This presentation was created by Karen Simone, PharmD, DABAT, Director, Northern New England Poison Center for the 11/29/10 CADCA town hall.

1. Northern New England Poison Center
Teen Poisonings
from RX Drugs to K2, Salvia and Monster
Karen E. Simone, PharmD, DABAT
simonk@mmc.org
1
207-662-7221

2. Contents
• Overview of poisoning (abuse, suicide, other)
• Types of teen substance abuse poisonings
• Most commonly abuse substances (by teens)
• Substances used in teen suicide attempts
• Information about the substances abused
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3. Northern New England Poison Center
Staff
• Physicians board-certified in Toxicology
• PharmD board-certified in Toxicology
• Nurses nationally-certified in Poison Information
• Nurses in Training
• Nurse Educators, some with Public Health Masters
• EMTs and other providers (under supervision)
• Administrative, including toxicsurveillance specialist
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4. Northern New England Hotline Calls
N = 107,533
Human Poisonings
30%
Animal Poisonings
2%
Confirmed Non-
Exposures
<1%
Questions ME, NH, VT; 2009
68% 4

5. Types of Poisonings
Hotline Call Reasons
• Unintentional
– General, environmental, misuse, therapeutic error,
occupational, food poisoning, bite/sting
• Intentional
– Abuse, misuse, suicide attempt
• Other
– Malicious, tampering/contamination, withdrawal
• Adverse effect
– Drug, chemical, other
• Unknown
5
– Drug, chemical, other

6. Types of Calls
Question Types
• Substance Abuse
– Identification, effects, drug screens, withdrawal
• Medication
– Pharmacology, adverse effects, interactions, withdrawal
• Toxicology
– General, environmental, food poisoning, pregnancy/lactation
• Prevention/safety
– Plants, lectures/health fairs, printed materials
• Occupation
– Safety, monitoring
• Medical/legal/other
– Drug, chemical, other
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7. Poisonings in Teens 13 - 18 years
N=926
Suicide Attem pt
24%
Unintentional:
26% therapeutic error
29% misuse
Substance Abuse/Withdraw al
12%
Other Intentional
11%
Adverse /reaction
3%
Unintentional Malicious/tam pering
47% 2%
Unknow n
1%
ME from July 2009 - June 2010
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8. Substance Abuse/Withdrawal
Children under 19 years
N=156 substances
Alcohol: Mostly
unknown beverage,
Other
some vodka and
9% tequila, Listerine spray
Dextrom ethorphan
Plants/m ushroom s and hand sanitizer
4% 21%
Antidepressants
5%
Inhalants: Keyboard
cleaner, disc cleaner,
Antihistam ines spray paint, markers,
6% helium, nail polish
remover, fire
extinguisher
Inhalants
6% Stim ulants/street drugs
18%
Sedatives/hypnotics
Plants: Nutmeg (3),
9% kratom (1)
Alcohol Analgesics (opioid m ostly)
10% 12%
Substance Abuse 8
ME from July 2009 - June 2010

9. Stimulants and Street Drugs
Children under 19 years
N=28
Cocaine
K2 4%
7%
Ecstasy and related
11% Marijuana
35%
Caffeine (pills/drinks)
14%
ADHD Medications Substance Abuse
29% 9
ME from July 2009 - June 2010

10. Analgesics
Children under 19 years
N=18
Unknow n opioid
6%
Hydrocodone (Vicodin, Lortab) Buprenorphine (Suboxone)
6% 21%
Tram adol (Ultram )
11%
Ibuprofen (Motrin)
11%
Acetam inophen (Tylenol)
17%
Codeine
11%
Oxycodone (OxyContin,
Percocet)
Substance Abuse
17% 10
ME from July 2009 - June 2010

11. Sedatives/Hypnotics
Children under 19 years
N=14
Antipsychotic
21%
Benzodiazepine (Xanax,
Ativan, Valium , Klonopin)
43%
Zolpidem (Am bien)
36%
Substance Abuse
11
ME from July 2009 - June 2010

12. Suicide Attempts
Children under 19 years
N=336 substances
Other
Sedatives/hypnotics 9%
13%
Antihistam ines
6%
Cough and cold
5%
Alcohols
Antidepressants
4%
19%
Stim ulants/street drugs
4%
Anticonvulsants
3%
Vitam ins
2%
Antibiotics
2%
Cardiovascular
Analgesics 2%
31%
Suicide Attempts
ME from July 2009 - June 2010 12

13. Analgesics
Children under 19 years
N=106 substances
Aspirin
10%
Acetam inophen (Tylenol) Opioids
30% 9%
Acetam inophen w ith
(diphenhydram ine, caffeine,
m enstrual)
9%
Acetam inophen and Aspirin
6%
Other (phenazopyridine)
1%
NSAIAs (ibuprofen, naproxen)
35% Suicide Attempts
ME from July 2009 - June 2010
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14. PCP (Phenycyclidine)-like
• Dextromethorphan (DXM) +/- antihistamine
– Slang: DXM, RoboTrip or Triple C
– Products: Robitussin DM, Coricidin HBP for Cough and
Cold, others
• Dissociative analgesic/anesthetic in overdose
– Caused by metabolite – dextrorphan
– Dissociation of thalamoneocortical from limbic systems
• Drowsiness or agitation
– Coma or seizures possible but not common
• Vertical or rotary nystagmus may be present
• Large or small pupils possible 14

15. Amphetamines
• Amphetamine brand names: Adderall,
Dexedrine, Vyvanse
• Amphetamine-like brand names: Ritalin,
Concerta, Methylin, Focalin
• Medical concerns:
– Increased heart rate and blood pressure (irregular
heart rhythm, heart attack, stroke)
– Increased body temperature
– Seizures
– Psychosis Similar to cocaine
– Addiction 15

16. What do all of these products have in
common?
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17. Caffeine
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18. Caffeine – Dietary Supplements
Yellow Swarm Extreme Energizer by Yellow Jacket
• Yellow Swarm Extreme Energizer, Yellow Jacket
• Ephedra Free,
• Herbal Dietary Supplement,
• Extreme Energy.
• Yellow Swarm Extreme Energizer is a proprietary blend of herbs that
combines Green Tea Extract, Yerba Mate, Guarana, Capsicum and Kola
Nut. Yellow Swarm (Yellow Jacket) provides you with an extreme boost of
energy when you need it.
• Supplement Facts
Serving Size: 1 capsule
Amount Per Serving % Daily Value
Caffeine (anhydrous) 300mg
Proprietary Blend 211mg
Green Tea Extract 60% (Leaves)(4.5 mg Caffeine Alkaloids),
Yerba Mate (leaves),
Guarana (Seeds),
Capsicum Annuum (fruit),
Kola Nut (seeds)(<1 mg Caffeine Group Alkaloids),
Ginseng (Root) 18

19. Caffeine Content:
• Tea (green-black) 40-50mg/8oz
• Coffee 100mg/8oz
• Starbucks Grande 330mg/16oz
• Coca-Cola Classic 35mg/12oz
• Mountain Dew 54mg/12oz
• Red Bull 76mg/8.3oz
• Monster 160mg/16oz
• No Doz 200mg/tablet
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20. What effects can occur?
• Stomach: upset stomach and vomiting,
sometimes abdominal pain and diarrhea
• Nervous System: anxiety, agitation,
irritability, tremor, headache, dizziness,
hallucinations (not common) and seizures
• Heart: rapid heartbeat, increased blood
pressure, chest pain and irregular rhythms
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21. Energy Drinks - Teenage
Problem?
• Large amounts are available in forms
marketed to teens and young adults.
• Teens and young adults often lack the
good judgment to limit dosing.
• Some ingest up to 5 cans of energy
drink (equivalent to 8 cups of coffee) in
one sitting.
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22. What about caffeine
with alcohol?
• More risky behaviors (possibly)
• Not safer to drive: performance not
significantly better, in some ways worse
• May not realize unsafe to drive: may
have false sense of ability to drive safely
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23. What about carbs and calories?
• Sobe Adrenaline Rush 16 oz (2 servings):
– Calories: 260
– Carbs: 68 g (22%) with 66 g as sugars
• Red Bull 8.3 oz (1 serving) – double if 16.9 oz:
– Calories: 110
– Carbs: 28 g (9%) with 27 g as sugars
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24. Which has more carbs?
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25. Winner – Most Carbs
• Sobe Adrenaline Rush 16 oz (2 servings):
– Calories: 260
– Carbs: 68 g (22%) with 66 g as sugars Coke and Pepsi
have ~ 40 g carbs
• Starbuck’s Grande Latte 16 oz: per 12 oz
– Calories: 280 (150 calories)
– Carbs: 36 (12%) with 34 g as sugars
• Krispy Kreme Donut – Chocolate Iced Kreme Filled:
– Calories: 350
– Carbs: 39 g (13%) with 23 g as sugars
• McDonald’s Big Mac:
– Calories: 540
– Carbs: 45 g (15%) with 9 g as sugars
Caloric intake (16 – 18 yrs): 1800 – 2400 (females), 2400 – 3200 (males)25

26. Mushrooms (Shrooms)
• Timing:
– Onset: 10 – 30 minutes
– Duration: 4 – 5 hours
– Back to normal: 6 – 12 hours
• Effects:
– Fast heart rate, increased blood pressure, large
pupils, dry mouth, nausea/vomiting
– Uncontrollable laughter, vivid hallucinations (bright
colors and shapes)
– Loss of sense of time, meditative
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27. Salvia divinorum
• Names:
– Diviner’s sage, magic mint, Maria Pastoria
• Use:
– Ceremonial healing
– Divination rituals
– An entheogen (“that which causes god to be within a
person”)
• Component: salvinorin A
– Type: ?dissociative hallucinogen?
• Similar to: PCP, ketamine and DXM
– Mechanism: Opioid kappa agonist
• Similar to: butorphanol (Stadol®) and pentazocine (Talwin®)
– Dose: 100 – 200 mcg 27

28. Salvia divinorum
• Routes:
– Oral: Chew leaves or drink extract from fresh leaves
• Onset: 5 – 10 minutes
• Peak: 1 hour
• Duration: 2 hours
– Inhalation: Smoke dried leaves
• Onset: 30 seconds
• Peak: 5 – 10 minutes
• Duration: 20 – 30 minutes
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29. Salvia divinorum
• Hallucinogenic effects:
– Type: out of body experience, entering another
reality, time and space displacement
– Effects: altered perceptions, hallucinations, ataxia,
depersonalization, hysterical laughter, incoherent
speech, unconsciousness
– Onset/duration: rapid/an hour or so
– Dose relationship (inhalation):
• Hallucinations: 0.2 – 0.5 mg
• Out-of-body experience: > 1 mg
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30. K2 (Spice, Spice Gold)
• Synthetic cannabinoid (JWH-
018 and JWH-073)
• Anticipate similar effects to
marijuana
• Probably not illegal yet
• Not anticipated to cross with
marijuana screens
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31. K2 (Spice, Spice Gold)
• Rapid heart rate, elevated blood pressure
• Anxiety/agitation/hallucinations
• Drowsiness/slurred speech
• Vomiting
• Numbness/tingling, tremors/seizures
• Pale appearance, dilated pupils
Dried herbs sprayed with synthetic cannabinoid-like substance
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32. Kratom – per label
Stimulant and Depressant?
Amazing legal high / herbal high!
Low dose: stimulating and euphoric
High dose: sedative at higher doses
Plant: mitragyna
Active ingredient: mitragynine
Mechanism: stimulates delta opioid receptors
Effects:
Calms the mind, lowers anxiety
Causes to feel: happy, strong, and active, with a
strong desire to do work
Onset: 5 - 10 minutes after use
Duration: several hours (longest with highest dose),
positive afterglow effect possible 1 day after use
High dose effect: a state of blissful euphoria with the 32
possibility of mild visuals

33. Kratum (mambog) – per science
• Mitragyna with mitragynine
• Psychoactive, opioid substitute
• Use: increase productivity and heat tolerance
• “Therapeutic” effects:
– Onset 5 – 10 minutes after chewing leaves
– Type: mild euphoria and stimulation
• Overdose:
– Effects: nausea, vomiting, flushing, stupor, vertigo, giddiness, tremors of
face, extremities and tongue, rombergism (loss of positional sense –
unable to balance standing with feet together and eyes closed)
• Chronic toxicity:
– Effects: anorexia, weight loss, abdominal distension and constipation,
skin discoloration (dry, unhealthy, tan without sun OR pallor), (numbness
and twitching)
• Withdrawal:
– Effects: aggression, tearfulness, runny nose, muscle aches, “jerky”
motions 33