12, 2022. https://area52.com/CBG-VS-CBN/

CBG binds to two types of cannabinoid receptors: CB1 and CB2. CB1 is expressed in brain and nervous system, while CB2 is expressed in immune system. It plays a role in enhancing pleasure, regulating sleep, and improving pain. However, it does not give a high.

CBN exerts a weak psychoactive effect. It binds to CB2 receptor more selectively than CB1 receptor. However, it still mildly binds to CB1 receptor.

DRUG INTERACTION / TOXICOLOGY

CBN is metabolized in liver, involving the enzymes: CYP1A1, CYP2C9, CYP3A4, CYP2B6, CYP2C9, CYP2E1.

CBG may have alpha-2 adrenergic effect; it may interact with cardiovascular medications.

CBN and CBG overdose is when one ingests extremely large doses. It may cause extreme tiredness, fatigue, and GI disorders.

LAWS

Cornwell AM. What’s the Difference between CBN and CBG. Oracle. Accessed October 12, 2022. https://cbdoracle.com/ cannabinoids/cbn-vs-cbg/

MONITORING / DRUG SCREENS

CBG is currently legal under federal law; but CBN is not federally legal. Hemp flowers are defined as cannabis flower which contains no more than 0.3% of THC. As long as CBG is derived from the hemp flowers, they are legal. However, CBN is only legal in some states where recreational or medical marijuana are legal.

CBG is non-psychoactive drug, while CBN may exert a mild psychoactive effect. They help reducing anxiety and calming one. Side effects are very mild, and they are known to be safe.

Both CBN and CBG may test for positive on a drug test, though CBN is known to have higher chances of testing positive. Because CBG has a different chemical structure from THC, it has lower chances, yet it still comes from hemp flowers. However, CBN resembles THC more than CBG does.

PROFESSIONALOPINION

CBNandCBGhavenotbeenstudiedasmuchas cannabidiol(CBD).Withoutpotentialforaddiction,they seempromisingtotreatmanydifferentdiseases:pain, insomnia,neuropathy,andinflammation.However, thereneedsmorestudiesforefficacyandsafetyinorder tobeapprovedbyFDA.

REFERENCES

CBG vs. CBN: What are

differences. Area 52. Accessed October 12, 2022. https://area52.com/CBG-VS-CBN/

1.CBG:ResearchedBenefits.RealmofCaring.AccessedOctober12,2022 https://realmofcaring.org/CBG-RESEARCHED-BENEFITS/

2.PertweeRG.Cannabinoidpharmacology:thefirst66years. British Journal of Pharmacology 2006;147:S163–S171.DOI:10.1038/ sj.bjp.0706406

3.CBGvs.CBN:Whatarethedifferences.Area52.AccessedOctober12,2022.https://area52.com/CBG-VS-CBN/

4.CBDvsCBN:BenefitsandDifferences.Healthline.AccessedOctober12,2022.https://www.healthline.com/health/cbd-vs-cbn#cbnbenefits-uses

5.OhwovorioleT.WhatisCannabigerol(CBG).Verywellmind.PublishedSeptember16,2022.AccessedOctober12,2022. https://www.verywellmind.com/cannabigerol-cbg-uses-and-benefits-5085266

6.GrittersJ.IsCBGthenewCBD.Elemental.PublishedJuly8,2019.AccessedOctober12,2022.https://elemental.medium.com/is-cbgthe-new-cbd-6de59e568008

7.MoralesP,HurstDP,ReggioPH.MolecularTargetsofthePhytocannabinoids-AComplexPicture. Prog Chem Org Nat Prod. 2017;103:103–131.DOI:10.1007/978-319-45541-9_4

8.Cannabinol-Uses,sideeffects,andmore.WebMD.AccessedOctober12,2022.https://www.webmd.com/VITAMINS/AI/ INGREDIENTMONO-1611/CANNABINOL-CBN

9.RobertsC.WhyCBG,anewandlegalcannabisplantproduct,issurging.PublishedDecember10,2020.AccessedOctober12,2022. https://observer.com/2020/12/WHATS-CBG-LEGAL-CANNABIS-BENEFITS-USES/#:~:TEXT=IN%20FACT%2C%20LIKE%20CBD% 2C%20CBG,CARDIOVASCULAR%20MEDICATIONS%2C%E2%80%9D%20VRANA%20WROTE.

10.IsDadgrasssafe(andCanyouoverdoseonCBD?).Dadgrass.AccessedOctober12,2022.https://dadgrass.com/blogs/dad-grassblog/is-dad-grass-safe-and-can-you-overdose-on-cbd

HISTORY/BACKGROUND

CBD is used therapeutically to treat seziures associated with Lennox-Gastaut syndrome and Dravet syndrome. Its first therapeutic use was in China in the year 2737. CBD is a compound found in cannabis that does not cause psychoactive effects.

CBD

SLANG TERMS

Although there not many slang terms for the CBD substance there are many for CBD+THC (Cannabis) such as:

• Weed

• Skunk

PHARMACOLOGY/ DRUG EFFECTS

GET A FREE ESTIMATE ABOUT US

-

• Mary Jane

• Pot

We offer a full line of services. From planting shrubs to lawn mowing to fertilizing, we do it all.

The exact mechanism of action of CBD is not fully known. However, it is known that CBD acts on cannabinoid receptors as a part of the endocannabinoid system. These receptors have effects on mood, appetite, pain, and memory.

DRUG INTERACTIONS/ TOXICOLOGY

CBD has many known drug interactions due to its metabolism by several enzymes. Examples of some drug classes that it interacts with include anticonvulsants, CNS depressants, hepatotoxic drugs, and mechanistic target of rapamycin inhibitors.

LAWS

CBD is legal in most states if it has been FDA approved, derived from hemp instead of marijuana, and is under state THC limits.

MONITORING DRUG/ SCREENS

Many drug tests do not screen for CBD because it does not cause intoxicating effects. However, one may still fail a drug test CBD if it is contaminated with THC.

PROFESSIONAL OPINION

In my professional opinion, there is not enough clinical evidence about CBD's safety and efficacy for me to feel comfortable recommending a patient this drug as treatment

There are several drug interactions with CBD and there is potential contamination with THC Until more clinical data is published on the use of CBD, I will not recommend it to patients

-C. Coryea, PharmD Student

REFRENCES

CANNABIDIOL (CBD).

HTTPS://ONLINE.LEXI.COM/LCO/ ACTION/H OME. ACCESSED

OCTOBER 14, 2022.

DOES CBD SHOW UP ON A DRUG TEST?MEDICAL NEWS TODAY.

HTTPS://WWW.MEDICAL NEWSTODAY.COM/AR TICLES/DOESCBD-SHOW-UP-ON-A-DRUGTEST#SUMMARY. ACCESSED OCTOBER 14, 2022.

JULIA N. WHAT IS THE HISTORY OF CBD? CFAH. HTTPS://CFAH.ORG/ HISTORY-OF-CBD/. PUBLISHED MARCH 1, 2022. ACCESSED OCTOBER 14, 2022.

FOR THE AGELESS. CBD GLOSSARY. FOR THE AGELESS.

HTTPS:// WWW.FORTHEAGELESS.COM/ PAGES/C BD-GLOSSARY. ACCESSED OCTOBER 14, 2022.

DRUGBANK ONLINE: DATABASE FOR DRUG AND DRUG TARGET INFO. DRUGBANK ONLINE |DATABASE FOR DRUG AND DRUG TARGET INFO. HTTPS://GO.DRUGBANK.COM/. ACCESSED OCTOBER 14, 2022.

IS CBD LEGAL? FINDLAW. HTTPS://WWW.FINDLAW.COM/ CRIMINAL/CRIMI NAL-LAW-BASICS/ IS-CBD-

LEGAL.HTML#:~:TEXT=FEDERAL% 20CANNABIDIOL%

20LAWS&TEXT=BOTH%20HEMP% 20AND%20MARI JUANA%

20CAN,FROM%20MARIJUANA%2C% 20IT%20IS%20ILLEGAL. PUBLISHED JULY 12, 2021. ACCESSED OCTOBER 14, 2022.

Cocaine

Fall 2022

History

People have chewed coca plants for thousands of years. Cocaine was first isolated from coca plants in 1859 from the Erythroxylon coca plant. Cocaine was widely used medically in the 19th century with the rise of many cocaine-containing tonics and elixirs that made claims to treat a variety of symptoms from headache, depression, and sexual impotence. Cocaine’s popularity skyrocketed in 1886 thanks to the creation of Coca-Cola and recreational use began to rise well into the 20th century.

Background

→ Cocaine is a naturally derived stimulant derived from the Erythroxylum coca plant grown in the Andean region of South America.

→ Cocaine is often snorted but also can be injected or used orally

→ Freebase cocaine, known as crack, is created from powdered cocaine made for smoking and has quicker, more intense effects

Pharmacology/Drug Effects

Onset → 0-5 minutes

Onset (crack) → Immediate, often before exhaling

Duration → 20-40 minutes

Duration (crack) → 5-15 minutes

Desired Effects → euphoria, mental/physical stimulation, increased sociability, increased energy, erotic/sexual stimulation

Neutral Effects → numbness and appetite suppression

Negative Effects → desire to do more cocaine, post-nasal drip, irritation in throat, dry mouth, insomnia, anxiety, paranoia, anger

Street Names

Coke Blow Snow

Nose Candy Crack (freebase cocaine)

Drug Interactions

Severe interaction with alcohol!

→ Cocaine combines with alcohol in liver to form cocaethylene which intensifies euphoric effects and increases risk of sudden death

Toxicology

Signs of overdose/toxicity

→ heart arrythmia, acute psychosis, tachycardia, seizure, death from heart attack or severe arrythmias

https://smarmore-rehab-clinic.com/wp-conntent/uploads/2022/05/ Effects-of-cocaine-2.jpg

Laws

Cocaine is currently labeled as a schedule II drug under the Controlled Substances Act passed in 1971. It is illegal to sell without a DEA license and illegal to buy or possess without a license or prescription

Drug Screening

→ Cocaine use is most commonly screened for and monitored via urine tests

https://www.google.com/url?sa=i&url=https%3A%2F%2Fen.wikipedia.org%2Fwiki% 2FLegal_status_of_cocaine&psig=AOvVaw1N3sRBsyeSOAJPQOOC6sR3&ust=166579 3265293000&source=images&cd=vfe&ved=0CAwQjRxqFwoTCID4sNG53voCFQAAAA AdAAAAABAK

→ is metabolized in the liver creating a primary metabolite benzoylecgonine which can be detected in urine up to eight days after consumption

Professional Opinion

Cocaine is one of the most commonly used illicit substances and there are no known medical benefits that outweigh the severe negative complications caused by cocaine use.

References

1. The history of cocaine - where does cocaine come from? - drug-free world. Foundation for a Drug-Free World. https://www.drugfreeworld.org/drugfacts/cocaine/a-short-history.html. Accessed October 13, 2022.

2. Erowid cocaine vault. https://erowid.org/chemicals/cocaine/cocaine.shtml. Accessed October 13, 2022.

3. Cocaine: Effects, hazards & warnings. Drugs.com. https://www.drugs.com/illicit/cocaine.html. Accessed October 13, 2022.

4. O’Malley GF, O’Malley R. Cocaine - special subjects. Merck Manuals Professional Edition. https://www.merckmanuals.com/professional/special-subjects/recreational-drugs-andintoxicants/cocaine?ruleredirectid=249&qt=&sc=&alt=. Published September 26, 2022. Accessed October 13, 2022.

What does It do?

The alkaloids In Datura compete with acetylcholine at muscarinic receptors and stimulate dopaminergic neurons causing euphoria, realistic auditory and visual hallucinations, slurred speech, amnesia and extreme disorientation and delirium sometimes resulting in dangerous behaviors. Users often lose sense oftime

being used for its hallucinogenic effects and intoxicating abilities to poison unsuspecting used. It's use is well-documented in Chinese medicine and sacred rituals. The plant contaings anticholinergic agents including atropine, scopolamine, and hyoscyamine. For this reason, it has also been used as a smokable asthma tratment to relax airways.

Nicknames

This plant produces white, pink, purple, or yellow trumpet-shaped flowers and can grow up to two meters tall. Both the flower and the plant emit a foul odor, earning its nickname Stinkweed. Datura is also known as: Jimson Weed, Devil's Apple, Thorn Apple, Devil's Weed, Malpitte, Moonflower, and Tolache.

https://www.google.com/url?sa=i&url=https%

3A2F2Fwww.newscientist.com%2Fdefinition%2Fpsychedelic%

2F&psig=AOvVaw1y7rBGM9ia0zqhuyZcUKue&ust=1668128355567000& source=images&cd=vfe&ved=0CA8QjRxqFwoTCLiogMO0ovsCFQAAAAA dAAAAABAF

IIs it legal?

Daturaiscurrentlyun-scheduledundertheControlled SubstancesActandunregulatedunderfederallaw. WhileIt'slegaltopossessanddistributeDatura withoutrequiringalicenseorprescription,Itmay showuponadrugscreen.Onlyspecialistlaboratory testscanreliablydetectthealkaloidspresent,but they'renotroutinelyusedfordrugscreening.

Metabolism

DaturaIsreadilyabsorbedandpartiallymetabolizedby theliver.It'smostlyeliminatedIntheurinewithahalflifeofaboutfourhours.It'snotcurrentlybelievedto beaddictingandusersareunlikelytodevelopphysical orpsychologicaldependence.Nowithdrawaleffects havebeenreported.

Interactions

Daturausersshouldavoidtakingotheranticholinergic drugs,asthisputspatientsatahigherriskof experiencingundesiredsideeffects.Additionally, Daturashouldbestoppedtwoweeksbeforeany surgerytoavoiddangerouslydecreasedrespirations.

References

Lexidrugs, https://online.lexi.com/lco/action/home. Accessed October 14, 2022.

Erowid Datura Vault, https://www.erowid.org/plants/datura/ datura.shtml. Accessed October 14, 2022

Datura Wrightii: Overview, Uses, Side Effects, Precautions, Interactions, Dosing and Reviews. WebMD. https:// www.webmd.com/vitamins/ai/ingredientmono-1491/daturawrightii. Accessed October 14, 2022

Corporate Author US Dept of Justice. Jimsonweed Datura Stramonium. https://www.ojp.gov/ncjrs/virtual-library/ abstracts/jimsonweed-datura-stramonium#:~:text=With%

20all%20the%20potential%20harmful,of%20legislat ion%

Is It Safe?

There is no way to determine a reasonably safe dose of Datura due to the variation in the potency of the plant material. Only 45g of dried Datura leaves can contain a lethal dose of alkaloids. Patients with moderate to severe toxicity may experience coma, seizure, delirium, severe agitation, and combativeness sometimes requiring restraints. Users' behavior is often irrational, putting them at risk for accidental injury. Datura causes an Inability to perspire, which can cause dangerous and potentially life-threatening hyperthermia at high doses.

So.... Should I Take It?

An overwhelming majority of users describe experiences as extremely unpleasant, both mentally and physically. The experience can be over whelming and uncomfortable, some even report lingering "weirdness" affecting coordination and speech for up to a week afteward.

DELTA 8&9 THC

HISTORY/ BACKGROUND

THC, the active ingredient in cannabis sativa, has been used recreationally and for medical purposes worldwide for thousands of years, until made illegal in the US in 1937. It remains one of the highest used recreational drugs, and is progressively being decriminalized and legalized across many states today.

Delta 8 became popular when the US had an overproduction of hemp, where CBD comes from, and the industry used CBD to create delta 8 THC. This became a popular item for states that have no legalized cannabis products.

WHAT'S THE DIFFERENCE?

Delta 8 stems from hemp (part of cannabis plant containing <0.3% THC) and delta 9 THC is derived for the marijuana part of the plant. Delta 8 is an analog to delta 9, making the structure just a difference in a singular double bond placement. Due to this, delta 8 THC has a weaker effect, about half as potent as delta 9, and many states can sell it at smoke shops or convenience stores.

SLANG TERMS

Delta-8 specifically:

PHARMACOLOGY

Inhalation: THC and other cannabinoids present make way to the bloodstream from the lungs when smoked. From there, THC binds to cannabinoid receptors in the brain and in other organs. The effect of THC achieves peak levels in 6-10 minutes. After absorption, the liver receives THC and it's metabolites to either clear it, or it will re-circle back to the bloodstream. It is lipophilic and taken up by adipocytes to be released slowly, therefore, the half life runs from 1- 13 days depending on chronic use.

Oral: THC is absorbed in the stomach and small intestine, which takes longer to reach peak effect, about 1-2 hours. It travels from the bloodstream to the liver, and is mostly excreted in the feces, but some metabolites re-enter the circulation. Edibles have a stronger effect due to the liver converting THC into a stronger metabolite when received from the GI tract.

Both routes have effects that usually last around 1-4 hours. Higher doses are more likely to produce stronger psychoactive effects.

DRUG EFFECTS

Short term effects: Paranoia, Dry mouth, Nervousness, Increased heart rate, Coughing, Reduced lung capacity, Psychoactive effects

Long term effects: Potential risk of heart problems (ongoing trials), Worsening of some mental illnesses, Short-term memory impairment.

DRUG INTERACTIONS & TOXICOLOGY

There has never been any confirmed cases of death caused by cannabis when taken by itself. Severe adverse events include hallucinations, vomiting, tremors, loss of consciousness, and extreme anxiety. These are more commonly reported with edibles.

Since THC is broken down mainly by CYP2C9 and CYP3A4, drugs metabolized by these in the liver may have interactions with THC. Some of these drugs are: benzodiazepines, statins, corticosteriods, PPIs, azole antifungals, and more. Interactions are still being studied. It is important to note that research has showed that THC increases effects of alcohol, and users should never drive due to increased of accidentrelated deaths.

LAWS

Hemp derived products (delta-8) are legal on a federal level, although some states have restrictions. Delta-9 products are not federally legal, but legal in states like Colorado, that have legalized recreational marijuana. There are currently 20 states with legalized use of delta 9.

Delta-8 is legal due to the 2018 Farm Bill. It states that hemp can be sold and grown legally as long as it contains <0.3% THC.

MONITORING & DRUG SCREENS

There is no regulatory oversight of delta-8 products, while delta-9 products are highly regulated by government parties before sold in dispensaries is legal states. Tested delta 8 products commonly find other cannabinoids and by-products.

THC can be tested by urine, blood, saliva, or hair, and detection varies across tests, Saliva will only show positive within hours after use, but hair will show use up to 90 days before. Test kits can be bought over the counter or persons can be tested in a lab.

USE

THC is mostly used through smoking or vaping, and cooked into a oil for edible ingestion. There are other medically used routes of administration, such as pills, transdermal patches, topicals, and powders.

Medical marijuana is used for symptom relief for chronic pain, MS, and neuropathic pain, and prescribed for diseases such as AIDS, cancer, and glaucoma. It is seen mostly used with chemotherapy patients, as it improves symptoms from therapy.

PROFESSIONAL OPINION

Due to no known deaths of monotherapy, and a debunked theory of marijuana being a gateway drug, in my professional opinion I believe both forms of THC should be legalized and decriminalized. THC should still be mildly used to do potential long term effects, but usage recommendations should be similar to alcohol. Use of cannabis should be regulated by restriction of amount purchased, regulatory overview of governing parties, and legal sales only coming from licensed dispensaries. ~ S.Sans

REFERENCES

5 things to know about delta-8 tetrahydrocannabinol – delta-8 THC. Food and Drug Administration. Updated May 4,2022. Accessed October 12, 2022. https://www.fda.gov/consumers/consumerupdates/5-things-know-about-delta8-tetrahydrocannabinol-delta-8-thc Cannabis. The Vaults of Erowid. Updated May 27, 2022. Accessed October 13, 2022. https://www.erowid.org/plants/cannabis /cannabis.shtml

Eckerson BE. Delta-8-THC craze concerns chemists. Chemical & Engineering News. Accessed October 12, 2022. https://cen.acs.org /biological-chemistry/natural-products/Delta8-THC-craze-concerns/99/i31

Virginia Code Guidance Document 110-32.

Cannabis: Potential Drug Interactions. Adopted June 6, 2022.

Julia N. Is Delta 8 THC Legal? Overview of D8 Legality by State. The Center for Advancing Health. Updated August 22, 2022. Accessed October 13, 2022. https://cfah.org/is-delta8-thc-legal/ Chayasirisobhon S. Mechanisms of Action and Pharmacokinetics of Cannabis. The PermantenteJournal. 2021;25:1. doi. 10.7812/TPP/19.200

Marijuana (THC) Testing. Testing.com. Updated November 19, 2021. Accessed October 13, 2022. https://www.testing.com /tests/marijuana-thc-testing/

DEXTROMETHORPHAN

HISTORY AND BACKGROUND

Dextromethorphan is a cough suppressant for treating dry cough. It has been available over the counter since 1958 and is found in over 120 cough and cold products. It has overtaken codeine as the most widely used cough suppressant. Abuse traditionally involved drinking large volumes of the liquid cough syrups. However, new tablet and gel capsule formulations containing higher doses makes it much easier to consume and conceal at school or work. Dextromethorphan powder is another formulation that is sold over the Internet, which offers snorting as another route of administration. Dextromethorphan can also be illicitly manufactured and dispensed in tablets mixed with other drugs, like pseudoephedrine or met hamphetamine. Abuse is most prevalent in teenage and young adult population, but is still misused by individuals of all ages. Since 2010, the prevalence of OTC cough medicine abuse has been declining due to efforts by the Consumer Healthcare Products Association to raise awareness to teens and their parents.

SLANG TERMS

o DXM

o robo

o rojo

o velvet

o skittles

PHARMACOLOGY

Dextromethorphan belongs to the antitussive medication group. It exerts its pharmacological action by crossing the blood-brain barrier to activate sigma opioid receptors in the medullary cough center. It desensitizes the cough receptors and therefore, suppresses the cough reflex. It is structurallly related to codeine and a non-opioid derivative of morphine.

https://www.youtube.com/watch?

v=ACSur7II7SQ&ab_channel=D emystifyingMedicineMcMaster

DRUG EFFECTS

When taken at high doses, dextromethorphan has a hallucinogenic effect that induces euphoria and other psychoactive effects, including confusion, agitation, sedation, loss of motor coordination and paranoia. Typical adverse effects are dizziness, drowsiness, nausea, and stomach upset.

DRUG INTERACTIONS

o MAO inhibitors

o SSRIs

o memantine

o disulfram

o CNS depressants (alcohol)

o quinine

o methotrimeprazine

MONITORING AND DRUG SCREENING

Dextromethorphan can cause falsepositive results for PCP urine drug screens. However, it is unlikely that consumption of dextromethorphan will produce a false-positive for opiate urine drug screens. Many states now require patients to be 18 years or older to purchase products containing dextromethorphan.

REFERENCES

Dextromethorphan is a legally marketed cough suppressant sold over-the-counter without a prescription. It is not considered a controlled substance and is not regulated under the Controlled Substance Act.

PROFESSIONAL OPINION

When used at the recommended doses and for its intended purpose, dextromethorphan is safe and effective. It can be sold behind the counter, like pseudoephedrine, in order to keep track of how much and how often someone is buying it. This could provide context for recognizing a pattern of behavior, so we can talk to patients to see what they are using it for and help them understand the risks of taking too much. ~

1. Spangler DC, Loyd CM, Skor EE. Dextromethorphan: a case study on addressing abuse of a safe and effective drug. Subst Abuse Treat Prev Policy. 2016;11(1):22. Published 2016 Jun 23. doi:10.1186/ s13011-016-0067-0

2. DXM drug fact sheet. Department of Justice/Drug Enforcement Administration. Accessed October 5, 2022. Available at: https://www.dea.gov/sites/default/files/2020-06/DXM-2020.pdf

3. Intelligence bulletin DXM (dextromethorphan). US Department of Justice. Accessed October 5, 2022. Available at: https://www.justice.gov/archive/ndic/pubs11/11563/11563p.pdf

4. The misuse of dextromethorphan. Demistifying Medicine McMaster. Accessed Ocotober 5, 2022. Available at: https://www.youtube.com/watch?

v=ACSur7II7SQ&ab_channel=DemystifyingMedicineMcMaster

5. Dextromethorphan. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 5, 2022. Available at: https://online.lexi.com

6. Michael F. Neerman, PhD, FACB, Chinemerem L. Uzoegwu, BSN, RN, Is Dextromethorphan a Concern for Causing a False Positive During Urine Drug Screening?, Laboratory Medicine, Volume 41, Issue 8, August 2010, Pages 457–460, https://doi.org/10.1309/LMC384VVWIPJFXCZ

7. Storrow AB, Magoon MR, Norton J. The dextromethorphan defense: dextromethorphan and the opioid screen. Acad Emerg Med. 1995;2(9):791-794. doi:10.1111/j.1553-2712.1995.tb03273.x

DIHYDROEPIANDROSTERONE (DHEA)

BRETT DUNCAN

SECOND YEAR PROFESSIONAL STUDENT

FALL 2022

HISTORY:

A GERMAN BIOCHEMIST NAMED ADOLF BUTENANDT FIRST ISOLATED DHEA IN THE 1930S. DHEA IS USED AS AN ANABOLIC STEROID FOR BOOSTING IN SPORTS.

PLAYERS WOULD USE IT TO INCREASE PERFORMANCE. THESE PLAYERS LIKE BARRY BONDS WOULD GAIN MASS AMOUNTS OF MUSCLE AND WOULD BREAK RECORD AFTER RECORD IN THEIR RESPECTIVE SPORTS

BACKGROUND:

DHEA IS A NATURAL HORMONE FOUND IN THE BODY. IT IS PRODUCED IN THE ADRENAL GLANDS AND IS A PRECURSOR TO OTHER HORMONES LIKE TESTOSTERONE.

SLANG TERMS/OTHER NAMES:

ANABOLIC STEROIDS

DHEA

PERFORMANCE ENHANCEMENTS

3B-HYDROXY-ANDROST-5-ENE-17-ONE

ANDROSTENOLONE

DEHYDROEPIANDROSTERONE

DHEA-S

GL701 PRASTERONE.

HTTPS://FINESTGEARS.TO/HOW-ANABOLICSTEROIDS-CAME-TO-BE/

LAWS:

THE FDA BANNED DHEA SALES THAT WERE OTC BUT SINCE THE IMPLEMENTATION OF THE DIETARY SUPPLEMENT HEALTH AND EDUCATION ACT OF 1994 DHEA IS AVAILABLE AND SOLD AS A DIETARY SUPPLEMENT. THIS PRODUCT IS BANNED UNDER WORLD ANTIDOPING CODE AND THE NATIONAL COLLEGIATE ATHLETIC ASSOCIATION.

HTTPS://ALONGTHEBOARDS.COM/2020/ 05/28/ANABOLIC-STEROIDS-FOR-SALE/

DRUG INTERACTIONS/ TOXICOLOGY:

• ANTIPSYCHOTICS

• CARBAMAZEPINE

• ESTROGEN

• TESTOSTERONE

• LITHIUM

• SSRIS

• TRIAZOLAM

• VALPROIC ACID

DHEA HAS BEEN SHOWN TO BE A CARCINOGEN IN RODENTS BUT NOT IN HUMANS. OTHER STUDIES SHOW CANCER PROTECTIVENESS. SIDE EFFECTS INCLUDE HIRSUTISM, GYNECOMASTIA, TESTICULAR WASTING, REDUCED HDL, INCREASED BLOOD PRESSURE

PHARMACOLOGY/DRUG EFFECTS:

DHEA IS USED TO HIT MANY DIFFERENT RECEPTORS INCLUDING NMDA, GABA, T-TYPE CALCIUM CHANNELS, PPAR-ALPHA, AND MANY MORE. THIS PRODUCT IS ALSO METABOLIZED TO FORM ESTROGEN AND TESTOSTERONE FOR MUSCLE BUILDING, SEX HORMONES, AND MUCH MORE.

MONITORING/SCREENING:

PLAYERS IN THE NCAA AND OTHER SPORTS ORGANIZATIONS ARE SCREENED YEAR-ROUND. TYPICALLY, SEVEN PLAYERS ARE RANDOMLY PICKED EACH WEEK FOR SCREENING. THEY ARE SUBJECTED TO A DRUG TEST TO SEARCH FOR VARIOUS DRUGS INCLUDING DHEA.

PROFESSIONAL OPINION:

HTTPS://WWW.NORTHCOUNTRYPUBLICR ADIO.ORG/NEWS/NPR/11662481/BONDSSHATTERS-BASEBALL-S-BIGGEST-RECORD

IN MY PROFESSIONAL OPINION I WOULD SUGGEST USING THIS PRODUCT FOR VAGINAL ATROPHY, DEPRESSION, AGEING AND OSTEOPOROSIS THE USE OF DHEA AS A PERFORMANCE ENHANCEMENT SHOULD NOT BE ALLOWED BECAUSE IT GIVES PEOPLE MORE OF AN ADVANTAGE. DHEA COULD ALSO LEAD TO FURTHER COMPLICATIONS IF USED INCLUDING ACNE AND HIRSUTISM IN WOMEN, GYNECOMASTIA AND TESTICULAR WASTING IN MEN, UNFAVORABLE EFFECTS ON LIPID METABOLISM LIKE REDUCED HDL, AND INCREASED BLOOD PRESSURE IN BOTH GENDERS.

REFERENCES

1. KLINGE CM, CLARK BJ, PROUGH RA. DEHYDROEPIANDROSTERONE RESEARCH: PAST, CURRENT, AND FUTURE. VITAM HORM. 2018;108:1-28. DOI:10.1016/BS.VH.2018.02.002

2. DEHYDROEPIANDROSTERONE. PEDIATRIC DRUGS ONLINE. LEXICOMP. WOLTERS KLUWER HEALTH, INC. RIVERWOODS, IL. ACCESSED SEPTEMBER 14, 2022. HTTP://ONLINE.LEXI.COM

3. DHEA. DRUGS.COM. PUBLISHED FEBRUARY 12, 2021. ACCESSED OCTOBER 11, 2022. HTTPS://WWW.DRUGS.COM/MCA/DHEA

4. 2. NCAA BANNED SUBSTANCES. NCAA.ORG. PUBLISHED JULY 14, 2022. ACCESSED OCTOBER 11, 2022. HTTPS://WWW.NCAA.ORG/SPORTS/2015/6/10/NCAABANNED-SUBSTANCES.ASPX

History& Background

N,N-dimethyltryptamine

N,N-dimethyltryptamine

WheredoesDMT originate?

DMT was first synthesized by Richard Manske in 1931, but its hallucinogenic properties were discovered in 1956 when Stephen Szara extracted DMT from the Mimosa hostilis plant and injected intramuscularly.

WhyDMT?

Hallucinogenics like DMT are commonly sought out as they impact effects on perception and behavior. Hallucinatory experiences are thought to help better understand the human brain.

Pharmacolo��

haveneverseenamental healthproviderbefore. https://www.talktofrank. com/drug/dimethyltrypta mine

Slang terms

Businessman'sTrip Fantasia

https://www.thelancet.com/ journals/lanonc/article/

https://adf.org.au/drugfacts/dmt/

Laws

DMTis a Schedule1 controlled substancewhich meansitisillegal tomanufacture, distribute,buy,or possess DMT. Thereareinstances whereDMTcanbe approvedfor studiestoconduct medicaluse research.

ProfessionalOpinion

Because DMT is a Schedule 1 Controlled Substance, it should not be used outside of approved clinical trials. There is proposed benefit in the mental health realm, but evidence is not concrete. Hallucinogenics perpetuate 'out of body' experiences that can be harmful to the substance user and those surrounding. With this, DMT should not be used recreationally.

References:

Interactions/ Toxicolo��

DMTinteractswith monoamineoxidase inhibitors (MAOIs) like selegilineby prolongingthe durationand intensityofDMT.

Monitoring/ DrugScreen

DMTisrapidly metabolizedbythe body-takeseffect quicklyandfalls belowdrug screeningdetection levelsquicklyas well.Ayahuasca preparationsor MAOIscan increase detectability.

Barker SA. N, N-Dimethyltryptamine (DMT), an Endogenous Hallucinogen: Past, Present, and Future Research to Determine Its Role and Function. Front Neurosci. 2018;12:536. Published

2018 Aug 6. doi:10.3389/fnins.2018.00536

Palo Alto Medical Foundation. Dimethyltryptamine. SutterHealth. Updated October 2013. Accessed October 12, 2022. https://www.sutterhealth.org/ health/teens/drugs/dimethyltryptamine-dmt Release. DMT. Accessed October 12, 2022.

https://www.release.org.uk/drugs/dmt/pharmacol ogy#:~:text=Dimethyltryptamine%20(DMT)%20belo ngs%20to%20a,throughout%20the%20central%20 nervous%20system

Smith L. Is DMT a controlled substance? Recovered. Updated August 31, 2022. Accessed October 12, 2022. https://recovered.org/hallucinogens/dmt/ dmt-controlled-substance

Smith L. How long does DMT stay in your system? Recovered. Updated October 11, 2022. Accessed October 12, 2022. https://recovered.org/hallucino gens/dmt/how-long-dmt-in-system

Ergot

Ergot is a fungus that grows on rye and other grasses like wheat. Originally, it was used to speed labor, but it was then realized that it was causing stillbirths. It used to be common to get ergotism from eating rye bread, but that is no longer a problem we face.

From 1000 BCE – 392 BCE, it was said that week-long celebrations involved drinking something that caused hallucinations and it had ergot derivatives in it. In 1039, the first outbreak of ergotism occurred in France, and once rye was introduced to Europe, ergotism breakouts were more common. In the middle ages, females used ergot during labor in order to quicken labor and reduce postpartum bleeding. 1807 is when ergot was first introduced in the US, and scientific research was beginning to be conducted. In the late 19th century, ergot derivatives were used to treat migraines. In 1938, a chemist in Switzerland discovered the compound LSD-25, and additionally found that LSD is a derivative of ergot.

ELANA CHUAPRASERT

STUDENT PHARMACIST FALL 2022

Indications: migraine and vascular headaches, acromegaly, parkinson’s, uterine atonia

DRUG ACTION

Neurological: serotonin and dopamine agonist

Cardiovascular: alpha-adrenergic agonist, serotonin agonist

Musculoskeletal: Cause uterine smooth muscle contraction

EFFECTS

history pharmacology slang terms

Ergotism, also called St. Anthony’s Fire, causes hallucinations, loss of limbs, and death

Cytochrome P4503A4 inhibitors: Drugs that inhibit CYP34A may increase the risk of ergot toxicity (e.g., amiodarone, clarithromycin, diltiazem)

Ergot derivatives: Increase risk of adverse effects when used with ergot. (e.g., bromocriptine, dihydroergotamine, ergotamine)

Serotonergic drugs: Ergot derivatives act as serotonin agonists, so using them with serotonergic drugs may increase risk of serotonergic side effects such as Serotonin syndrome, cerebral vasoconstrictive disorders) (e.g., fluoxetine, sertraline, sumatriptan)

Stimulant drugs: May increase the risk of vasoconstriction (e.g., albuterol, dopamine, pseudoephedrine )

drug screens

The MycoSep® 150 Ergot test is used to find ergot alkaloids in all food and feed commodities.

REVEAL® Q+MAX is a simple rapid lateral flow test to identify ergot alkaloids.

drug interactions the law

Ergot itself is legal to possess. However, it is considered a poison, so anything made from ergot needs to be labeled "external use only" and "poison."

Jacquin D. Barley grains with ergots. Wikipedia. https://en.wiktionary.org/wiki/ergot#/media/File:Hordeu m_vulgare_Claviceps_purpurea_23-7-2009.JPG. Published July 23, 2009. Accessed October 13, 2022.

professional opinion

Although ergot doesn’t have good evidence proving that it should be used it practice, ergot is seen to be used for menstrual periods, expelling placenta after childbirth, and more. There is also not enough evidence to determine a dose for patients, but it is widely accepted that ergot is unsafe to be taken by mouth.

1. Ergot. EROWID. Updated November 15, 2015. Accessed October 13, 2022. https://www.erowid.org/plants/ergot/2.

2. Ergot timeline. EROWID. Updated October 16, 2017. Accessed October 13, 2022. https://www.erowid.org/plants/ ergot/ergot_timeline.php

3. Ergot. Natural Medicines. Updated December 10, 2021. Accessed October 13, 2022. https://naturalmedicinestherapeuticresearchcom.ezproxy.lib.purdue.edu/databases/food,-herbssupplements/professional.aspx?productid=431

4. Ergot legal status. EROWID. Updated September 16, 2016. Accessed October 13, 2022. https://erowid.org/plants/ergot/ ergot_law.shtml

5. Ergot Alkaloid Testing. Romer Labs. Accessed October 13, 2022. https://www.romerlabs.com/en/analytes/mycotoxins/ ergot-alkaloid/

Beyond Ecstasy

WATCH OUT: Fentanyl Hits the Streets!!!

What is fentanyl ?

History Behind fentanyl

Fentanyl is a synthetic opioid that is 50-100 times stronger than morphine. Pharmaceutical fentanyl was developed to manage pain for specifically cancer treatment. It comes as a patch that is applied to the skin. It is used for abuse because of its powerful opioid properties. Fentanyl is added to other drugs, mainly heroine, on the street to increase its potency. Normally, this is masked from the buyer which often results in overdose deaths of the user.

It was first developed in 1959 in Mexico and introduced to the United States in the 1960s. In the time span of 2011-2018, fatal overdoses and abuse of the drug both drastically increases. According to the CDC fentanyl was involved in 2,600 overdose deaths in 2011 and it increased dramatically each year. In 2018, the overdoses deaths involving fentanyl and its analogues were 31,335.

Image: Kounang N. What you need to know about fentanyl. CNN. Published November 5, 2018. Accessed October 10, 2022. https://www.cnn.com/2016/05/10/health/fentanylopioid-explainer/index.html

Pharmacology of fentanyl

The effects of the drug

Fentanyl acts on the mu-o pioid receptor. It has a rapid onset and effects with a short duration. Fentanyl has a rapid onset because it passes through the blood-brain barrier. Fentanyl is abused for its euphoric effects. It can cause muscle rigidity at a higher frequency unlike other opioid receptor agonists. Fentanyl, unlike other opioid receptor agonists, does not release histamine and only has minimal depressant effects on the heart.

Image: Thrasybule L, Sullivan K, Rauf D, Rapaport L, Jagoo KK. What is Fentanyl?

EverydayHealth.com. Accessed October 10, 2022.

https://www.everydayhealth.com/opioidaddiction/fentanyl/.

Slang names of fentanyl

Street Names

Crazy One, Dance Fever, Dragons Breath, Fire, Friend, Goodfella, Great Bear, He-Man, Heineken, Jackpot, Murder 8, Nal, Nil, Tango Crash, TNT

Slang terms of fentanyl

Street names played on the name

F, Fent, Fenty, Freddy, Fuf, Opes

Fentanyl is like other commonly used opioids. It produces effects on the body such as relaxation, euphoria, pain relief, sedation, confusion, drowsiness, dizziness, nausea, vomiting, urinary retention, pupillary constriction, and respiratory depression.

The effects on the body during an overdose can include stupor, changes in pupillary size, cold and clammy skin, cyanosis, coma, and respiratory failure that can lead to death. If the patient is in a coma, has pinpoint pupils and respiratory depression then the patient has opioid poisoning.

Slang terms of fentanyl

Derived from the color/origin

Color: Blue Diamond, Blue

Dolphin, Blues, China White, Gray Stuff, King Ivory, Snowflake, White Girl or Ladies

Origin: China Girl, China Town, China White, Chinese Buffet, Pharmacy, Lollipop

Beyond Ecstasy

WATCH OUT: Fentanyl Hits the Streets!!!

Dr u g I n t er acti on s? Toxicology of fentanyl

Fentanyl is a depressive agent. It depresses the central nervous system and respiratory function. Due to this, over exposure to fentanyl can be fatal. It is 50-100 times more potent than morphine and 100s of times more portent than heroine.

Drug Interactions: Fentanyl should not be used at the same time with macrolide antibiotics or azole-antifungal agents, and protease inhibitors. The use of fentanyl and these three drug classes should be avoided because it can increase the plasma concentrations of fentanyl which increases the opioid drug action and exacerbating the opioid induced respiratory depression.8

L aw s

The possession of fentanyl is a felony. Possessing even the smallest amount of fentanyl will lead to felony charges. If one possesses more than a gram worth of fentanyl, they will be looking at third and second-degree felony charges. If a person is in possession of a certain amount of fentanyl, really depends on the state, they can be charged with a first-degree felony.5 When it comes to prescription fentanyl it is dosed in mcg per hour, and can be prescribed in many ways like a spray, a patch, a transdermal lozenge, buccal tablets, etc.6

Monitoring/Drug Screens:

There are fentanyl testing strips that can detect the presence of fentanyl in drugs before a person uses the drug. This can help prevent fentanyl overdosing.

When a patient is given fentanyl in the hospital, the doctor might have to change the dosages of medicines and will monitor the patient very carefully.7

Professional Opinion:

Fentanyl will always be a problem until people quit producing it, which will be never. I think because of this the regulations on it should be kept the same, and if someone is caught with it, they should be charged with a felony. I also believe all adults should be taught on everything wrong and current going on with fentanyl. They should be taught how to test for fentanyl in drugs. They should be taught how to give Narcan to reverse an overdose for fentanyl and other drugs like it I believe they should be taught all about this because drug dealers are starting to produce fentanyl has tiny colorful tablets to sell them to kids and get them addicted. This is a current problem going on called “Rainbow Fentanyl.” L. Eckert

Image: Jones C. Education on fentanyl, other drugs often optional in California schools, if offered at all. EdSource. Published October 5, 2022. Accessed October 10, 2022. https://edsource.org/2022/education-on-fentanyl-other-drugs-often-optional-in-schools-if-offered-atall/679216.

References:

1. Drug Enforcement Administration Diversion Control Division Drug. Accessed October 10, 2022. https://www.deadiversion.usdoj.gov/drug_chem_info/fentanyl.pdf.

2. Drug fact sheet: Fentanyl - dea.gov. Accessed October 10, 2022. https://www.dea.gov/sites/ default/files/2020-06/Fentanyl2020_0.pdf.

3. Slang for fentanyl (street names). The Hope House. Published July 24, 2022. Accessed October 10, 2022.

https://www.thehopehouse.com/opioid-addiction/related/fentanyl-street-names/.

4. Fentanyl - StatPearls - NCBI Bookshelf. Accessed October 10, 2022. https:// www.ncbi.nlm.nih.gov/books/NBK459275/. 5.

5. Possession of fentanyl. The Law Office of Kevin Bennett. Published April 22, 2022. Accessed October 10, 2022.

https://www.kevinbennettlaw.com/drug-charges/possession-of-fentanyl/.

6. Fentanyl Dosage. Drugs.com. Last Updated March 31, 2022. Fentanyl Dosage Guide + Max Dose, Adjustments - Drugs.com

7. Fentanyl test strips to prevent drug overdose. Accessed October 10, 2022. https://www.health.state.mn.us/communities/opioids/documents/ftsforph.pdf.

8. Fentanyl: Medlineplus drug information. MedlinePlus. Accessed October 10, 2022. https://medlineplus.gov/druginfo/meds/a605043.html.

9. Fentanyl: Incapacitating agent. Centers for Disease Control and Prevention. Published May 12, 2011 Accessed October 10, 2022 https://www.cdc.gov/niosh/ershdb/ emergencyresponsecard_29750022.html.

FLAKKA ALPHA-PVP

HISTORY

Thechemicalcompoundisfoundinkhat leavesinArabiaandEastAfrica,whereitis waschewedontocreateastimulanteffect. (1,2)Alpha-PVPitselfusedtobeusedforADHD ornarcolepsyafteritwaspatentedin1967.It wasfirstdispensedintheUnitedStatesin2013 andpopularizedin2014,butthenbecamea schedule1drugsoitwasnotdispensed.

PHARMACOLOGYAND DRUGEFFECTS

Thisdrugisacathinoneandworkssimilarlyto amphetamine.(2,3)Whentakeninextreme doses,itleadstoparanoiaandhallucinations, bothofwhichcancauseviolentaggression andself-injury.Typicaleffectsareeuphoria, extremefocus,stimulation,andanincreased sexdriveandsociability.

GRAVEL FLOCKA, ZOMBIEDRUG

CRYSTALLOVE

VANILLASKY

SNOWBLOW

DRUGINTERACTIONS ANDTOXICOLOGY

Adverseeffectsofthisdrugincludeliverand renalfailure,hypertension,arrhythmias, heartattacks,strokes,aneurysms,and eventuallydeath.(4)Sincethisdrugissimilar toamphetamines,itwouldlikelyhave similardruginteractionswithantidepressantssuchasduloxetineor bupropion.(5)Itwouldalsolikelyactas duplicatetherapyforamphetamineslike Adderall,increasingthechancesofadverse effects.

https://www.pharmadrugtest.com/urine-drugtests/109-flakka-alpha-pvp-urine-test.html

LAWS

FlakkabecameaScheduleIdrug2014,thus beingdefinedashighlyaddictivewithvery limitedmedicinaluse.(7)Possessionof Flakkacanleadtoatleasta10yearprison sentence,aswellasfinesandfelony charges.

MONITORINGAND DRUGSCREENING

Thestandardurinedrugtestdoesnotdetect Flakka.Howeverthereisaspecifickindoftest thatdoesdetectFlakkaamongstotherbath saltdrugscalledtheSyntheticCathinones TestKit.(6)Flakkaisalsodetectablethrough abloodtest.

https://depositphotos.com/100283954/stock-illustration-

PROFESSIONAL OPINION

Inmyprofessionalopinion,Ibelievethat flakkaisadrugthatdeservestobea ScheduleIdrugandhasnorealpurposein beingspread.Withitcausingviolent behavior,itspresenceintheUSshouldbe eradicated.~

hthttps://delamere.com/blog/top-10-most-dangerousdrugs

REFERENCES

Flakka(alpha-PVP).DEA.AccessedOctober2,2022.

https://www.dea.gov/factsheets/flakka-alpha-pvp FlakkaAddictionAndAbuse.AddictionCenter.Accessed October2,2022.

https://www.addictioncenter.com/drugs/flakkaaddiction-abuse/

SwainE.Flakka(ZombieDrug).AddictionGroup. AccessedOctober2,2022.

https://www.addictiongroup.org/drugs/illegal/flakka/ RhondaA.EverythingYouWantedtoKnowAboutFlakka. OnTheWagon.AccessedOctober2,2022.

https://www.onthewagon.org/flakka/ AmphetamineInteractions.Drugs.com.Accessed October2,2022.https://www.drugs.com/druginteractions/amphetamine.html

SyntheticCathinones(BathSalts)CathinonesTestKit. M.M.C.Store.AccessedOctober2,2022.

https://shop.narcotictests.com/products/specialnarcotic-tests/synthetic-cathinones-bath-saltscathinones-test-kit/details

FlakkaDrugLawyers.LegalMatch.AccessedOctober2, 2022.https://www.legalmatch.com/lawlibrary/article/flakka-drug-lawyers.html

FLUMAZENIL

Abby Fisher, Student Pharmacist

Fall 2022

HISTORY AND BACKGROUND

Received FDA approval on December 20, 2021

First benzodiazepine antagonist approved for clinical use

https://mms.mckesson.com/ product/787797/Hikma-PharmaceuticalsUSA-00143978410

SLANG TERMS

Benzodiazepine antagonist

Antidote

MECHANISM OF ACTION

Antagonizes the actions of benzodiazepines on the central nervous system

Competitively inhibits the activity at the benzodiazepine recognition site on the GABA/benzodiazepine receptor complex

Used for the complete or partial reversal of the sedative effects of benzodiazepines in conscious sedation and general anesthesia in adult and pediatric populations

DRUG EFFECTS

Dizziness

Sweating

Nausea

Blurred vision

Vomiting

Flushing

Headache

Injection site pain

DRUG INTERACTIONS AND TOXICOLOGY

Black Box Warning: Seizures

No known drug-drug interactions

Contraindicated in patients who have been given a benzodiazepine for control of a potentially lifethreatening condition and in patients who are showing signs of serious cyclic antidepressant overdose

MONITORING AND DRUG SCREENS

Monitor patients for respiratory depression, benzodiazepine withdrawal, and other residual effects of benzodiazepines

Monitor patients for possible return of sedation

PROFESSIONAL OPINION

I believe flumazenil is an appropriate therapy option when patients present with anesthesia, conscious sedation, or overdose and are receiving the drug for reversal of a single benzodiazepine exposure ; however, it is critical to monitor these patients closely to ensure positive health outcomes.

LAWS

Flumazenil is not a controlled substance

Because it is only available as a sterile parenteral dosage form for intravenous administration, it must be given in a clinical setting

REFERENCES

1. Flumazenil. Package insert. Akorn-Strides, LLC; 2008.

2. Flumazenil uses, side effects & warnings. Drugs.com. https://www.drugs.com/mtm/flumazenil.html. Accessed October 13, 2022.

3. Evidence based medicine - statpearls - NCBI bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK470182/. Accessed October 13, 2022.

4. Flumazenil. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 13, 2022. http://online.lexi.com.

Gabapentin/Pregabalin

Slang Terms:

G abapentin-specific denoted with (G); Pregabalin-specific denoted with (P)

• Gabbies (G)

• Johnnies(G)

• Budweisers(P)

• Buds(P)

History/Background:

Gabapentin was approved by the FDA in 1993. It was originally used as a muscle relaxer and an anti-spasmodic. It was later found to have significant anti-convulsive properties. Because the mechanism of action of gabapentin was not initially understood, it was believed to have a low addiction potential.

Pregabalin was approved by the FDA in 2004 for neuropathic pain associated with various conditions. Pregabalin is one of the top 30 most prescribed medications.

Both drugs are notable for their many off-label uses. Both are used for recreational drug withdrawal has lead to an increase in abuse. Those addicted to recreational drugs have found the effects, in high enough doses, to be similar to drugs such as cocaine.

Pharmacology/Drug Effects:

Gabapentin and pregabalin are structurally similar to gamma-aminiobutyric acid (GABA), however, they have not been found to interact with any GABA receptors. Both have a high affinity to voltagegated calcium channels, specifically in the alpha-2-delta-1 subunit. Upon binding, they inhibit the release of excitatory neurotransmitters including: norepinephrine, dopamine, serotonin, glutamate, substance P, and calcitonin gene-related peptide receptors.

By inhibiting these excitatory neurotransmitters, these two drugs effectively reduce anxiety, seizures, restless leg syndrome, pain associated with neuralgia, and withdrawal (alcohol and cocaine).

Pharmacokinetics:

Bioavailability

• 60%-27%; inversely proportional to dose (G)

• >90% (P)

Time to Peak

• 2-4 hours; 8 hours for extended release (G)

• 8 hours for extended release with food (P)

Half-life Elimination:

• 5-7 hours; increased with renal impairment(G)

• 6.3 hours (P)

Absorption

Variable; absorbed by proximal small bowel by L-amino transport system. Pregabalin absorption is a saturable process. The higher the concentration of drug saturating transporters, the less bioavailable it becomes.

Interactions/Toxicology:

Bioavailability is reduced if either is taken on an empty stomach. Administer with food. There have not been any reports of serious overdoses of gabapentin or pregabalin. Overdose could lead to mild sedation, confusion, apathy, and rarely seizures. Gastric lavage and single-dose charcoal activated charcoal are common treatments for overdose.

Common side effects include bradycardia, hypotension, diarrhea, nausea, vomiting, dizziness, drowsiness, lethargy, slurred speech, tremor

Gabapentin/pregabalin withdrawal symptoms include anxiety, difficulty sleeping, nausea, pain, and sweating.

Worsened withdrawal and rebound symptoms occur if either are not gradually discontinued

Laws:

Gabapentin is not controlled everywhere in the US except Kentucky.

Pregabalin is classified as a Schedule V drug

Rising abuse has called into question the previous classifications of both gabapentin and pregabalin

Professional Opinion:

While Pregabalin is classified as a controlled substance, I believe that Gabapentin should become classified as well. The urgency of monitoring for abuse increases sharply as a substance becomes controlled. This is especially important as both, when abused, can increase suicidal thoughts in patients. Although the lethal overdose potential of both has been determined as low, the risk of severe harm when unregulated is very high.

References:

Avoid use with:

• Other CNS depressants

• Alcohol

• Cocaine

• Antisiezure drugs

• Sedatives

Monitoring/Drug Screens:

When patient is taking either, it is important to monitor the following:

• Efficacy (pain intensity/seizure frequency)

• Degree of sedation

• Mental alertness

• Suicidal thoughts

• Respiratory depression (Respiratory impairment)

• Assess for history of drug abuse

Screening:

• Blood: 5-7 hours

• Urine: three days

• Hair follicle: 90 days

• Saliva: Undetectable

Abuse Potential:

Studies have shown that patients with a history of opioid use and psychiatric disorders are at a higher risk of abusing gabapentinoids.

An increasing number of fatalities has been observed in people who abuse gabapentinoids with other psychoactive substances simultaneously.

Pregabalin is more commonly misused than gabapentin

1. Extern. Pregabalin: Guidance for People Working with Pregabalin Users https://www.publichealth.hscni.net/sites/default/files/Pregabalin%20Guidance%20Booklet%20A4%20Final%20Web_0.pdf

2. Hoeg N, Parisi T, Bhatt A. Gabapentin Addiction And Abuse. Addiction Center. Published July 17, 2022. Accessed October 5, 2022. https://www.addictioncenter.com/drugs/gabapentin/#:~:text=The%20drug’s%20known%20street%20names,changes%20in%20a%20user’s%20behavior

3. Lexicomp. Gabapentin. Published 2022. Accessed October 5, 2022. https://online-lexicom.ezproxy.lib.purdue.edu/lco/action/doc/retrieve/docid/patch_f/6961?cesid=46zBOwf4Dbg&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3Dgabapentin%26t%3Dname%26a cs% 3Dfalse%26acq%3Dgabapentin#

4. Lexicomp. Published 2022. Accessed October 6, 2022. https://online-lexicom.ezproxy.lib.purdue.edu/lco/action/doc/retrieve/docid/patch_f/152621?cesid=5qpKs1xAmep&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3Dpregabalin%26t%3Dname%26 acs% 3Dtrue%26acq%3Dpregabalin#foi

5. Cross AL, Viswanath O, Sherman Al. Pregabalin. [Updated 2022 Jul 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470341/

6. Yasaei R, Katta S, Saadabadi A. Gabapentin. [Updated 2022 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493228/

7. Schifano F. Misuse and abuse of pregabalin and gabapentin: cause for concern? CNS Drugs 2014 Jun;28(6):491-6 doi: 10.1007/s40263-014-0164-4 PMID: 24760436.

8. Rietjens SJ, Sikma MA, Hunault CC, Lange DW, Hondebrink L. Pregabalin poisoning: Evaluation of dose-toxicity relationship. British Journal of Clinical Pharmacology 2021;88(3):1288-1297. doi:10.1111/bcp.15073

9. Erowid Gabapentin (Neurontin) Vault : Law. Erowid.org. Published 2017. Accessed October 6, 2022. https://www.erowid.org/pharms/gabapentin/gabapentin_law.shtml

10. Hägg S, Jönsson AK, Ahlner J. Current Evidence on Abuse and Misuse of Gabapentinoids. Drug Saf. 2020 Dec;43(12):1235-1254. doi: 10.1007/s40264-020-00985-6 PMID: 32857333; PMCID: PMC7686181.

Gamma hydroxybutyrate (GHB)

Jake Frederick, PharmD student Fall 2022

Background/History

GHB is a depressant that was developed in 1960 as an anesthetic for surgery due to its ability to cause patients to sleep and induce a medical coma. However, it failed due to its inability to mask pain and seizurelike symptoms. In the late 80s, it saw overthe-counter use as a sedative and a growth hormone stimulator for bodybuilders, but was banned by the FDA in 1991 due to adverse reactions. Today, it is used frequently at parties as a euphoriant and aphrodisiac. Due to these effects on the body, it is a substance that has been identified as a “date rape” drug.

Slang Terms

• G

• Grievous bodily harm

• Liquid ecstasy

• Liquid E

• Liquid X

• Georgia Home Boy

• Soap

• Cherry meth

• Blue nitro

• Fantasy

Pharmacology/Drug Effects

GHB is an agonist of the GABA-B receptors in the central nervous system and acts as a depressant, similar to ethanol. However, ethanol acts on the GABA-A receptor complex to act. When these GABA-B complexes are activated, they reduce the rate that nerve transmissions occur, causing sedation.

Drug Interactions/Toxicology

• GHB taken with alcohol and other sedative medications (such as benzodiazepines) can increase the sedative effect of the drug.

• Taking GHB with amphetamines and other stimulants can lead to an increased incidence of side effects due to opposing mechanisms of action.

Laws

https://www.google.com/imgres?imgurl=https%3 A%2F%2Fwww.aidedrogue.ca%2Fwpcontent%2Fuploads%2F2022%2F01%2Fdar-ghbscaled.jpg&imgrefurl=https%3A%2F%2Fwww.aide drogue.ca%2Fen%2Fthe-differentsubstances%2Fghb%2F&tbnid=b5feqsU-xpznM&vet=12ahUK

Up until 2000, there were no restrictions on the use of GHB. However, President Bill Clinton signed H.R. 2130 (the Hillory J. Farias and Samantha Reid Date-Rape Drug Prohibition Act of 2000) into law, and now GHB is a schedule-I drug.

• GHB increases the risk of seizures, so using it with an anticonvulsant would decrease these medications’ effectiveness in preventing seizures

• Naloxone (Narcan) can decrease GHB action on the brain

• Overdose can cause blackouts, memory loss, confusion, loss of consciousness, and death.

Monitoring/Drug Screens

GHB is primarily used in the teenager and young adult population, but screening should be utilized for everyone. The HEADSS (home life, education, activities, drugs, suicide, sex) assessment as well as a social history should be taken at medical office visits. If the patient confirms they are using GHB, the provider should inform the patient of GHB use and provide resources for rehabilitation programs

Professional Opinion

Due to its lack of studies in human subjects, side effects, overdose potential, and use as a date rape drug, GHB should remain a schedule-I drug. In the past it has been used in the medical setting, but the drawbacks far outweighed the benefits, meaning that there is no place for it in the medical field let alone the general population.

References

Busardò FP, Jones AW. GHB pharmacology and toxicology: acute intoxication, concentrations in blood and urine in forensic cases and treatment of the withdrawal syndrome. Curr Neuropharmacol. 2015;13(1):47-70. doi:10.2174/1570159X13666141210215423

Gamma-Hydroxybutyrate (GHB): Overview, uses, side effects, precautions, interactions, dosing and reviews. WebMD. https://www.webmd.com/vitamins/ai/ingredientmono-950/gamma-hydroxybutyrate-ghb. Accessed October 13, 2022.

GHB. GHB - Alcohol and Drug Foundation. https://adf.org.au/drug-facts/ghb/#:~:text=Other%20names,meth%2C%20blue%20nitro%2C%20fishies. Accessed October 13, 2022.

O'connell T, Kaye L, John J. Plosay I. Gamma-Hydroxybutyrate (GHB): A newer drug of abuse. American Family Physician. https://www.aafp.org/pubs/afp/issues/2000/1201/p2478.html. Published December 1, 2000. Accessed October 13, 2022.

Hashish

Street Drug Monograph

Names

Hash, Dry Herb, Hay1

What is it?

Hashish is a cannabis product made from the trichomes (flowering buds containing resin glands) of the cannabis plant that have been compressed or purified. It can be smoked or used orally.2

History

Hashish has been used for several thousand years. Some of the first records of its use come from 900 AD in Arabia. Its use spread to Europe in the 1800s.3

Modern popularity rose in the 1960s, becoming popular in the US for those with “alternative lifestyles”. Many Western tourists also were exposed to Hashish when traveling to India and Nepal.3

Pharmacology

Hash contains the same cannabinoids found in other cannabis products (such as marijuana), but at a higher concentration. For example, Hashish resin usually contains 20-60% THC.4

Cannabinoids are fat soluble, meaning that it can stay in the body for longer than water soluble substances. It has a half life of seven days in the body. Cannabinoids are metabolized in the liver, and are secreted 25% in the urine and 65% in the GI, leading to reabsorption. They interact with cannabinoid receptors (CB1 and CB2), increasing dopamine secretion. People are able to develop resistance to cannabinoids.4

Effects

Cannabinoids have anxiolytic, sedative, analgesic, and psychedelic properties. They can also increase appetite, lead to euphoria or dysphoria, distorted space and time perception, and (at high doses) hallucinations. They can lead to long term impairment with chronic use.4

Drug Interactions

● Increases clearance of drugs metabolized by CYP1A2.5

● Decreases clearance of drugs metabolized by CYP2C19.5

● Additive effects with sympathomimetics (tachycardia, hypertension).5

● Additive effects with CNS depressants (drowsiness, ataxia).5

● Additive effects with anticholinergics (tachycardia, confusion).5

● Increases bleeding risk of Warfarin.5

● CYP3A4 and CYP2C9 inhibitors can increase cannabinoid effects.5

Laws and Regulation

Cannabis products are illegal at the federal level, but state legislation varies heavily.

Indiana: “Possession of more than two grams of hashish or concentrate, or if the person has a prior conviction of an offense involving marijuana, hash oil, or hashish and is in possession less than two grams, then the crime is a level 6 felony, punishable by six months to 2 ½ years imprisonment and a maximum fine of $10,000.”6

Monitoring and Drug Screening

Drugs to detect THC exist in urine, blood, and hair forms.7

The most common type of test are urine tests. If someone tests positive with a urine test, they usually perform a second, more-sensitive urine test to rule out false positives.7

These tests can appear positive 3-30 days after cannabis use.7

Professional Opinion

Hashish is higher potency than other cannabis products, increasing the risk of overdose. With cannabis products, overdose is almost impossible when smoked, but oral products carry a higher risk.

Cannabis can be a good alternative to other, more dangerous substances. It can still be dangerous, especially when driving or performing other tasks requiring high alertness.

Sources

1.Difference Between Hashish And Marijuana? | Sunrisehouse.com. Sunrise House. Accessed October 6, 2022. https://www.google.com/url?q=https://sunrisehouse.com/quit-abusing-marijuana/hashish/&sa=D&source=docs&ust=1665082878697254&usg =AOvVaw0ci1NtV_udsl9L3cbvZBm0

2.What is Hashish (Hash Drug)? (Effects, Addiction & Withdrawal). Published May 14, 2021. https://www.addictiongroup.org/drugs/other/hash/

3.Hashish—A Short History. Narconon International. https://www.narconon.org/drug-information/hashish-history.html

4.Ashton CH. Pharmacology and effects of cannabis: A brief review. British Journal of Psychiatry. 2001;178(2):101-106. doi:10.1192/bjp.178.2.101

5.Antoniou T, Bodkin J, Ho JMW . Drug interactions with cannabinoids. CMAJ. 2020;192(9):E206-E206. doi:10.1503/cmaj.191097

6.Indiana Laws and Penalties. NORML. Accessed October 6, 2022. https://norml.org/laws/indiana-penalties-2/

7.Marijuana (THC) Testing | Labcorp. www.labcorp.com. https://www.labcorp.com/help/patient-test-info/marijuana-thc-testing

Images

https://weedmaps.com/learn/dictionary/hash

https://www.istockphoto.com/photo/hemp-or-cannabis-leaf-isolated-on-white-background-top-view-flat-lay-template-or-gm1158372978-3163 96506

Hawaiian Baby Woodrose

Fall 2022

History/ Background

Hawaiian Baby Woodrose is considered to be a climbing vine characterized with light purple flowers and seeds that grow in pods. This natural plant is native to India and it has been introduced to Hawaii , the Caribbean, as well as other tropical or subtropical climates. For thousands of years, Hawaiian Baby Woodrose has been cultivated in various cultures for medicinal (treatment of pain) and religious purposes.

https://www.alamy.com/stock -photo/hawaiian-baby -woodrose.html

Slang Terms/Other Names

There are very few slang terms for this drug, but the following equivalent names were found:

Argyreia Nervosa

Woolly Morning Glory

Elephant Creeper

LSA

https://www.worldseedsupply.com/product/hawaiian -babywoodrose-ayurvedic -strain-seeds/ https://sensiseeds.com/en/blog/hawaiian

Drug Effects/Pharmacology

The seeds contain a chemical called LSA, which is similar to LSD, a hallucinogen . LSA is a weak agonist of the dopamine type -2 receptor, so dopamine levels will be altered. The number of seeds eaten will determine the level of psychoactive effects that the user will experience. Users have reported being in a dream-like state when using Hawaiian Baby Woodrose.

Drug Interactions/Toxicology

Hawaiian Baby Woodrose and SSRIs have a moderate drug interaction due to the combined action of increasing serotonin levels in the brain. Serious side effects can result from this drug interaction. These side effects include severe headache, confusion, anxiety, loss of temperature control, and heart problems.

Laws

There are no restrictive laws or regulations about the possession of Hawaiian Baby Woodrose, however it is not approved for human consumption.

Once LSA is extracted from the seeds, it is considered to be an illegal possession. LSA is regulated in the US as a Schedule III drug.

Monitoring/Drug Screens

No information was found on drug screenings for Hawaiian Baby Woodrose. Monitoring parameters can include watching for side effects, such as nausea, vomiting, sweating, dizziness, blurred vision, hallucinations, dilated pupils, and increased heart rate and blood pressure.

Professional Opinion

In my professional opinion, Hawaiian Baby Woodrose should be illegal to freely purchase and possess by the average person. similar to LSD, so there need to be tight regulations and laws on the use of Hawaiian Baby Woodrose. The risks outweigh the benefits, so I would advise looking into different treatment options. ~

References:

1. Hawaiian Baby Woodrose Plant What Is It and What Is It Used For? Sensi Seeds. Updated September 9, 2020. Accessed October 12, 2022. https://sensiseeds.com/en/blog/hawaiian-baby -woodrose-plant-what-is-it-and-what-is-it-used-for/

2. Hawaiian Baby Woodrose Uses, Side Effects, and More. WebMD. Accessed October 12, 2022. https://www.webmd.com/vitamins/ai/ingredientmono-325/hawaiian-baby -woodrose

3. Hawaiian baby woodrose seeds. The Mix. Accessed October 12, 2022. https://www.themix.org.uk/drink-and-drugs/legal-highs/hawaiian-baby

-woodrose-seeds-9848.html

4. Hawaiian Baby Woodrose Legal Status. The Vaults of Erowid. Accessed October 12, 2022. https://erowid.org/plants/hbw/hbw_law.shtml

HEROIN

Dope, Smack, H, or Junk

November 9 2022

HISTORY/BACKGROUND

1874: Heroin is synthesized for the first time by CR Alder Wright at St. Mary's hospital in London.

1897: Heroin is made by Felix Hoffman at Bayer Pharmaceutical. Company recognized drug's potential and began marketing it for the treatment of respiratory ailments.

1898: Bayer began exporting heroin to other countries. Use became widespread as people saw the drug was more effective than morphine and thought it had less side effects.

1911: many experiments were done that determined heroin is as addictive as morphine.

1913: Bayer stops production of heroin.

1920: House of Delegates of the American Medical Association announced that heroin be eliminated from all medicinal preparations and should not be prescribed or dispensed.

1924: All legitimate production of heroin stopped due to Heroin Act.

1965-1970: Vietnam war was happening and people blamed U.S. involvement in the war for an increase in illegal heroin being imported into the U.S.

1971: It was found that many American soldiers were addicted to heroin.

PHARMACOLOGY

Synthesized from the acetylation of morphine (diacetylmorphine)

The activate metabolites are 6-O-acetylmorphine and morphine.

Drug is an opioid analgesic and euphoric depressant

Binds and activates the mu-opioid receptors of the CNS. This binding mediates respiratory depression, euphoria, and physical dependence.

Due to nature of the receptor, tolerance is obtained quickly

Route of Administration includes snorting, smoking, or injecting intravenously.

FUN FACT: Heroin was most likely named from "heroisch", the German term meaning large, powerful, or one with pronounced effect even in small doses.

PHARMACOLOGY

Bonkers Institute. 2008. 1901 Bayer Heroin ad. http://www.bonkersinstitute.org/medshow/bayer heroin1901.html

TOXICOLOGY

Short Term Adverse Effects: flushing of the skin, dry mouth, nausea, vomiting, severe itching, drowsiness, respiratory depression, and decreased heart action.

Long Term: Deterioration of brain white matter, tolerance, and withdrawal symptoms. The respiratory and heart depression can lead to death

Concurrent use of Alcohol or Benzodiazepines can increase CNS depression.

MONITORING/DRUG SCREENS

Can be detected in standard and extended drug tests.

Detected in urine for 1-4 days.

LAWS

NEUROtiker. March 7 2007. Heroin. https://en.wikipedia.org/wiki/Heroin

Heroin is a schedule 1 controlled substance. For possession of heroin a person can face up to 1 year in prison and a minimum fine of 1000 dollars. Law regarding trafficking of heroin are as follows: trafficking involves movement of 100-999 grams of heroin.

First offense not less than 5 years and not more than 40 years in prison. Fine of 5 million if individual person and 25 million if not an individual.

Second Offense not less than 10 years and not more than life. If death of serious injury occur penalty if life in prison. Fine of 8 million dollars if an individual and 50 million if not an individual.

PROFESSIONAL OPINION

After research and learning more about heroin I think that it should remain a schedule 1 drug. Although it does have powerful analgesic effects, the toxicities and addiction risk associated with heroin make it unsafe to use in any medical setting. Furthermore, newer and safer options have been developed since the time that heroin was discovered for treatment of respiratory ailments.

RESOURCES:

Heroin street names, nicknames & slang terms. American Addiction Centers. https://americanaddictioncenters.org/heroin-treatment/ slang-names. Published July 13, 2022. Accessed October 13, 2022.

Heroin. Erowid heroin vault : Timeline. https://www.erowid.org/chemicals/heroin/heroin_timeline.php. Accessed October 13, 2022. S; H. [heroin, part III: The pharmacology of heroin]. Acta pharmaceutica Hungarica. https://pubmed.ncbi.nlm.nih.gov/15112443/#:~:text=The%20analgesic%20effects%20of%20heroin,depression%2C%20euphoria%20and%2 0physical%20dependence. Accessed October 13, 2022.

University leadership. University Leadership | Seattle Pacific University. https://spu.edu/university-leadership. Accessed October 13, 2022. UNODC - Bulletin on narcotics - 1953 issue 2 - 003. United Nations : Office on Drugs and Crime. https://www.unodc.org/unodc/en/dataand-analysis/bulletin/bulletin_1953-01-01_2_page004.html. Accessed October 13, 2022.

IGOBAINE

Fall 2022

USES

Ibogaine has been used for its psychoactive and stimulatory effects, but it has also been used to treat opioid addiction and withdrawal symptoms2 .

OTHER NAMES

Other names include Iboga, Bois Sacré, and Eboka with the scientific name of Tabernanthe iboga1

HISTORY

Iboga is a naturally psychoactive stimulating drug found in the Ibogaine plant. The drug is more concentrated in the root than in other parts of the plant. It is found in various countries in Africa including Republic of Congo, Gabon, Cameroon, and Guinea and has been used in various religious activities. One such example is the Bwiti religion. It was discovered by European countries in the 1800s where it was continuously researched until 1901 when the compound was experimentally isolated. France was a country that started to sell ibogaine as Lambarene for a stimulant in the 1930s-1960s until it became illegal in 1966. In addition to France making it illegal, the World Health Organization (WHO) and Food and Drug Administration (FDA) also declared Ibogaine as illegal and classified it as a Schedule I drug1,2 .

MONITORING/DRUG SCREENING

There is not much monitoring/drug screening done for ibogaine as it is not used clinically in the United States. Research has been done with varying results showing that ibogaine is helpful in reducing opioid withdrawal symptoms and helped people recover from an opioid addiction. One study showed that most of the people who used ibogaine relapsed after treatment while another study showed that it reduced opioid cravings of the participants2,4 .

Drug Interactions/Toxicology

There are many toxicological effects of ibogaine throughout the body. The use of ibogaine has been shown to cause dysrhythmias, “agitation, hallucinations, vomiting, ataxia, muscle spasms, weakness, seizures, paralysis, arrhythmias, urinary retention, respiratory insufficiency, and cardiac arrest”3 .

There are no absolute contraindications with this drug nor are there any documented interactions. It has been shown though to cause more fatalities with people who take this and have comorbidities including opioid use, cardiovascular disease, depression, schizophrenia, and other autonomic nervous system disorders3 .

Pharmacology/Drug Effects

Ibogaine has been classified as a Schedule I hallucinogenic with many different possible mechanisms of action. It appears to have various effects with different doses. At a lower dose, it works mainly on the cerebella of the sympathetic nervous system and causes euphoria and an increase in muscle strength and endurance. This happens through many ways including kappa agonist effects, serotonergic effects, and nicotinic and N-methyl-Daspartate (NMDA) antagonism2. Some of these are considered options for why ibogaine could be used to treat opioid withdrawal symptoms. The kappa agonist effects increase the concentration of the chemical dynorphin, which creates cocaine aversion. The NMDA antagonism can help reduce the withdrawal symptoms. Also, the ibogaine metabolite noribogaine can treat opioid withdrawal as it binds to mu receptors2 .

At a medium dose, it starts to produce psychedelic effects and the person can experience dreams while awake. It also starts to stimulate the parasympathetic nervous system which can be so drastic as to cause a “feigned death”. It can decrease the amount of time spent in the rapid-eye movement (REM) stage of sleep which is a factor in the stimulatory effects. At a high dose, it causes hallucinations which is due to it being an indole alkaloid2,3

Laws

Ibogaine is a Schedule I hallucinogenic drug that is illegal in the United States of America1 .

Professional Opinion

While ibogaine has been shown to have some effect reducing opioid withdrawal symptoms and helping people transition out of substance abuse, not enough studies have been done to demonstrate its superiority to other treatments. Additional studies also need to be done proving types of dosing and the safety of the drug in general. Due to its main psychedelic effects of hallucinations and its lack of clinical efficacy, people should not be taking this drug and it should remain illegal in the United States.

References

1. Iboga. Natural medicines - databases. https://naturalmedicines.therapeuticresearch.com/datab ases.aspx. Accessed October 11, 2022.

2. Scottsdale Recovery Center. What is ibogaine? Scottsdale Recovery Center. https://scottsdalerecovery.com/what-is-ibogaine/. Published August 19, 2019. Accessed October 11, 2022.

3. Iboga. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 11, 2022.

4. Mash DC, Duque L, Page B, Allen-Ferdinand K. Ibogaine detoxification transitions opioid and cocaine abusers between dependence and abstinence: Clinical observations and treatment outcomes. Frontiers in Pharmacology. 2018;9. doi:10.3389/fphar.2018.00529

Isoflurane anesthetics

https://redwoods medicaledge.com

/2012/10/19/putme-to-sleepanesthesiology/

History

https://vetpharma.com

/producto/isoflurane/

The need for a new generation of nonflammable volatile anesthetic originated around 1960 when Ohio Medical Products initiated a research project with the goal to synthesize non-flammable fluorinated ethers and hydrocarbons anesthetic with less cardiovascular toxicities and more ideal metabolism than the first generation of fluorinated compounds. Ohio Medical Products assigned two senior chemists, Louise Speers Croix, Ph.D. and Ross C. Terrell Ph.D. to synthesize fluorinated methyl ethyl ethers and fluorinated methyl isopropyl ethers, which resulted in the discovery of isoflurane. After meeting all required standards of volatility, nonflammability, stability, it was improved for clinical use in 1972.

Background

Primary therapy for preoperative sedation and adjunctive anesthesia maintenance to intravenous anesthetic agents in the perioperative setting. It induces muscle relaxation and reduces pains sensitivity by altering tissue excitability. Inhaled anesthetics allow for rapid introduction of an agent into arterial blood via the pulmonary circulation, essentially the significance of rapid therapeutic effects allows for efficient induction and discontinuation of sedation induced by these agents.

Drug Abuse

Flurane anesthetics cause effects such as dysphoria, intoxication, and hallucinations. Abusers may sniff or snort fumes from a dispenser or aerosol directly into their nose. The high from inhalants only last a couple of minutes so abusers prolong repeating sniffing over several hours. Some abusers may pour inhalants onto their shirt collar and sniff it periodically.

Slang terms: Poppers, Snappers

Pharmacology

www.dnaindia.com/india/reportdna-exclusive-children-glued-toinhalants-as-drugs-1860440/amp

The mechanism of action of inhaled anesthetics consists of deregulating neurotransmission of excitatory paths involving acetylcholine, glutamate, and serotonin within the central nervous system triggering respiratory depression. It may depress myocardial contractility, decrease blood pressure through a decrease in systemic vascular resistance, and decrease sympathetic nervous activity.

Onset- 7-10 minutes post-inhalation, Metabolism: Minimally hepatic (<0.2%), predominantly CYP2E1,minimal biotransformation in man, Excretion: Exhaled gases, Renal Excretion 0.17%

Drug interactions

Risk X: Avoid combinations due to enhanced CNS depression, hypertensive effect, or arrhythmhttps://www.istockphoto.com/ illustrations/anesthesia-mask-cartoonogenic effects: azelastine, bromperidol, dexmethylphenidate, ephedra, ephedrine, flunarizine, isoproterenol, Kratom, levoketoconazole, metaraminol, olopatadine, orphenadrine, oxomemazine, paraldehyde, pimozide, sertindole, thalidomide

Minor decrease in metabolism occurs with CYP2E1 inhibitors and minor increased metabolism with CYP2E1 inducers

Toxicology

Acute exposure- Nephrotoxicity, dizziness, loss of consciousness, asphyxia, due to airway irritation. Chronic exposure-nausea, dizziness, fatigue, headache, irritability, reduced mental performance, liver and kidney disease, carcinogenicity, teratogenic/ birth defects (crosses the placenta), and reproductive effects: sterility or infertility. Warning- All anesthetic gases have shown a depression of cardiac contractility. Decrease in BP is dose dependent due to peripheral vasodilation; cardiac output is maintained. Use caution in patients who are hypovolemic, hypotensive, or hemodynamically compromised; use caution in patients with coronary artery disease to avoid risk of myocardial ischemia. May prolong the QT interval and rarely torsades de pointes; use caution in patients at risk of QT prolongation

https://medicare24.onlin e/details/disease/1097

Laws

The average of 50 ppm for isoflurane has been defined as a non-regulatory occupational exposure limit by the American Conference of Governmental Industrial Hygienists (ACGIH). The exposure limit for isoflurane is 50 ppm since OSHA has not developed a regulation permitted exposure level for it.

Monitoring/drug screens

Blood pressure, electrocardiogram, serum potassium, oxygen saturation, respiration, end-tidal CO2 and QT interval in patients at risk for QTc prolongation. Isoflurane concentrations should be monitored prior to and throughout anesthesia QT interval in patients at risk for QTc prolongation

Professional opinion

I believe this form of volatile gas inhalant anesthetics are more beneficial than harmful. They are less abuse prone than the majority of other inhaled anesthetics such as nitrous oxide or chloroform. This class of inhalants are mostly present in surgical settings oppose to easily accessible items such as cleaners or sprays.

References

1. Anesthetic gases - statpearls - NCBI bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK537013/. Accessed October 14, 2022.

2. Pubs.asahq.org. https://pubs.asahq.org/anesthesiology/article/108/3/531/8240/TheInvention-and-Development-of-Enflurane. Accessed October 13, 2022.

3. Isoflurane. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 13, 2022. http://online.lexi.com

4. Isoflurane Anesthetic Gas Guidelines. Isoflurane Anesthetic Gas Guidelines | Environmental Health and Safety. https://ehs.research.uiowa.edu/isofluraneanesthetic-gas-guidelines. Accessed November 7, 2022.

5. Luo A, Zhang X, Li S, Zhao Y. Sevoflurane addiction due to workplace exposure: A case report and literature review. Medicine (Baltimore). 2018;97(38):e12454.

https://www.123rf.com/clipartvector/anesthesia_anaesthesia.htm

SLANG TERMS:

1. Spice/K2

2. Bliss

3. Black Mamba

4. Blaze

5. Bombay Blue

6. Snax

7.Fake Weed

8.Legal Weed

9.Genie

10.Zohai

11.Red X

12.Dawn Scooby Skunk

PHARMACOLOGY:

“Spice” binds to and acts on the same receptor as marijuana These receptors are known as cannabinoid receptors (CB1 and CB2). Currently, synthetic cannabinoids like Spice/K2 are not well tested or well understood resulting in very minimal understanding of its pharmacology. Despite minimal research, scientists do know that Spice/K2 binds to cannabinoid receptors more strongly than marijuana. This gives it the capability to produce much stronger effects on the human body. The drug appears to be metabolized via the liver and excreted through the urine and feces.

DRUG EFFECTS:

Spice/K2 has a range of effects. Some of these are similar to the effects of marijuana. These effects include elevated mood, relaxation, altered perception, and symptoms of psychosis. Psychotic effects have also been seen with synthetic cannabinoid usage. These effects include extreme anxiety, confusion, paranoia, and hallucinations.

HISTORY:

“Spice” is another term for synthetic marijuana which was first used in Europe and the United States in 2004 and 2008, respectively, although; the chemicals used to make Spice were first created in laboratories decades prior. Components of synthetic marijuana created by experimentation include CP 47,497 (developed by Pfizer in the 1980’s), HU-210 (developed in 1988 at Hebrew University in Jerusalem), and JWH-018 (founded at Clemson University in 1995). Its use has been difficult to track Once a chemical was illegalized, a new chemical, not tested for on a drug screen, would be made in the lab to replace it.

BACKGROUND:

“Spice” is a synthetic form of tetrahydrocannabinol (THC), a psychoactive ingredient that is typically found in marijuana. It often comes as an herbal mixture that contains a mixture of plant material that has been sprayed with chemical additives that create its psychoactive effects. It can resemble the appearance of potpourri, so it is often labeled with “not for human consumption”. Users consume this substance by smoking it or inhaling it through ecigarettes or other devices.

U S. Army. Accessed November 9, 2022. https://www.army.mil/article/157559/substance_abuse_coodinator_ warns_of_spice_dangers

PROFESSIONAL OPINION:

The capability of manufacturers to develop new synthetic cannabinoids in a laboratory quickly and the inconsistency in the make-up of Spice/K2 makes this substance both dangerous and unpredictable. This combined with the drug’s capability to effect the mind with delusions severe agitation and violence makes this drug a danger to the public leading me to the conclusion that this drug should stay illegalized and not be used for medical treatment.

DRUG INTERACTIONS:

“Spice” is a substrate for various P450 isoforms. These isoforms include CYP2C9 and CYP1A2. Drugs that are inhibitors of these enzymes possess the ability to cause drug-drug interactions with Spice/K2. These drugs include:

1. CYP2C9 inhibitors (valproic acid, sertraline)

2. CYP1A2 inhibitors (ciprofloxacin, fluvoxamine) “Spice” is metabolized in part by CYP2C9 which can affect the metabolism of other drugs that utilize this enzyme like warfarin, phenytoin, tolbutamide, losartan, and ibuprofen.

TOXICOLOGY:

The Centers for Disease Control has associated the use of Spice/K2 to overdose deaths as a result of myocardial infarction. In addition, the smoked substance has led to acute kidney injury requiring hospitalization and dialysis. The drug has an extensive list of adverse effects including tachycardia, elevated blood pressure, tremors, vomiting, hallucinations, and agitation.

LAWS:

Due to the lack of medical benefit and high potential for abuse, there is currently no accepted medical use for Spice/K2 in the United States, and it is illegal to buy and sell. For this reason, 26 synthetic cannabinoids are currently listed as schedule I substances under the Controlled Substances Act, in addition to many other substances that meet the definition for cannabimimetic agent However, there are a few synthetic cannabinoid substances that have been sold as the result of a workaround, selling the product as incense or potpourri. There is an act termed the Controlled Substance Analogue Enforcement Act that has allowed these uncontrolled synthetic cannabinoids to be subject to persecution as a Schedule 1 controlled substance if a list of criteria is met.

REFERENCES:

DRUG SCREENING:

Due to the ever-evolving list of synthetic cannabinoid substances and components, it can be hard to design tests that target this type of drug. There are blood, hair, urine, and saliva tests that can detect levels of Spice. Saliva tests have proved useful and have shown detection 20-60 minutes after inhaling the drug.

“Synthetic Marijuana: A Short History.” Foundation for a Drug-Free World, https://www.drugfreeworld.org/drugfacts/synthetic/syntheticmarijuana-short-history.html.

“Spice/ K2, Synthetic Marijuana.” DEA, https://www.dea.gov/factsheets/spice-k2-synthetic-marijuana.

“Spice (Synthetic Marijuana).” National Institute of Drug Abuse, https://nida.nih.gov/sites/default/files/pdf/nmassist.pdf

“Synthetic Cannabinoids (Spice, K2).” Release, 28 Jan 2019, https://www.release.org.uk/drugs/synthetic-cannabinoids-salvia-spicek2/pharmacology

Tai S, Fantegrossi WE. Pharmacological and Toxicological Effects of Synthetic Cannabinoids and Their Metabolites. Curr Top Behav Neurosci 2017;32:249-262. doi:10.1007/7854_2016_60

PHARMACOLOGY

Kava Kava is a depressant drug. It slows down the messages travelingbetween the brain and the body.

Kava Kava works by:

• blockage of voltage-gated sodium ion channelsenchanced ligand binding to GABA type A receptors

• diminished excitatory neurotransmitter release due to calcium ion channel blockade

• reduced neuronal reuptake of noradrenaline

• reversible inhibition of monoamine oxidase B and suppression of the synthesis of the eicosanoid thromboxane A2, which antagonizes GABA-A receptor function

Kava Kava can be used to treat anxiety and insomnia. It can also create a similar effect to alcohol. It has a sedative, anxiolytic, antistress, analgesic, local anesthetic, anticonvulsant, and neuroprotective properties.

Kava Kava can be used to treat anxiety and insomnia1. It also creates a similar effect to alcohol1. It has sedative, anxiolytic, antistress, analgesic, local anesthetic, anticonvulsant, and neuroprotective properties.

Kava Kava has been used in the Pacific Islands as a ceremonial drink^1. It is made from the root or the stump of the keva shrub^2. Kava Kava can cause similar effects as alcohol. The roots of this plant are ground up and then added to cold water that results in a “thick brew.” It is a drink that is prestigious and is offered to guests. It can be used to relax, “elevate mood, well-being, and contentment.” It can also be used to treat some disorders including anxiety, insomnia, and other types ofnervousdisorders^1.

SLANG TERMS WAKA

KAVA-KAVA KAWA LEWENA

https://www.nccih.nih.gov/health/kava

LAWS

PROFESSIONAL OPINION

MORE TO KNOW

MONITORING DRUGSCREENS

Kava Kava will not show up on drug tests due to the fact that the tests most organizations use do not look for it. If a drug screen identifies it, kava kava can be found in the urine, blood, or hair.

References

1. KavaKava.MountSinaiHealthSystem. https:// www.mountsinai.org/health-library/herb/kavakava. Accessed October 13, 2022.

https://www.natrol.com/products/kava-kavamood-stress-capsules?bvstate=pg:2/ct:r

Kava Kava is legal in the United Statesandissoldasadietary supplement.

Studies have shown that kava kava can reduce the symptoms of anxiety. It was significantly moreeffective when compared to a placebo. It has also been found to improve mood and cognitivefunction.

2. Kava.Kava-AlcoholandDrugFoundation. https://adf.org.au/drug-facts/kava/ #:~:text=Other%20names,and%20wati%20(New%2 0Guinea). Accessed October 13, 2022.

3. NN; SYNS. Therapeutic potential of kava in the treatment of anxietydisorders.CNSdrugs. https:// pubmed.ncbi.nlm.nih.gov/12383029/#:~:text=The% 20pharmacological%20properties%20of% 20kava,reduced%20neu ronal%20reuptake%20of% 20noradrenaline%20.Accessed October 13, 2022.

4. Singh YN, Singh NN. Therapeutic potential of kava in the treatment of anxiety disordersCNS drugs. SpringerLink. https:// link.springer.com/ article/10.2165/00023210-200216110-00002. Published August 29, 2012. Accessed October 13, 2022.

5. Is kava legal where I live? Kava laws around the world. Kava Guides.https://kavaguides.com/ kava-laws/.Published August 18, 2021. Accessed October 13, 2022.

6. DoesKavashowupondrugtests?KavaGuides. https://kavaguides.com/kava-drug-test/.

PublishedAugust 21, 2021. Accessed October 13, 2022.

Drug Name: Ketalar

History/Background

Ketamine is typically produced commercially in many countries.

It is an injectable, short-acting anesthetic used in surgery. It’s considered a dissociative anesthetic that makes the user feel detached from their pain and environment. The patient’s vital signs need to be monitored closely by the anesthesiologist once administered for the procedure.

Ketamine comes in a clear liquid when injected, but it can also come in a white or off-white powder. The powdered form is packaged in small glass vials, bags, capsules.

It is abused for its ability to produce dissociative sensations and hallucinations and has been used to facilitate sexual assault.

• Special K

• Cat Valium

• Kit Kat

• K

• Super Acid

• Super K

• Purple

• Special La Coke

• Jet

• Vitamin K

Ketamine is a general anesthetic. These render patients reversibly unconscious and unresponsive. It prevents the patient from feeling pain and will likely cause some memory loss upon waking.

• Hallucinatory effects last 30-60 minutes

• Distorts sights and sounds

• Induces feelings of calmness and relaxation

• relief from pain

• immobility

• amnesia

Drug Interactions

• Reacts with other drugs that make you sleepy or slows your breathing; such as opioids, anxiety medications, sleeping pills, and muscle relaxers; making it take longer to wake from the anesthesia.

It is possible to test for the presence of ketamine metabolites in urine, blood, & hair. But ketamine is not standardly tested for in the basic drug test nor in extended drug tests.

The breakdown product of ketamine, norketamine, is detectable in blood and urine for 7-14 days.

Laws

Ketamine is a Schedule III substance under the Controlled Substances Act.

Toxicology

May cause: painful/difficult urination, increased urination, loss of bladder control, blood in urine, light-headed feeling, bradycardia, weak/shallow breathing, jerky muscle movements, confusion, or dream-like feeling.

• Prescription and over-the-counter medicines, vitamins, and herbal products may also affect ketamine.

• 386 drugs are known to interact/affect ketamine, so all current medications need to be disclosed before use

Professional Opinion

Ketamine is a good and safe drug to use as an anesthetic for surgical operations. It almost always should be used in an operating room as it has the potential to be abused. It has recently been found to be helpful for treating depression though, so it could also be used in that manner as well.

• Ketamine: Drug Testing. Erowid. Updated March 8, 2020. Accessed October 10, 2022. https://www.erowid.org/chemicals/ketamine/ketamine_testing.shtml

• Ketamine. Just Think Twice. Accessed October 10, 2022. https://www.justthinktwice.gov/drugs/ketamine

• Ketamine. Drugs.com. Updated October 10, 2022. Accessed October 10, 2022. https://www.drugs.com/mtm/ketamine.html

• Ketamine Molecule Rainbow Chemistry Sticker. TeePublic. Accessed October 10, 2022. https://www.teepublic.com/sticker/12570586-ketaminemolecule-rainbow-chemistry

• Burness, A. Colorado Doctors' Group: Ketamine Safe, With More Oversight. EMSworld. Published December 3, 2021. Accessed October 10, 2022. https://www.hmpgloballearningnetwork.com/site/emsworld/news/colorado-doctors-group-ketamine-safe-more-oversight

Khat

Streetnames

AbyssinianTea,Chat,Catha,Oat

History

Khatisafloweringshrubscientifically knownasCathaedulis.Originally,Khat becameacceptedasaritualisticcustomin AfricanandArabianculture.Itsusedates backtothe13thcenturyinAbyssinia(also knownasEthiopia)andbroughttoYemen intheearly15thcentury.Itbecamealarge partofYemeniculturewhereitisusedin religiousandsocialsettings.InYemen, 90%ofmalesuseKhatmultipletimesdaily. 73%ofwomenandalmost20%ofchildren alsouseKhatonadailybasis.

Howisitused?

Khatismostcommonlychewed.Youcanfindusersstuffingwadsofthisshrubintotheircheeks similartotobacco.Itcanalsobedriedandputintotea,incorporatedintofood,andsmoked.The globaldistributionhassharplyincreasedinthemoderneraduetothedevelopmentofcathinone (Khat’sactiveingredient)capsulesandothersyntheticformsofcathinone.

Pharmacology

Manydifferentcompoundscanbeextractedfromthisplant.The mainactiveingredientinKhat,cathinone,isknowntocausea stimulated,euphoricstateofmind.ThemajoreffectsofKhatcome fromitsactiononthenervoussystemcausingincreasedalertness, dependance,tolerance,andotherpsychiatricsymptoms.Italsoacts onthegastrointestinaltractcausingconstipation,urineretention, andacutecardiovasculareffects.Cathinoneispharmacologically unstableandbeginstodecomposeoncetheplantisharvested.This iswhyfreshKhatleavesarepreferredamongitsusers.Itisbelievedthatothercompoundsinthis planthavebeenoverlookedandunderstudiedandarethoughttocontributetoKhat’svasteffects onthebody.Khatchewerswereshowntohaveincreaseddepressionandpsychologicaldistress duetotheirdependance.

Chronickhatusehasbeenshowntohaveeffectsonfetaldevelopmentandlactation.Pregnant mothersareatincreasedriskofbecominganemicduringpregnancy.Thedrugmayalsoreduce placentalbloodflowcausinglowerbirthweights.Itspsychoactiveeffectsmayalsocause increasedmotorandcognitivedysfunctionaswellasdependancetothefetus.

Drug Interactions

The gastrointestinal absorption of Khat is shown to decrease the bioavailability of certain antibiotics, thus making them less effective. Nicotine and caffeine increase the stimulatory effects of Khat. Concurrent use of these substances is common.

Khat is also known to cause increased blood pressure which may compete with antihypertensive medications.

Adverse Reactions

The most serious adverse reactions to Khat include: depression, insomnia, suicidal ideation, loss of appetite, nausea, vomiting, numbness, severe migraines and difficulty concentrating.

Laws

Khat is illegal in the United States. Cathinone is classified as a Schedule I Stimulant and Cathine (another known active ingredient) is a Schedule IV stimulant under the Controlled Substance Act. This means there are no known medical uses with a high potential for abuse. Today, Khat consumption is limited to EastAfrica and SouthwesternArabia. It has been made illegal in nearly allArab Gulf states except for Yemen.

Monitoring

Cathionone and cathine can be detected in urine and picked up on a urine drug screen. Khat users should monitor for decreased cognitive function as well as abnormal heart rate.

Professional Opinion

Khat began as an accepted drug for religious and social matters. At that point it was just a plant and not widely accepted as a drug for abuse. With the modern production of cathinone tablets, we are seeing a dramatic increase in the distribution and abuse of this compound. With its many negative effects on the cardiovascular and nervous system, it is becoming an issue for the health and finances of specified countries. More research must be done to truly understand the effects of Khat’s compounds on the human body. ~

References

El-Menyar,A., Mekkodathil,A.,Al-Thani, H., &Al-Motarreb,A. (2015, March). Khat use: History and heart failure Oman medical journal. Retrieved November 9, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4412450/#:~:text=Origin%20and%20spread%20of%20 khat%20use text

Griffiths, P., Lopez, D., Sedefov, R., Gallegos,A., Hughes, B., Noor,A., & Royuela, L. (2010, May 7). Khat use and monitoring drug use in Europe: The current situation and issues for the future Journal of Ethnopharmacology. Retrieved November 9, 2022, from https://www.sciencedirect.com/science/article/pii/S037887411000303X?via%3Dihub

Home | dea.gov. (n.d.). Retrieved November 9, 2022, from https://www.dea.gov/sites/default/files/2020-06/Khat-2020_0.pdf

Lexicomp. Khat. Login. (n.d.). Retrieved November 9, 2022.

Kratom

Haylie Dickson

Fall 2022

History/background

Kratom is an herbal extract native to Southeast Asia and has a scientific name of mitragynine and 7-hydroxymitragynine. Users commonly brew it into tea, swallow it as a pill, crush the pills and smoke it, or chew on the leaves 1 Kratom can also be made into a liquid form that is used for muscle pain, cramps, diarrhea, or to suppress hunger.2

Slang terms

• Thang

• Kakuam

• Thom

• Ketum

• Biak

Patient.practicalpainmanagement.com

Pharmacology/drug effects

At low doses, kratom acts as a stimulant and binds to the opioid receptors in the brain.2,3 The mu-opioid agonist effects of kratom is thought to be ten times as potent as morphine. Users may feel energetic and have increased alertness while taking it. With higher doses, euphoria and relief of pain can happen for the user. With the use of very high doses, it is thought to act as a sedative.

Drug interactions/toxicology

Kratom can interact with CNS depressants, sympathomimetics, and drugs that are metabolized by the CYP-450 enzymes.4 Addiction is a risk with this drug and the patient can go through withdrawal symptoms that are similar to other stimulant withdrawals. Symptoms like dry mouth, drowsiness, and constipation are also common with kratom.

Verywell mind. What is Kratom? Accessed October 13, 2022. Verywellmind.com/kratom-for-painmanagement

Laws

In 2016, the DEA wanted to classify kratom as a schedule I drug, but was met with protests and petitions by people who are for the drug. Before this decision, kratom was considered an herbal product and was legal in most parts of the US. The abuse potential was a huge concern to the DEA, but the backlash from the public caused them to delay making a decision on the matter. Currently, kratom is legal at the federal level, but states may vary on their policies regarding the drug.5

Monitoring/drug screens

Users should watch out for respiratory depression, hallucinations, and overdose with high doses of drug. Kratom cannot be detected with a standard drug test, but can be found with a urine or blood test for an average of 5 days after use.6

Professional opinion

Kratom has cultural significance that should be respected, but clinical use of the drug has not been thoroughly studied. Using this drug for opioid withdrawal symptoms is not recommended, as kratom has some abuse potential itself. ~

References

1. Kratom. Natural Medicines. Therapeutics Research Center. Stockton, CA. Accessed October 13, 2022. https://naturalmedicines-therapeuticresearch.com

2.Mayo Clinic. Kratom: Unsafe and ineffective. Accessed October 13, 2022. https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/kratom/art-20402171

3.DEA. Kratom. Accessed October 13, 2022. https://www.dea.gov/factsheets/kratom

4. Kratom. Natural Products Database. Facts & Comparisons eAnswers. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 13, 2022 http://online.factsandcomparisons.com

5.US Pharmacist. The DEA Changes Its Mind on Kratom. Accessed October 13, 2022. https://www.uspharmacist.com/article/the-dea-changes-its-mind-on-kratom

6.The Recovery Village. How Long Does Kratom Stay in the System? Accessed October 13, 2022. https://www.columbusrecoverycenter.com/blog/how-long-does-kratom-stay-in-system/

KrokodiL

Background

Desomorphine,commonlyreferredtoaskrokodil, isahighlyabusedSchedule1substance,derived fromcodeine Krokodilisoftenformulatedina homeenvironmentandmaycontainsolventssuch asgasoline,paintthinner,iodine,hydrochloric acid,redphosphorus,orlighterfluid Longterm usersofthedrugoftendevelopskinulcersand gangrene,askinconditioncharacterizedbyits green,gray,orblackscale-liketexture Other commonsideeffectsofkrokodilincludedamage toveinstructure,softtissuenecrosis,bone infection,kidneydamage,liverdamage,and motorskillimpairment.1

https://novarecoverycenter.com/drugs/krokodil/

https://wwwdrugaddictionnowcom/drug-information/krokodil/

Other Commonly Used names: Crocodil, Russian Magic, Poor Man’s Heroin, and Zombie Drug1

Pharmacology

Similartootheropioidsandheroin,desomorphinehasanalgesicandsedatingeffects Thedrugis administeredintravenously,anditseffectsbeginwithintwotothreeminutes.However,itsdurationof actionislessthantwohours Asaresult,manyusersrepeatadministrationcontinuouslytoavoid withdrawalsymptoms.Desomorphineismorepotentthanmorphineandconsideredtobemoretoxic.1 Thedrugworkssimilarlytootheropiods;whentheopioidentersthecentralnervoussystem,itbindsto opioidreceptorsresultinginbothpainreliefanddopaminerelease Dopamineelicitsfeelingsof pleasureandeuphoria,makingopioidshighlyaddictive.2

https://pubsacsorg/doi/pdf/101021/acschemneuro0c00495

Drug Interactions

Opioidmedicationsshouldnotbeusedinconjunctionwithalcohol,anti-seizuremedications,some antibiotics,someantidepressants,someantifungals,medicationsforpsychiatricdisorders,muscle relaxants,sedatives,orotheropioidmedications.3

Laws

KrokodilhasnoknownoracceptedmedicalusesandislabeledasaSchedule1substance.1 Thereare fewregulationsaboutthepossessionanddistributionofkrokodilspecifically;however,therearelimits onthesaleofmedicationscontainingcodeinewithintheUnitedStates.KrokodilusewithintheUnited Statesiscontrolledincomparisontoheroinandotheropioiduse.Since2004,therehavebeenlimited reportsofkrokodildistribution.4

Monitoring and Drug Screening

Accordingto Time Magazine,krokodilisthedrugofchoicefor manyacrossEasternEuropebecauseitcanbeeasilymadeusing medicationseasilyobtainedinthepharmacyandsolventsfound withinthehome.Typicalsignsofkrokodiluseincludeopenulcers, rottinggums,toothloss,speechimpairment,motorimpairment,and difficultyfocusing.4 Liquidchromatographytandemmass spectrometryisusedtodetecttraceamountsofdesomorphineina urinesample.Theurinesamplemusthaveavolumeofatleast3mL andbestoredinaplasticcontainerwithoutpreservatives.The expectedturnaroundtimeforthetestis7to21days.5

ProfessionalOpinion

https://www.redlakenationnews.com/story/2 013/10/30/news/krokodil-recipe-for-disfiguri ng-addiction/17077.html

Although more effective than morphine and cheaper than heroin, desomorphine is highly toxic and should be avoided due to its high addiction profile and dangerous side effects. ~

References

1.KrokodilDrugFacts:Effects,Abuse&Warnings.Drugs.com.https://www.drugs.com/illicit/krokodil.html.AccessedOctober 13,2022.

2.Opioidsandthebrain-howdochangesinthebrainbegin?PursueCare.https://www.pursuecare.com/opioids-and-the-brain. PublishedOctober8,2021.AccessedOctober13,2022.

3.MedicationsO.Risksforotherdrugsinteractingwithopioidmedications-mayoclinicnewsnetwork.MayoClinic. https://newsnetwork.mayoclinic.org/discussion/risks-for-other-drugs-interacting-with-opioid-medications/.PublishedMay16, 2018.AccessedOctober13,2022.

4.Krokodil:ThenewestopioidtohittheUnitedStates.NorthpointWashington. https://www.northpointwashington.com/krokodil-newest-opioid-hit-united-states/.PublishedMay3,2017.AccessedOctober 13,2022.

5.Desomorphine,ScreenandConfirmation,Urine.LaboratoryCorporationofAmerica.https://www.labcorp.com/tests.Accessed November8,2022.

LSD (Lysergic acid Diethylamide)

History/Background of Use

Fall 2022

Seoyeon (Yuna) Hong Student pharmacist

1938: Accidentally discovered by Sandoz pharmaceuticals while searching for lysergic acid’s active derivative

1950: Introduced to induce temporary psychotic like states in normal people. Then, later used to enhance psychotherapeutic treatments 1960s, People began using LSD for recreational and spiritual purposes

Pharmacology/ Drug Effect

Semi-synthetic product of lysergic acid (a natural substance from parasitic rye fungus)

Dose dependent hallucination effect

Active at multiple receptors: 5-HT1A, 5-HT2A, and 5-HT2C serotonergic receptors and serotonin transporter (SERT), but also active at the D1, D2, D4 dopaminergic receptors, the NMDA, mGlu2/mGlu3 glutamatergic receptors, and the TAAR1 receptor

High bioavailability (71%), a threshold dose of 15mcg, and duration up to 8-12 hours

High BP

Flashbacks

Altered sounds

SLANG TEMRS:

“Superman” “Mellow yellow”

“Pane acid” “Looney tunes”

“Blotter acid” “Blue heaven”

“Boomers” “Yellow sunshine”

Changes in mood

Distorted visual perception

Increased feeling of euphoria and relaxation

Confusion andtrouble concentrating

Mind altering, hallucination

Toxicology/Drug Interaction

Toxicity mediated by alterations in serotonin concentration within CNS

LSD acts in CNS as partial agonist of serotonin receptor

Leads to distorted transmission, processing, and perception of external stimuli

LSD TOXICITY INCLUDES:

Respiratory arrest Coma, emesis

Hyperthermia

Autonomic instability

Fear of death, panick attack

Impaired perception and identity

Drug interactions:

Antidepressant, Alcohol: Increase risk of serotonin syndrome

Amphetamine/Ecstasy: Increase chance of bad trip and panic

Other drug/OTC: Unpredictable and dangerous.

Law

ILLEGAL

Schedule 1 Controlled Substance: No currently accepted medical use and high abuse potential

Monitoring and Drug Screen

No Monitoring parameter

Most routine drug screens do NOT detect LSD

(Recent) Radioimmunoassay can detect pharmacologically inactive metabolite of LSD in urine: 2-oxy-lysergic acid

References:

1.Passie T, Halpern JH, Stichtenoth DO, Emrich HM, Hintzen A.The pharmacology of lysergic acid diethylamide: a review. CNS Neurosci Ther. 2008;14(4):295-314. doi:10.1111/ j.1755-5949.2008.00059.x

Professional Opinion:

While it may be used for psychiatric treatment at very low dose, its risk for addiction and side effects offsets its benefit. LSD addiction is very strong and success rates of treatments are known to be very low. Providers should educate patient on ways to seek psychological assistance and importance of avoiding needle share. ~ S. Hong

2.Hwang KAJ, Saadabadi A, eds. Lysergic Acid Diethylamide (LSD. National Library of Medicine. 1st ed. Treasure Island ,FL: Stat Pearls Publishing;2022.

3.Lysergic acid diethylamide. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed September 30, 2022. http://online.lexi.com

4.Alcohol & Drugs: LSD. Alcohol and Drug Foundation. Accessed September 30, 2022. https:// touchbase.org.au/alcohol-and-drugs/lsd

Street Drugs Today Featuring: MDMA

What is MDMA?

3,4-methylenedioxymethamphetamine, MDMA, or “ecstasy” is a synthetic (manmade) drug that affects mood and perception of reality. It has stimulant and psychedelic effects on the body, which can create senses of euphoria, energy, and distortions of time and place.1

MDMA is derived from methamphetamine and amphetamine, and therefore produces similar effects on the mind and body. MDMA has been tested clinically in patients with PTSD and other mental disorders with some efficacy, but it was not approved by the FDA and was deemed illegal in 1985 by the DEA.2

It is not usually known to cause physical dependence, but it can cause psychological dependence due to its strong euphoric effects. Those who consistently use MDMA and wish to quit should seek out behavioral therapy to help with any emotional stress they may experience during the process.3

Often called a “party drug”, MDMA gained its popularity at raves and parties for making people feel social, empathetic, and energized. However, it has now made its way out of just the nightclub venue.1

What does MDMA do to the body?

MDMA affects brain chemicals associated with energy and mood changes.

Increased dopamine in the brain results in increased energy and activation of the reward system. This causes the user of MDMA to feel good and continue using the drug. However, this feeling will fade over time and cause damage to the reward system.

Increased serotonin in the brain results in emotions like trust, empathy, and sexual arousal (the high levels of serotonin are thought to be mostly responsible for the psychedelic effects of MDMA). The user may also experience mood, appetite, and sleep changes.1,2,4

Unfortunately, MDMA will also produce unwanted effects in the body.

Physical effects: muscle tension and cramps, tremors, teeth clenching, chills, sweating (due to increased body temperature), nausea, or blurry vision.

Increased norepinephrine results in increased heart rate and blood pressure. Therefore, MDMA should be avoided in people who have heart issues.

Psychological effects: confusion, depression, anxiety, sleep issues, paranoia, and cravings.1

Common Street Names

https://www.bbc.com/news/uk-wales-61734334

Colorful tablets are the most common, but MDMA can also come in capsules, powder, and liquid form.

https://positivechoices.org.au/img/library/Ecstasy-gGlnx.png

Drug Interactions and Toxicology

“Ecstasy” tablets may come as MDMA mixed with other substances such as methamphetamine, cocaine, ketamine, heroin, and others. Unless the substance is tested for purity before ingesting, there is no way to really know its contents. MDMA and alcohol interact together to enhance and increase the euphoric effects of both substances.

Amphetamine-like substances (such as MDMA) can interact with opioids and cocaine to produce too much serotonin, resulting in serotonin syndrome. If it is too severe, the user may need to seek medical attention.

Opioids, cannabinoids, ketamine, and alcohol can produce central nervous system depression when taken together.5,6

Monitoring MDMA

Effects of MDMA can occur within 30-45 minutes of ingesting the drug, and they usually last 4-6 hours, but they may stick around for days or weeks. Taking another dose of MDMA while the first dose is still in the body will prolong its presence in the body and increase the risk of unwanted side effects.

MDMA is detectable in blood and saliva tests for 3 days after last use, up to 5 days after for urine tests, and for months in strands of hair.3

Laws and Regulations

MDMA has a high abuse potential, no accepted medical use in the U.S., and lacks safety information. This makes it a Schedule I substance (under government discretion) and is therefore considered illegal to use or posess.1

MDMA is heavily metabolized by CYP2D6 enzymes in the liver. Some of the metabolites are reactive and can cause damage to the liver, causing jaundice, hepatitis, bleeding, and even liver failure if not taken care of.

As mentioned earlier, the increase in norepinephrine can lead to increased heart rate and blood pressure, leading to cardiovascular issues like heart failure. Since MDMA can affect the body’s ability to regulate temperature, it can lead to high fevers and dehydration. The body may also experience irregular water retention in the body from alterations in hormones. Changes in temperature and water retention can lead to seizures or compression of the brain. High body temperatures can also lead to other tragic events such as muscle degradation, kidney failure, and serotonin toxicity.2

Monitoring MDMA

Effects of MDMA can occur within 30-45 minutes of ingesting the drug, and they usually last 4-6 hours, but they may stick around for days or weeks. Taking another dose of MDMA while the first dose is still in the body will prolong its presence in the body and increase the risk of unwanted side effects.

MDMA is detectable in blood and saliva tests for 3 days after last use, up to 5 days after for urine tests, and for months in strands of hair.3

References

1.DEA. Ecstasy/MDMA. DEA.gov. Home. DEA.gov.

https://media.istockphoto.com/photos/guy-taking-drug-pill-young-people-is-having-fun-in-night-club-with-pictureid1324037312?k=20&m=1324037312&s=612x612&w=0&h=WdTzsaf5t_oVp5ZaBfJFfgJBROSUMpWwyBD8afm_m6E=

Professional Opinion: Hunter Skelton, Student Pharmacist

“Although not everyone has used ecstasy, many people have probably heard about it. MDMA is being considered for therapeutic use in certain patient populations. Putting stigma aside and testing MDMA in safe and ethical ways might prove its efficacy in psychotherapy. It should always be remembered that ecstasy off the street may not be pure, and therefore can be very dangerous to unsuspecting users. Negative effects from polydrug use may lead to some of the stigma associated with ecstasy, but the use of any substance can cause harm.”

2. Kalant H. The pharmacology and toxicology of "ecstasy" (MDMA) and related drugs. CMAJ. 2001;165(7):917-928.

3. NIDA. MDMA (Ecstasy/Molly) DrugFacts. National Institute on Drug Abuse website. https://nida.nih.gov/publications/drugfacts/mdmaecstasymolly. June 15, 2020 Accessed October 13, 2022.

4 Hardey S, Thomas S, Stein S, Kelley R, Ackermann K. Is Ecstasy (MDMA) Addictive? American Addiction Centers.

5.Drug Interactions. IBM Micromedex Solutions. Truven Health Analytics, Inc. Ann Arbor, MI. Accessed October 13, 2022.

6.Mori T, Iwase Y, Uzawa N, et al. Synergistic effects of MDMA and ethanol on behavior: Possible effects of ethanol on dopamine D2receptor-related signaling. Addict Biol. 2021;26(4):e13000.

doi:10.1111/adb.13000

https://www.drugfoundation.org.nz/matters-ofsubstance/archive/matters-of-substance-november2014/about-a-drug-mescaline/

MESCALINE

Fall 2022

WHAT IS MESCALINE?

Mescaline is a hallucinogen that is found naturally in the peyote cactus.¹

HISTORY OF USE

Mescaline has been used for many years. Most interestingly, it has been used by indigenous groups from southwest USA and northern Mexico for religious ceremonies.²

WHAT ARE THE EFFECTS OF MESCALINE?

Mescaline is a hallucinogen. It causes the user to experience euphoria and hallucinations. It can also cause anxiety, shakiness, increased heart rate, and increased blood pressure.¹

COMMON SLANG TERMS²

buttons

cactus

mesc

peyoto

https://www.economist.com/books-andarts/2019/06/29/a-mind-bending-history-of-mescaline

https://www.forbes.com/sites/benjaminadams/2021/07 /07/is-mescaline-a-key-component-in-the-future-ofmedicine-xphyto-aims-to-find-out/?sh=79ddb47a1e90

IS MESCALINE LEGAL?

Mescaline is a schedule 1 drug meaning it serves no clinical purpose. Mescaline is not legal to possess or purchase in the United States. However, it is allowed to be used during certain Native American religious ceremonies.³

PROFESSIONAL OPINION ON MESCALINE

Mescaline serves no clinical purpose as of now. Because of this, there is no reason to legalize mescaline to be marketed to the public. However, it does not benefit society to criminalize use of mescaline. ~ I.

WHAT ARE DRUGS THAT INTERACT WITH MESCALINE?

No studies exist to show significant drug interactions with other medications. However, due to the effects of mescaline on the CNS and circulatory system, it may cause issues if taken with antidepressants, antipsychotics, or medications that increase heart rate and blood pressure.³

HOW DO WE SCREEN FOR MESCALINE USE?

A urine test can be used to screen for mescaline in a person's system.⁴

REFERENCES

Abuse NI on D. Commonly Used Drugs Charts. National Institute on Drug Abuse. Published August 20, 2020. Accessed October 14, 2022. https://nida.nih.gov/researchtopics/commonly-used-drugs-charts#mescaline

WHAT ARE PEYOTE and MESCALINE? WHAT IS ITS ORIGIN? What Is Its Effect on the Body? Which Drugs Cause Similar Effects? What Are Common Street Names? What Does It Look Like? https://www.dea.gov/sites/default/files/2020-06/Peyote%20and%20Mescaline2020_0.pdf

Mescaline (hallucinogen) Uses, Effects & Hazards. Drugs.com. https://www.drugs.com/illicit/mescaline.html

Mescaline. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed September 19, 2022. http://online.lexi.com

again-as-a-potential-medicine/

Methadone

Jilian Banzon, 3rd year Professional Student, Fall 2022

History/Background

Methadone is a medication approved by the Food and Drug Administration (FDA) to treat Opioid Use Disorder (OUD) as a medication-assisted treatment (MAT), as well as for pain management. Methadone's origin started when German scientists wanted to develop a drug to help avoid opiate withdrawal due to the opium supply being cut off in World War 2.As a result, methadone was synthesized and the drug not only worked, but also lasted a long time.

https:// americanaddictioncenters.org/ wp-content/uploads/2018/10/ how-long-does-methadone-stayin-your-system.jpg

Slang terms/Street names

Methadone goes by numerous slang terms or street names and on streets it is commonly referred to as Amidone, chocolate chip cookies, fizzies, Maria, pastora, Salvia, street methadone and water.

https://img.medscape.com/ thumbnail_library/gty_220713 _opiods_methadone_syringe_800x450.jpg

Pharmacology/drug effects

Methadone is a synthetic full agonist at the m-opioid receptor. It has an asymmetric carbon atom, and the racemic mixture is generally used in maintenance therapy. When a user takes methadone they use it for detoxification and maintenance of opioid addiction and as a pain reliever for moderate to severe pain. When someone uses methadone they can experience physical symptoms like sweating, itchy skin, or sleepiness. When use is stopped, individuals may experience withdrawal symptoms including Anxiety, muscle tremors, nausea, diarrhea, vomiting, and abdominal cramps.

https://s3.wp.wsu.edu/uploads/ sites/2797/2021/1 0/ iStock-503756218_wp.jpg

Drug interactions/Toxicology

https:// janaburson.files.wordpress.com /201 4/03/aaaapilsfighting.jpg

People who use methadone at high doses, or in naïve users or idiosyncratically at much lower doses, depresses respiration and may interfere with cardiac function, either or both of which can lead to death. Methadone is a central nervous system (CNS) depressant, and there is a very high risk of negative complications when it is combined with other depressants such as alcohol and benzodiazepines.

Methadone is a Schedule II drug under the Controlled Substances Act. While it may legally be used under a doctor’s supervision, its non-medical use is illegal. It is considered a schedule II drug due to its high potentially addictive qualities. Methadone is a highly regulated drug and while it has medicinal purposes the fact that it is a powerful opiate is the reason why it is highly regulated when used as a medical treatment for opioid use disorder.

https://t4.ftcdn.net/

Monitoring/drug screens

https://cdn.jjkeller.com/wcsstore/

Since methadone is a highly regulated drug, patients who are prescribed Methadone in an outpatient setting have to go to a clinic every day to be administered their dose. After a period of stability, patients may be allowed to take methadone at home between program visits. Patients on methadone must also be on the drug for a minimum of 12 months. Methadone is not usually screened for on a urine drug test unless otherwise specifically requested.

Professional opinion

In my professional opinion, I believe that is properly regulated and the medical use for the drug is justified. Since it is a highly powerful opiate I understand the need for patients to come to a methadone clinic , but that still doesn't prevent medical professional to have a negative stigma towards people wanting to use methadone for opioid use disorder. I believe that methadone is a useful and effective drug for users and it should continue its current use in the medical world.

References

1.Methadone. SAMHSA. https://www.samhsa.gov/medication-assisted-treatment/medications-counselingrelated-conditions/methadone. Accessed October 14, 2022.

2.McDermott P. McDermott's Guide to the Depressant Drugs. Erowid opiates vault : Mcdermott's guide. https://www.erowid.org/chemicals/opiates/opiates_mcdermotts_guide.shtml. Accessed October 14, 2022.

3.Methadone. DEA. https://www.dea.gov/factsheets/methadone. Accessed October 14, 2022. Drug fact sheet: Methadone - dea.gov. https://www.dea.gov/sites/default/files/202006/Methadone-2020.pdf. Published April 2020. Accessed October 14, 2022.

4.Methadone addiction and abuse. Addiction Center. https://www.addictioncenter.com/opiates/methadone/. Published April 14, 2022. Accessed October 14, 2022.

5.Green M, Kellogg S, Kreek M. Methadone: History, pharmacology, neurobiology, and use -westbridge. https://www.westbridge.org/wp-content/uploads/2014/06/Enc-of-Neuroscience-Methadone.pdf. Accessed October 14, 2022.

6.Lipman J. The methadone poisoning "epidemic". DEA Meetings and Events. https://www.deadiversion.usdoj.gov/mtgs/. Accessed October 14, 2022. Medical Advisory Secretariat. Optimum methadone compliance testing: an evidence-based analysis. Ont Health Technol Assess Ser. 2006;6(21):1-54.

https://www.apsf.org/article/practice-considerations-for-the-anesthesia-professional-for-

Slangterms

Therearemanyslangterms forMethamphetaminesome oftheminclude:

-Meth

-Speed

-Chalk

-Ice

-rocketfuel

-Cyrstal

Pharmacology/drug effects

History& background

https://ew.com/tv/10-essential-moments-breaking-bad-first-episode/ https://twitter.com/idmethproject/status/1064571740506992642?lang=gu https://www.emcdda.europa.eu/publications/drug-profiles/methamphetamine_en

Methamphetamineisahighly addictivestimulantthatacts onthecentralnervoussystem. Itischemicallysimilarto amphetaminewhichisusedto treatADHDandnarcolepsy.It wasfirstsynthesisedbya japanesechemistin1893.It wasusedforavarietyof thingssuchasasthma,weight loss,andnarcolepsy.Itwas alsousedtokeepsoldiers awakeonboththeaxisand alliespowersduringWWII.

https://www.radiotimes.com/tv/drama/

Monitoring/drug screens

Monitoringanddrugtesting forMethamphetamineare easy.Youcanfinda10 panelor14paneldrugurine testatalocalpharmacy thatwilldetectfor methamphetamine. methamphetaminecan stayinurineforupto2-4 daysafteruse.

TheLaw

Methamphetamineisa schedule1drugmeaningit hasmedicaluseandit's highlyaddictive.IntheUS itsillegaltomanufacture, possess,transport,orsell illicitmethamphetamine.If caughtyouarefinedand couldspendtimeinjail.

Drug interactions/ toxicology

https://en.wikipedia.org/wiki/Los_Pollos_Hermanos

https://www.walgreens.com/store/c/

Professional opinion

In my professional opinion

Methamphetamine is not good and should be taken. It is highly addictive and has many long term side effects. If you or you know someone that is addicted call 1-800-662-4357 to get help. ~ J. Dycus

Methamphetaminehasmany druganddiseaseinteractions.It hasover209druginteraction with43ofthembeingmajor interactions.Mostofthemajor interactionsareantidepression/anxietyand benzodiazepinesdrugs.Thisdrug alsohasover15drug-disease interactions.Someofthemajor onesareCardiovascularand psychiatricdisorders.Inlayman's termsthisdrugisverytoxic.Itis highlyaddictiveandcancause someseriousadverseeffects.

OtherReferences:

https://nida.nih.gov/publications/drugfa cts/methamphetamine

https://www.history.com/topics/crime/h istory-of-meth

https://americanaddictioncenters.org/ meth-treatment/slang-names

https://www.drugs.com/druginteractions/methamphetamineindex.html?filter=3

https://drugpolicy.org/drugfacts/current-meth-laws

- MG Seeds1

- Glories1

- Heavenly Blue1

- Pearly Gates1

- Summer Skies1

- Wedding Bells1

- Blue Stars1

Jailyn Jones, Student Pharmacist

Fall 2022

https://gardenerspath.com/plants/flowers/save-morningglory-seeds/

https://sandiegoseedcompany.com/product/flowers/color-mix-morning-glory-seeds/

- Morning glory seeds were used anciently for their medicinal properties on the human mind among the indigenous peoples of Mexico.1

- The Aztecs would take morning glory in religious ceremonies.1

- They referred to the seeds as tlitliltzin (black) Turbina corymbose (round thing).1

- In 1959, Albert Hofmann, the Chemist who discovered LSD, identified the main psychoactive constituent to be lysergic acid amide (LSA).1

- The vine of morning glory blooms only in the morning.2

- The seeds of morning glory vine contain some of the bioactive ergot alkaloids that are present in LSD causing a hallucinogen effect on the mind.2

- The seeds can be taken whole, or the active alkaloid (LSA) is able to be extracted.3

- Due to structural similarities of the active component of morning glory seeds, LSA, with LSD, many of the drugs that interact with LSD also interact with LSA.4

- The following are drug interactions with LSD/LSA

o MAOI1

o MDMA (ecstasy)4

▪ LSD increases the potency of MDMA which can cause a bad trip.

o Alcohol4

▪ Enhances the effect of alcohol which leads to increased nausea, vomiting and blackouts.

- Morning glory seeds are not regulated by the US federal government.3

- Both plants and seeds are regularly sold by botanical supply companies.3

- LSA (the active chemical in morning glory), is a schedule III drug.

- When the LSA is extracted from morning glory, it is illegal to possess. In Arizona, the consequences are 1st or 2nd degree misdemeanor.3

https://www.amazon.com/Morning-Glory-SeedsHeavenly-Blue/dp/B075T7ZTQQ

- Morning Glory is not tested for in standard or extended drug tests.5

- You can test for LSA specifically.5

- LSA may show up positive when testing for LSD due to the structural similarities.5

References

- Morning glory resembles the actions of LSD due to the active component LSA. It can cause mental alterations such as hallucination which can be worsened by alcohol. Morning glory can cause severe toxicities and should not be used recreationally due to these risks.

1. Beard D. Morning Glory Guide: Seeds, Effects, Common Uses, Safety. Reality Sandwich. Published June 6, 2020. Accessed October 10, 2022. https://realitysandwich.com/morning-gloryguide/

2. Bronston B. Study shows common flower species holds promise for beneficial psychedelic drugs. Published December 21, 2021. Accessed October 10, 2022. https://news.tulane.edu/pr/studyshows-common-flower-species-holds-promise-beneficialpsychedelicdrugs#:~:text=The%20best%2Dknown%20ergot%20alkaloid,pro duced%20by%20their%20fungal%20partners.

3. Morning Glory Legal Status. Erowid. Published June 07, 2001. Updated September 15, 2016. Accessed October 10, 2022. https://www.erowid.org/plants/morning_glory/morning_glory_l aw.shtml

4. LSD. Alcohol and Drug Foundation. Updated August 26, 2022. Accessed October 10, 2022. https://adf.org.au/drug-facts/lsd/

5. LSA Drug Testing. Erowid. Updated February 10, 2015. Accessed October 10, 2022.

https://www.erowid.org/chemicals/lsa/lsa_testing.shtml

(J. Jones)

MUSCLE RELAXANTS MUSCLE RELAXANTS

Claudia Chiang, Student Pharmacist, Fall 2022 Slang Terms

History/ Background of Use/Abuse

Muscle relaxants were known as curare and were introduced to Europe from South America during the 1700s. Curare was known as “arrow poison” at the time and was used for hunting. Hunters used plants to create a paste and apply it to their arrowheads. When preys were struck by the arrowhead, it died within minutes. The mechanism of how curare worked was found to act as a competitive antagonist of nicotinergic neuromuscular synaptic junctions. Curare was first used clinically in anesthetic practice in 1942. This began the start of discovering derivates and developing modern drugs.

Wallace 200's

Soma Coma

Holy Trinity

Houston Cocktail

Las Vegas Cocktail

DS DANCE

Pharmacology/Drug Effects

Muscle relaxants can target cells in the muscle, neurons, or in the central nervous system (CNS). To relax the muscles, the relaxants work by the following mechanisms:

An example of an abused muscle relaxant is cyclobenzaprine which targets the CNS to relieve muscle spasms. When this medication is abused, patients commonly report effects of sedation, relaxation, and euphoric “highs ” It is commonly abused in many ways of administration such as taking it orally, crushing it to snort, mixing with other drugs, or dissolving it into alcohol. Abusing cyclobenzaprine, and other muscle relaxants targeting the CNS, can lead to an increased risk of addiction and dependence.

Releasing excitatory neurotransmitters which inhibit afferent nerves

Inhibit interneuron activity which leads to prevention of nerve signal transmission

Release of acetylcholine, the neurotransmitter involved with muscle contraction, is blocked

Prevent release of calcium in the skeletal muscle cells; decrease in calcium activity

Increase GABA levels which results in neuronal activity being blocked

Depress CNS which leads to sedation and relaxation in muscles

Drug Interactions Toxicology

Consuming alcohol can be toxic

Alcohol amplifies the effect of muscle relaxants, especially depressant effects in the CNS, and the combination of the two can lead to overdose risks. It can also cause increased risk of addiction.

Medications that cause drug-drug interactions include opioid drugs, benzodiazepines, tricyclic antidepressants, monoamine oxidase inhibitors, fluvoxamine (SSRI), and ciprofloxacin (antibiotic).

Laws

There are a select few muscle relaxants that are controlled substances. carisoprodol and diazepam are schedule IV-controlled substances.Schedule IVcontrolled substances are drugs that can result in limited dependence and abuse potential. As these are controlled substances, these medications require prescriptions. There are also medications that are not under the Controlled Substances Act, like cyclobenzaprine, but still require a prescription to be legally obtained.

Monitoring/Drug Screens

There are many factors that indicate how long a drug can stay in the system based on the type of muscle relaxant, the amount of dose taken, the type of drug test used, and biological measurements of the patient. For instance, it may take 5.5 to 16.5 days for cyclobenzaprine to clear out of a patient’s system. Carisoprodol, on the other hand, has a shorter duration of about four days.

https://www.gnhindia.c om/products/usndc/carisoprodolsoma-0037-2001/

https://www.dailymed.nlm. nih.gov/dailymed/fda/fdaDr ugXsl.cfm?setid=b12fb4ea182e-462b-b6edcfd2f6bb71e8&type=display

Professional Opinion

Based on my opinion, I would still recommend the use of muscle relaxants. From a clinical standpoint, muscle relaxants can be a useful treatment option for many patients that experience severe pain. There are risks for abuse in all drugs, but there are ways to reduce harmful abuse by giving patients proper education and counseling.

References

Carl J, Schwarzer M, Klingelhoefer D, Ohlendorf D, Groneberg DA. Curare--a curative poison: a scientometric analysis. PLoS One 2014;9(11):e112026. Published 2014 Nov 19. doi:10.1371/journal.pone.0112026

Suitable Treatment for Cyclobenzaprine (Flexeril) Abuse. American Addiction Centers. Updated September 15, 2022.

https://americanaddictioncenters.org/cyclobenzaprine-flexeril-abuse.

Muscle Relaxer Addiction: Side Effects, Detox, Withdrawal, and Treatment. Nova Recovery Center. Accessed October 13, 2022. https://novarecoverycenter.com/drugs/muscle-relaxer/#h-street-names-for-muscle-relaxers.

Khan S. How Do Skeletal Muscle Relaxants Work? Rxlist. Updated September 22, 2021. Accessed October 13, 2022. https://www.rxlist.com/how_do_skeletal_muscle_relaxants_work/drug-class.htm.

Can You Mix Muscle Relaxers and Alcohol? Healthline. Updated on June 24, 2019. Accessed on October 13, 2022. https://www.healthline.com/health/muscle-relaxers-and-alcohol#if-youve-already-had-alcohol.

Controlled Substance Schedules. Diversion Control Division. Accessed October 13, 2022. https://www.deadiversion.usdoj.gov/schedules/.

Drug Scheduling. United States Drug Enforcement Administration. Accessed October 13, 2022. https://www.dea.gov/druginformation/drug-scheduling.

Cyclobenzaprine. Diversion Control Division. Updated March 2020. Accessed October 13, 2022. https://www.deadiversion.usdoj.gov/drug_chem_info/cyclobenzaprine.pdf.

Fall 2022

Naloxone

History and Background

Naloxone was created in the 1960's as an attempt to reduce one of the adverse effects of opioid use: constipation. It gained FDA approval in 1971 and was first used as a response to the heroin epidemic in Italy in the 1990's. Many programs in countries across the world implemented naloxone as harm reduction in the early 2000's.

Other Names Narcan® Kloxxado

https://www.kelley-ross.com/polyclinic/naloxone/ Naloxone is an opioid reversal agent. It is an opioid antagonist that attaches to the opioid receptor and reverses/blocks the effect of other opioids in the system. It allows for the return of normal breathing if the person's breathing had become labored or stopped due to the opioid overdose. It has no negative effects if it is given to someone who has no opioids in their system.

https://www.cdc.gov/ stopoverdose/nalo xone/index.html

Pharmacologic Effect

naloxone is LIFE SAVING in the event of an overdose.

Laws

• As of July 1st 2017, all 50 states and District of Colombia have enacted naloxone access laws, including immunity for persons who administer the drug.

• These laws also discuss third party prescribing and enabling pharmacists to prescribe naloxone without a patient-specific prescription through a standing order, collaborative practice agreement, or pharmacist prescribing power

• In Indiana, the Senate Enrolled Act 406-2015 "Aaron's Law" allows Indiana residents to get a prescription of naloxone if they know someone they think is at risk of an opioid overdose. Previously only emergency responders could carry naloxone.

Side effects of naloxone are very rare, but people may have allergic reactions to the medication.

People who have a physical dependence on opioids may go into withdrawal within minutes of administering naloxone and experience symptoms such as headaches, sweating, vomiting, tremors, and rapid heart rate.

Toxicology Monitoring

Naloxone reverses an opioid overdose for 30 to 90 minutes. Opioids can remain in the system for longer than that, so it is important to call 911 so the patient can receive the medical attention they need.

Professional Opinion

I believe that the more widely available naloxone becomes, the closer we will get to helping stop the opioid crisis. Naloxone is an extremely safe drug. If someone were to administer naloxone to a person who was not overdosing on an opioid, there would be zero adverse effects. All health care professionals should be discussing naloxone with their patients if they or someone they are close to use opioids. -K

references

• Campell N. Naloxone as a technology of solidarity: history of opioid overdose prevention. Canadian Medical Association Journal. 2019; 191(34): E945-E946. doi: 10.1503/cmaj.190257

• NIDA. Naloxone DrugFacts. National Institute on Drug Abuse website. https://nida.nih.gov/publications/drugfacts/naloxone. Accessed October 11, 2022.

• DOL: Overdose Prevention (Aaron's Law). Accessed October 11, 2022https://www.in.gov/dol/overdose-prevention-aaronslaw/#:~:text=Senate%20Enrolled%20Act%20406%2D2015,signed%20into% 20law%20April%202015.

--PDAPS. Naloxone Overdose Prevention Laws. Accessed October 13, 2022.https://pdaps.org/datasets/laws-regulating-administration-ofnaloxone-1501695139

NIGHTSHADE

History of Nightshade:

Nightshade or Atropa Belladonna is a Eurasian perennial. Other names for this plant are Devil’s Berries, Naughty Man’s Cherries, Death Cherries, Beautiful Death, and Devil’s Herb. Historically women have used the herb’s oils to dilate and enlarge the pupils for seductive effect. It is best known as the plant of choice for assassins throughout history. This plant grows wildly in many parts of the United States. It grows mostly in dumps, quarries, near old ruins, under shade trees, or atop wooded hills. The toxins that grow in this plant cause delirium and hallucination. Deadly nightshade berries pose the greatest danger to children since they are attractive and sweet at first bite. Two berries are enough to kill a child and it takes 10-20 to kill an adult. A single leaf being consumed is enough to kill a human.

Slang Terms:

à Atropa Belladonna

à Devil’s Berries

à Naughty Man’s Cherries

à Beautiful death

Pharmacology

Uses:

à Minor burns, abrasions, and skin irrigations

Dosing

à 1 to 3 g/day usually given as decoction or infusion in 250 mL of water

Adverse Reactions

à Dilated pupils

à GI effects

Mechanism of action:

à Th e active components of belladonna act as competitive antagonist at muscarinic receptors and block the binding of acetylcholine to the CNS and parasympathetic postganglionic muscarinic receptors.

https://medium.com/@magicalhistoricity/d eadly- nightshade-garden- on -roof-of-coittower-blooms-six- years- early8ef938cd4084

Botany:

https://allth atsinteresti ng.com/dea

Bittersweet Nightshade is a member of the same family as the potato, tomato, and belladonna. It is a vine like perennial that can grow to three meters. It has alternating heart-shaped oval leaves that have two small ear like segments at their bases. It’s star shaped flowers bloom from April to September. These flowers are a pink-purple color with bright yellow stamens. The flowers produce berries that turn bright red when mature.

Laws regarding Nightshade:

à Nightshade is uncontrolled in the United States. This means that all parts of the plant and its extracts are legal to cultivate, buy, possess, and distribute without a license.

Monitoring Nightshade: The flowers are easy to spot from midMay to late fall. It is important to monitor these areas.

Drug testing monitoring: Scopolamine Test

Professional opinion:

Toxicology:

Both the immature and ripened fruit are toxic. The FDA classifies this as an unsafe poisonous herb because of the presence of the toxic spirosolane glycoalkaloids. These cause hemolytic and hemorrhagic damage to the GI tract.

Symptoms of poisoning

à Circulatory and respiratory depression

à Convulsions

à Diarrhea

à Dilated pupils

This drug in the last history was used to help women feel young by the dilution of their eyes. This drug has tons of interactions and has such a fatal dose. I would not recommend this drug or plant to anyone, since th e berries are so potent and easy to kill

Anastasiia Nastyna. Drawing of Nightshade. https://www.dreamstime.com/hand - drawn-deadly- nightshadeflower-set -purple-flowers-green-leaves- buds-berries- beigebackground-vector-floral-elements-image157108244

References:

à Nightshade. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 13, 2022. Http://online.lexi.com

à Nightshade. The Vaults of Erowid. Accessed October 13, 2022. https://www.erowid.org/herbs/nightshade/nightshade.shtml

à 6 Facts You Didn’t Know about Nightshade. Accessed October 13, 2022. https://chhs.source.colostate.edu/6-facts-didnt-know-nightshades/

à Michael Largo. The Big, Bad Botany: Deadly Nightshade. https:// slate.com/technology/2014/08/poisonous-plants-belladonnanightshade-is-the-celebrity-of-deadly-flora.html

Nitrous oxide (NO)

Student pharmacist

Fall 2022

Slang Terms

The following are other names used for nitrous oxide1

Laughing Gas

N2O

NOS Nitro

Nangs

Hippy Crack

Whippet

Balloons

History and Background

The discovery of nitrous oxide was in the year 1772 by an English scientist named Joseph Priestly. It was first used by a dentist named Dr. Horace wells as an anesthetic for dental procedures. 2 It is gas drug and is taken by inhaling froma mask in a dentist’s office, or fromsomething like a balloon or a canister when it is abused. 1

Drug Effects

Some effects a person uses nitrous oxide will feel are1

Euphoria

Sedation

Blurry Vision

Sweating

Hypotension

Numbness

Uncontrolled Laugh

Confusion

Fainting

Weakness

Drug Interactions and Toxicology

There are a fair amount of different interactions nitrous oxide has with other medications. Of note, any drugs that may also cause CNS depressant effects such as alcohol, opioids, and other medications like Ambien. Therefore, it is very important to avoid taking this medication while on any other depressants, because of the enhanced depressive effect.3

Monitoring and Drug Screens

When this drug is being used, it is important to watch for any rebound hypertension that can result.3 Also, it is not on routine drug screening panels, but can be detected in the urine.5

Professional Opinion

My professional opinion about the use of nitrous oxide is that it is applicable for dental procedures, but should not be prescribed for any other reason than anesthesia to help prevent supply from reaching the general public.

Laws

It is illegal for a person to possess or sell nitrous oxide with the intention of abusing it. It is also illegal to sell this medication to anyone under the age of 18. However, this medication is not a controlled substance. Therefore, it is able to be prescribed by providers. It is specifically supposed to be used as an anesthetic for dental procedures.4

References

1. Nitrous oxide - Alcohol and Drug Foundation. Adf.org.au. Accessed October 7, 2022. https://adf.org.au/drug-facts/nitrousoxide/#:~:text=Other%20names

2. Nitrous Oxide common use is also called laughing gas or happy gas due to its intoxicating effects when inhaled. www.cornerstonedentistrybrantford.ca. Accessed October 7, 2022. https://www.cornerstonedentistrybrantford.ca/site/blog/2016/04/05/a-brief-history-of-happy-gas-nitrousoxide#:~:text=Nitrous%20Oxide%20is%20also%20called

3. Nitrous Oxide. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 13, 2022. http://online.lexi.com

4. Is Nitrous Oxide Legal - What You Need to KnowAbout N2O. ARISE® Network. Accessed October 7, 2022. https://www.arisenetwork.com/is-nitrous-oxide-legal/

5. Jamanetwork.com. Published 2022. Accessed October 13, 2022. https://jamanetwork.com/journals/jamapediatrics/fullarticle/204517#:~:text=Inhaled%20nitrous%20oxide%20can%20be

NUTMEG – WHAT IS IT? IS IT ABUSIVE?

PURDUE COLLEGE OF PHARMACY

FALL 2022

HISTORY OF NUTMEG

SLANG TERMS

Buah Pala, Jaatipatree, Jaiphal, Jatiphal, Jatiphala, Jatiphalam, Magic, Muscade, Muscade et Macis, Muscadier, Muskatbaum, Muskatnuss, Myristica, Myristica Oil, Myristicae Semen, Noix de Muscade, Noix de Muscade et Macis, Nuez Moscada, Nuez Moscada y Macis, Nutmeg, Nux Moschata, Ron Dau Kou

Nutmeg and mace are two commonly used spices originating from the same tree, Myristica fragrans. The tree is indigenous to the Banda Islands of Indonesia, and is now cultivated in other tropical regions, such as Malaysia and the Caribbean.

Nutmeg from Indonesia is known to have been in the medieval diet of peoples living as far away as the modern Czech Republic. There are reports of nutmeg intoxication dating back to 1576. During the 1990s, plant drugs such as nutmeg increased in popularity among recreational drug users. More recently, the nutmeg challenge has involved the ingestion of large quantities of nutmeg by children in order to gain a natural "high."

PHARMACOLOGY/DRUG EFFECTS

Analgesic effects

Traditionally, nutmeg is used topically as an analgesic. There is evidence from animal research that nutmeg has analgesic effects, possibly by decreasing the inflammatory enzyme cyclooxygenase-2

Antidepressant effects

Nutmeg has traditionally been used for anxiety. Some evidence from animal research suggests that nutmeg extracts exhibit antidepressant-like activity. This is possibly related to the activation of either the 1-adrenoceptors or dopamine (D2) receptors.

Sexual effects

Nutmeg is traditionally used as an aphrodisiac. Evidence from animal research suggests that oral intake of 50% ethanol extract of nutmeg increases libido and potency in male rats.

www.medicalnewstoday.com

DRUG INTERACTIONS/TOXICOLOGY

Cholinergic Drugs

Evidencefromanimal research suggests that nutmeg extract can inhibit acetylcholinesterase and might increase acetylcholine levels. Theoretically, concurrent use of nutmeg with other cholinergic drugs might have additive effects and increase the risk of cholinergic side effects.

Phenobarbital

Some evidence from animal research suggests that myristicin, a constituent of nutmeg, can reduce sleeping time in rats pretreated with phenobarbital. Theoretically, concomitant use may decrease the therapeutic effects of phenobarbital.

LAWS BEHIND NUTMEG

Nutmeg legal in all states. ABC news in 2010 wrote an article about nutmeg saying that “FDA has no plans to regulate the spice.”

DRUG SCREENS FOR NUTMEG

The drug screenings for nutmeg are not very common for patients. According to a search on PubMed, there were evidence that when high dose of nutmeg was ingested, it would show up in the urine. To detect the nutmeg in the urine, the researchers had to isolate it by gas chromatography and mass spectroscopy.

REFERENCES

1. Maloney C. Indonesia's great frontier and migration policy. UFSI Rep. 1987; (30):1-11.

2. Culíková V. Assortment of the plants in the Medieval diet in Czech countries (based on archaeobotanical finds). Acta Univ Carol Med (Praha). 2000;41(1-4):105-118.

3. Atherton RR. The 'Nutmeg Challenge': a dangerous social media trend [published online ahead of print, 2020 Jul 3]. Arch Dis Child. 2020;archdischild-2020-319407. doi:10.1136/archdischild-2020-319407

https://www.news-medical.net/

PROFESSIONAL OPINION

Nutmeg is a very common spice we can find in grocery stores. A lot of products in the grocery store also include nutmeg as an ingredient. Since it is a very common spice as an ingredient, I believe that someone or some child could accidentally overdose on nutmeg.

I believe that nutmeg is not a type of ingredient/drug where frequent substance users would go out and intentionally ingest large amount of nutmeg. In conclusion, I believe that nutmeg is a safe and should not be regulated, but just to be careful when adding too much of nutmeg as an ingredient.

https://www.costco.com/

4. Nutmeg, Natural Medicine. TRC. Accessed October 11, 2022. https://naturalmedicines.therapeuticre search.com/

5. Nutmeg Treated as Drug for Hallucinogenic High. ABC News. Accessed October 12, 2022.

https://abcnews.go.com/Health/largedoses-nutmeg-hallucinogenichigh/story?id=12347815

Beyer J, Ehlers D, Maurer HH. Abuse of nutmeg (Myristica fragrans Houtt.): studies on the metabolism and the toxicologic detection of its ingredients elemicin, myristicin, and safrole in rat and human urine using gas chromatography/mass spectrometry. Ther Drug Monit. 2006;28(4):568-575. doi:10.1097/0000769 1-200608000-00013

6. Neukamm MA, Schwelm HM, Vieser S, Schiesel N, Auwärter V. Detection of nutmeg abuse by gas chromatography-mass spectrometric screening of urine. J Anal Toxicol. 2020;44(1):103-108. doi:10.1093/jat/ bkz054

History of PCP/ Background of Use/ Abuse

PCP was first synthesized in 1956. It was initially tested as an intravenous anesthetic with potential to be more effective than other drugs used in the same way. Soon, it became evident that PCP can lead to harmful side effects like severe agitation and delirium.

Even though it was soon restricted to veterinary medicine, PCP became a popular drug of abuse. As a powder, the drug can be rolled and smoked. The crystalline form as well as the powder can be injected.

Small doses of PCP are reported to give the user a feeling of numbness. As doses increase, users note feelings associated with analgesia as well as effects like hallucinations and confusion.

Slang terms

Just like many illicit drugs, there are a plethora of slang terms used to identify PCP. Some examples of these terms include Angel dust, belladonna, black whack, CJ, cliffhanger, crystal joint, Detroit pink, elephant tranquilizer, hog, magic, Peter Pan, sheets, soma, TAC, trank, white horizon and zoom.

A Guide to Phencyclidine

Jacob Lindsey

Student Pharmacist

Fall 2022

Pharmacology/ Drug Effects

Phencyclidine is believed to have many effects throughout the brain. Primarily it has a strong affinity for the NMDA receptor where it binds and blocks it. This causes reduced activity of glutamate, which is an excitatory neurotransmitter in the brain that deals with memory and cognitive function.

Additionally, PCP deals with serotonin, norepinephrine, and dopamine modulators. The drug blocks the reuptake of these neurotransmitters so that more is readily available in the brain. Since, these chemicals are associated with reward, alertness and happiness, the mechanism of action and drug effects correspond.

PCP also has stimulatory effects on the enzyme tyrosine hydroxylase. This enzyme works to convert tyrosine to molecules like dopamine and norepinephrine. In turn, even more dopamine and norepinephrine become available in the brain.

Panel Drug Test Kit. Amazon. Accessed Oct. 13, 2022.

https://www.amazon.co m/Prime-Screen-PanelMulti-TDOA7125/dp/B072B5T14T

Professional Opinion

On the matter of PCP, I believe that this drug had some promising effects as an anesthetic. However, due to its ability to cause aggression and irritability, it is rightfully not used often. With this in consideration, a Schedule II designation is appropriate because PCP obviously has a high abuse potential with little therapeutic use. ~ J. Lindsey

Drug Interactions/Toxicology

At around 2-5 mg of PCP, effects of the drug are often described as euphoria, unpredictability, disorientation, and aggression. By the time the dose is increased to 25 mg, PCP becomes a lot more toxic. 25 mg of PCP is associated with coma, hyperthermia, convulsions and death.

The effects of PCP can be magnified when the drug is used alongside other drugs with similar effects. For example, severe hypotension can result from the combined use of PCP and chlorpromazine. In addition, drugs like barbiturates and alcohol become much stronger CNS depressants in the presence of alcohol.

Laws

PCP is an illegal substance. It is recognized as a Schedule II drug according to the Controlled Substance Act. This means that the drug has a very high potential for abuse. The conscious possession of PCP is automatically a level 6 felony which constitutes at least a 6-month sentence.

Monitoring/Drug Screens

PCP can be monitored through several different drug tests. These include urine, hair, and saliva drug tests. Testing the urine will detect PCP that has been in the system for five hours to two weeks. The hair test will detect PCP that has been in the system for up to 90 days. The saliva test will detect the drug for up to three days after use.

References

The PCP story. California Narcotics Officers’ Association. Published Oct 13, 2012. Accessed Oct 13, 2012. https:// www.cnoa.org/documents/NPCP.pdf

A parent’s guide: drug slang. Department of Behavioral Healthcare Developmental Disabilities and Hospitals. Published Oct 2015. Accessed Oct 13, 2012. Dhttps:// bhddh.ri.gov/sites/g/files/xkgbur411/files/docu ments/ Drug-Slang- guide-FINAL.pdf

Bey T, Patel A. Phencyclidine intoxication and adverse effects: a clinical and pharmacological review of an illicit drug. Cal J Emerg Med. Feb 2007;8(1):9-14.

Daubner SC, Le T, Wang S. Tyrosine hydroxylase and regulation of dopamine synthesis. Arch Biochem Biophys. Apr 1, 2011;508(1):1-12. doi: 10.1016/j.abb.2010.12.017

Effects and Dangers of PCP use. American Addiction Centers. Updated Sep 9, 2022. Accessed Oct 13, 2022. https://americanaddictioncenters.org/pcp-abuse/effectsand-dangers

Fort Wayne attorney defends PCP charges throughout Indiana. The Law Offices of Ryan E. Lackey. Accessed Oct 13, 2022.

https://www.defendingfortwayne.com/practiceareas/drug-crimes/pcp/

Phencyclidine (PCP) Drug Test. National Drug Screening, Inc. Accessed Oct 13, 2022. https://www.nationaldrugscreening.com/phencyclidinedrug-test/

Finding Professional PCP Addiction Treatment. New Beginnings. Accessed Oct. 13, 2022. https://www.newbeginningsdrugrehab.org/pcp-rehab/

History/Background

Slang.terms

Peyote is a cactus containing the hallucinogen mescalineThe crown of the cactus is full of small disc like buttons. It is native to the southwestern United States and northern Mexico but is cultivated all over the world. Peyote has been used in tribal ceremonies by indigenous cultures in North America since 1000 BC.l)

oru_ginteractions TOXICOiogy

Drug slang and code words are often used to describe controlled substances, designer drugs,and synthetic compounds, which may cause confusion for clinicians attempting to treat patients under the influence. Some slang terms for peyote are black button, britton, button,cactus; green button, half moon, hikori, hikuli, hyatari, nubs, seni, shaman, or tops.2) , .

Pharmacology/drug effects

The secondary metabolites found in peyote produce psychosis-like symptoms and can alter perception, feelings, thoughts,and mood, without being addictive. Peyote is reported to initiate states of introspection and insight that have been described as being of a spiritual nature. Hallucinogens bind with high affinity and activate the serotonin 5-hydroxytryptamine receptor.3)

None well documented, but additive effects are likely if used with other hallucinogenic compounds. . ·

Mescaline from peyote is distributed to the liver and brain. A revie_w of the California Poison Control System database records from 1997 to 2008 suggest mild to moderate toxicity from peyote consumption or . insufflation; adverse reactions include hallucinations, tachycardia, agitation, and mydriasis. Addiction and dependence are mostly absent, and most intoxications appear to be mild and unlikely to produce lifethreatening symptoms.3)

By 1930, over a dozen states in the United States had outlawed possession ofpeyote,and in 1967,peyote was banned nationwide by

PROPOFOL PROPOFOL

Other Names

History & Background

Propofol was approved by the FDA in 1989 for induction and maintenance of anesthesia during surgeries.

It is also indicated for ICU sedation of intubated and mechanically ventilated patients.

It was initially developed as an alternative for thiopental and methohexital, which both had significant post-op fatigue, nausea, vomiting, and cognitive impairment.

Propofol gained worldwide attention in 2009 when singer Michael Jackson died of a propofol overdose while using the drug as a sleep aid.

Today, propofol abuse is almost exclusively seen in medical professionals, especially anesthesia providers.

Propofol abuse accounts for 1.6% of all healthcare addiction cases.

Animal studies have found that propofol use can result in physical dependence due to dose-dependent symptoms of a "high".

Diprivan® (Brand)

"Milk of Anesthesia"

Pharmacology

Propofol is thought to produce its sedative/anesthetic effects by positive modulation of the inhibitory function of the neurotransmitter GABA through GABAa receptors.

IV Propofol usually induces anesthesia within 40 seconds after the start of administration.

The duration of sedative action is 3 to 10 minutes depending on the dose, rate, and duration of treatment.

Half-life is bi-phasic, with the initial being 40 minutes and the terminal being 4 to 7 hours.

Propofol has a large volume of distribution and is highly lipophilic.

Metabolism is mainly hepatic, and excretion is via urine.

Interactions/Toxicology

Propofol should be avoided in use with other CNS depressants such as alcohol, azelastine, bromperidol, flunarizine, kratom, olopatadine, orphenadrine, oxomemazine, and thalidomide.

Propofol may enhance the QTc- prolonging effect on QT-prolonging agents and combination may increase the risk for ventricular arrhythmias.

Propofol may cause bradycardia and should be used with caution with other medications such as betablockers, neostigmine, neuromuscular blockers, and opioids.

Propofol can cause hypertriglyceridemia, which can lead to acute pancreatitis.

Propofol may cause severe hypotension and should be used with caution in those with hypovolemia, sepsis, and shock.

Propofol abuse has been linked to mortality rates greater than 33%.

References

White PF, Warner DS. Propofol: its role in changing the practice of anesthesia. Anesthesiology. 2008; 109:1132–1136.

doi:10.1097/ALN.0b013e31818ddba8

Study shows rising rate of propofol abuse by health care professionals. ScienceDaily. Accessed October 12, 2022.

https://www.sciencedaily.com/releases/2013/03/130318131212 .htm

Propofol: the drug that killed Michael Jackson. Harvard Health. Accessed October 12, 2022.

https://www.health.harvard.edu/blog/propofol-the-drug-thatkilled-michael-jackson201111073772#:~:text=Aglio%20showed%20me%20a%20small

Propofol. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 12, 2022. http://online.lexi.com

Statement on Safe Use of Propofol. www.asahq.org. https://www.asahq.org/standards-and-guidelines/statementon-safe-use-of-propofol

Propofol Injectable Emulsion. Package insert. Dr. Reddy's Laboratories Inc; 2017

Office of the Federal Register. Schedules of Controlled Substances: Placement of Propofol Into Schedule IV; Proposed Rule. 2010.

Propofol Drug Test. Health Street. Accessed October 13, 2022. https://www.health-street.net/drugtests/substances/prescription/propofol/#:~:text=to%20Quick% 20Links-

Laws & Restrictions

In a statement by AANA and ASA:

“Whenever propofol is used for sedation/anesthesia, it should be administered only by persons trained in the administration of general anesthesia, who are not simultaneously involved in these surgical or diagnostic procedures. ... failure to follow these recommendations could put patients at increased risk of significant injury or death.”

In 2010, the US DEA proposed the classification of propofol as a schedule IV controlled substance, which was not successful.

There are currently no federal or state laws surrounding propofol use or administration, and it is not considered a controlled substance.

Monitoring/Drug Screens

Per the American Society of Anesthesiologists, vital signs should be taken continuously during propofol administration to monitor signs of hypotension, bradycardia, apnea, airway obstruction, or oxygen desaturation, as well as to assess consciousness. Exhaled CO2 should also be monitored.

Exposed neonates should be monitored for hypotonia and sedation.

Propofol can be detected by Health Street’s Propofol Hair Test approximately 90 days back, although it is not normally included in standard drug tests.

Professional Opinion

In my opinion, I believe that propofol should be considered a controlled substance due to the increasing abuse by healthcare professionals and the high instances of mortality (>33%) resulting from abuse. I also find that the proven physical dependence after use qualifies the drug to be classified as a controlled substance.

Since propofol is an IV drug and is only available for use in in-patient settings, classification as a controlled substance would not directly affect patient acquisition for anesthesia, but instead would increase security of storage and decrease the ease of access for medical professionals.

PSILOCYBIN PSILOCYBIN

Kristen

History

There are over 180 different types of mushrooms that contain psilocybin. They have been used in different parts of Mexico for over 2,000 years. It has also been used in spiritual and ritual ceremonies.

Is it Legal?

Psilocybin is an illegal substance. It is a Schedule 1 under the Controlled Substance Act. In 1968, the possession of psilocybin mushrooms became illegal in the United States

Pharmacology

Psilocybin is a prodrug that gets converted to psilocin which has psychedelic properties similar to LSD.

2nd-Year

Student Fall 2022 Slang Terms

How is it abused?

Psilocybin-containing mushrooms are one of the most commonly available natural psychedelics

The mushrooms are ingested orally. They can be brewed into tea or mixed with other flavors to hide their taste.

It has a high potential for abuse and there is no known medical benefit for it in the United States

Drug

PSILOCYBIN PSILOCYBIN

Kristen Lyons, 2nd-Year Professional Student Fall 2022

Interactions Do they show up in a drug test?

This drug should not be taken with MOA Inhibitors such as antidepressants

You should not drive or operate machinery while taking this drug

References

1. Psilocybin Mushroom Basics. Erowid. Created January 29, 2000. Updated November 9, 2018. Accessed. October 12, 2022. https://www.erowid.org/plants/mushrooms/mushrooms_basics. shtml.

2. Psilocybin Fast Facts. National Drug Intelligence Center. Created August 2003. Accessed October 12, 2022. https://www.justice.gov/archive/ndic/pubs6/6038index.htm#:~:tex t=To%20Top-,Is%20psilocybin%20illegal%3F,purpose%20in%20the% 20United%20States.

3. Psilocybin. American Chemical Society. Published October 2, 2022. Accessed October 12, 2022. https://www.acs.org/content/acs/en/molecule-of-theweek/archivepsilocybin.html#:~:text=In%201958%2C%20Swiss%20ch emist%20Albert,%E2%80%9Cfather%20of%20LSD%E2%80%9D.)

4. Psilocybin. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 12, 2022. Available at: http://online.lexi.com

5. Lowe H, Toyang N, Steele B, et al. The Therapeutic Potential of Psilocybin. Molecules. 2021;26(10):2948. Published 2021 May 15. doi:10.3390/molecules26102948

Psychadelic mushrooms do not show up in a common 5, 8, 10, 12 panel test, but there are drug screens specifically designed to detect mushrooms

Effects

Onset: the effects are normally

seen within 30-60 minutes effects usually last 4-6 hours

Duration: When taken orally, the

Visual effects: the pupils will dilate which makes colors seem brighter. Colors can shift and the visual field can seem smeared "tripping" or "shrooming"

The experience is called

Since there are no known medical benefits, psilocybin mushrooms are not accepted by the medical society or the general public.

~ K. Lyons

The main physical effects include nausea, vomiting, euphoria, muscle weakness, relaxation, lack of coordination, and drowsiness

PSUEDOEP HEDRINE

History and Background

It was first characterized in 1889, by the German chemists Ladenburg and Oelschlägel who used a sample that had been isolated from Ephedra Vulgaris by the Merck pharmaceutical corporation of Darmstadt, Germany

Pseudoephedrine as we know it has been around since the 1920s Although the drug occurs naturally in certain plants (eg ma huang) the majority that is produced derives from the yeast fermentation of dextrose in benzaldehyde

Pharmacology

Pseudoephedrine causes vasoconstriction which leads to a decongestant effect. It has a short duration of action unless formulated as an extended release product. Patients should be counselled regarding the risk of central nervous system stimulation.

Pseudoephedrine is a sympathomimetic with a mixed mechanism of action direct and indirect. It indirectly stimulates alpha-adrenergic receptors causing the release of endogenous norepinephrine (NE) from the granularity of neurons while it directly stimulates beta-adrenergic receptors [11,12,13].

Drug Interactions

Some products that may interact with this drug include stimulants (such as caffeine, dextroamphetamine, methamphetamine, herbal products like ephedra/ ma huang), and terbutaline

Taking MAO inhibitors with this medication may cause a serious (possibly fatal) drug interaction Avoid taking MAO inhibitors (isocarboxazid, linezolid, metaxalone, methylene blue, moclobemide, phenelzine, procarbazine, rasagiline, safinamide, selegiline, tranylcypromine) during treatment with this medication Most MAO inhibitors should also not be taken for two weeks before treatment with this medication Ask your doctor when to start or stop taking this medication

Pseudoephedrine may decrease the effectiveness of blood pressure medications (such as beta blockers, calcium channel blockers, guanethidine, and methyldopa)

The Law

The Combat Methamphetamine Epidemic Act of 2005 has been incorporated into the Patriot Act signed by President Bush on March 9 2006 The act bans over-the-counter sales of cold medicines that contain the ingredient pseudoephedrine which is commonly used to make methamphetamine The sale of cold medicine containing pseudoephedrine is limited to behind the counter The amount of pseudoephedrine that an individual can purchase each month is limited and individuals are required to present photo identification to purchase products containing pseudoephedrine In addition, stores are required to keep personal information about purchasers for at least two years

https://en.wikipedia.org/wiki/ Pseudoephedrine https://americanaddictioncenters.org/over-the-counter-medications/pseudoephedrine

Drug Screens

Pseudoephedrine is commonly used for sinus and nasal congestion, pseudoephedrine may cause false positive test results for amphetamine or methamphetamine.

Slang Terms

Pseudoephedrine has no street nicnames by it self its street names most coincide with what drug it is being used in to make. Some examples of those slang terms include Chalk, Crank, Meth, Speed.

Professional Opinion Abuse

Pseudoephedrine (PSE) is a drug with a long history of medical use; it is helpful in treating symptoms of the common cold and flu, sinusitis, asthma, and bronchitis Due to its central nervous system (CNS) stimulant properties and structural similarity to amphetamine, it is also used for non-medical purposes The substance is taken as an appetite reducer, an agent which eliminates drowsiness and fatigue, to improve concentration, and as a doping agent

According to the Pharmaceutical Journal “Pseudoephedrine is a proven nasal decongestant, for which there is subjective and objective evidence that it reduces blockage, improves breathing and helps patients feel better "

8

The onset of action occurs after 30 min and after 1–4 hours the drug reaches its maximum concentration in the blood. When using the extended-release formulation, this time is twice as long.

Teens may be more likely to abuse pseudoephedrine and a common practice is to combine it with alcohol. This practice is very dangerous and may result in overdose because the stimulating effects of pseudoephedrine can dampen the effects of alcohol, making a person more likely to drink more than they normally would.

The most common form of pseudoephedrine abuse is using it to make methamphetamine This involves chemically altering the pseudoephedrine into an ingredient that can be used in the meth “cooking” process While the process of converting pseudoephedrine to make meth is fairly simple, it’s also extremely dangerous and can cause explosions or fires

Misusing pseudoephedrine in this way is extremely addictive and meth can cause serious physical and psychological side effects that can last for weeks, months, years, or even a lifetime

Although the Combat Methamphetamine Epidemic Act has made pseudoephedrine more difficult to acquire, the abuse of methamphetamine is still rampant in the U S and contributes to the number of ER visits, law enforcement resources used, crimes committed, and serious health problems plaguing Americans

References

Pseudoephedrine. React (Auckl). 1988;213(1):11-11. doi:10.1007/bf03280830

PubChem. Pseudoephedrine. Nih.gov. Accessed November 7, 2022. https://pubchem.ncbi.nlm.nih.gov/compound/Pseudoephedrine

Głowacka K, Wiela-Hojeńska A. Pseudoephedrine-benefits and risks. Int J Mol Sci. 2021;22(10):5146. doi:10.3390/ijms22105146

Bezrutczyk D. Drug street names. Addiction Center. Published November 8, 2018. Accessed November 7, 2022. https://www.addictioncenter.com/drugs/drug-street-names/ Drugs.com. Accessed November 7, 2022. https://www.drugs.com/druginteractions/pseudoephedrine.html Center for Drug Evaluation, Research. Legal Requirements for the Sale and Purchase of Drug Products Containing Pseudoephedrine, Ephedrine, and phenylpropanolamine. U.S. Food and Drug Administration. Accessed November 7, 2022. https://www.fda.gov/drugs/information-drugclass/legal-requirements-sale-and-purchase-drug-products-containing-pseudoephedrineephedrine-and Gragnolati AB. 10 medications that can cause a false positive on drug tests. GoodRx. Published July 18, 2017. Accessed November 7, 2022. https://www.goodrx.com/drugs/side-effects/thesemedications-can-cause-a-false-positive-on-drug-tests

Bryan J. Pseudoephedrine is a tough product to challenge as a nasal decongestant. The Pharmaceutical Journal. Published July 17, 2012. Accessed November 8, 2022. https://pharmaceutical-journal.com/article/news/pseudoephedrine-is-a-tough-product-tochallenge-as-a-nasal-decongestant

Pyro (nitazine)

History/Background:

• Nitazenes were developed about 60 years ago and were originally used for pain relief.

• Nitazenes are synthetic opioids- they are not naturally occurring.

• They are easy to manufacture and cheap to make

• They are being compared to fentanyl.

• Nitazenes are 20 times more powerful than fentanyl, which is 50 times more potent than other opioids!!

• They were originally sourced from China and recently brought into the United States.

Slang terms:

• There are no real slang terms because nitazene is “slang” for the synthetic benzimidazole

• Similar to fentanyl and fentanyl slang terms include:

o Murder 8

o Shine

o Friend

o Goodfella

o TNT

o Percopop

o China Girl

https://www.dea.gov/stories/2022/2022-06/2022-06-01/newdangerous-synthetic-opioid-dc-emerging-tri-state-area.

Pharmacology/drug effects:

• In the form of a powder, ISO (isotonitazene) can look yellow, brown, or off-white in color.

• Side effects from Nitazenes overdoses can include:

o shallow, slow, or stopped breathing

o bluish nails or lips

o pale or clammy skin

o confusion

o drifting in and out of consciousness

o limp muscles

o pinpoint pupils

o vomiting

o weak or no pulse

https://www.dea.gov/stories/2022/2022-06/2022-06-01/newdangerous-synthetic-opioid-dc-emerging-tri-state-area.

Drug interactions/Toxicology:

• Nitazenes may be laced with illicit drugs

o including illicitly sold marijuana.

• Nitazene overdose is common.

Laws:

• There are currently no laws specifically for nitazenes.

• However,

o Illegal forms of fentanyl are usually in the form of powders or pressed into counterfeit tablets.

o Fentanyl is illegal to possess if it is not prescribed to you.

o Fentanyl is a schedule II drug since it has a high potential for abuse.

Monitoring/drug screens:

• Since nitazene is being compared to fentanyl, the fentanyl drug screens can be done with

o Urine

o Hair (past 90 days)

o Blood (not as common)

References:

Professional opinion: This drug is new and recently introduced to the United States. With that being the case, there is not a ton of information available regarding this drug. I think it would be best for officials to get ahead of the making and distribution of this drug since it is being compared to fentanyl which is incredibly dangerous and has a high abuse rate.

1. Silverman SH. Dangerous opioid nitazene - a deadly newcomer in the current drug epidemic. American Addiction Foundation.

https://www.americanaddictionfoundation.com/news/dangerous-opioid-nitazene-a-deadlynewcomer-in-the-current-drug-epidemic/. Published December 28, 2021. Accessed October 13, 2022.

2. B M. Nitazenes: New opioids 20 times stronger than fentanyl. American Addiction Foundation.

https://www.americanaddictionfoundation.com/news/nitazenes-new-opioids-20-times-strongerthan-fentanyl/. Published December 31, 2021. Accessed October 14, 2022.

3. New, dangerous synthetic opioid in D.C., emerging in Tri-State Area. DEA.

https://www.dea.gov/stories/2022/2022-06/2022-06-01/new-dangerous-synthetic-opioid-dcemerging-tri-state-area. Accessed October 14, 2022.

4. Opioid use terms. Opioid Help. https://www.opioidhelp.com/opioids/opioid-use-terms/. Published August 19, 2020. Accessed October 14, 2022.

5. FentanylDrugTest.NationalDrugScreening.https://www.nationaldrugscreening.com/fentanyldrug-test/.AccessedOctober 14,2022.

Pyrovalerone Pyrovalerone

Natalia Fijas, Student pharmacist

common Names

Bath salts

Ivory wave

Vanilla sky

Energy-1

MDPV

https://www.google.com/url?

sa=i&url=https%3A%2F%2Fwww.aacc.org%2Fcln%2Farticles

%2F2014%2Fmarch%2Fbathsalts&psig=AOvVaw0rIafKHu8pICtV8EtN4Tee&ust=16657877

37346000&source=images&cd=vfe&ved=0CAwQjRxqFwoTC Oj4-oal3voCFQAAAAAdAAAAABAE

FALL 2022

Structure of Pyrovalerone

https://www.google.com/imgres?

imgurl=https%3A%2F%2Fupload.wikimedia.org%2Fwikipedia%2Fcommons%2Fthumb%2F2%2 F22%2FPyrovalerone.svg%2F1200pxPyrovalerone.svg.png&imgrefurl=https%3A%2F%2Fen.wikipedia.org%2Fwiki%2FPyrovalerone& tbnid=fZPSbLXiSolRlM&vet=12ahUKEwjg_5KZpN76AhVJbDABHY4UBhwQMygAegUIARCQAQ..i &docid=EhF_nFO8U2tsWM&w=1200&h=778&q=Pyrovalerone&ved=2ahUKEwjg_5KZpN76AhVJ bDABHY4UBhwQMygAegUIARCQAQ

Mechanism of Action

Pyrovalerone is a synthetic cathinone. Cathinones act by inhibiting dopamine, serotonin, and norepinephrine transporters in the central nervous system. As a result, extracellular concentrations of these neurotransmitters are increased leading to increased activity of them.

History of Drug Abuse

The class of this drug, cathinone, was discovered in the 18th century as a stimulant alkaloid located in the leaves of the khat bush. It used to be commonly consumed in teas. Substances within this drug class were not seen to be abused until the early 21st century when people began to sell them on internet sites as "legal alternatives" to MDMA.

https://www.google.com/url?

sa=i&url=https%3A%2F%2Fstock.adobe.com%2Fimages%2Ffresh -leaves-of-a-khat-or-qat-bush-cathaedulis%2F300202119%3Fas_campaign%3Dftmigration2%26as_c hannel%3Ddpcft%26as_campclass%3Dbrand%26as_source%3Df t_web%26as_camptype%3Dacquisition%26as_audience%3Duser s%26as_content%3Dclosure_asset-detailpage&psig=AOvVaw3vQzdk8sIzUaihFmE7HfcB&ust=16657902190

28000&source=images&cd=vfe&ved=0CAwQjRxqFwoTCLiJoKWu

3voCFQAAAAAdAAAAABAm

how is it used?

Laws about Pyrovalerone

In 2012, the DEA classified substances found in bath salts, including pyrovalerone, as Schedule I controlled substances. This means there is no legally defined medical use for pyrovalerone and that it has a high potential for abuse.

Drug Screening for pyrovalerone

Interactions with prescription Medications

The class of drugs pyrovalerone lands under, cathinones, has an overlapping metabolic pathway with antidepressants and ADHD medications. When combined, cathinones can increase the serum concentrations of these medications.

https://www.forbes.com/site s/melaniehaiken/2012/06/04 /bath-salts-a-deadly-newdrug-with-a-deceptivelyinnocent-name/? sh=77c0a4d1121e

Professional Opinion

Pyrovalerone is a complex drug with a high risk for abuse. It is interesting to see how it used to be tried to be sold as a legal alternative to MDMA but shortly after was defined as a Schedule I controlled substance with no medical use. I believe the government has taken the necessary steps and percautions to ensure the safety of people and hopefully prevent the use of this drug. ~N.

SYmptoms to watch for

references:

Drug Enforcement Administration. 3,4-Methylendioxypyrovalerone (MDPV). 2019.

Bauman MH, Bukhari MO, Lehner KR, et al. Neuropharmacology of 3,4Methylenedioxypyrovalerone (MDPV), Its Metabolites, and Related Analogs. Curr Top Behav Neurosci. 2017;32:93-117. doi:10.1007/7854_2016_53.

Souders CL, Davis RH, Qing H, et al. The psychoactive cathinone derivative pyrovalerone alters locomotor activity and decreases dopamine receptor expression in zebrafish (Danio rerio). Brain Behav. 2019;9(11). doi:10.1002/brb3.

Karila L, Megarbane B, Cottencin O, et al. Synthetic Cathinones: A New Public Health Problem. Current Neuropharmacology. 2015;13(1):12-20. doi:10.2174/1570159X13666141210224137

5.Pucky M. Bath Salts Drug. Drugs.com. Updated May 19, 2022. Accessed October 13, 2022. https://www.drugs.com/illicit/bathsalts.html

6.Erowid. MDPV Legal Status. The Vaults of Erowid. Accessed October 13, 2022. https://www.erowid.org/chemicals/mdpv/mdpv_law.shtml

7.Lindsay Glicksberg, Kelsie Bryand, Sarah Kerrigan. Identification and quantification of synthetic cathinones in blood and urine using liquid chromatography-quadrupole/time of flight (LC-Q/TOF) mass spectrometry. Journal of Chromatography B. 2016;1035:91103.

History/Background History/Background

Rohypnol, generically known as flunitrazepam., originated in Switzerland when Hoffman La Roche Pharmaceuticals developed it for insomnia and anesthesia induction in 1975.¹ It was then used recreationally in Europe in the late 1970s. In 1983, Rohypnol received a Schedule IV classification, making it illegal to use without a prescription.¹ However, the FDA banned the use of it in the USA, so it was only used in foreign countries. In the early 1990s, it began being imported to the USA illegally, mainly through Mexico, and started to be used as a date-rape drug due to its sedating effects.¹ Rohypnol was seen mainly throughout the 1990s and early 2000s and has since fallen off, though use of it is still seen in the USA, mainly in states bordering Mexico and in cocaine users who use Rohypnol to relieve the uncomfortable side effects of cocaine.

Roofie Ruffies

Circles

Forget-me-pill

La rocha

Lunch money drug

Mexican Valium

Wolfies²

MADI ROBERTSON

2nd YEAR PROFESSIONAL STUDENT FALL 2022

https://www.dea.gov/sites/default/files/2020-06/Rohypnol-2020_

SLANG SLANG TERMS TERMS

Pharmacology/Drug Effects Pharmacology/Drug Effects

Rohypnol is a benzodiazepine used as a sleep medication. It comes in both tablet and suppository dosage form with strengths of either 0.5 or 1 mg. It was developed specifically for sleep, as it has a very rapid onset and long duration. Rohypnol binds nonspecifically to benzodiazepine receptors BNZ1 and BNZ2, thus enhancing the effects of GABA, resulting in a hyper-polarized cell membrane that cannot excite the cell further. The half-life of Rohypnol is over 14 hours, and it has an active metabolite, thus increasing its duration even more.

Rohypnol slows down the functioning of the CNS, so patients taking it will feel drowsiness, decreased anxiety, impaired judgement and mental functioning, confusion, aggression. Rohypnol is so potent that patients can often experience amnesia and pharmacological hypnotic sleep.

Drug interactions/toxicology Drug interactions/toxicology

Rohypnol interacts poorly with other CNS depressant drugs. Some examples of those include alcohol and heroin. When taken in combination, it significantly increases the risk of overdose. Sedation, slowed heart rate, unconsciousness, and even death can result from the breathing suppression that happens as a result of these interactions.

LAWS LAWS

Rohypnol is currently a Schedule IV substance. It is not approved for manufacturing, use, sale, or importation in the United States. This is only in the United States, though, as Rohypnol is manufactured and used legally in other countries.

Monitoring/ Drug Screens: Monitoring/ Drug Screens: Rohypnol is not tested for in Standard Drug Rohypnol is not tested for in Standard Drug Tests, but it can be tested for in Extended Drug Tests, usually only Tests, but it can be tested for in Extended Drug Tests, usually only when use is suspected. Rohypnol can be detected in the urine for 2-4 when use is suspected. Rohypnol can be detected in the urine for 2-4 days after use. days after use.

P Prrooffeessssiioonnaall O Oppiinniioon n

Studies have shown that Rohypnol, as a benzodiazepine, works well. It produces muscle relaxant effects, anti-anxiety effects, and sedation. Its long duration helps with insomnia patients, however, its misuse can have extremely damaging and scary effects. The United States views the drug as "not worth the risk", whereas it is used clinically around the world. With the availability of so many other benzodiazepines that do not have such an infamous history, Rohypnol is not a medication whose legal status needs to be reconsidered. ~

R

Hoffman La Roche History. Roche. Accessed October 13, 2022.

http://www.roche.com/home/company/com_hist_intro

Staten C. Roofies: the new 'date rape' drug of choice. Emergency Response & Research Institute. Accessed October 13, 2022.

http://www.emergency.com/roofies

Inaba D, Cohen W, Holstein M et al. Uppers, downers, and all arounders. CNS. Accessed October 13, 2022.

http://www.erowid.org/library/books/uppers_downers

Rohypnol. United States Drug Enforcement Administration. Accessed October 13, 2022. http://www.dea.gov/factsheets/rohypnol

RX STIMULANTS FOR ADHD – “STUDY DRUGS”

HISTORY OF ADHD DRUGS

ADHD has been described since the early 1900s, the first report coming from Sir George Frederick Still in 1902 However, it wasn’t until 1937 that the first medication Benzedrine (a racemic mixture of amphetamine) was used for ADHD. Ritalin came to the market in 1955 followed by Obetrol (now known as Adderall) in 1960, and since then these prescription drugs have found their way onto the streets. Also known as “study drugs,” these stimulants are known to enhance concentration and increase energy.

PHARMACOLOGY

ADHD stimulants work by increasing the amount of dopamine and norepinephrine (NE) in the brain. Methylphenidate does this by blocking the reuptake of these neurotransmitters. Amphetamines are sympathomimetics that promote the release of these neurotransmitters and may also block their reuptake. Increased levels of dopamine and NE can improve memory, concentration, wakefulness, motivation, and attention. Amphetamines also may increase serotonin, histamine, and epinephrine levels, which may lead to other effects such as improvement of mood.

Toxicology

Too much dopamine and NE can have negative effects such as anxiety, disorganized thinking, and the “jitters.” Negative physiologic effects include increases in blood pressure and heart rate and decreased sleep.

Methylphenidate (Concerta, Ritalin) and Amphetamine (Adderall, Vyvanse)

AKA

Vitamin R, R-ball, Rids, Rit, Diet Coke, Kiddie Cocaine, Skippy, Pineapple, Skittles, Smarties, Poor Man’s Cocaine and Addys, Uppers, Speed, Dexies, Zing, Beans, Black Beauties, Pep Pills

Image From: Reference 11

Drug Interactions:

• Antidepressants

• MAOIs

• Antihypertensive drugs

• Other CNS stimulants

• Alcohol

• Caffeine

• Antacids

Fun fact:

In 2014, 20% of college students reported abusing prescription stimulant drugs.

Image From: Reference 12

LAWS

Prescription ADHD stimulants are classified as Schedule II controlled substances, which identifies them as having a high potential for abuse and dependence. While these are legal prescription drugs, possession without a prescription can lead to substantial lawful penalties. The federal penalty for possession of a CII (1st offense) can be up to a year in prison, a $1000 fine, or both. A 2nd offense can be up to two years in prison, a $2500 fine, or both. Illegal sale and distribution of CIIs can lead to up to 20 years in prison, a $1 million fine, or both.

References:

1. Street or Slang Names for Drugs. Snohomish Health District. Accessed October 5, 2022.

https://www.snohd.org/DocumentCenter/View/2516/Drug_Names_Sla ng_2019_05_09?bidId

2. Iannelli, Vincent. ADHD History and Medication Timeline. Verywell Mind. Updated May 12, 2022. Accessed October 5, 2022. https://www.verywellmind.com/adhd-history-of-adhd-2633127

3. Gunnerson, Tate. A Brief History of ADHD. WebMD. Updated August 25, 2022. Accessed October 5, 2022. https://www.webmd.com/addadhd/adhd-history

4. History and Statistics of “Study Drugs.” American Addiction Centers. Updated May 6, 2022. Accessed October 5, 2022. https://drugabuse.com/stimulants/adderall/history-and-statistics-ofstudy-drugs/

5. Pirius, Rebecca. Sale and Possession of Amphetamines: Criminal Penalties and Laws. Criminal Defense Lawyer. https://www.criminaldefenselawyer.com/resources/distributionamphetamines-criminal-penalties-and-laws

6. Methylphenidate. Lexi-Drugs. Lexicomp Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 5, 2022. http://online.lexi.com

7. Amphetamine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 5, 2022. http://online.lexi.com

8. Estrellado, Nicko. Methylphenidate (Ritalin) Interactions. Addiction Group. Updated September 15, 2022. Accessed October 5, 2022. https://www.addictiongroup.org/drugs/stimulants/ritalin/methylphenid ate-interactions/

9. How Long does Ritalin Stay in your System? American Addiction Centers. Updated August 19, 2022. Accessed October 5, 2022. https://americanaddictioncenters.org/ritalin/how-long-in-system

10. Amphetamines Drug Test. National Drug Screening Inc. Accessed October 5, 2022.

https://www.nationaldrugscreening.com/amphetamines-drug-test/

11. Coping with an Adderall Crash. Medical News Today. Accessed October 5, 2022. https://www.medicalnewstoday.com/articles/321492

12. Sohl, Dalya. Adderall Abuse. The Evanstonian. Accessed October 5, 2022. https://www.evanstonian.net/archivedfeature/2014/03/10/adderall-abuse/

Monitoring:

Methylphenidate and amphetamine can be detected with a drug urine analysis for 1-3 days following use. Many drug tests used by employers will include amphetamines on the drug panel.

Professional Opinion:

Prescription stimulants have been used for many years to treat ADHD and narcolepsy. They are effective drugs in medical conditions that may benefit from an increase of dopamine and NE. However, because they act on these popular neurotransmitters, these drugs have the potential for abuse and addiction, which has been verified by the reports of misuse over the years. However, I don’t think it is beneficial to remove these drugs from the market, since they have positive medical effects and are not as deadly as other abusive drugs. ~L.

Salvia divinorum

Background: Salvia divinorum belongs to the mint family, it is a perennial that is often used due to its hallucinogenic effects. This plant is found in Mexico, more specifically the Sierra Mazatec region in Oaxaca. This plant was used in rituals by the Native Mazatec people as a means of ‘medical divination’. They used salvia to treat illness and symptoms that were caused by spiritual means or by evil sorcerers. Salvia would also be used for spiritual and learning purposes through religious leaders using it to induce ‘shamanic visions’

Slang terms

https://www.wwf.org.mx/que_hace mos/programas/oaxaca/

Ska Pastora Shepherdess’s Herb ska Maria Pastora yerba de Maria

Sally-D Magic Mint Sage of the Seers

Pharmacology/Drug Effects: Salvia contains a compound names Salvinorin A, which is a selective full agonist of the kappa-opioid receptor. Binding to this receptor is the main cause of the hallucinogenic side effects of salvia; this is interesting as other hallucinogens often bind to serotonin receptors. Some of the most common symptoms people face while using salvia, include vivid and random hallucinations, inability to distinguish time and location, and in some cases can cause psychotic disturbances. After the hallucinations wear off, users often feel dizzy, exhausted and sometimes have no memory of the time they were hallucinating.

https://www.emcdda.europa.eu/publications/drugprofiles/salvia_en

https://psychonautwiki.org/wiki/Salvia_divinorum

Drug Interactions/Toxicology: As of now there is limited information regarding any drug interactions with Salvia divinorum, more tests need to be done in order to see whether it is contraindicated along with other therapies. In terms of its toxicity, there has been no documented case of death directly as a result of Salvia divinorum use.

Laws: Salvia is not approved for medical use in the US and is not controlled under the Controlled Substance Act. There are individual states that have decided to control salvia. Due to its lake of control, there are many online sites and individual producers who advertise Salvia as a legal alternative to other hallucinogenic drugs.

Monitoring/Drug Screens: Salvia’s subtypes like hispanica and miltiorrhiza are considered as plants and are completely legal. Salvia Divinorum is not commonly tested for on standard drug tests. Most times you would need to request a specially ordered, very expensive, test to detect it. It is difficult to test for it as it does not show up in sweat and we don’t have a way to test for it in hair. The only ways to test for it are through urine, spit and blood tests. Another limitation on testing is that it does not last very long in the body, there are minimal studies determining the exact amount of time it lasts in the body as well.

Professional Opinion: Salvia divinorum is a plant rooted in the history of the native Mazatec people While it may still be used in religious rituals for certain groups of people, recreational use of salvia is still questionable. The lack of studies around its use and potential of interactions are of concern, but we still haven’t come across a case where salvia has caused death. It should be up to the user to do their own research about salvia use and make an educated decision on whether or not to use it. -V.

References

• Drug fact sheet: Salvia divinorum - dea.gov. https://www.dea.gov/sites/default/files/202006/Salvia%20Divinorum-2020_0.pdf. Accessed October 14, 2022.

• Salvia Divinorum. Erowid salvia divinorum (ska pastora) vault. https://www.erowid.org/plants/salvia/salvia.shtml. Accessed October 14, 2022.

• Cambron M. A comparison of historical and current use of salvia divinorum in the United States and Mexico. lakeforest.edu. https://www.lakeforest.edu/news/a-comparison-of-historical-and-current-useof-salvia-divinorum-in-the-united-states-and-mexico. Accessed October 14, 2022.

• Salvia Divinorum Drug Profile. emcdda.europa.eu. https://www.emcdda.europa.eu/publications/drugprofiles/salvia_en. Accessed October 14, 2022.

• LaNeve N. How long does salvia stay in your system? - columbus recovery center: Ohio Drug and Alcohol Rehab Facility. Columbus Recovery Center | Ohio Drug and Alcohol Rehab Facility.

https://www.columbusrecoverycenter.com/blog/longevity-of-salvia-in-your-system/. Published August 3, 2021. Accessed October 14, 2022.

Scopolamine Scopolamine

"Devil's Breath" "Devil's Breath"

https://www.theweek.co.uk/65068/devils-breath-one-of-the-most-dangerous-drugsin-the-world

Pharmacology and Drug Effects Pharmacology and Drug Effects

Scopolamine is an anticholinergic drug that is often used to help prevent and/or treat motion sickness, as well as postoperative nausea and vomiting. It works by competitively inhibiting muscarinic receptors, causing peripheral antimuscarinic effects as well as central sedative, antiemetic and amnestic effects. By prescription, this medication is available as a transdermal patch. However, this drug can also be administered via oral, intravenous and inhalation routes, which seem to be the common methods causing intoxication and overdoses. Toxic doses can present clinically as tachycardia, dry mouth, blurred vision disorientation and insomnia. It has been noted throughout different articles that high doses may result in hallucinogenic properties in addition to amnesia, which could leave someone incapacitated.

History and Background of Use

History and Background of Use

“Devil’s Breath”, more commonly referred to as scopolamine, originates from the flower of the borrachero shrub found most often within South America. Extracts from the seeds can be made into a powder, which is then referred to as burundanga. According to literature, native South Americans have used borrachero in spiritual rituals for hundreds of years. This drug is chemically similar to scopolamine, and is thought to have amnesic and hallucinogenic effects. Though there is not sufficient evidence to support this claim, it has been rumored that this drug has historically been used by the Nazis and Soviets as a “truth serum”, as well as being used to render victims incapacitated to perform robberies and sexually assault.

Slang Terms Slang Terms

Scopolamine

Devil's Breath

Transderm Scop

"Zombie Drug"

"Date-Rape Drug"

Burundanga

Drug Interactions

Drugs that are contraindicated with the use of scopolamine include potassium and potassium citrate, which can lead to an increased risk of GI irritation and ulcers.

Drugs that increase the risk of anticholinergic side effects: Revefenacin, Quetiapine, Amantadine

Drugs that can cause a reduced seizure threshold: Donepezil, Bupropion, Amifampridine

Drugs that may cause CNS depression: Methacholine, Oxybates

Laws

Scopolamine is not a controlled substance in the US, but requires a prescription. There are no other specific laws or regulations regarding the use of this drug.

Monitoring and Drug Screens

Scopolamine is not commonly included in drug screens since it is rarely used recreationally, however, it can be detected by urine toxicology tests. Though detection of this drug is possible, it is often challenging because it is fully excreted unchanged in the urine within only 12 hours of use.

Professional Opinion

In my professional opinion, I do not believe that there is sufficient evidence to support the addition of regulations to the prescribing of scopolamine. Though high doses of this drug are potentially dangerous, the misuse of scopolamine does not seem to be very prevalent. Additionally, very little evidence exists to prove that this drug is what is being used to commit these alleged crimes. While I do not think changes to the regulation of this medication should be made, I do believe that it would be beneficial to bring awareness to the adverse effects that this class of drug can cause.

References References

Micromedex Products. Micromedexsolutions.com. Published 2019.

https://www.micromedexsolutions.c om/micromedex2/librarian/PFDefa ultActionId/evidencexpert.DoIntegra tedSearch?

navitem=topHome&isToolPage=true #

Drugs.com. Devil’s Breath: Urban Legend or the World’s Most Scary Drug? Drugs.com. Published September 7, 2015.

https://www.drugs.com/illicit/devil s-breath.html

Reichert S, Lin C, Ong W, Him CC, Hameed S. Million dollar ride. Canadian Family Physician. 2017;63(5):369-370. Accessed November 9, 2022.

https://www.ncbi.nlm.nih.gov/pmc /articles/PMC5429053/

“Devil’s breath”: one of the world’s most dangerous drugs?. The Week UK. Accessed November 9, 2022.

https://www.theweek.co.uk/65068/ devils-breath-one-of-the-mostdangerous-drugs-in-the-world Devil’s Breath: Why Scopolamine Abuse is So Terrifying. Northpoint Washington. Published May 9, 2019.

https://www.northpointwashington. com/blog/devils-breathscopolamine-abuse-terrifying/ Inc MP. Scopolamine - Mylan Pharmaceuticals Inc., Page 4. RxDrugLabels.com. Accessed November 9, 2022.

https://rxdruglabels.com/lib/rx/rx -meds/scopolamine/page/4/

Toad Venom (5-MeO-DMT)

Fall 2022

History and Background:

A species of toad, Bufo Alvarius, native to the Sonoran Desert produces a psychoactive chemical, 5-methoxy-N,Ndimethyltryptamine, or 5-MeO-DMT.1 5MeO-DMT is a tryptamine that also naturally occurs in seeds, bark, and leaves in the Amazonian rainforest. The chemical was mainly consumed by licking the toad’ s back, but for many years now, shamans in Mexico and southwest US have been collecting the venom, make it into a dry paste, and smoking the venom. Five minutes after ingestion of the substance, the hallucinogenic effect takes place that causes a hour long trip.

Laws:

5-MeO-DMTisa

ScheduleIcontrolled substanceintheUS. Thereisa10-yearprison sentenceforpossession of5-MeO-DMT.

Slang Terms:

Toad Venom, Cane Toad, Colorado River Toad, Sonoran Desert Toad, and Otac (the venom).

Pharmacology Drug Effects:

5-MeO-DMT is a non-selective serotonin (5-HT) receptor agonist.4 It has the highest affinity for the 5-HT1A subtype. The substance can cause decreased locomotor activity, investigatory behavior, and disturbed thalamocortical oscillations, which are behaviors selective to 5-HT1A receptor activation. The effects of this substance are like other tryptamine psychedelics such as psilocybin and DMT. Toad venom can cause effects like visual, auditory, and time perception distortions, memory impairment, and emotional experiences.

Drug Interactions/Toxicology:

There are only a few studies of 5-MeO-DMT in rodents and animals. In mice , administering 5-MeO-DMT with a low dose of monoamine oxidase inhibitor blocks MAOA-dependent elimination. In rodent studies,therewerepotentialdruginteractionswithTHC,mitragynine, lithium, haloperidol, benzodiazepines, and antidepressants. There are studies of 5-MeO-DMT toxicity in rodents, cats, sheep, and monkeys; high doses can cause ataxia, mydriasis, lateral head weaving, head nodding, tremors, shivering, convulsions, tachycardia, loss of consciousness,andrespiratoryfailure.

Professional Opinion:

I think that there is not enough research and data on toad venom. Although, there are a few articles suggesting toad venom's anticancer qualities and ability to treat depression. There needs to be more studies conducted on the substance. I do not think it should be used recreationally. The outcomes could be detrimental to one's health.

Colorado river toad by GETTY on February 2, 2020 https://www.forbes.com/sites/davidcarpenter/2020/02/02/5-meo-dmt-the-20minute-psychoactive-toad-experience-thats-transforming-lives/?sh=25f73c2e38a1

Monitoring/Drug Screening:

There are no clinical studies on toad venom suggesting the importance of monitoring and screening. The Hofmann DMTspotkitcanidentify5-MeO-DMT.

References

Psychoactive toad venom. Erowid. Updated February 28, 2020. Accessed October 9, 2022. https://www.erowid.org/animals/toads/toads.shtml

Reckweg JT, Uthaug MV, Szabo A, et al. The clinical pharmacology and potential therapeutic applications of 5methoxy-N,N-dimethyltryptamine (5-MeO-DMT). J Neurochem. 2022;162(1):128-146. doi:10.1111/jnc.15587

Hilliard, Jena. Psychedelic toad venom is the new trendy hallucinogen. Addiction Center. Published October 11, 2019. Accessed October 9, 2022. https://www.addictioncenter.com/news/2019/10/trendy-psychedelic-toad-venom/ Ermakova AO, Dunbar F, Rucker J, Johnson MW. A narrative synthesis of research with 5-MeO-DMT. J Psychopharmacol. 2022;36(3):273-294. doi:10.1177/02698811211050543

Li FJ, Hu JH, Ren X, Zhou CM, Liu Q, Zhang YQ. Toad venom: A comprehensive review of chemical constituents, anticancer activities, and mechanisms. Arch Pharm (Weinheim). 2021;354(7):e2100060. doi:10.1002/ardp.202100060

Wormwood

“green ginger, madder wort, wormwood sage”

What is It?

An extract and main ingredient in absinthe, a toxic liquor that causes “absinthism”

Absinthism

is a syndrome characterized by addiction, hallucinations, brain damage, epilepsy, GI problems, and increased risk of psychiatric illness and suicide

Pharmacology

thujone, the volatile oil component of wormwood →produces excitement

→is strong convulsant

Dosage Forms

Available in essential oil, capsule, tablet, tincture, and aqueous extract

https://www.verywellhealth.com/wormwood-5082001

Use and Abuse

This perennial herb has been used for thousands of years with multiple indications including use as a(n)

1. antiparasitic

2. component of alcoholic beverages

3. “general remedy for all diseases” in the Middle Ages.

Botanical Aspects: Artemisia absinthium (wormwood) is a perennial herb with a strong sage order that blooms annually between July to September.

https://substanceabusepolicy.biomedcentral.com/ articles/10.1186/1747-597X-1-14

History of the “Green Fairy”

• In B.C. times, wine-soaked wormwood leaves were used to alleviate labor pains, menstrual cramps, and rheumatism.

• A bitter spirit containing wormwood is called absinthe and was such a popular drink in the late 19th century in Europe that numerous bars and cafes would have “green hour” and famous artists such as Van Gogh would paint while indulging in the hour.

• In the 20th century, severe neurological disorders were found among the heaviest consumers of the absinthe.

Still Life with absinthe (Paris 1887) by Vincent

https://

substanceabusepolicy.biomedcentral.com /articles/ 10.1186/1747-597X-1-14

Interactions and Toxicity

• The toxic component of wormwood is attributed to the volatile oil of Artemisia absinthium which stimulates the CNS system in such a way that it may cause damage, mental deterioration, and even seizures.

• The toxicity of this essential oil is predominantly caused by the toxic ketone monoterpene β-thujone component of the essential oil from the herb.

May have negative drug Interactions with:

1.phenobarbital – by lowering seizure threshold

2.warfarin – may enhance coagulant effect

3. Proton pump inhibitors (PPIs), antacids, histamine receptor antagonists, and sucralfate - efficacy affected

https://www.history.com/news/francesgreen-fairy-flies-again

Potential Drug Effects

1. reducing inflammation such as in Crohn’s disease & arthritis (more research needed)

2. reducing pain - bellieved to have antioxidants

3. improving digestion - such as heartburn and constipation

HOWEVER, the FDA classifies wormwood as unsafe for internal use unless thujone free!

Professional Opinion

Consumption of wormwood should be avoided unless used as a last line treatment for a condition that has failed all other treatment methods. Risks greater than benefits

Drug Screening

Wormwood will only show up on a drug test if it contains thujone

Unlikely to produce a positive test unless person consumed absinthe

https:// substanceabusepolicy.biomedce ntral.co m/ articles/10.1186/1747-597X-1-14

Laws and Prohibitions in the USA

• Only thujone-free absinthe is legal in the U.S.

• This is referred to as “American Absinthe” and must contain less than 5-10ppm (10mg/L).

• Note: this is nowhere near what pre-ban absinthe used to be that was known for its hallucinogenic and dangerous nature

→ pre-ban absinthe as high as 260mg/L

REFERENCES

1. Wormwood. Lexi-Drugs. Lexicomp. Wolters Kluwer Health Inc. RIverwoods, IL. Accessed October 13, 2022. http://online.lexi.com

2. Curtis L. What is Wormwood? Verywell Health. https://www.verywellhealth.com/wormwood-5082001. Accessed October 13, 2022.

3. Artemisia absinthium. Artemisia Absinthium - an overview | ScienceDirect Topics. https://www.sciencedirect.com/topics/agricultural-andbiological-sciences/artemisia-absinthium. Accessed October 13, 2022.

4. Padosch SA, Lachenmeier DW, Kröner LU. Absinthism: A fictitious 19th century syndrome with present impact - substance abuse treatment, prevention, and policy. BioMed Central. https://substanceabusepolicy.biomedcentral.com/articles/10.1186/1747-597X-1-14. Published May 10, 2006. Accessed October 13, 2022.

5. Fairy GA. Illegal absinthe - absinthe legal status in the United States. Absinthe Original. https://www.originalabsinthe.com/absinthe-blog/ absinthe-united-states-legal-status.html. Published September 30, 2021. Accessed October 13, 2022.

Yohimbe

Fall2022

https://www.nccih.nih.gov/health/yohimbe

History/Background

Yohimbe,anherbalsupplement,ismadefromanevergreen treebarknativetocentralandwesternAfrica.Traditionally, yohimbine,acoumpundfoundinthebarkisusedtotreat erectilydysfunction,lowsexdriveinwomen,orunwatedsexual sideffectsofantidepressentmedications.Yohimbeisalso promotedasanaphrodisiacandusedforfatigue,highblood pressure,diabeticneuropathy,andheartproblems.Thereare reportsofpatientsusingyohimbetoincreaseathletic performanceorloseweight.

Yobimbinehydrocholifde,astarndardizedformofyohimbine, isavailableintheUnitedStatesasanFDAprescriptiondrug. However,thisproductisdifferentfromthedietarysupplement, yohimbe.Yohimbeisanunproved,unstudiedtreatmentwith nostandarddosethathaslesskeycomponentsandbenefits.

1. 3.

SlangTerms

ThereareseveralnamesforYohimbe: aphrodien,corynantheyohimbi, corynine,johimbi,Pausinystalia yohimbe,andquebrachine.

Phamacology

Theexactmechanismforusehasnotbeenfullystudied. However,ithasbeenconcludedthatYohimbeworksby blockingalpha-2aderbergicreceptorsthatinhibition erectionswhilesimultaniouslyactingasasympatholyticand stimulatingnervecentersinthespine,therebyimproving capacityforerectionwithoutincreasingsexualexcitement.

Yohimeisalsothorughtopromotethereleaseofnitricoxide thatcanleadtodilationofbloodvesselsandincreasedblood flowtosexualorgans.Theincreaseinsympatheticdrivealso increasesnorepinephrinereleaseandfiringrateofcellsinthe brainfordopamine,serotonin,andcholinergicreceptors.

https://www.amazon.c

om/Puritans-PrideYohimbe-2000Count/dp/B004R671O6

2. 4.

DrugEffects

Some side effects include skin flushing, rash, agitation, anxi insomnia, dizziness, rapid heartbeat, increased urination, headache, nausea, and vomiting.

There are more serious risks associated with yohimbe including chest pain, heart attack, atrial fibrillation, kidney failure, and seizures. High doses have been shown to cause breathing problems, paralysis, low blood pressure, heart failure, and death.

Drug Interactions/Toxicology

Yohimbehasshowntointeractwith antidepressants,stimulantssuchascaffeine, diabetesdrugs,antihistamines,bloodpressure, tranquilizers,andantibiotics.Patientsshould takecautionifusingsupplements,monoamine oxidaseinhibitors,orareeatingfoodshighin tyraminesuchaswine,agedcheese,andcured meats.

https://entranceexam.concor dlawschool.edu/pages/cours es/course/? course_code=CLSEXAM

5. 7. 9.

Laws

Dietarysupplementsarenotstrictlyregulated bytheFDA.Therehavebeenreportsof inaccuratelabelingoftheamountofyohimbe inaproduct.Theinaccuracycanleadto harmfulsideeffects. YohimbehasbeenFDAapprovedinanimals, however,notinhumans.

Monitoring/Drug Screening

Noconclusiveinformationwasfoundonmonitoringanddrug screenings.Thedrugisrapidlyabsorbeduponoral administration,however,bioavailabilityhasbeenfoundtobe highlyvariable.Yohimbeundergoesextensivemetabolismin liversandkidneys,howeverprecisemethodhasnotbeenfully determined.Routeofeliminationhasnotbeendetermined.For safety,patientswithlowrenalclearanceandliverfunction shouldtakecautionwithyohimbecontainingdrugs.Patients shouldalsobemonitoredforadverseeffectsandtoxicitiessuch asanxiety,weakness,overstimulation,paralysis,hallucinations.

6. 8.

ProfessionalOpinion

Yohimbe is not recommended for the treatment of sexual performance. It has a narrow therapeutic index with a small dosing range. It is unclear if yohimbe is safe as there is evidence of the drug benign associated with heart attacks, seizures, anxiety, and other conditions. The drug is also not FDA approved for the treatment of erectile dysfunction.

References

1. Griffin RM. Yohimbe. WebMD. Accessed October 12, 2022.https://www.webmd.com/diet/supple ment-guide-yohimbe

2. Yohimbe. NCCIH. https://www.nccih.nih.gov/health/yohimbe

3. Yohimbe: Benefits, Uses and Side Effects. Healthline. Published October 13, 2017. Accessed October 12, 2022. https://www.healthline.com/nutrition/yohimbe#TOC_TITLE_HDR_3

4. Yohimbine. go.drugbank.com. https://go.drugbank.com/drugs/DB01392

5. What Is Yohimbe? Verywell Health. https://www.verywellhealth.com/safety-concerns-ofyohimbe-89535