The New Face of Drugs & Addiction is the name of an ongoing lecture series by Dr Lisa Marzilli, head of Applied Clinical Research and Education for Dominion Diagnostics in Delaware. Dr Marzilli and Darryl discuss the rapid evolution of designer drugs over the last few years, particularly the pseudo-cannabinoids, and the stimulant "bath salts" which have become widspread because they are often not illegal, and hard to test for; unfortunately, they can also be much strong then the marijuana and cocaine they mimic, sending a significant numbers of users to the ER.
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DARRYL: Hello and welcome once again to our CNS Podcast. I am Dr. Darryl Inaba I'm here in Providence, Rhode Island with Dr. Lisa Marzilli. Lisa is a doctor of pharmacology working with …
LISA: Dominion Diagnostics.
DARRYL: Lisa is working Dominion Diagnostics and she just has a wealth of information about things I’m very much interested. And one of the things…well, first of all, welcome Lisa.
LISA: Thank you very much. Pleasure to meet you!
DARRYL: Great to meet you! I was really interested in your work as we explore the new face of drugs and addiction. It’s a growing epidemic, where designer chemicals are replacing standard cocaine, opiates, psychedelics, and replacing marijuana. …what are your thoughts?
LISA: Well, it’s actually been an education in progress - the first lecture I gave was about a year ago in February. I spoke at a school in North Carolina, and it was my first exposure to organizing and putting together a lecture and at that time, February 2011, what was hot included synthetic cannabinoids – your K2 and spice. We touched a little on bath salts. No one had heard of it. Kratom, or you corrected me…what’s the pronunciation?
DARRYL: Well, I pronounce it Kratom, but I find that in East coast and West coast we pronounce things differently, so…it could be Kratom.
LISA: Well, and interestingly when I talk about that product, depending on the region it is grown in Southeast Asia, it’s sometimes known as lthang, so the annunciation and pronunciation of it varies. But at any rate, back to what we were chatting about - so we give this lecture in February of 2011 and inside of 6 months, I returned to the same area of North Carolina and you know, 6 months before no one had heard of bath salts and all by then it was all the rage. So much so that the discussions became so involved at the different addiction facilities we went to that I felt like I learned more from the clinicians than I was actually giving them.
DARRYL: So you think it first started with the synthetic cannabinoids - with spice and K2, or was it K9…and then bath salts, which are more like cocaine and methamphetamine?
LISA: Here at the lab it seems like the first thing we heard about nationwide was the fake marijuana or K2. Shortly on its heels, came bath salts, which are synthetic stimulants, mimicking cocaine and that became widespread so quickly, did you see it on Dateline NBC, the Chris Hanson files in May, there was a huge piece on the underground laboratory production of bath salts. But I agree with you - not that K2 was the gateway, but it kind of put the focus on these synthetic products because they were legal at the time and it’s very, very difficult for law enforcement and the DEA to keep up. Small tweaks in the molecular structure of a molecule, drug or chemical… will manifest with the same effects, but won’t register on drug tests… urine or blood, so it’s a way to evade the law. Easily accessible. You can purchase these products on the internet and in fact, I don’t know if this is true in your area…but here in the Northeast, before K2 or spice was illegal, you could buy it at a gas station, a smoke shop, Cumberland Farms (grocery store). And the purported advertising of these substances as “natural”, I think also gives a false sense of safety.
DARRYL: That’s my understanding too, manufacturers try and avoid scrutiny by the FDA by saying these are not to be ingested - “not for human consumption” printed on the package. The fake marijuana was called incense I believe, and the bath salts, of course are called, “bath salts”. They aren’t called a stimulant. And as the law catches up with these products and recognizes what they really are - and as Dominion Diagnostics, tries to keep up by creating a standard that can test for them - they keep morphing. They keep changing, as you say, manufacturers keep tweaking them to be different - to be something that’s outside the law and outside diagnostic criteria. The most recent thing I’ve seen, and maybe you’re seeing it here too, is legal herbal incense, not for human consumption of course, what they’re now calling potpourri. I always think that’s funny because it’s spelled POT -pourri - legal herbal potpourri just adds fragrance to your room and I’ve seen it with the stimulants, the bath salts, called Boost or human herbal abstract or something like that.
LISA: Its fertilizer… SOC ... and labeled as plant food or fertilizer. In fact, I was in Nashville and I had never heard the term, “Molly’s Plant Food”, but Molly’s Plant Food is another name for bath salts. Initially we were asking, is this methamphetamine?, but when I came home just over the weekend, I looked it up and in the Tennessee area, bath salts are called Molly’s plant food. So, whether they’re labeled "not for human consumption, fertilizer plant food, or potpourri," it all empirically implies a connotation of safety that, you know, is not there. In fact, one of the first testimonials that my supervisor distributed to our clinical services department was titled, “Bride that floated away with the bath salts”. She was looking for a product to lose weight for her wedding day and the bath empirically salts that she purchased touted "wellness, feel better, lose weight, feel your best" - the sad story was she became highly addicted, she lost an inordinate amount of weight, and she also had a MI heart attack, ended up in a coma and passing. So, it was very, very serious.
DARRYL: Do you think these products are actually as dangerous or more dangerous than cocaine, methamphetamine, or the regular marijuana that is out there?
LISA: Well, the thing is….what is actually in the package? If it says "not for human consumption" - for example, bath salts - there is one stimulant – MDPV – and I won’t bore you with the long name - but there could be methedrone in there. There could be other types of stimulants, but who’s to say there are not toxic chemicals? As we hear about products like oxidado, which is byproduct remnants of the cocaine production in Bolivia and Brazil, there are gasolines, biprozines, kerosene’s, so they sound potentially more toxic. Now you used the example of cocaine and methamphetamine…if we take it back to the beginning when we talk about spice and K2, cannabinoids are a natural product. Not that I’m purporting their usage, but at least we know where they come from. With the synthetic cannabinoids, or actually a chemical sprayed on natural product and there are hundreds of synthetic cannabinoids, but again, once they’re packaged, distributed, sold on the internet or at the gas station, who’s to say what’s actually in the product - so the toxicities and danger may be greater than what we see with typical illicit drugs.
DARRYL: That’s what I hear, that there is actually a link to schizophrenia and psychosis due to marijuana…synthetic marijuana being so potent. A lot more medical problems are showing up with bath salt use as well as psychosis. It’s amazing that this is happening and how… innovative and clever street people are to keep one step ahead of the law. It’s not just the stimulants and marijuana or Kratom or Kratom, depending on how you pronounce it, - I’ve seen clients relapse back into opiate addiction because of Kratom capsule usage, which are still non-detectible in urine. It’s still legal to use it because there’s no law against Kratom. In Oregon we’re noted for our synthetic psychedelics like bromo-dragon FLY things like that. Where is this going? It’s….it’s a new age, isn’t it?
LISA: It is and actually, I’ll refer to the very first lecture I gave in February of 2011. I called it keeping up with designer drugs and I think my boss thought it was a little corny, but the truth of the matter is, I’m not sure there is a way to keep up. You know, drugs of years gone by, like the phenotriptamines that are making a huge come back with small tweakings and an increase of potency. It’s the next thing and the next thing and the next thing. So, it’s very difficult to stay on top of it because it’s a huge industry that offers a businessman and a chemist in an an underground laboratory a way to make billions of dollars. Young teen recreational use and exploration is something that is always going to be a part of human nature, however, the dangers that are attached to these substances are quite concerning.
DARRYL: And is Dominion Diagnostic and other laboratories trying to at least develop or keep up with some of it by testing for the newest most popular ones that are coming out?
LISA: Yes, but again…we were one of the first labs to develop a spice assay, but we were looking for the metabolites of 3 particular excretion products, not the parent drug itself. And just to give you a thumbnail sketch, developed say a year and a half - two years ago and now we’re seeing other synthetics - right now we test for JWH073, JWH018….we’re not noticing that it’s gone into a completely different series…CP series, HU series, so the reality is…it’s not that simple to create an assay, only to discover it is the parent or metabolite or what you’re finding excreted in the urine. So, it does seem like they are always going to be one step ahead. But interestingly, at one of the sites we visited in South Carolina, one of the clinicians said a client came in post bath salts ingestion and asked if a urine drug test was necessary to tell her something was wrong. And in these cases, …the bath salt is a stimulant, but the client is presenting psychotic because there is a dose effect relationship. And I’m going to digress - back to your question of schizophrenia….does it spur on different mental illnesses? What we’re starting to question - and time and data will confirm this - is this individual already predisposed to mental illness? Is their brain already at risk for addiction? Is this insult of taking this drug….bath salts, K2, the insult that kicked them over the edge? It’s difficult to say, but I certainly, you know, in my heart of hearts, with the toxic chemicals involved that we’re talking about and their production, you know, it could be multifactorial what is happening and what we’re seeing manifested in the patient and then the brain chemistry.
DARRYL: You know, one of the interesting things I think we’re seeing in Oregon, or in Southern Oregon is that we are testing people because of drug courts and because of family courts or human services and child custody type of requirements and whenever there is a new test that can test for Hebrew University series of say cannabinoids or new bath salts…another derivative of the cathinone series that is tested for…we find a ton of people on them that we hadn't been able to recognize because they weren’t taking a high enough dose yet or they hadn’t developed negative effects, but nonetheless they are abusing those drugs and getting themselves into deep trouble. So …all of a sudden there’s a JWH series test that comes out and all these guys in the Navy get busted and they’re kicked out of the Navy, so maybe the only way we can deal with this is to keep developing tests, but not announce what they are because what my clients are doing now is they go on the internet to our urine testing provider because they list the specific chemicals they’re testing for and then the client will go to the head shop and buy some other chemical to use to avoid testing positive.
LISA: And it’s true. There is a new designer drug called, “Crocodile” that has not reached the U.S. and I hesitate to even speak of this because it hasn’t hit landfall, so to speak. It’s rampant in Russia, but the more we talk about it, the more widespread it becomes. So to your point about the drug assay development and urine drug testing assay development, yes it would ideally, you know, in the world of clinical as opposed to business - it would be probably be more helpful nationwide if we didn’t announce what we’re developing. But unfortunately, that’s not the way business rolls. Maintaining a competitive edge today in the world of urine drug testing requires trying to stay current with the various assays. A lot of the spice and K2 products will actually say, “does not contain the 5 constituents that are now federally considered a Schedule 1”, which means nationwide. Because as you know, federal law is more stringent than state law - Federal law trumps. So, manufacturers actually label some of the spice products as not containing the 5 constituents, the JWH’s, the CP’s, so they’re onto one of the other hundreds that are out there. It’s a lot to wrap your head around and clearly a problem that is not going away any time soon.
DARRYL: You know, the legal thing is one thing and but clinically, I found urine testing to be tremendously effective as an asset to promoting positive outcomes in recovery. Clients who are serious about their addiction want to be tested because it helps them socially with the peer pressure thing, they can resist when people say, "hey, try this stuff" - they can say, "oh no, I’m tested regularly" and that helps them…it is one tool that they can use to avoid getting sucked in by peer pressure to use. But more importantly, the testing itself helps promote continued abstinence, promotes the idea that you can’t ever take another hit and get away with it and so, the more frequent they test, the better the outcomes. Some of the papers I reviewed have actually showed empirically that to be true. So it is kind of scary …as we go to things that can’t be tested for yet, what’s going to happen to my clinical ability to use urine tests effectively in helping clients stay sober?
LISA: Well, the upside is…we are continually developing assays. We have a spice assay. We have a bath salt assay and we certainly hope within the next 6 to 12 months to have a broader panel of testing. The difficult part in assay development is because these products are new….we don’t know how long they are detectible in the urine. Is it possible to track the patient? Clearly, your clinical interpretation of the patient’s presentation will have the largest impact on how you treat them. But to digress to the first part of your question regarding urine drug testing, it certainly provides a monitor for continued adherence to the treatment program. It can certainly help to target level of care….when it needs to be notched up or ratcheted back….but as we talk of this particular topic with designer drugs, I do think it’s going to be a little bit difficult to rely solely on a urine drug test, …that is just one piece of information - the most important is what you observe face to face with your client. Because nothing can replace the personal aspect.
DARRYL: As it should be actually. A urine test is a good tool to help confirm or help you deal with the clinical interaction. We’ve got to wrap up soon, but I am curious - where do you get the standards? Where do you get the basic assay? How do your chemists or your clinical professionals come up with the standard comparison that can then be used to develop a test given so many of these drugs are developed by illicit laboratories?
LISA: Well, some of the companies that we work with, - post spice do have standards available, but out of the gate, the first designer drug we were really faced with was spice and our R&D department actually had to await the product. So, many times, when our sales folks are on the road someone will say "hey…test this out" …and that’s how some of these substances come back. But as time marches on we find that standards are available at some of the bigger chemical companies that we do business with in our R&D division. That was what the challenge and delay was due to in the spice assay. We were kind of shooting in the dark so to speak.
DARRYL: Thank you so much, Dr. Marzilli.
LISA: It was a pleasure to meet you.
DARRYL: It’s great meeting you and learning about the new world of designer drugs that I think will be here forever because of the almost infinite number of changes that are possible. We'll have to talk again when the next wave happens. But if any of you out there have any questions or have any comments or want to know more about this topic, visit us on our website, cnsproductions.com, or give us a call - we would be happy to follow up.