Addressing Synthetic & Designer Drugs in Adult Drug Treatment Courts

Addressing Synthetic & Designer Drugs in Adult Drug Treatment Courts


BLAINE STUM: Well,
welcome everybody. My name is Blaine Stum. As Anna Koozmin said, I am
a Program Assistant here at the Justice Programs Office. And I am actually going to
introduce our two presenters for today who are
going to give us sort of a rundown on the science
and practitioner perspectives on synthetic drugs
and drug courts having to deal with synthetic
and designer drugs. Our presenters today
are Dr. Leo Kadehjian, who is an independent
biomedical expert based out of California in Palo Alto. And he has a ton of experience
doing onsite testing and doing expert
testimony on drug testing and sort of drug science. And so we’re really
excited to have him. He’ll be explaining the
science behind the drugs. And then we also
have Natalie Reyes, who is the Program Coordinator
for Multnomah County’s START Drug Court program
in Portland, Oregon. And she’ll be giving
us a rundown of sort of a practitioner
perspective and how to deal with synthetic drugs and
designer drugs as a drug court. And any questions you might
have afterwards, we’ll be happy to address those. So we’re going to hand
it over to Dr. Kadehjian to start his slides. And like we said, if
you have any questions, we’ll address those at the end. LEO KADEHJIAN: All right. Well, thank you,
Blaine and Anna. And I especially want to
thank American University and the Justice Programs
Office for giving me another opportunity to serve you
and your audience here today. I also want to thank
Natalie, my co-presenter. You know, she’s really
the practitioner here. I’m a bit of an interloper. Well, not really. But she’s the one who faces
these issues like you, the audience, on a
day-to-day basis. And I deal with them from
a scientific standpoint. And so I want you to look
forward to her presentation. So I start out with
synthetic drugs, but there are a number
of terms that are used. Novel Psychoactive
Substances, NPS. They’re also called
designer drugs, because they have been designed. And also legal highs, and
that’s certainly an area that we deal with, whether they
are, in fact, legal or not. And the drug designer
people are trying to stay one step ahead
of law enforcement. I’m going to speak
about four groups. The synthetic cannabinomimetics,
the synthetic cathinones or the bath salts, some
synthetic hallucinogens. And I would be remiss
if I didn’t talk about natural products as well. So this is why we’re all
here, our human brain, our vulnerability to altered
states of consciousness. We like our drugs. Drugs make us feel good or
they make us feel less bad. And we can’t do
anything about that. Our biochemistry is fixed. This is a great article, our
“Pursuit of Intoxication: 100 Century Romance with
Psychoactive Substances.” So we have long sought
out these altered states and drugs that provide those. This last year, I gave a
presentation in Rome that dealt with synthetic drugs. And because of the historical
aspect of the city, I decided I would bring
us to this current point. So I’m going to show
you a few of the slides that I showed in Rome. And this is from
mythology to synthetics. So we had drugs in the
gods and goddesses. We’ve long, in
our mythology, had drugs named after gods
and gods using drugs. And then we as humans
discovered natural products. We learned about what
plants had these effects. And ultimately, we
were able to isolate those active constituents. We learned about the structures. We learned about
the body chemicals that respond to those structures
like neurotransmitters and neurotransmitter receptors. And then by the 1800s,
we had the golden era of synthetic organic chemistry
where humans figured out how to make molecules,
their shapes. And that led to the development
of the pharmaceuticals we use. But unfortunately,
some of those drugs turned out to be
modern drugs of abuse, and we call them designer drugs. And so the challenges
that we face are this myriad of new
drugs that we’ve created. And how can we identify them? And I’ll address some of those
challenges as we go ahead. This is a book called
The Pursuit of Oblivion: Our History of Narcotics. And what’s wonderful about
this is this illustration on the cover done by Evelyn
De Morgan in the 1870s. And it shows the
mother Nyx, which is night, the night,
and her son Hypnos. And that’s where
hypnotics comes from. The Roman word is somnus,
where we get insomnia. And notice what
Hypnos is holding. He’s holding poppies, and
he’s spreading poppies down onto the Earth. So this is how night comes to
us is bringing the soporific qualities of poppies
and morphine down to us. And I should note that
Hypnos’ son is Morpheus. And where does the word
morphine come from? Morphine. The Greek god of
dreams, Morpheus. So the poppies are
a great illustration of how we get to designer drugs. And this is where we’ve
isolated morphine from, from Papaver somniferum,
the poppy plant. And chemists
ultimately figured out how to convert morphine, the
natural product, into heroin. So heroin is a great
example of a designer drug. In fact, there’s an
interesting correlation between heroin and aspirin. I’m going to leave
this for a second to see those of you who might
know what the connection is. Well, it turns out that they’re
both synthetic derivatives of natural product. Heroin, diacetylmorphine,
the acetylated morphine. And aspirin is
acetylsalicylic acid. And salicylic acid was used,
but it caused GI disturbance, and they learned that if they
acetylated it that it would then not have those properties. So they started to
acetylate everything, and they acetylated
morphine and made heroin. So these are two designer drugs. In fact, they were both
marketed the same year at the turn of the
last century, and both marketed by the same company. So it’s a great example of
our history of chemists, figuring out how to
make designer drugs. All right. Now relax. Chemistry 101. Everyone who’s ever heard
one of my presentations knows that you have
to see some molecules. Trust me, it’s good for you. OK. Just squint your
eyes a little bit. I’m sorry, I don’t have a
pointer available to me. But in the upper
left corner, you see the structure of morphine. And below it, you see
the structure of codeine. And those are two natural
products from the poppy plant. Well, all of these others– hydromorphone, hydrocodone,
oxymorphone, oxycodone, dihydromorphine,
dihydrocodeine– these are all synthetic
derivatives from morphine. And you see how they
kind of all look alike. The chemists have tweaked
a molecule here and there, and you can understand how
they all act as opiates on our bodies’ receptors. And that’s what
chemists are doing. They’re trying to
tweak these molecules. And in the same way that those
opiates bind to receptors, you can pick them all
up with your drug test, because the drug tests
are like receptors too. And it’s lock and key
fit, and they recognize these molecular shapes. And this will be important
when we think about, how do we identify these
new synthetic drugs? OK. I’m going to show you a couple
of more molecule slides. Just hang in there. So you see the structure
of morphine and codeine, the natural products,
and the synthetic ones, semi-synthetic ones. Well, there’s
heroin on the left, and it’s got these
two acetyl groups. And it looks just like
morphine, but it’s been changed a little bit. And then we have buprenorphine. And you can see they’ve stuck
on lots of different groups on that molecule. But it still binds to opiate
receptors in some way. And down below we
have naltrexone, which is used to treat alcoholism. And you have no naloxone. And again, the chemists have
stuck these different molecules on there, still based on
the morphine skeleton. So these are
semi-synthetic drugs that have certain properties. Well, now we have other
opiate-active drugs like tramadol and demerol– meperedine– fentanyl. We’re starting to break
the molecule apart. Fentanyl doesn’t look
anything like morphine, but it’s 100 times more potent. So the chemists, the
synthetic organic chemists, are tweaking molecules all
the time to make new drugs. And sometimes they’re trying
to make them more potent. Sometimes they’re trying
to avoid side effects. I’m going to show you
a few more molecules. Have you have Krokodil,
which, it looks like morphine, but they’ve changed, again,
some of the structures. And then another molecule,
W-18, doesn’t look anything like morphine, but it is
10,000 times more potent. So this is what
chemists are doing when they’re trying to
make these designer drugs, is they’re tweaking these
molecules to trick our bodies’ receptors more so
than they were ever designed to withstand in
terms of the natural products of our world. And here is
methadone that’s used as a substitute for
morphine and heroin. Doesn’t look anything
like morphine. And similarly,
propoxyphene, Darvon, also binds to opiate receptors. So chemists have this huge
capability of making molecule after molecule. So this is 1985
Doonesbury cartoon. And it shows them, you
know, tweaking this. “We just removed this
molecule and voila!” “Legal as sea salt!” So this is about MD&A,
actually, ecstasy. So this is a perfect
example of the chemists trying to bypass the law. This interestingly is a patent
from Merck where they actually got a patent for making MDMA. And the date on this is 1912. So this is when the
pharmaceutical companies are getting these
organic chemists and teaching them
how to make all sorts of different molecules that
have different properties. So amphetamine,
methamphetamine, MDMA. These were all made at
the turn of the century. Well, now we have, in more
modern times, a whole variety of psychoactive substances. These two books are
PiHKAL and TiHKAL. PiHKAL stands for
Phenethylamines– that’s like amphetamine– I Have Known And Loved. And TiHKAL is Tryptamines–
that’s like LSD– I Have Known And Loved. And these books are
hundreds of pages of how to make designer drugs
and what effects they have. And you see the authors are
Alexander and Anne Shulgin. And I have to give a call out
to Sasha Shulgin, Alexander Shulgin. He died 2014. And he’s an organic chemist
who lived in the hills above Berkeley, and
he wrote these books and made all these drugs. And he’s really famous
for all of this. So I have to give a
shout out in recognition of Sasha Shulgin and all
the work that he’s done. And we are haunted even today
by some of his designer drugs. So where do we stand now? We have many publications
about these designer drugs, and I’ll have a list at the
end of some of these resources. So we’re learning about the
huge number of these drugs. This is from the Journal
of Psychoactive Drugs. And you can see the third
column from the left, the number of substances identified, 650. There’s cannabinomimetics,
cathinones, tryptamines, psychedelic drugs, herbal
plants, huge numbers of drugs. And look at the number of
brand names on the far right. I was just at the Society of
Forensic Toxicology meeting in Dallas, and 27% of
all of the presentations were about these designer drugs. There were 43 various
presentations, either poster or oral presentations. So our toxicology
community is dealing with this myriad of new drugs. We have this pilot program, the
Community Drug Early Warning System. And then that expanded to NDEWS,
which is the National Drug Early Warning System. And these sites have
tremendous information available on all
these different drugs, like the fentanyls, which
are very powerful opiates. We also have the Drug
Enforcement Administration, who publishes a lot of information. So you see synthetic
cannabinoids, the tryptamines that are like
opioid analgesics, for example. The cathinones, the bath salts. So there’s a lot of
really useful information. We’re also getting
information from Europe. There is the European Monitoring
Center for Drugs and Drug Addiction, EMCDDA. And they put out
these drug reports, and they survey many
European countries. So many of the designer drugs
that we see here actually have come from information
from Europe and the Far East. So what’s the
legal history here? You remember the
Doonesbury cartoon. If we tweak this molecule,
we can make it legal. So I’ve got just a few sites
on how we’re dealing with this. So 1906, we had
the Food and Drugs Act when these patent medicines
were poisoning everybody and they said, we
need to regulate this. And then we had drug
control treaties that we deal with
internationally. And our first law was in 1914,
the Harrison Narcotic Act, where we tried to regulate
opium and cocaine. And then by 1970,
we have probably one of the most significant,
the comprehensive Drug Abuse Prevention Act. And this is where
the five schedules– Schedule 1, 2, 3, 4, 5. And Schedule 1
drugs are the drugs that have no
approved medical use and have addictive potential. So marijuana under federal
law is a Schedule 1 drug, for example. And that’s part of the
Controlled Substance Act. The Drug Enforcement
Administration established shortly thereafter. 1986, the Anti-Drug Abuse Act. And then importantly for
these designer drugs, we have the Federal
Analogue Act. And that’s saying,
well, do we have to pass a new law every time a
chemist tweaks a molecule here or there? These are called analogues. Kind of looks like it. Like we change a chlorine for
a bromine or a fluorine atom. So they said, if a
drug is substantially similar in its molecular
structure and its effects, then it can be
regulated, even though we don’t have a
regulation specifically for that individual
drug at the time. And it has to be intended
for human consumption. Well, you know all these
bath salts and spice that you get at
7-Eleven, they all say, not intended for human
consumption, winky, winky. And there’s a real
legal issue surrounding, what is substantially similar? So they get these
chemists to go into court and argue whether a molecule is
substantially similar or not. So the cannabinoids got the
first regulatory attention by the Drug Enforcement
Administration of these designer drugs in 2011. And the DEA can
temporarily schedule it until they have a
chance for full review. And then we have the
bath salts that were then regulated shortly thereafter. And then in 2012,
we had a major act to deal with this issue,
Synthetic Drug Abuse Prevention Act. And it lumped together
a lot of these drugs. The bath salts, the
synthetic stimulants, the cannabinomimetics,
hallucinogens. And the most recent
action is on mitragynine, 7-hydroxymitragynine. That’s known as kratom. And that acts on
opiate receptors. And the DEA had
intended to schedule it, and that’s what they
published in August. But there was a furor
about it, so they’ve since withdrawn that notice of
intent, and it will now come under review, and there’ll
be a comment period that lasts, I think, until December. So that’s sort of an
update on where we stand. But it’s this Analogue Act that
covers a lot of these drugs. So let’s go class by class. Let’s first talk about the
synthetic cannabinomimetics. I like that word, because it
mimics the action of cannabis. These molecules don’t look
anything like cannabis or the structure
of THC, but they mimic the properties
of cannabis, and so we call them
cannabinomimetics, or maybe cannabinoids. So all right. Here’s our marijuana. And then we have a long
history of the natural product going back thousands of years. 1964, we learned about
the active constituent in marijuana. It’s THC. 1988, the receptors have
started to be cloned. 1992, we find our body has its
own internal marijuana called anandamide, another
receptor clone. And now with all of
that science base, we now have these
synthetic drugs, now that we’ve learned
about these molecules and their receptors. So here we have synthetic
marijuana sold as incense. This is a New York
Times article. And you know, do
her parents know that she was in The
New York Times, smoking what’s called spice? So this is where the synthetic
cannabinomimetics come from. OK. At the bottom is THC. And you see, it’s a
very fatty molecule. That is, it’s only
got two oxygens on it. No nitrogens. It’s just a carbon and hydrogen.
This is like fat, wax, oil. Well, look at spice up
there on the upper left. It’s also very fatty, but it
doesn’t look anything like THC. And there’s another WIN up
there in the upper right. Doesn’t look anything like THC. So even though these drugs bind
to your cannabinoid receptors in the body, they
look so different that your typical
marijuana drug test isn’t going to pick them up. They look too different. And they’re generally tens to
hundreds of times more potent. So you understand
the nomenclature. I’m going to make
you [INAUDIBLE].. The JWH, that stands
for John W. Huffman. And here he is, John W. Huffman. He’s a synthetic
organic chemist, and he was at
Clemson University. And he synthesized a whole
family of these molecules, these JWH molecules. Well, other people have
been making these molecules. So if you see HU-210,
that’s Hebrew University. JWH, John Hoffman. WIN, Sterling Winthrop,
a pharmaceutical company. SR, Sanofi Research. AN, Alexandros Makriyannis. CP, Pfizer. AB, Abbott. So pharmaceutical
companies are very interested in these cannabinoid
receptors, CB-1, CB-2 receptors for a number of reasons. And therefore, they’re
making these molecules. Well, the designer
drug people say, well, we can make
some of them too, and maybe we have a different
goal than the others, and we’re going to make
different molecules. So this shows the
number of publications now for these
synthetic cannabinoids. And you see down in the
middle when the receptors were identified and the
natural neurotransmitter was identified, and
then suddenly there’s this explosion in
these synthetic drugs and synthetic cannabinomimetics. The United Nations
Office on Drugs and Crime has brought this issue up
and has documents about it. The European Monitoring
Center has information. You can download all of
these, learn everything you want about these drugs. And just to illustrate
the complexity here, the middle of the circle
shows the basic structure of these synthetic
cannabinoid mimetics. They have a core structure. But around the left
part of the circle, you see all the different
cores they have. And then the tail is
then this greenish color, and you can see all
the different tails that have been made. And then the ring, all
the different rings that have been made. And you can imagine
the huge number of combinations that exist. So the designer drug people
just move around the circle and make one new
drug after the next. And the regulatory people have
a terrible time keeping up, and the same with the drug
testing people keeping up. How do we identify these drugs? It’s a huge challenge. Well, because they’ve
been around for a while, we’re starting to learn more
and more about the pharmacology of these drugs, how they act on
receptors, the adverse effects, the toxicology. So we do have information
available about these drugs. We understand the effect
of these drugs in driving. They’re showing up in
drug driving cases. We also have the Drug Abuse
Warning Network, DAWN. And they survey emergency
rooms around the country. And so we’re learning about the
adverse effects of these drugs and how they’re showing
up in emergency rooms. But a great challenge
is that they often don’t know what the person
took unless a friend comes in and says, yeah, he
bought this at 7-Eleven. We don’t know what it is. And generally, the
hospital laboratories, they don’t know how to
test for these things. So it’s very difficult to get
real information about these. We are learning about
adverse effects. I showed you the
impaired driving. This is psychosis. We know that psychosis is
associated with marijuana use to some degree,
and I’ve certainly seen that with these very
powerful cannabinomimetics. Again, these are many
times more– tens to hundreds of times more
powerful than marijuana. So we are learning about
how the body handles them and detection methods. We can’t really do
controlled dosing studies. I can’t invite some
people in and say, here. You want to take this? We don’t know what it is
and we don’t know what’s going to happen to
you, but we want to find out what comes out
in your urine or in your hair or in your sweat. So very difficult to get
accurate information. But you know, we are
starting to get information about these drugs. We’re learning about how
long they can be detected. And because they’re
fatty like marijuana, they can stay in the body. And we’re developing a
simple test, amino assays, the analyzer-based test. But because there are
so many molecules, this shows no cross-reactivity. Table 3 up on the
left, it says, drugs showing no cross-reactivity. And those are all
cannabinomimetics that don’t react
with the antibodies that they make in these kits. But the kits are improving
now, so we’re now getting kits that
have cross-reactivity to a wide variety
of these drugs. I don’t expect you to pay too
much attention to this other than to understand the
developments that we’re making in drug testing and being
able to identify many of these. But again, remember, these
change on a day-to-day basis. So that’s the situation
for cannabinomimetics. I know Natalie is going to talk
about them a little bit more. I’m going to jump now to the
bath salts, so the cathinones. And this all started with Ma
Huang, which is Ephedra sinica. And that’s where ephedrine comes
from, from the Chinese plant, and it’s called Ma Huang. And this has, again, been
known for thousands of years. But the next
development was khat, this Catha edulis which
grows in Ethiopia and Yemen. And understanding
those structures led to the synthesis of
amphetamine, methamphetamine, and ecstasy, and now
are designer cathinones. So these are khat
leaves, and they’re wrapped in banana
leaves and shipped. And people then chew
the khat leaves and get this molecule called cathinone. And khat comes from
the Horn of Africa. Yemen, Ethiopia, Somalia. That area. That part of the world. And then it’s shipped around. So again, more molecules. You see our natural
neurotransmitters at the top left, dopamine
and noradrenaline. Ephedrine, Sudafed. These are natural products. Well, at the upper right
corner, you cathinone, and that is the active
constituent of khat. And it’s just got
this extra keto group, this extra oxygen on there. So it kind of looks
just like amphetamine and methamphetamine, which
is in the middle there. And now we have all these
cathinone derivatives, and you can understand
why they are stimulants, because they have
molecular structures that look like amphetamine
and methamphetamine and other natural
neurotransmitters. And on the right, you see more
of these cathinone derivatives where the chemists are
starting to add molecules and tweaking them around. And again, the
chemists are putting all sorts of different groups
on these various bath salts. And you can see how
they’re mimicking ecstasy in the bottom two molecules. You have ecstasy on the
left and MDPV on the right, and they’ve tried to mimic
ecstasy a little bit. And here you have
a little article about a Chinese professor
who is making these drugs and shipping them
over to the US. He started a company. So a lot of these
synthetic drugs are actually coming from
other parts of the world. OK. I’m going to move on in
the interest of time. But we’re learning
about these drugs, and we’re learning
about drug testing. So this is a paper,
a recent paper on testing for
designer stimulants. And they looked at 16 of
these synthetic cathinones, and can you pick them up
with conventional tests? What shows up in
urine when somebody uses one of these drugs? And it turns out, some of them
can be picked up with urine [INAUDIBLE] assays,
and some can’t. And the challenge is,
you get a positive result with your amphetamines kit
and you send it to the lab. But unless they’re
testing for all of these different
cathinones, they may report that as a negative. So it’s a frustration in
the drug testing world. OK. On to synthetic hallucinogens. So these are drugs like LSD. And again, a long history
of natural products. Like psilocybin was
called the Flesh of the Gods back in 6000 BC. We had the North American,
Mesoamerican tribes doing peyote and mescaline. We learned about ergot alkaloids
in the Salem witch trials, and then that ultimately led
to the development of LSD. Salvinorin A. Again,
Mesoamerican, and it’s the most potent natural
hallucinogen known. And Ayahuasca where they
take two plant materials from the Amazonian
jungle and get their hallucinogenic effect. So these are all the
natural product side of things except for the LSD. And now we have, back to
Sasha Shulgin, his books, where he’s teaching
you how to make a lot of these molecules
that are hallucinogens. And here’s one of
the NBOMe series. You may have heard of this. The NBOMe. It’s N-B-O-M-E. And I want
you to understand where the nomenclature comes from. So you can go back and look
at this molecule later. But the NBOMe 25I. It all– from the chemists
want to name these things. So now you can understand
where the naming comes from. I won’t spend any
more time with it. But these are very
powerful designer drugs. And we really don’t have good
tests for them that are easy. They really would have to be
tested for in the laboratory. And finally, I’m going to
go to natural products, and I’m going to
talk about Ayahuasca. On the right, you have two
molecules that are one plant, and on the left, you
have two molecules that are in another plant. And when you take this plant,
these two plants together, the molecule on the
right inhibits the enzyme that would break down the
molecules on the left, and you wouldn’t
have any effect. But when you take them together,
the molecules on the right allow the molecules on the
left to go through the body and have their
hallucinogenic effect. And this is amazing that
these natives figured out how to do this when you
took these two together. And you can go into the
Amazonian rainforest and have your
Ayahuasca experience. So here we have another
natural hallucinogen that you may have
heard of, and this is Salvia, Salvia divinorum. That’s not my back
porch, by the way. I want you to understand that. And this got a lot of
attention by some claim that Miley Cyrus was,
in fact, smoking Salvia. But they said, no, no. That was not Salvia
she was smoking, but that’s how it
got written up. So this is Salvinorin
A. It is the most potent natural hallucinogen known. And we don’t really have easy
drug tests for this molecule. But again, chemists
understand the structures and they can now
play with these. And now we have kratom. This is, again,
a natural product that you’ve heard about. Mitragyna speciosa. It’s in the same
family as coffee, and one of the Ayahuasca
molecules, interestingly. And these are many times
more potent than morphine. Bind to the opiate receptors. And recently, as I showed
in the regulatory area, they are trying to put
a damper on availability of these molecules. But people said, but,
but, but wait a minute. We like kratom. Kratom acts on opiate
receptors like methadone does. And there’s a discussion
that addicts can actually use kratom and avoid
relapse by using this. So the DEA got all of these
letters and decided, OK, OK. We’ll hold off. Let’s get some
research from the FDA. So to sum up, we have
this Pandora’s box that’s suddenly been opened
by all these chemists. We’ve been lucky that it
hasn’t lasted longer– that didn’t start sooner
is, I’m sorry, what I meant. So we have these designer drugs,
and the challenge is to know, what are these molecules, and
how do they act in the body? And what shows up in urine
or hair or oral fluid or sweat if we want to
detect these things? So we have to understand
their pharmacokinetics, how the body handles them. And ultimately, their effects. So we have to know how they go
through the body, how they’re metabolized, how
they’re eliminated. And it’s very difficult
to do these studies, because these are unknown
and dangerous drugs. So it’s truly a challenge now. And the drug that we take that
binds to our brain receptors may not be the same thing
that comes out of our body, because our body, our liver, and
our kidneys filter the drugs. Our liver breaks them down. So we need to know what
shows up in each specimen. And I’ve got urine down
on the bottom right there, this antibody in yellow
because of urine. And we have to remember
that these drugs can all be affected by urine dilution. So if you’re doing
urine drug testing, the dilution will affect these
drugs, the concentration, just as they will
affect any other drugs. So if you’re doing
urine testing, you’ve got to take
this into account. So they are now studying
these immunoassays and how they bind to all of
these different designer drugs. What can your test pick up? What can’t they pick up? And laboratories are
constantly trying to develop these techniques. So what are our challenges here? Hundreds of compounds, uncertain
legal and regulatory status. How do we detect them? What are our methods? Immunoassays take a long time
to develop those cup-type tests or analyzer tests. Mass spectrometry. They can identify these,
but it’s expensive. And you can’t develop the
test unless you know what standards you’re looking for. Are you looking for the parent
drug and the metabolites? And then how are
they broken down? Do they stay in the
body a long time? A little time? What are their effects? We can’t really do
controlled dosing studies with any of these drugs
because they’re so dangerous. And then there’s
this issue of, how do we treat people who
are using these drugs? What treatments will work? So this is my last slide. So here’s a list
of some resources. The National Institute on
Drug Abuse, the drugabuse.gov, has a tremendous amount
of current information. The DEA has several
documents available to you on what they’re
finding in drug busts and what drugs are showing up. I showed you the National
Drug Early Warning System that you can see. That’s out of the
University of Maryland. The European Monitoring Center. Look, they have identified
over 560 substances in their European
Warning system. And just in 2015,
there were 98 new ones. So it’s just hard to
keep up with all of this. But at least these
are all places where you can get
accurate information about their status, what’s
showing up, and their effects. Another website I
like is called Erowid. And this is a balance
between actual users and PhD scientists. So you get a little
bit of the science and a little bit
of the street lore. It’s a great website to explore
those two issues together. We have maps where
there are studies going on on psychedelic
substances who believe that these are useful. And then another
one, lycaeum.org, which is about entheogens,
these drugs that make you have feel-good experiences. So I went through a lot
of material very quickly. Hopefully, I’ve
given you a sense of the scope of these drugs,
the challenges we face, and the limitations. Now we will turn
it over to Natalie who has to deal with this
on a day-to-day basis. And she can now give
you the practical issues of how she deals with it. NATALIE REYES: All right. Thank you, Dr. Kadehjian. I’ll go on and also thank
the Justice Programs Office for giving me this
opportunity, and Blaine and Anna. They’ve both great
partners on this as well. So I think that was a great
background and tie-in to what I’m going to talk about here. I’m really looking at this
more from the adult drug court practitioner’s
perspective, and what we’re seeing in drug
courts, some strategies on how to address it, funding
issues that come up here. So moving into my slides
here, the first patterns I want to talk about
are four main substances that we’re seeing reoccurring
in adult drug courts. So as Dr. Kadehjian mentioned,
the synthetic cathinone use, also known as
bath salts or flakka. I’ve heard flakka
a lot in the South, but mostly bath salts
it’s commonly known by. Our big issue we’re
seeing in drug courts, synthetic cannabinoid use as
Dr. Kadehjian also mentioned. Spice, K2, incense. And then kratom. That’s actually a big
one I’m going to spend a good amount of time on. That’s a big one
here that’s really causing a lot of
problems in drug courts. He mentioned the fentanyl. It’s also knows as China white. Are there other substances
that are out there? Yes, of course. Listening to Dr.
Kadehjian, there’s a wealth of synthetic drugs,
natural products out there that are being used by
drug court participants. But I just kind of want
to focus on these ones. But of course,
policy and practices, all that will apply
to the broader scope of the synthetic
substances out there. So what does it look like
in a drug court participant? And I think that’s
important to understand, especially when we get to the
part of incorporating this drug testing into the program. So synthetic cathinone use. So it mimics, as Dr.
Kadehjian mentioned, similar to amphetamine use. So you’ll a lot of folks with
anxiety, euphoria, confusion, weight loss. Red flags for me are when you
have a methamphetamine user that’s testing clean, but
just something’s not right. They’re missing
appointments, you might see some weight loss,
some of that hyperactivity. That might be some
red flags to look at. In terms of availability,
this is actually getting a little harder
to find for participants. I think there’s some
liability issues with the head shops, which is where
they used to get it a lot, because of the high rate
for addiction and abuse for bath salts, so it’s
getting harder to find. But it is also
sold on the street. So this is kind of
a new area for drugs being sold on the street
are synthetic drugs. So that’s one thing
to keep in mind. Synthetic cannabinoids, as
Dr. Kadehjian mentioned, they’re more potent most
times than marijuana use. And it’s actually
the compound itself that’s sprayed onto dry
leaves, which are then smoked. So it’s not the actual
leaves that cause the effect. It’s actual compounds they’re
spraying on the leaves. It’s available in
liquid form for vaping. It’s available at head shops. And this one’s
relatively easy to find. So kratom. This as, as I mentioned, a
big one for us right now. I actually took this picture. I went into a local head
shop, which I like to do, and I encourage
practitioners to do as well to see what’s going
on out there, what’s being sold over the
counter to participants, and just how it’s
marketed and everything. So I took this picture. This is just an example of
how much shelf space they’re dedicating to just kratom. And this was only one section,
all the different types that you can purchase. I mean, there’s different
names there, as you can see. So it’s just sort of interesting
to see how much space they’re dedicating to this. So kratom is similar– folks report that it’s
similar to an opiate use. As Dr. Kadehjian
mentioned, it binds with the opiate receptors. Clients report a mixed
stimulant and sedation effect. I see a lot of folks that are
using kratom get really sweaty. I’ve seen weight loss. And then also, as I
mentioned before, there’s discussion around using
this for recreational, at this point, pain
management, opiate addiction, which has put a
halt on the proposal to move it to a Schedule I. And also, as I mentioned,
it’s very, very available at head shops. It’s very popular. When the ban was going on,
there was huge clearance sales, so it was pretty
reasonably priced. I think this is something
that folks really need to be aware of, that
drug participants can very easily get their hands on. So fentanyl, this was
mentioned before as well. It’s similar to opiate use, as
Dr. Kadehjian also mentioned. According to drugabuse.gov,
it’s 50 to 100 times more potent than morphine. So you can imagine
the effect on someone who’s using this with
the slurred speech, the heavy sedation. We’ve had folks that
were on it that were drooling and very unresponsive. So it’s very concerning,
and these are dangerous. Most of this is purchased
online or on the street. I haven’t seen it in any
local head shops at least. So this is something that’s
regularly dealt on the street as well. So in terms of synthetic
drugs and the impact and specifically on
drug courts, I mean, I think there’s
a lot of research that still needs to be done. But one thing we do know is
that participants are using it. There was a study
done here that I’ve referenced that in a
residential treatment facility, 71% of the patients
reported using synthetic cannabinoids to
get high without having a positive drug test. So that’s a very
significant number of people in a
residential facility. And of course, you know,
some of these barriers are that they’re specifically
designed to avoid detection. The testing’s expensive. There’s not a standardized
cutoff limit, et cetera. So this is a little bit
of a challenge we face. If you want more information
on designer drugs, the effects, the history, et cetera, this
is a really good practitioner sheet to read by the NDCI. They specifically get
into a lot more detail. But I want to kind of more
dive into some of the policies, procedures, and things. So what does this mean
for us as practitioners in terms of policy
and just an awareness? I think it’s important for
us to have these discussions with our teams and things. So I want to look
into the adult– here we go– the Adult Drug
Court Best Practice Standards Volume II. So this is a very frequent
guide for practitioners, and it does mention in
here synthetic drug use. So looking at Section
D under Drug Testing, they mention it’s important
to have a wide range, here on the last
part of the section. It says, “drug courts should
select test specimens randomly and frequently and examine
them for a wide range of potential drug
abuse that might be emerging in their population.” And above that, they had
mentioned synthetic drug use. So it’s very
important that we’re doing a random and
frequent wide range of drug testing in our programs. So some suggested policy
for synthetic drugs in drug court programs, I
think it’s very important to have a clear understanding
in any participant manuals, any drug testing contracts, any
intake paperwork, processing, et cetera, orientations
that synthetic drugs and natural products,
they’re not allowed. So one way to do that is to
ban the use of substances sold as not for
human consumption. So as Dr. Kadehjian
mentioned, that’s one way it’s typically– they
go around laws around that, and they’re typically marketed
not for human consumption. I think it’s important to also
let participants know that they will have regular and random
expanded drug testing if that’s true, which hopefully
this will help programs get to that point. But I think it’s very
important to let them know. This isn’t something that
they haven’t thought of or they haven’t heard of. Synthetic drugs, you won’t
be introducing them to them. Most of our folks have heard
about them, at the very least. Another important
factor is to have policy discussions on how to
address positive synthetic drug use. There will be opinions– you know, it varies
from the defense to the district
attorney’s office. So I think it’s important
to have these discussions before it happens. So how are folks going to
address positive synthetic drug use? So let’s get into
that a little bit. This is also pulled from the
Adult Drug Court Best Practice Standard Volume II. So basically what
they’re saying here is that there are two
possible behaviors to address if someone
does admit or have positive UA for synthetic drugs. You have the new use, of course. And then also this
added layer of effort at deception, which occurs
a lot more frequently with synthetic drug users
just because of the nature of how they’re designed. Let me break that
down a little bit. So you have the new use. I would recommend following just
the proximal/distal goal model. Most folks are
familiar with that. Proximal goal is the goal
that you have the skill set to accomplish and sustain. So for someone with
significant clean time, a proximal goal would be
to maintain that same time. Just [INAUDIBLE] is something
they’re working towards. So sanctioning
model around that. And the efforts of deception. This one’s pretty easy
to just tease out. Did they admit to using
synthetic drugs before the UA or for being
confronted with the UA? If the answer’s yes,
then I would say there probably wasn’t an
attempt to defraud the test. If they say no,
then it’s possible. Then then there’s another
sanction here for the effort act assessment. And what to do next? So you have a positive
test, you’ve addressed it. Then what would
I recommend next? I would definitely make
sure that the treatment team is well aware of what’s
going on with this participant. They might need to do
some reassessments, look at their needs,
look at the case plan around what’s going on. It’s very important to
make sure treatment’s in the loop on this. Especially if you’re testing
it through additional testing, make sure they’re
getting those results. Just the communication can
be really important here. Also if you get somebody
that has admitted to or has a positive UA
for synthetic drugs, it’s very, very, very
important to make sure you’re continuing
to test them or continuing to have expanded
drug testing with them. It’s both for accountability,
for program fidelity. Also to make sure they’re
getting their needs met. If they’re using substances
we’re not detecting, then we’ll likely not applying
the right treatment for them, so we want to make sure we’re
well aware of what’s going on with these participants. Also, we’ve seen a lot
that these synthetic drugs and these substances
can expand within groups of the participants. So for example, we had sort
of a bath salts epidemic for a short period where we had
a large group of participants that were friends, and
one person tested positive for bath salts,
and it kind of led to a string of multiple
folks that we found out were using them. So it’s very important to
make sure you’re really looking at your population. And that might be a good
idea and a good strategy for especially
risk-based testing, which we’ll get into for monitoring
for these synthetic drugs. So how to incorporate these
expanded testings for– I mean, as Dr.
Kadehjian mentioned, there’s a lot, a lot of
challenges around this. But this is some good
advice that I can pass along as sort of a starting point. I know the toxicology
side of things is always ongoing
and developing. But just in terms of
policy, here’s what we have. So first off, I
encourage you to find out what your local
Medicaid plans cover. We actually locally are able
to bill our local Medicaid plan for some expanded testing. So that’s pretty helpful. If you’re using your
community justice agency for drug
testing, I’d consider, if you can’t move all of
your drug testing over there, just consider maybe doing
some random expanded testing through the treatment
agency so they can bill. That’s one strategy we’ve
implemented in our program, just to help with some
of the costs associated with the expanded testing. Also, if you’re
considering bringing in some outside or additional
support around testing, shop around. There are lots of
labs out there, lots of different
prices, products, et cetera that can
meet your needs. There’s places that
will do custom panels and lab testing, instant
testing, et cetera. So I’d just encourage
you to shop around. Another suggestion
is to consider incorporating into this request,
into your grant request funding in your grant request. It’s an argument that
you could easily make. As I mentioned, it’s in the
drug court, NADCP Drug Court Standards. There’s lots of research out
there that this is an issue. So I think it would
be a good point to make in the grant request. Also, consider creating a
budget that you have right now– for any finances
you have right now, consider creating a
budget specifically for expanded testing. So are you able to
reallocate any resources? Are you able to request
additional resources from any funders,
being armed with some of these arguments in the
Adult Drug Court Standards? And I think it’s important
to discuss synthetic drug use within the team so
there’s an awareness of it. Also, this will go back
to all of the funders as well that this is
an important issue. So I think that’s
the important part, is to make sure your programs
are having these discussions. So as I mentioned,
risk-based testing. This was a good
strategy for those that have limited funding. Most do. So if you’re looking
to do and target specific participants
for different testing, I think there’s some relations
here that can help determine who to test and what. So the marijuana users,
obviously, you’re probably going to want to
watch a little bit more for the spice and K2. Synthetic cathinones would be
more like your methamphetamine, amphetamine, and cocaine users. And the kratom would be more– I’ve seen mostly opiate
users turn to kratom, but some stimulant users as
well or the polysubstance users. Fentanyl is definitely
comparable to opiates, so that’s the one I would watch
for for your opiate users. There’s also some additional
research out there if you want to look on
some of the demographics. So feel free to do that. This is just a good
general guideline I go by. So just some tips on
drug testing in general that will help with
synthetic drug testing issues that we’re seeing. I encourage folks
to not disclose when you’re doing drug testing
and you’re sending samples to the lab, to not disclose
to the participants necessarily what it’s
going to be tested for. And I do that, I would
suggest that coming from a place of trying to not
catch them doing something wrong, but just make sure that
you’re encouraging honesty and discouraging any
efforts at deception. So just create
this understanding in your participant manual. I think it’s also
cost-effective as well. If the clients just– if they know
exactly what they’re going to get tested
for, then they know exactly what they can
use and not get caught using. So I think it’s important to
sort of just leave it more open and just talk about
understanding. I’d recommend creating a
disputed drug test agreement. This is especially because
synthetic drug testing is so expensive. So what that looks like is
the participants provide, say, an instant test if you’re
using instant, onsite testing. And they’re disputing
it, and it’s showing positive
for spice, and you are going to have to
send it to the lab to get a confirmation result,
which is very expensive. I think it’s important to
have some sort of agreement where they stop and think
about the situation, and they’re playing the
tape all the way through, I guess you could say,
in treatment terms of what the potential
consequences could come from having to go
through that whole process if it is, in fact,
a true positive UA. So I think it’s
important to point out there might be
further sanctioning for continued dishonesty. And possibly, they’re
subject to lab fees if they’re found to be
dishonest and in violation. I just think this
is a nice way to get them to really stop and think. A lot of the
participants are nervous, especially if they’re
being caught for something such as synthetic substances. I think it’s important to
just have that moment for them to just stop and think. And there’s a good teaching
moment there as well. And as I mentioned before, just
talk about synthetic drug use. You’re not introducing
them to something they haven’t
already heard about, haven’t already
maybe seen or tried. So I think it’s
important to just show from a competency-level
perspective that we’re aware of
this problem and we’re aware that this is going on. I mean, especially if
you’re testing for it, I think it’s a good conversation
to have with participants. And just be open with them
so they know we’re not, you know, sort of out of
the loop of what’s going on. So yeah. Thank you. I am open to taking
any questions. I think we’re going to have
a little short period here for questions. Also my email address
is there if anybody has any additional
questions as well that they don’t necessarily want
to ask here on an open session. BLAINE STUM: All right. Well, thank you, Natalie
and Dr. Kadehjian for those great slides and
wonderful comments regarding synthetic drugs and designer
drugs and drug courts. I did have a quick
question while we wait. People in the audience, if
you want to ask any questions, you can type them in in
the bottom on the Q&A box. So please feel free to do that. But I wanted to ask Natalie,
I know that prices probably vary a little bit on
the expanded testing, but in your experience, what
has sort of the price range been like? And is that something
that drug courts can afford to do, at least
on a semi-routine basis? NATALIE REYES: Yeah. I mean, I’ve seen– it varies, obviously,
if it’s an instant test or if it’s a lab confirmation. For example, kratom,
I’ve seen cost anywhere around $60 to $80,
unfortunately, for a test. But again, that’s
something that we can bill for at least
locally with our Medicaid plan, bill insurance for. So that’s a big
strategy that we’ve been utilizing is to bring
in the insurance companies. Some of the other instant
tests are less expensive. But again, if you have a
dispute issue in your program, requires confirmation
testing, then you’ll have to spend that money
if they do go on and dispute. So that’s another suggestion of
why I have that dispute form. So it’s just really
shopping around and trying to utilize Medicaid
and other resources out there. BLAINE STUM: OK. Fantastic. And then I also had a quick
question for Dr. Kadehjian. You delved a lot into
the science of synthetic and designer drugs. And I was curious,
I guess, as to what you see the future of
these drugs looking like. I know that the
designers of these drugs aren’t necessarily
trying to make them more potent
or dangerous, but I was curious if you see
that as something that could happen as a consequence
of continued sort of tinkering with these molecules. LEO KADEHJIAN: As I indicated,
the designer drug people for the most part are
not pharmacologists trying to get the best
drug that they can. I think the motivation
for all these changes has really been one of
legal and regulatory status. Obviously, they want the drug
to have some desired effects. Otherwise, there’ll
be no market for it. But what we’ve seen
is this ability of these synthetic
chemists to really make molecules that are incredibly
potent with all this knowledge of the receptors. They have computer-assisted
design of receptor sites to design molecules. So I think, you
know, the future is what we are seeing currently,
that these new drugs have a wide spectrum of
effects and potencies and adverse effects. So I just see this continuing. Granted, the Analogue Act
allows for grouping these drugs together. And I know there’s been
some case law addressing, what is an analogue? If you just change
this one little thing, is that an analogue or not? But you also have to demonstrate
that it has comparable effects, and that’s not always
easy to show as well. So I think from the
turn of the century when we had the
organic chemists trying to synthesize these drugs,
the pharmaceutical companies, we’ve lived like
a Goldilocks era where we only have a handful
of drugs to worry about. We call them the 9:00 to 5:00. You know, we only worried
about marijuana and cocaine and opiates and such. And now suddenly we
have this explosion, and we’ve just been lucky,
in effect, that that didn’t occur decades and decades ago. But I think as that
article showed, the Pandora’s box
has been opened. So I just think we face
greater, greater challenges. And from the drug
testing standpoint, I think it’s going to offer
continued challenges too. There probably will not
be simple, easy tests that are going to pick up all
of these new designer drugs as they change on a
weekly basis even. And so testing may
be forced to go to more sophisticated
laboratories where, as Natalie
indicated, the cost per test can be $60, $80 or such. And that was certainly
something that was brought up at the most
recent toxicology meeting, that the toxicology
labs are the ones who are really trying to stay on
top of all of these new drugs. Anyway, that’s my sort of not
good to hear news, let’s say, about the designer
drug situation. I think Natalie’s
information about what to look for, create
more targeted responses, knowing what the properties
of these drugs are and knowing what to
look for, and then having the ability to have
some way of identifying them. One final thing I want to note. You have the slide
Contact Information up. And I just want to point
out that my last name is not spelled correctly there. But that’s OK. It took me a long time to
learn how to spell my name, so it’s OK. BLAINE STUM: Apologies for that. I just have one more question
then that came in for– different questions
for each of you. But Dr. Kadehjian, I was
wondering if you could just briefly– we didn’t
really touch on it, but I think a lot
of people don’t have a sense of
how dangerous some of these synthetic and
designer drugs are. And I was just wondering if
you could talk a little bit about what you’ve
seen in the work that you do as far as some
of the public health impacts. LEO KADEHJIAN: Sure. Well, as I said, it’s
certainly shown up in impaired driving issues. And there are YouTube
videos of people who are having schizophreniform
psychosis as a result of use of these very potent drugs. I mean, if we even think
about the medical marijuana situation where people have
very high THC concentrations in their cookies, for example,
or in their gummy bears, and they unfortunately don’t
know how much they can ingest, and the oral ingestion doesn’t
allow you to titrate your dose. And for many of these
new drugs, I mean, I thought the kratom slide that
Natalie showed was spectacular. I mean, who knows what
the actual mitragynine, 7-hydroxymitragynine
concentration is in every one of those? So what you thought was OK
to take at one point is not. And the same is true
in the opioid epidemic where if you have
Vicodin or Oxycontin, you know what
those pills contain and how much you’re taking. When you switch over to heroin
on the street or designer fentanyl, you have no
idea how those correlate. So I put up a slide of DAWN,
the Drug Abuse Warning Network. So we’re seeing a lot of
these adverse effects. Marijuana. The synthetico
cannabinomimetics, there are really no deaths
associated with marijuana use. I mean, toxicology deaths
associated with marijuana use in the literature. But there are deaths
associated with synthetic cannabinomimetics
where people are jumping off of buildings, et cetera. So I would say the
toxicology literature is rife with examples of
how dangerous the drugs are. BLAINE STUM: OK. Thank you for that. And then Natalie, I just had
one other question for you, if you would be so kind. And I guess I was curious what
you think kind of like– you laid out a lot of
great strategies, and I wanted to know if
there was one in particular that you think is sort of
the most important strategy for drug courts to
implement in the short term to start addressing synthetic
and designer drug use, like, right away. NATALIE REYES: The most
important, I would say, is to contact your
local Medicaid providers and see what can be covered. I mean, that potentially is a
very, very low-cost or no-cost solution to doing some
of the expanded testing, at least for some of them most
common synthetic substances. So that would be the
most important strategy. I mean, we did that
and we were immediately able to increase the
amount of expanded testing we were doing just
based on that. It didn’t cost us as much,
you know? $30, $80 a test. It adds up pretty quickly. So that, I think, would be the
most realistic and feasible, quick solution to just
see what’s covered. I think that would be
a good place to start. BLAINE STUM: OK, great. Thank you for that. LEO KADEHJIAN: I’d like to
chime in on that, Blaine, if I have a moment. BLAINE STUM: Yeah, absolutely. LEO KADEHJIAN: Yeah, one of
the issues that we deal with– and Natalie brought up
the issue of deception– I can never testify about
the intent of a donor from the toxicology information. I never know what the
intent of the donor is. But I do know that
people can attempt to distort the drug test results
that distorts the tryer’s ability to truly understand the
drug use status of the donor. And since we’ve been
talking about urinalyses, I’m want to reemphasize
that important role that dilution plays. Anyone who knows anything
about drug testing in urine knows that they can consume lots
of fluids prior to their test. And that can be as
short as 15 minutes to as long as two hours. And by this super normal
fluid consumption, you dilute the concentrations
in your urine by a factor of 10 to even 20-fold. And this has long been
known as an issue, and that’s why in the
workplace testing, every urine is now tested for
creatinine and/or specific gravity. I prefer creatinine measurement. But this is absolutely going to
be true for all of the designer drugs as well. Any of the synthetic
cannabinomimetics, the cathinones,
the hallucinogens. These are all going to be
affected by urine dilution. So an important strategy
for all of your drug testing is to make sure you
monitor dilution and have that in your policy
and procedures where they’re notified upfront that
dilution is not acceptable, you know, absent a note from a
qualified renal pharmacologist or you know, renal expert. So again, that’s another
very practical thing to remember to consider with
these designer drugs as well. BLAINE STUM: All right. Thank you for that,
Dr. Kadehjian. I think that’s great advice,
along with Natalie’s advice on sort of ranking
policies and strategies. I think we are done
with questions. I don’t see any more coming in. So I don’t know if
either one of you have some closing
comments you want to make before we
end this webinar, but you’re free to
do so if you’d like. NATALIE REYES: Yeah. I would just like to say,
I think it’s important just for all the practitioners
in the local areas to really get together and
look at patterns that they’re seeing within their own areas. So if there’s any kind
of listserv going around maybe with the coordinators
across the state or the DAs across the state,
to talk about the patterns they’re seeing in their area. Because I’m sure
these patterns change within different regional areas. So I think it’s just
important to communicate just with each other, and then
just look at patterns and ask for more strategies. That’s how I’ve learned a
lot of different strategies, just by talking to my fellow
colleagues and practitioners. So I think that’s
really important. And feel free to contact me if
there are any more questions as well. LEO KADEHJIAN: And
I’ll add to that that there are numerous
sources in your communities that help you
target your program. So for example, find out what
the police are encountering. Find out what’s showing up
in your local emergency room. These are also
resources that can let you know what’s going
on in your community so you can tailor your
testing program appropriately. So those resources are
also useful to consider. BLAINE STUM: All right. Well, I want to thank Dr. Leo
Kadehjian and Natalie Reyes for presenting with us today. And I wanted to
also thank everybody who joined us on the webinar. If you have any other
follow-up questions, please feel free to
contact Justice Programs Office or the
contact information for Dr. Kadehjian and Natalie. NATALIE REYES: Thank you.


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