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| Public Safety Substance Abuse Newsletter |
April 2009 |
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Corrections and Notices:
In the January edition of our newsletter we indicated that Oxycontin (sustained release oxycodone) was currently available in generic preparations. Purdue Pharma has prevailed in litigation that extends Oxycontin's patent protection and bars the distribution and sale of generic alternatives. Oxycontin is only available in the brand name format that is produced by Purdue Pharma. LP. | |
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If you have suggestions, questions or articles you would like to see featured in future issues please contact Lisa Mize at: lmize@medtox.com
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MEDTOX
University
Training Announcements
"The Essentials Guide for Practitioners"
MEDTOX University announces the first release of a new series of cutting edge training seminars titled, "The Essentials Guide for Practitioners."
This four-part series of workshops is designed specially for social workers and mental health professionals who work in high-risk, high stress children and family services environments.
These courses are taught by MEDTOX University faculty who are some of the country's foremost experts in the fields of drug abuse, child abuse and domestic violence.
These seminars provide students with critical and empowering information that will immediately impact their relationships with clients and their performance in the workplace. This MEDTOX University certificate program comprehensively deals with all aspects of the professional duties associated with this type of work (i.e. children and family services; mental health outreach programs) including often ignored issues pertaining to personal safety and well-being in the field. These courses are certified to meet demands for continuing education hours and credits that are often imposed by state and federal regulatory agencies.
These special seminars are offered to qualified MEDTOX customers and clients for FREE. Non-customers can obtain MEDTOX University course instruction for a fee. Interested individuals and organizations can obtain more information about this seminar and other MEDTOX University workshops by calling Lisa Mize at 800-832-3244 (lmize@medtox.com) or Donald Mac Neil at 661-993-2566 (dmacneil@medtox.com).
The Essential Guide series of courses can be taught in any workshop order that suits the needs of our clients. Workshops II and III can be combined together to create one, 8 hour training session.
Essential Guide for Practitioners I: Identifying Signs and Symptoms of Substance
Abuse in the Home. Available for 8 hours CEU.
Essential Guide for Practitioners II: Understanding the Role of Mental Illness: Dual Diagnosis in Substance Abuse and Addiction. Available for 4 hours CEU.
Essential Guide for Practitioners III: Techniques for Personal Safety in the Field.
Available for 4 hours CEU.
Essential Guide for Practitioners IV; Modern Concepts and Treatments of Substance Abuse and Dual Diagnosis Disorders. Available for 8 hours CEU. | |
Street Buzz: "Yaba" is Here! A New Amphetamine Menace?
Pronounced "yar-bah," Yaba is a psychoactive-stimulant drug that has come to the attention of drug enforcement authorities in the Far East. Although there is plenty of rumoring and street talk dealing about Yaba, there are no official reports of the drug here on the streets of America. Nevertheless, it's worthwhile to discuss what is known about the drug and those who use it. The DAR Hotline has received several calls from juvenile probation officers who have picked up on the name of this drug from clients they happen to be supervising. It seems that Yaba has made it to the streets and it's finding a way into Asian adolescent drug scenes.
Here's what we know about Yaba:
Yaba principally consists of the powerful central nervous system stimulant methamphetamine. The Far East was for many years a source region for much of the world's illicit methamphetamine; the drug was a product of post-World War II Japan. The methamphetamine found in Yaba is mixed with a variety of other drugs in order to bring about a modest hallucinogenic effect. In the United Kingdom, Yaba is mixed with caffeine and Ecstasy (MDMA). This compounding produces a unique drug, one that's capable of bringing about profound feelings of increased energy, excitement and social bonding. Ecstasy is an amphetamine-based drug that is widely abused in America and abroad.
Mixed with methamphetamine to make Yaba; Ecstasy carries with it serious side effects and long-term consequences. Methamphetamine is a powerful stimulant drug that is regarded as dangerous and highly addictive. Some reports on Yaba indicate that in addition to methamphetamine, over the counter drugs such as caffeine and pseudo-ephedrine are added to the mixture. Over the counter drugs can be quite dangerous when they're used at levels and concentrations that exceed recommended dosages. Whatever the added ingredients are, the Yaba powder is typically colorized and run through pill presses to create small-customized tablets that look remarkably similar to Ecstasy tablets. Yaba tablets are usually round and single-scored. Emblems and symbols may be stamped on the side of the pill that's opposite the scoring. Pill colors range from dark green to bright pink. The drug is consumed orally in its pill form, but it can be easily crushed into a fine powder for snorting or smoking. In Asia, smoking seems to the principal means of Yaba ingestion.
Because methamphetamine is the core psychoactive ingredient in Yaba, users of the drug will present with classic signs of central nervous system stimulant use. If a Yaba dose contains Ecstasy or over the counter stimulants, a user may become hyper-stimulated and hyperactive. DAR signs and symptoms may reveal very elevated findings for pulse and Romberg. Pupil size will be dilated with the potential for little or no reaction to light. Physical symptoms of Yaba use may range from 6-12 hours. Methamphetamine is a long acting drug; Yaba users may exhibit much of the same sorts of behaviors that are regularly found in populations of hard-core methamphetamine users. With the inclusion of Ecstasy in Yaba, a user may experience a mixed set of symptoms. The effects of Ecstasy may bring about a profound sense of calm and contentment that tugs a user's euphoria in the opposite direction of the stimulant effects caused by methamphetamine.
This sort of combination is not unlike a classic cocaine-based drug combination that evolved in the 1980's called a "speedball." In a "speedball, " antagonistic drugs (cocaine and heroin for example) are ingested concurrently to bring about a highly unusual set of conflicting, bi-polar directed feelings and symptoms. Methamphetamine's central action results from its ability to stimulate neurons containing nor-epinephrine and dopamine into a hyper-agitated state of excitement. Ecstasy (MDMA) works similarly, except that its action is singularly directed at neurons containing serotonin, a neurotransmitter that among other things balances mood and makes sensory inputs more acute and pleasurable.
Questions and information relating to Yaba and other drugs of abuse can be obtained by contacting the MEDTOX Drug Abuse Recognition (DAR) program at darsprogram@mac.com |
 Can Alcoholic Drug Cravings be Reduced? Hypertension Reducing Drug Shows Promise.
Results from a small pilot study were recently published in the journal of Alcoholism Clinical and Experimental Research,[1] the essay sheds light on the direction that clinicians might turn with the use of medicine to reduce alcohol cravings amongst abstinent and non-abstinent alcoholics. Animal studies have clearly established that the alpha-1 adrenergic receptor plays a prominent role in cravings and consumption reinforcement for many people who abuse and/or who are dependent on alcohol. The alpha-1 adrenergic receptor antagonist Prazosin was the subject of this Journal article. This drug is widely known by its brand name of Minipress. Prior editions of this newsletter have evaluated the use and efficacy of Campral (acamprosate), another drug that has been utilized to reduce alcohol cravings amongst abstinent alcoholics. Prazosin works differently than Campral; early results tend to indicate that Prazosin may be more effective and more profound in its effects.
Prazosin has been the source of medical and scientific curiosity for sometime. Originally brought to market as a drug to reduce blood pressure (anti-hypertensive), the drug was discovered to have some broader effects and capabilities. Besides the instant study where Prazosin's alpha-1 adrenergic properties are linked to reductions in unwanted drinking and cravings, Prazosin has been successfully used to treat Post Traumatic Stress Disorder (PTSD). A number of published studies have seemingly established Prazosin's abilities in reducing unwanted awakening and the incidence of frightening dreams for patients who suffer from PTSD. Many Iraq war veterans have been or are currently being treated with the drug. Interestingly, animal studies have suggested that the alpha-1 adrenergic receptor also mediates the desire for alcohol and the reinforcing effects that an alcohol abuser feels while he/she drinks.
Randomized experimental groups of twenty-four treatment seeking individuals were placed in a double-blind controlled study. One group was treated with placebo, the other with Prazosin. Patients were all classified as being alcohol dependent; none met the criteria established for PTSD. Other than attendance at regular Alcoholics Anonymous (AA) meetings, participants received no other treatment while participating in this study. Researchers made daily telephonic contact with participants to monitor and confirm that the Prazosin or placebo had been taken and to obtain the necessary self-report information. Participants in the experimental group were put on a regimen of Prazosin that titrated their daily doses incrementally upwards over the course of the 6-week study period.
The results from the 20 participants who completed the study were assessed; the data obtained over the course of the study's final 3 weeks was especially clear in contrast, this was the period where maximum Prazosin dosage levels had been reached. The difference in the mean number of drinking days for participants taking Prazosin as compared to those taking placebo was startling, a near 84% reduction in the number of days for those who were taking Prazosin. The mean number of drinks consumed over the course of a week was very different. Those participants taking Prazosin presented a mean number of drinks consumed per week of 2.6, those participants assigned to placebo experienced a mean number of drinks/ consumed per week of 20.8. The Prazosin experimental group reported a mean of 88% fewer weekly drinks consumed compared to the placebo group's mean weekly total number of drinks consumed.
A study such as this is very provocative and hopeful, but there were significant limitations to it. The small study size, the self-reporting of the effects and the limited number of women are all restraining factors. It's likely that there will be an increased number of studies in the future that will build upon what has been uncovered. There are now several different drugs physicians can reach for in the battle to treat alcoholism. Vivitrol (naltrexone) is one proven therapy that can be considered in situations where there may be dubious control of a patient's drinking and/or alcohol cravings. Campral (acamprosate) is clinically available.
Not addressed in this study is the value and potency of a 12-step sobriety program. Both groups, placebo and experimental continued their program engagements. It would be interesting to see what differences would exist between a Prazosin-only population and Prazosin therapy coupled with 12-step participation.
Readers with questions about this drug or other issues related to this topic can obtain assistance by emailing the MEDTOX DAR program at darsprogram@mac.com.
[1] Simpson TL et al. A pilot trial of the alpha-1 adrenergic antagonist prazosin for alcohol dependence. Alcohol Clin Exp Res 2009 Feb; 33:255.
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| A DAR Report from the Field: More Than A Headache?
Not long ago, hospital emergency room staff summoned a DAR trained officer to investigate claims a patient's claims that her spouse was trying to kill her. The patient was alleging that her husband had been poisoning her bottled water and that she was becoming very ill because of it. The DAR trained officer met with the doctor and the charge nurse. He was told that the patient had been admitted to the emergency room with fatigue, nausea, migraine headaches, tingling sensations in her extremities and severe stomach cramps. The hospital lab had analyzed some blood and urine samples she provided and they were awaiting the results. The police had been called to investigate the patient's claim that her husband had been poisoning her; the patient's symptoms were posited as being the result of poisoning.
When the officer arrived, he saw a frail woman in her 50's who exhibited drug use signs consisting of droopy eyelids (ptosis), dilated pupils and a rapid heart rate of 100 beats per minute. The patient told the officer that she was suffering from bad headaches, nausea and vomiting; she communicated her strong belief that her symptoms were the result of poisoning undertaken by her husband. The patient told this story several times. The stories built on one another and resulted in the creation of what appeared to be a fantasy-conspiracy involving her otherwise loveable husband and some of his nefarious friends. The patient seemed to be extremely paranoid and delusional; she could have easily been mistaken for someone who'd experienced a nervous breakdown. The officer had a gnawing feeling that he was dealing with someone who was experiencing the effects of hallucinogen use, but he needed to more closely assess the signs and symptoms exhibited by the patient.
The officer began to more carefully evaluate and take in the patient's symptoms. The officer observed eyelid tremors every time the patient closed her eyes, in his mind this was a telltale sign. The temperature in the room felt normal, yet the patient exhibited goose bumps (piloerection) on both arms. The observed symptoms fit with the information provided by the doctor, this situation was becoming very clear to the DAR trained officer, all signs and symptoms were pointing to hallucinogenic drug intoxication.
The officer proceeded with a methodical DAR evaluation of the patient. Adhering to the DAR 7 Step evaluation, the officer worked through the screening process. The patient's internal clock was 10 seconds (very fast clock); pupils were equal and dilated to 8.0 mm in room, the reactions to light were normal. There was "no" nystagmus and "no" non-convergence present. There were no signs of rebound dilation or hippus during the direct light phase of the eye exams. The patient's pulse held steady (fast) at 100 beats per minute. These signs are all classic findings associated with the use of hallucinogens, drugs such as LSD, "Magic Mushrooms," Morning Glory seeds, DMT and peyote. The lack of nystagmus ruled out the use of other hallucinogen-like drugs such as ketamine and inhalants.
After a short dialog, the officer learned the following:
The patient had not slept or eaten anything for three days. She had been suffering with a migraine headache that began three days prior. Her doctor had prescribed medication for the migraine headaches, but she could not remember the name of it. She did recall that the medicine contained caffeine along with some other chemical. The woman grabbed a brown prescription bottle from her purse and handed it to the officer. The medication label listed the contents as Cafergot, the prescription was three days old; Cafergot is a chemical blend of ergot and caffeine. Inside the bottle were half a dozen tablets, the original prescription was for 30 tablets. The patient couldn't remember how many tablets she'd taken, she did relate however that she'd taken a tablet every time that her head had hurt. It appeared that this patient was taking 2-3 tablets every four to six hours.
The officer then realized that this patient had probably overdosed on Cafergot, the drug that she'd been prescribed for her migraines. Leaving the patient's bedside, the officer headed to the nurses station to ask for a PDR reference book. The officer looked through the guide and learned that Cafergot is an effective therapy for some types of people who suffer migraine headaches. He learned that in high or overdose amounts, some very negative side effects can occur. The officer waited for the examining doctor to return. The officer told the doctor that he believed the patient was not a victim of poisoning, but rather she was "high" on Cafergot.
Cafergot is an odd drug with a very unique chemical constitution, it is a compound made up of caffeine and ergotamine. The latter is a member of the family of ergot alkaloids. The first of these was isolated from the ergot fungus in 1921 by Arthur Stoll. The drug was initially sold and marketed under the product name of Gynergen. The drug was used to induce childbirth, prevent post-partum hemorrhage and to treat migraine headaches. Digging a little deeper, the officer learned that LSD, a potent hallucinogen, is derived from that very same ergot fungus. In fact, there's a rich history involving nefarious behaviors as a result of unintended ergot ingestion. There are epic stories of accidental ingestion of ergot contaminated bakery bread by people who subsequently complain of hallucinations and out of body experiences. Ergot poisoning and resultant bizarre behaviors are alleged by some to be at the heart of the events that prompted the Salem Witch-Hunt Trials of 1692. It was evident that the patient in this situation had ingested much more Cafergot than she should have, she had in fact overdosed on the drug. Considering Cafergot's pharmacology and chemical lineage to LSD, this patient was exhibiting a classic set of hallucinogen signs and symptoms. The patient was stabilized and later released into the custody of her husband. (Her broom was impounded by the police for safekeeping.)
This case involving a DAR trained police officer points out the need for evaluators to ask about prescribed and over the counter medications that may have been ingested by someone who is otherwise suspected of being under the influence of a drug. Cafergot is an unusual drug, one that's not often prescribed. Newer and safer drugs are now available to treat migraine headaches. Drugs such as Imitrex, Zomig and Relpax represent a new genre of migraine drugs that are safer and more effective than Cafergot. But in some situations, cases where these newer drugs are ineffective, it is quite possible that a reader may find Cafergot.
Mr. Rich Ulrich provided the material for this essay. Rich is a Drug Recognition Expert (DRE) and a veteran MEDTOX Drug Abuse Recognition (DAR) instructor. Rich was the officer involved in this vignette. Rich's appropriate use of the DAR 7-step screening system is what led him to the unusual diagnosis that was made of hallucinogen intoxication. For questions you have regarding this case or of others like it, Rich can be reached at rulrich@medtox.com. |
What's the Depth of Your Drug Knowledge?
The subject drug in this rendition of "name that drug" is an increasingly popular drug. It is as pervasive on the street as it is in the modern medicine cabinet. The drug can be obtained from a physician by way of a telephoned or written prescription. Although widely available and identified as a generic, the drug is readily known on the street by its original brand and trade name. This drug has central and peripheral pharmacological actions: it is a central nervous system (CNS) depressant, and it is also quite effective as a muscular skeletal relaxant. The drug's brand name can be found in well-known essays of Aldous Huxley and William Burroughs. In Huxley's seminal Brave New World, an enlightened and cultured citizenry ingested this drug for the purpose of curbing nefarious counter-social thoughts and urges.
First developed in the 1950's, this drug became instantly popular for its roll in relieving acute muscle spasms, associated with back and spine problems. This drug is a pro-drug of an older and alternatively popular sedative called meprobamate. Two meprobamate (carbamate family of sedatives) products were very popular in the 50's and 60's as alternatives to highly abused barbiturate sedatives, they were available by prescription and were known by their brand names of Miltown and Equanil. In modern pharmacy, the benzodiazepines (Valium, Librium, etc.) have now largely displaced the carbamates as frontline sedatives and anxiolytics. Once thought to be safe and of low abuse potential, the carbamates turned out to possess addiction and physical dependency characteristics that were not all that different from the barbiturates they tried to replace.
If a user of this drug were to be evaluated by DAR or DRE diagnostic technique, classic depressant signs would likely be present. Use of this drug will likely cause nystagmus and non-convergence. Higher doses of the drug may lead to the display of vertical nystagmus. The Romberg internal clock and pulse would likely be slow. Psychophysical tolerance can develop as a result of chronic use of this drug. Drug combination synergy will occur if this drug is taken concurrent to the consumption of alcohol.
This drug is available in several compound formats; one of these combinations includes a partnership with codeine and aspirin. This drug is available in the form of a white tablet in strengths of 250 mg and 350 mg. Wallace Laboratories produces a form of this drug; users sometimes identify and refer to the drug by the Wallace name and number that's stamped onto the tablet. On the "street", this drug is sought after because of its ability to enhance the sedative effects of alcohol and opiates such as hydrocodone. On the street this drug is sometimes referred to as "Dance". Stimulant abusers often seek the drug for the purpose of creating a sought after antagonistic set of effects that are referred to as a "speed-ball". The drug can also take the hard edges off methamphetamine (speed) agitation. Adolescent drug abusers like this drug because of its perceived safety and diminished direct effects. The drug is frequently found in the club and rave drug scenes. In addition to the development of tolerance, consistent and long-term use of the drug can result in classic addiction and physical dependency. Sudden discontinuation of the drug will likely cause physical withdrawal.
Although this drug can be quite effective in the treatment of acute muscle spasms, physicians tend to prefer the use of less abused medications such as Robaxin and Skelaxin. However, for the right price, this drug can be bought through Internet sources.
What drug am I?
I am carisoprodol, aka: Soma, Soma Compound, Soma Compound and Codeine. | |
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