Street drugs guide Fall 2023

Street Drugs Guide

Created by pharmacy students in PHPR 48600 Beyond ecstasy: Street drugs Compiled by Cynthia P. Koh-Knox Sharp, PharmD, RPh Purdue University College of Pharmacy Fall 2023 Graphic from www.office.com

TABLE OF CONTENTS Street drug

Author

Page

2C-B ......................................................... Lizzy Raven............................................................................... 4 Acetaminophen ....................................... Olivia Williams ......................................................................... 6 Amanita ................................................... Dalton Huffman ....................................................................... 8 Amyl nitrate/nitrous oxide/ inhalants ...... Alton Adams .......................................................................... 10 Anabolic steroids ..................................... Aleksander Pejnovic ............................................................... 12 Anorectics (Rx) ......................................... Ainsley Rodrick ...................................................................... 14 Anti-diarrheals ......................................... Anya Wappler ........................................................................ 16 Ayahuasca ................................................ Allyson Willson ...................................................................... 18 Barbiturates ............................................. Bardia Asadi ........................................................................... 20 Bath salts ................................................. Brooke Hilderbrand ............................................................... 22 Benzodiazepines ...................................... Ben Burton ............................................................................. 24 Bromo-dragonfly ...................................... Amy Cho ................................................................................ 26 Buprenorphine ......................................... Emery Frey ............................................................................. 28 Caffeine .................................................... Sarah Cole .............................................................................. 30 Cannabidiol/THC/ hashish........................ Meghan Collins ...................................................................... 32 Cocaine .................................................... Chioma Olumba ..................................................................... 34 Devil's breath ........................................... Claire Reyes ........................................................................... 36 Dextromethorphan .................................. Naomi Davis ........................................................................... 38 DHEA ........................................................ Emily Byford........................................................................... 40 Diphenhydramine .................................... Grace Garland ........................................................................ 42 Disulfiram................................................. Faiz Inamdar .......................................................................... 44 Diuretic abuse in sports ........................... Tyler Lengerich ...................................................................... 46 Ethylene glycol ......................................... Zayaan Habib ......................................................................... 48 Fentanyl and carfentanil .......................... Abby Hamilton ....................................................................... 50 Flakka (alpha-PVP) ................................... Sarah Hauser.......................................................................... 52 Flumazenil ................................................ Bethany Hayden .................................................................... 54 Gabapentin/pregabalin ............................ Andrew Hess .......................................................................... 56 Gamma hydroxybutyrate (GHB)............... Stephanie Hessong ................................................................ 58 Gray death ............................................... Isabella Eichmann .................................................................. 60

TABLE OF CONTENTS, continued Street drug Author Page Heroin/ diacetylmorphine ........................ Jake Brattain .......................................................................... 62 Hydrocodone ........................................... Justin Cree ............................................................................. 64 Ibogaine ................................................... Jordan Keuneke ..................................................................... 66 K-2 Spice .................................................. Jonah Lenters ......................................................................... 68 Kava kava (Piper methysticum) ................ Connor Lubbehusen............................................................... 70 Ketamine .................................................. John Ton ................................................................................ 72 Khat.......................................................... Dillon Kish .............................................................................. 74 Kratom ..................................................... Karen Robles-Garcia............................................................... 76 Krokodil .................................................... Khoa Thai ............................................................................... 78 Laxatives .................................................. Lauren Mikell ......................................................................... 80 Lysergic acid diethylamide (LSD) .............. Allison Mack .......................................................................... 82 MDMA ..................................................... Blake Mathis .......................................................................... 84 MDPV ....................................................... Johnny Tran ........................................................................... 86 Mescaline ................................................. Emma Ronk ............................................................................ 88 Methamphetamine .................................. Maggie Rose .......................................................................... 90 Morning glory (Ipomoea violacea) ........... Madeline Russow................................................................... 92 Muscle relaxants ...................................... Cole O'Connor........................................................................ 94 N,N-dimethyltryptamine (DMT) ............... Daniel Fuchs........................................................................... 96 Naloxone .................................................. Maurine De La Paz ................................................................. 98 Naltrexone ............................................... Corey Brend ......................................................................... 100 NBOMe .................................................... Madelynn Packer ................................................................. 102 Nightshade (Atropa belladonna) .............. Addison Smith ...................................................................... 104 Peyote ...................................................... Spencer Stringham............................................................... 106 Phencyclidine ........................................... Emily Wood ......................................................................... 107 Psilocybin ................................................. Sameer Varma ..................................................................... 109 Salvia divinorum....................................... William Haines ..................................................................... 111 Stimulants (Rx) ......................................... Alexa Carnahan .................................................................... 113 Toad venom (5-MeO-DMT) ...................... Jongmin You ........................................................................ 115 Vapes/e-cigarettes ................................... Nicole Przybycien ................................................................. 117 Xylazine .................................................... Sabrina Zheng ...................................................................... 119 Yohimbe ................................................... Hunter Craig......................................................................... 121

2C-B

By Lizzy Raven Student Pharmacist Fall 2023

Pharmacology/Drug Effects

History and Background

2C-B is a psychedelic drug that affects your thinking, emotions, and sense of time. 22C-B is seen as an ecstasy replacement. 2There is a faster absorption of the drug on an empty stomach.1 The first effects are described as something being off in your head.3 As the effects intensify visual patterning and color vision can happen. 3When people close their eyes, they can see visuals and pictures.3

The drug 2C-B was invented by Alexander Shulgin in 1974 and was marketed as an MDMA replacement in the 1980s.1 In 1914 2C-B was labeled as a Schedule 1 in the U.S.1 By 1999 it was illegal in most of the world.1 •

Slang Terms • • • • • •

Nexus Bees Venus Bromo Mescaline BDMPEA Cloud 9

Drug Interactions

It is recommended to don’t use 2C-B if taking an MAOI inhibitor. An MAOI inhibitor includes Nardil and Parnate.1 Having 2C-B and marijuana together can lead to a more intense feeling leading to anxiety.2 Increasing the risk of a bad experience happening. Taking 2C-B and tramadol at the same time could increase the risk of having seizures.2

Monitoring

2C-B comes as a white powder or a tablet.2 There haven’t been any reports of straight 2C-B overdose.3 There have been overdoses of different combinations or types of 2C-B.3 The side effects of 2C-B are headache, sweating, nausea, and anxiety.2 2C-B has similar monitoring and drug screens similar to ecstasy.

Acute effects of the Novel Psychoactive Drug 2C-B on emotions

There were 20 active 2C-B participants to elevate the emotional and subjective effects of 2C-B. One conclusion was a reduction in anger among the participants after experiencing 2C-B. There was reported a more intense reaction to negative emotional stimuli. There was a decrease in the ability to recognize expressions of happiness.5

Laws

2C-B is a Schedule 1 Drug in the U.S. and there is no safe level of use.4 There are federal and state laws regarding the selling and possessing of 2C-B.4 There are also federal and state laws about being under the influence of 2C-B while driving. 4

Professional Opinion

In my professional opinion, I wouldn’t advise using this drug.

There isn’t any regulation of the safety and efficacy of manufacturing this drug There isn’t an official therapeutic use for 2C-B. -L Raven, PHARM D student

References: 1) 2C-B Basics. The Vaults of Erowid. Published August 21, 2000. Accessed October 1, 2023. https://www.erowid.org/chemicals/2cb/2cb_basics.shtml 2) 2C-B. Alcohol and Drug Formation. Updated November 8, 2022. https://adf.org.au/drug-facts/2c-b/ 3) Keuma C. What is 2C-B? Facts & Information. American Addiction Centers. Updated November 30, 2022. https://recovery.org/2c-b/ 4) Congress Agrees to Add 26 Synthetic Drugs to Controlled Substances Act. United States Drug Enforcement administration. Published June 19, 2012. https://www.dea.gov/press-releases/2012/06/19/congress-agrees-add-26-synthetic-drugs-controlled-substances-act 5) González D, Torrens M, Farré M. Acute Effects of the Novel Psychoactive Drug 2C-B on Emotions. Biomed Res Int. 2015;2015:643878.

Doi:10.1155/2015/643878 6) Image 1 (left bottom on page 1) 2C-B. Alcohol and Drug Formation. Updated November 8, 2022. https://adf.org.au/drug-facts/2c-b/ 7) Image 2 (right bottom on page 1) 2C-B. Alcohol and Drug Formation. Updated November 8, 2022. https://adf.org.au/drug-facts/2c-b/

Olivia Williams Student Pharmacist Fall 2023

ACETAMINOPHEN

Olivia Williams Student Pharmacist Fall 2023

~

Drug Monograph Author: Dalton Huffman

Fall 2023

Amanita History and Background: The Amanita muscaria was used in the pre-Christian religious traditions in Siberian culture. It spread far across Russia and Siberia. The psychedelic component achieves trance-like states that could previously only be found through dance and drumming. In Eastern Siberia, the mushroom was not used specifically for religious purposes. It was also used in a recreational way. However, not just anyone was allowed to eat this religious psychedelic. That was reserved specifically for the shamans of the village. After the consumption of the mushroom, the shaman would distribute his urine to after consumption. This would act as a buffer for everyone who consumed after him. Their body would get rid of all the major toxicities like stomach pain, and twitching. We also see the bright nature of the Amanita muscaria in folklore. It is currently the most well-known mushroom in the world.

Slang terms: Alice

Boomers

Buttons

Caps

Champiñones

Hongos

Magic

Mushies

Pizza Toppings

Shrooms

Tweezes

Pharmacologic Effect: The entire effects of the drug are not entirely known. The two primary components are the ibotenic acid and muscimol. These two compounds are what is responsible for the psychedelic effects of the drug. The ibotenic acid is a prodrug neurotoxin to the muscimol. The FDA has classi<ied it into 4 main categories, which are protoplasmic poison, neurotoxin, gastrointestinal irritant, and disul<iram like toxin.

Drug interactions/Toxicology: Nitrates, nitrites, alkalinizing agents, primidone, thioxanthene, methylphenidate, disopyramide, procainamide, and quinidine.

Laws: The Amanita mushroom is still considered legal within the United States. However, you are not able to sell them because they are labeled as not safe for consumption.

Louisiana is the only state that has prohibited the growing, selling, or possession of mushrooms.

Monitoring/Drug screen: This drug will not show up on a simple 12-panel drug screening. It takes a special test to be able to see muscimol within the urine. This would be a single-drop microextraction technique in line with capillary electrophoresis. This is the only way that you would be able to pick up the Amanita mushroom in the urine.

Professional opinion: The rise in usage of the Amanita mushroom has caught the eyes of many researchers. Some of them have decided to perform an experiment to see what the reason behind consumption was. It was concluded based on the experiment that considered 5600 comments. Men primarily took the mushroom to relieve stress, manage depression, and combat insomnia. However, for women, it was used to reduce pain and skin problems. It was found by researchers that the Amanita mushroom should be classified as a highly poisonous mushroom due to the fact that it contains psychoactive alkaloids: muscarine, ibotenic acid and muscimol.

References: 1. Are amanita mushrooms dangerous - Google Search. www.google.com. Accessed October 1, 2023. https://www.google.com/search?client=safari&rls=en&q=are+amanita+mushrooms+dang erous&ie=UTF-8&oe=UTF-8 2. Mikhaylova S. A Cultural History Of The Amanita Muscaria Mushroom. Psychedelic Spotlight. Published October 25, 2022. https://psychedelicspotlight.com/a-culturalhistory-of-the-amanita-muscaria-mushroom/ 3. Voynova M, Shkondrov A, Kondeva-Burdina M, Krasteva I. Toxicological and pharmacological profile of Amanita muscaria (L.) Lam. – a new rising opportunity for biomedicine. Pharmacia. 2020;67(4):317-323. doi:https://doi.org/10.3897/pharmacia.67.e56112 4. Nih.gov. Published 2017. Accessed October 1, 2023. https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=b41b73c4e604-46a7-96b4073721aa2c1c&type=display#:~:text=Drug%20Interactions%3A&text=Nitrates% 2C%20nitrites%2C%20alkalinizing%20agents%2C 5. Ordak M, Galazka A, Nasierowski T, Muszynska E, Bujalska-Zadrozny M. Reasons, Form of Ingestion and Side Effects Associated with Consumption of Amanita muscaria. Toxics. 2023;11(4):383. doi:https://doi.org/10.3390/toxics1104038

Amyl nitrate/nitrous oxide/inhalants

Alton Adams Student Pharmacist Fall 2023

Chemical name – nitrous oxide (N2O) Slang names – laughing gas, cartridges, hippy crack, N2O, Nangs, whippets1 Description: Nitrous oxide is an anesthetic gas mostly used in dental surgeries and as a whipped cream propellant. It is commonly available and it has short lived effects.2

Laws: Nitrous oxide not a controlled substance and is therefore legal to possess if being used for the correct purpose. The Food and Drug Administration (FDA) regulates use of this product, not the United States Drug Enforcement Administration (DEA). Some states do not allow anyone under the age of 18 to purchase products containing nitrous oxide because teens are the majority population that use nitrous oxide recreationally.4

Minhas R. Nitrous Oxide: How Does it Work & Why Is It Used? Available at https://west85thdental.com/nitrousoxide-how-does-it-work-why-is-it-used/.

Accessed October 1st, 2023.

Monitoring/drug screenings: Nitrous Oxide does not show up on routine drug screening panels but can be detected in blood or urine shortly after exposure.5

Cleveland Clinic. Whippets: What you need to know about these drugs. Available at https://health.clevelandclinic.org/what-arewhippets/. Accessed October 1st, 2023.

Medical use: Used in dental surgeries and other doctors’ offices as a pain reliever and in whipped cream cans as a propellant.1 Illegal (Street) use: People inhale the nitrous oxide from the whipped cream can propellant to get high.1 History/Background: Nitrous oxide was first discovered by English scientist Joseph Priestley. In 1799, Humphrey Davy of the Pneumatic Institute in Bristol, England experimented on the effects of nitrous oxide upon respiration. He administered the gas to patients in his institute and after observing its effects on people, coined the term “laughing gas”. From 1800-1840, it was only used recreationally in travelling medicine carnivals, where individuals would pay to use the gas for its effects. Then, in 1844, a dentist named Dr. Horace Wells, showed the effects of nitrous oxide in dentistry. By 1880, nitrous oxide is generally accepted by the public for surgery and childbirth and has continued to be used ever since.

More recently, it has been used by teenagers in whipped cream cans and concert goers in balloons and other various forms to get a sense of euphoria and relaxation.1

Notable drug interactions: CNS depressants: CNS depressants may enhance the CNS depressant effects of nitrous oxide. The most notable of these are alcohol, Azelastine, bupivacaine, buprenorphine, cannabinoidcontaining products, Doxylamine, hydroxyzine, isoflurane, Kava Kava, magnesium sulfate, methotrexate, metoclopramide, opioids, pramipexole, ropinirole, and zolpidem.6

Hamilton I, Summall H. How dangerous is laughing gas? The history of the drug and its risks, explained. Available at https://www. independent.co.uk/news/uk/home-news/ how-dangerous-is-laughing-gas-legal-highshippy-crack-nitrous-oxide-safety-factsexplained-a7088226.html.

Accessed October 1st, 2023

Pharmacology/drug effects: Nitrous Oxide is a central nervous system (CNS) depressant that works by displacing the air in your lungs and preventing oxygen from reaching your blood and your brain. As a result of this you get a ‘high’ feeling that may come with giggling and mild hallucinations.3

Molekuul Science Photo Library. Nitrous Oxide. Available at https://www.sciencephoto.com/media/107 4288/view. Accessed October 1st, 2023.

Professional opinion: Professionally, as a pharmacy student, my opinion on this street drug is that it has many negative effects and interactions with many drugs that can lead to horrible side effects including seizures and death. This drug has good uses when used correctly and in a professional setting, however it should not be used any other way, outside of doctors’ offices, hospitals, or dentist offices. !

References: 1.

2.

3.

4.

5.

6.

Erowid. Nitrous Oxide. Available at https://erowid.org/chemicals/nitrous/. Accessed October 1st, 2023.

Benisek A. What are Whippets? Available at https://www.webmd.com/mental-health/addiction/what-arewhippets#:~:text=Doctors%20use%20nitrous%20oxide%20as,an%20inhalant%20to%20get%20high. Accessed October 1 st, 2023.

Capehart C. This is How Nitrous Oxide Sedation Affects your Brain. Available at https://www.capehartdentistry.com/blog/2019/11/07/this-is-hownitrous-oxide-sedation-affects-your-brain/#:~:text=When%20you%20inhale%20nitrous%20oxide,the%20effects%20wear%20off%20quickly.

Accessed October 1st, 2023.

Rodriguez SG. Nitrous Oxide. Available at https://www.lacriminaldefenseattorney.com/legal-dictionary/n/nitrousoxide/#:~:text=Nitrous%20Oxide%20is%20not%20a,the%20regulations%20governing%20Nitrous%20Oxide. Accessed October 1 st, 2023.

Levy S, Harris SK, Sherritt L, et al. Drug Testing of Adolescents in Ambulatory Medicine. Available at https://jamanetwork.com/journals/jamapediatrics/fullarticle/204517#:~:text=Inhaled%20nitrous%20oxide%20can%20be,of%20routine%20drug %20screening%20panels. Accessed October 1st, 2023.

Lexicomp. Lexi-drugs. Nitrous Oxide. Interactions. Available at https://online-lexicom.ezproxy.lib.purdue.edu/lco/action/doc/retrieve/docid/patch_f/7366?cesid=7QXgpdKCSyO&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3D nitrous%2Boxide%26t%3Dname%26acs%3Dfalse%26acq%3Dnitrous%2Boxide. Accessed October 1st, 2023.

Anorectic is a drug used to produce appetite suppression or loss of appetite.

It is commonly used as a weight management drug in obesity and as an aid to help with weight loss.

Anorectics are also referred to as diet pills, appetite suppressants, crank, speed, fastin, and Fen-Phen.

How Do Anorectics Work?

Appetite suppressant Decreasing the rate of fat absorption in the body Induction of the feeling of fullness Prolongation of stomach emptying process.

https://c8.alamy.com/comp/F2MJ1E/diet-pills-and-appetitesuppressing-medication-as-a-prescription-drug-F2MJ1E.jpg

Pharmacology: Anorectics stimulate the central nervous system. Tolerance has been shown to occur commonly in these drugs.

A common anorectic, phentermine, is a sympathomimetic amine with properties that increase norepinephrine, dopamine, and serotonin. It inhibits the neuropeptide Y, a signaling pathway that induces hunger.

Effects of Anorectics Increased risk for cardiovascular events Severe gastrointestinal conditions Reduction of vitamin D, E, and betacarotene Increased risk of osteoporosis Irreversible hepatotoxicity and nephrotoxicity

Ainsley Rodrick, Student Pharmacist, Fall 2023

History of Anorectics FDA approval of weight loss drug, phentermine, dates to 1959. Phentermine was removed from the market due to results in patients with abnormal valve issues. The initial phentermine product was a combination of fenfluramine and dexfenfluramine. Phentermine was later approved alone in combination with topiramate in 2012.

Background of Use Commonly prescribed in patients with an eating disorder Several anorectic drugs are amphetamine-like substances, these drugs potentiate a high-risk for abuse and addiction. https://th.bing.com/th/id/OIP.ix8nWKJAHBoG7stHGAZUP wHaJ4?w=115&h=180&c=7&r=0&o=5&dpr=1.5&pid=1.7

Anorectics

Drug Interactions

Professional Opinion

Anorectics as a drug class have many drug-drug interactions.

Phentermine alone shows over 700 possible drug-drug interactions. It is best to consult with a physician before starting any type of anorectic treatment.

Interactions occur with MAOinhibitors, space out 14 days to avoid interactions.

Prescription anorectics can aid in weight loss for patients experiencing obesity. Overweight and obese patients can reduce their risk of other harmful complications through weight loss and weight management of anorectics. When used correctly, I think anorectics are a good addition to adjunct diet and exercise habits. While they can be a good option, I think it is necessary to address the potential for harmful use and addictive probability. As a healthcare worker, it would be necessary to follow-up with patients taking anorectics and pay attention to their drug therapy timeline. Many anorectic therapies are not longterm. This is a good opportunity to connect with your patient taking anorectics.

Monitoring Sudden stop of anorectics can lead to symptoms of withdrawal.

Avoid withdrawal symptoms of anorectics by allowing a gradual reduction in the drug dose as directed by a doctor.

Drug Screening Prescription anorectics are often in class III and IV schedule drugs, and they will show a positive drug screen result.

Laws

Section XLV-6907 - Use of Schedule III-IV Anorectics; Conditions; Limitations “A physician shall not prescribe, dispense, or administer a Schedule III or Schedule IV anorectic for the purpose of weight reduction or control in the treatment of obesity, except as an adjunct to a therapeutic regimen of weight reduction based on prescribed sound nutrition, caloric restriction, exercise, and behavior modification and otherwise in accordance with the FDAapproved indications for the medication and contraindications for unapproved combinations of anorectic agents.” -This is a limitation on anorectic prescribing in Louisana.

References: Stotts I. What Are Diet Pills: The Dangers of Diet Pill Abuse.

Addiction Resource. May 31, 2022. October 1, 2023. https://addictionresource.com/drugs/diet-pill-abuse The Partnership. Diet Pills (Anorectics). Partnership to End Addiction. September 25, 2023. October 1, 2023. https://drugfree.org/drugs/diet-pills-anorectics Health Jade Team. Anorectic drugs list, uses, dosage & anorectic drugs side effects. Health Jade. July 21, 2019.

October 1, 2023. https://healthjade.net/anorectic DrugBank Online. Phentermine. DrugBank Online. June 13, 2005. April 7, 2023. October 1, 2023. https://go.drugbank.com/drugs/DB00191 RxList. Didrex (Benzphetamine): Uses, Dosage, Side Effects, Interactions, Warning. RxList. September 22, 2022. October 1, 2023. https://www.rxlist.com/didrexdrug.htm#interactions Health Street. OTC Appetite Suppressants Drug Test. Health Street. September 26, 2023. October 1, 2023. https://www.health-street.net/drug-tests/substances/overthe-counter/otc-appetite-suppressants

Anya Wappler, Student Pharmacist, Fall 2023 Background/History Many anti-diarrheals exist, but loperamide has the highest abuse potential Loperamide (Imodium) is available over-thecounter or with a prescription1

Pharmacology Loperamide acts directly on intestinal muscle opioid receptors in order to prevent peristalsis3 It does not cross the blood-brain-barrier unlike other pain relievers2

Drug Effects Loperamide increases the anal sphincter tone3 When taken in large amounts, it can produce euphoric effects similar to opioids. It can be used to get high or help with withdrawal.2

Walmart. Imodium A-D Diarrhea Relief Caplets, Loperamide Hydrochloride, 24 ct.

Dose The maximum recommended daily dose is 8mg/day OTC or 16mg/ day with prescription1,3

People who abuse loperamide take 50-400 pills/day1

Slang Terms “the poor man’s methadone”1 Loperamide is the only opioid available without prescription Considered safe with low potential for abuse unless taken in extremely high doses Large doses can produce dangerous effects1

Toxicology/Side Effects Side effects include dizziness, constipation, nausea, abdominal cramps, abnormal heartbeat, chest pain, palpitations, fainting, or severe respiratory depression1,3

Drug Interactions Consider therapy modification with lonafarnib or sincalide Avoid combination with kratom3 Laws

Professional Opinion In my opinion, loperamide abuse should be monitored in a similar way to Sudafed. Perhaps scanning IDs into a system that all pharmacies use could decrease the number of abusers by detecting when someone has purchased a large amount in a short duration of time.

As of September 2019, the FDA approved changes to packaging for loperamide to discourage abuse Packaging now limits each carton to 48mg or less in individual doses5

Monitoring/Drug Screens Loperamide does not show up on routine drug screens but It can be detected in specialty tests for blood and saliva.

It can stay in the blood for 2 days

When being tested, loperamide will not show up as positive for opioids4

Made-in-China. Loperamide Hydrochloride Capsule 2mg GMP Medicine.

References: 1.

Nova Recovery Center. Imodium Addiction: Side Effects, Detox, Withdrawal, and Treatment. Nova Recovery Center. Accessed October 1, 2023. https://novarecoverycenter.com/drugs/imodium/

2.

Hilliard, J. Loperamide Addiction and Abuse. AddictionCenter. Updated April 17, 2023. Accessed October 1, 2023. https:// www.addictioncenter.com/drugs/over-the-counter-drugs/loperamide-addiction-abuse/

3.

Loperamide. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 1, 2023. http:// online.lexi.com

4.

George O. Imodium Half-Life and Dose Loperamide Show on Drug Tests. AddictionResource. Published July 12, 2022. Accessed October 1, 2023. https://addictionresource.com/drugs/imodium/stays-in-system/

5.

FDA Drug Safety Communication. FDA limits packaging for anti-diarrhea medicine loperamide (Imodium) to encourage safe use. FDA. Published January 30, 2018. Updated September 20, 2019. Accessed October 1, 2023. https://www.fda.gov/drugs/ drug-safety-and-availability/fda-limits-packaging-anti-diarrhea-medicine-loperamide-imodium-encourage-safe-use

ALLYSON WILLSON STUDENT PHARMACIST FALL 2023

Ayahuasca PHARMACOLOGICAL/DRUG EFFECTS:

Ayahuasca is a plant-based psychadelic agent that affects the senses. Common effects a person experiences is visual hallucinations, euphoria, paranoia, and vomiting. Its active compounds include dimethyltryptamine and harmala alkaloids. DMT binds to the 5-HT2A seretoin receptor in the brain which causes some of the visual and auditory hallucinations. The harmala alkaloids work as monoamine oxidase inhibitors and prevent the breakdown of DMT for more of the euphoric effect.

History/Background -Also known as yage

Slang Terms

-Plant medicine from Amazon

-Aya

rainforest

-Yage

-It is made from the Binesteriopsis caapi vine -A psychedelic agent -Has been used by indigenous tribes in South America -Used for religious, spiritual, and healing purposes

-The vine -Mother ayahuasca -La purga – “the purge” -Spirit Vine

Monitoring/ Drug Screening

Drug Interactions /Toxicology

-There is a urinary screening for DMT,

-MAOIs

which is the main component of Ayahuasca

-SSRIs

that will detect based on up to two days after the last intake. It is about $5 for a test.

-Antihypertensive Medications -Stimulants

Professional Opinion

-Antipsychotic Medications -Other psychedelic Substances

-People have commonly used ayahuasca in indigenous tribes mainly in the Amazon rainforest. This drug primarily is used for healing and cultural or traditional

Laws

practices. It is stated that the effects of this drug can

-Illegal: US (unless for religious use); illegal

minimize pain, both physical and mental. I think this

in most countries

drug has very strong psychedelic effects on people including hallucinations, which would be dangerous if

-Legal in: Mexico, Peru, Costa Rica, Chile

it was commonly used on a regular basis. This drug

(controlled), Brazil

while relatively safe, would not be the recommended

References:

Barbosa

PC,

Giglio

JS,

choice for treating pain in my opinion because of its

Dalgalarrondo

P.

Altered

states

of

consciousness and short-term psychological after-effects induced by

the first time ritual use of ayahuasca in an urban context in Brazil. J

PsychoactiveDrugs.2005;37(2):193-201.

Kjellgren A, Eriksson A, Norlander T. Experiences of encounters with

ayahuasca--"the

vine

of

the

soul".

J

Psychoactive

Drugs.

2009;41(4):309-315. doi:10.1080/02791072.2009.10399767.

Labate BC, Cavnar C. The expansion of the field of research on

ayahuasca: some reflections about the ayahuasca track at the 2010

MAPS "Psychedelic Science in the 21st Century" conference. Int J Drug

Policy. 2011;22(2):174-178. doi:10.1016/j.drugpo.2010.09.002

1.

Hamill J, Hallak J, Dursun SM, Baker G. Ayahuasca: Psychological and

Physiologic Effects, Pharmacology and Potential Uses in Addiction and

Mental Illness. Current Neuropharmacology. 2019;17(2):108-128.

doi:https://doi.org/10.2174/1570159x16666180125095902

effect on levels of consciousness.

Street Drugs Guide: Barbiturates Author:

Bardia Asadi, Student Pharmacist, 2023

Barbiturates are sedative-hypnotic medicines that were first introduced in the early 20th

History and Background of Abuse

century, and their abuse has a complicated history. They were initially given for medical disorders like anxiety and insomnia, but their sedative and euphoric effects made them popular among the general public. The high likelihood of overdose and their limited therapeutic index, however, caused reliance, tolerance, and countless instances of unintentional or purposeful overdose. A decrease in medical use was brought on by the emergence of safer substitutes like benzodiazepines in the 1960s and 1970s.

Barbiturates are already subject to strict regulation, yet the possibility of abuse and addiction still exists, calling for continual oversight and management.1,2

Slang Terms

Barbs, Downers, Yellow jackets, Blue heavens, Blue devils, Red devils, Blockbusters, Goofballs, Rainbows, Christmas trees.3

Barbiturates are drugs that suppress the central nervous system and increase the

Pharmacology and Drug Effects

activity of the inhibitory neurotransmitter GABA, which causes drowsiness, muscular relaxation, and induction of sleep. They are categorized according to how long they take to take effect, with ultra-short acting versions to long-lasting ones. These medications have a strong ability to reduce anxiety and promote sleep, but their usage is restricted due to serious dangers. Due to their low therapeutic index, barbiturates pose a considerable risk of tolerance, physical dependency, and overdose. In clinical practice, safer substitutes have essentially taken their place. Barbiturates are now mostly used to induce anesthesia and treat particular seizure disorders; their use as recreational drugs has decreased.1,3

Barbiturates can interact with other medicines, intensifying their sedative effects

Drug Interactions and Toxicology

because they are central nervous system depressants. Additionally, they could impede the metabolism of other medicines, which might lessen their effectiveness or result in toxicity. Barbiturates and alcohol or opioids can be particularly harmful when taken together since they can cause respiratory depression and overdose. In toxicology, signs of a barbiturate overdose include bewilderment, respiratory depression, and even coma.

In serious situations, activated charcoal or specialized countermeasures like flumazenil are used as treatments. When utilizing barbiturates in a medical environment, it is essential to monitor patients and be aware of potential drug interactions.3,4 Barbiturates are generally under stringent control due to their potential for misuse and

Laws

health hazards, while the rules governing them differ by nation and region. They are frequently categorized as controlled substances, which lays strict regulations on their manufacturing, distribution, and possession. Generally speaking, medical use is only permitted under specified conditions with strict prescription criteria.1,3 Various techniques are used to find barbiturates in people during drug testing and

Monitoring and Drug Screens

monitoring. Testing using urine, blood, and hair are typical methods. In medical settings, these screenings are used to guarantee safe usage, spot abuse or overdose, and assess the efficacy of treatment. Because barbiturates are prohibited substances, forensic analysis is used to determine unlawful use.3 The history of the medication class known as barbiturates in medicine is complicated.

Professional Opinion

They used to be often recommended for illnesses like anxiety, sleeplessness, and seizures, but because of safety worries, their use has substantially decreased.

Barbiturates are prone to dependency and overdose because of their limited therapeutic index. For many medicinal applications, safer substitutes like benzodiazepines have essentially taken their place. Barbiturates are mostly used in specialized medical conditions, such as the induction of anesthesia. When used in clinical settings, their potential for abuse and related dangers highlight the significance of prudent prescribing and rigorous monitoring.

References: 1. Griffin CE, Kaye AM, Bueno FR, et al. Benzodiazepine Pharmacology and Central Nervous System-Mediated Effects. Ochsner J. 2013;13(2):214-223.

2. Freemon FR. The Drug Abuse Problem. NIDA Res Monogr. 1981;37:21–30.

3. Barbiturates Drug Profile European Monitoring Center for Drugs and Drug Addiction Accessed October 1, 2023. https://www.emcdda.europa.eu/publications/drugprofiles/barbiturates_en#:~:text=Numerous%20synonyms%20and%20proprietary%20names,sleepers%2C%20 yellow%20jackets%2C%20etc.

4. Barbiturates. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 1, 2023. http://online.lexi.com 5. Jann M. Kennedy WK. Lopez G. Benzodiazepines: a major component in unintentional prescription drug overdoses with opioid analgesics. J Pharm Pract. 2014;27(1):5-16.

Bath Salts By: Brooke Hilderbrand, Student Pharmacist

History/Background Bath salts are derived from the leaves of the khat plant.1 Chewing khat originates from East Africa and the Arab Peninsula where it was highly popular.1 In 2009 the abuse of bath salts became much more prevalent in the United States, and they are still widely abused today.1 Bath salts are considered designer drugs, which means they are chemical precursors that can be used to develop effects similar to illicit drugs by using over the counter products.1

Slang Terms Bliss, Blue silk, Cloud Nine, Drone, Energy1, Ivory, Purple Wave, Red Dove, Snow Leopard, Stardust, Vanilla sky, White Dove, White Knight, and white Lightning.2 https://www.solsticehw.com/bathsalts-a-synthetic-drug-you-dontwant-in-your-bath/

Pharmacology & Drug Effects Bath salts fall beneath the synthetic cathinone class which are a class of central nervous system stimulants that block the dopamine-norepinephrine reuptake system.3 They have a similar structure to dopamine, and methamphetamine.1 They are designed to mimic products like cocaine, methamphetamine and MDMA also known as ecstasy.2 Some common effects that regular users of bath salts experience include intense euphoria, increased concentration, talkativeness, empathy, an urge to move, and a heightened sexual desire.1 https://www.emcdda.europa.eu/publicatio ns/drug-profiles/synthetic-cathinones_en

Monitoring & Drug screens Bath salts don’t show up on current routine drug testing screens. However, some commercial laboratories are starting to offer specialized synthetic cathinone testing.5 Some monitoring parameters for someone who is abusing bath salts include close observation of the person until they are sober.6 During this time, they can also be given IV fluids and IV sedatives to help with the withdrawal process.6

Drug Interactions & Toxicology Drug-drug interactions with cathinone’s can include other stimulants, depressants, and other hallucinogens.4 Signs of serious toxicity from the use of bath salts include tachycardia, agitation, hyperthermia, hypertension, and confusion, seizures, tolerance from pain, breakdown of muscle (rhabdomyolysis).6

Professional Opinion Due to the potential of life-threatening risks such as tachycardia, seizures, and muscle breakdown and the fact that abusing the chemicals found in bath salts is not recommended. Not only that but there is no known medical benefit of the use of bath salts which is another reason it is not recommended that bath salts are used in any capacity.

-Brooke Hilderbrand

Laws In 1970 The Controlled Substances Act was put in place to classify drugs based on their medical use, abuse liability, and risk of developing dependence.1 Many drugs such as bath salts were abused because they mimicked the effects of drugs that were put under regulation of the controlled substances act.1 Under this act the government wasn’t able to prosecute anything related to the use of bath salts.1 Therefore, the Controlled Substance Analogue Enforcement Act of 1986 was created.1 This act said that any drug that had a similar chemical structure to a schedule I or II drug that also has a greater or equal stimulant, depressive, or hallucinogenic effect should be treated as a schedule I substance.1 This help put a stop to people circumventing the Controlled Substance Act.1 In 2011 a law aimed more specifically towards bath salts was created.3 The DEA announced emergency scheduling to control MDPV, mephedrone/methylone (Cathinones) and all chemicals found in bath salts.3 The scheduling of these substances made having possession or selling these chemicals or any product that contains them illegal in the US.3

References: 1. German CL, Fleckenstein AE, Hanson GR. Bath salts and synthetic cathinones: An emerging designer drug phenomenon. Life Sci. 2014;97(1):2-8. doi: 10.1016/j.lfs.2013.07.023 2. Bath Salts. Department of Justice/Drug Enforcement Administration. Accessed October 1, 2023. https://www.dea.gov/documents/2020/2020-06/2020-06-05/bath-salts-drug-factsheet#:~:text=their%20legal%20status.-,Download,-DESIGNER%20DRUGS 3. Bath Salts Drug. Drugs.com. Accessed October 1, 2023. https://www.drugs.com/illicit/bathsalts.html 4. Assi S, Gulyamova N, Kneller P, Osselton D. The effects and toxicity of cathinones from the users’ perspectives: A qualitative study. Human Psychopharmacol Clin Exp. 2017. Doi: 10.1002/hup.2610 5. Synthetic Cathinones (Bath Salts): An Emerging Domestic Threat-situation Report. The United States Department of Justice Archives. Accessed October 1, 2023. https://www.justice.gov/archive/ndic/topics/srs.htm#:~:text=2011%2DS0787%2D004-,PDF,(1%2C132%20KB) 6. Bath Salts (Cathinones). Merck Manual. Accessed October 1, 2023. https://www.merckmanuals.com/home/special-subjects/illicit-drugs-and-intoxicants/bathsalts

Benzodiazepines

BY BEN BURTON, STUDENT PHARMACIST, FALL 2023

HISTORY The first benzodiazepine, chlordiazepoxide (Librium), was discovered and marketed in 1960 by Hoffman-La Roache. Following came diazepam in 1963. In the mid-to late1970’s, benzodiazepines became one of the most frequently prescribed medications. By the 1980’s clinicians found benzodiazepines to be a concern for abuse and dependence. This led to many guidelines and legislations regarding the use of benzodiazepines.

SLANG TERMS • • • • • •

Bars Downers Chill pills Benzos Zannies Tranks

PHARMACOLOGY Benzodiazepines are a class of CNS depressant drugs that were given their name due to a benzene ring and a diazepine ring in their structures. They are often used for anxiety disorders, seizures, and insomnia. They act by binding to the inhibitory neurotransmitter known as GABA which is found in many locations in the central nervous system (CNS). This mechanism produces a calming effect on the brain leading to its uses for anxiety, sleep, and seizures.

INTERACTIONS / TOXICOLOGY

MONITORING:

Benzodiazepines interact with other Opioid prescription drugs like Oxycodone as well as alcohol.

When taken together, these drugs can intensify the effects of each other which can be fatal. Some benzodiazepines are predominantly metabolized by CYP3A4, so food or drugs that inhibit CYP3A4 can reduce the clearance rate for some benzodiazepines. Benzodiazepine toxicity will result in central nervous system depression displaying symptoms likes impaired coordination, slurred speech, confusion, coma, and diminished reflexes.

Benzodiazepine use can be detected and monitored through the use of a urine drug screening.

Some overdose monitoring parameters are loss of consciousness, confusion, dizziness, faintness, shallow breathing, and lack of coordination.

LAWS Benzodiazepines are classified as C-IV Controlled substances in the U.S., meaning it is illegal to obtain them without a prescription. CIV controlled substances have a risk of abuse and dependence, but the risk is lower than for C-II and C-III controlled drugs.

PROFESSIONAL OPINION Benzodiazepines are good for the treatment of short-term anxiety problems but are not for long term. They are very effective in treating panic attack on an as needed basis. Due to their higher risk for abuse and addiction, benzodiazepines should be used cautiously for the treatment of anxiety.

REFRENCES: Drug Street Names: The Ultimate List - Addiction Center. Accessed September 30, 2023. https://www.addictioncenter.com/drugs/drug-street-names/ Wick JY. The history of benzodiazepines. Consult Pharm. 2013;28(9):538-548. doi:10.4140/TCP.n.2013.538 Benzodiazepines. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed September 30, 2023. http://online.lexi.com Benzodiazepines. Accessed September 30, 2023. https://www.dea.gov/factsheets/benzodiazepines

Bromo Dragonfly Amy Cho, Student Pharmacist Fall 2023 Slang Terms: - Dragonfly - DOB-Dragonfly - Fly - BDF - B-Fly

Background/History ● First synthesized in late 1990s ● Analogue of amphetamine ● Related to phenethylamine family of drugs ● Schedule 1 drug

Drug effects ● Physical ○ Agitation ○ Tonic-clonic seizures ○ Vasoconstriction ○ Necrosis ○ Death ● Mental ○ Severe,vivid and often frightening hallucinations ● Longterm ○ DEA is still studying effects of the drug

Pharmacology: ● High affinity for 5-HT2A serotonin receptors ● Potent hallucinogen ● Alpha-1 agonist ○ Intense peripheral vasoconstriction and end organ damage ● Symptoms include: ○ Agitation, tachycardia, mydriasis, hallucinations, seizures, and limb ischemia

What does it look like? ● In its purest form, it is a white powder. ● It can be colored or mixed with other ingredients that may change its appearance. ● It could be dissolved and made into liquid.

Cayman Chemicals. Bromo-DragonFLY. Available at https://www.caymanchem.com/product/11561/bromodragonfly-%28hydrochloride%29

Drug Interactions: ● No information was reported yet about Bromo Dragonfly due to lack of research.

Laws: ● Illegal in several countries. ● Still unscheduled and unregulated in the US. ● Schedule 1 drug in Oklahoma

Professional Opinion: ●

Bromo dragonfly is a hallucinogen that is produced from amphetamine and has LSD-like effects. Considering that it does not have much research nor information on this drug other than serious side effects and adverse events such as end organ damage and tachycardia, this drug should be scheduled 1 and should not be used.

This drug is hard to monitor with addicts because it will not show up on typical drug screens, making it hard to support those in need. ~ACho

Toxicology: ● Several fatalities attributable to use of Bromo Dragonfly have been reported internationally.

Monitoring/Drug Screen ● Some specialized drug tests will detect Bromo Dragonfly. ● Most normal drug tests do not show this drug.

Article Summary: ● In an article regarding bromo dragonfly, it talked about the pharmacokinetics of this drug. It stated that it is the most potent 5-HT2A-receptor agonist, leading it to have an effect for 2-3 days. It has vasoconstriction effects which could lead to fatalities that have already been reported. After an experiment being done on this drug, it showed that bromo-dragonfly is also a competitive inhibitor of of MAO-A. However, the article stated that there has to be a lot more research done on this drug to show its full true effects.

References: 1.

2.

3.

4.

5.

Bromo Dragonfly:An Odd Drug. Clearbrook Treatment Centers. Accessed October 1, 2023. https://www.clearbrookinc.com/news/bromo-dragonfly-an-odd-drug-pennsylvania/ What is Bromo-Dragonfly? Vanderbilt University Medical Center. Accessed October 1, 2023. https://www.vumc.org/poison-control/toxicology-question-week/april-26-2016-what-bromo-dragonfly Wood DM, Looker JJ, Shaikh L, et al. Delayed onset of seizures and toxicity associated with recreational use of Bromo-Dragonfly. Journal of Medical Toxicology. doi:10.1007/BF03178273 What could be wrong with a little dragonfly? Drug and alcohol testing compliance services. Accessed October 1, 2023. https://datcs.com/2012/03/21/what-could-be-wrong-with-a-little-dragonfly/ Noble C, Holm NB, Mardal M, Linnet K. Bromo-dragonfly, a psychoactive benzodifuran, is resistant to hepatic metabolism and potently inhibits monoamine oxidase A. Toxicol Lett. doi:10.1016/j.toxlet.2018.07.018

Buprenorphine Emery Frey, Student Pharmacist Fall 2023

History/Background: Medication-Assisted Buprenorphine was first discovered in 1966 Treatment.

Recovery Binder.

by John Lewis at Reckitt and Coleman, a Published March 12, 2018. Accessed pharmaceutical company that is now known October 2, 2023. as Reckitt. The company had been trying to https://www.recove rybinder.org/resour develop an opioid for pain relief with less ces/medicationabuse potential. 9 years later, buprenorphine assisted-treatment is proposed as an alternative to methadone for the treatment of opioid use disorder, and studies begin. It wasn’t until 1985 that buprenorphine was approved for the treatment of acute or post-operative pain in the parenteral form.3 Then in October 2002, the FDA approved buprenorphine, in the sublingual form, for the treatment of opioid use disorder. Although it’s used for the treatment of addiction, it can still be abused. Users can take more than the prescribed amount to experience a high by snorting pills, dissolving the sublingual film and injecting it, etc.10 Slang names: boxes, bupes, oranges, sobos, stop signs, stops, subs 1 Pharmacology/Drug Effects: Buprenorphine Buprenorphine is a synthetic opioid indicated for the Sublingual 8 mg treatment of pain and opioid use disorder (OUD). It is a Tablet – VistaPharm. partial agonist at the mu-opioid receptor, although it is a vistapharm.com.

Accessed October 2, potent analgesic in the central nervous system. It binds 2023. with high affinity to the mu-opioid receptor and https://vistapharm. com/product/bupre dissociates slowly. For this reason, withdrawal is much norphineless mild as compared to a full agonist opioid, like sublingual-8-mgtablet-rhodes/ morphine or fentanyl. In general, it has a slow onset of action and prolonged duration of action. When used for OUD, buprenorphine is used as a substitute for a full agonist opioid; the patient will then be slowly tapered off buprenorphine, and the patient will only experience mild withdrawal symptoms. It is also safer than methadone in treating OUD since it displays ceiling effects on respiratory depression. 5

Drug Interactions/Toxicology: •

•

•

Sedating agents: Buprenorphine should not be taken with any sedating drugs, as it will cause additive sedation and can lead to overdose. These drugs include benzodiazepines, alcohol, certain antidepressants, and sedative antihistamines.4 Full agonist opioids: Buprenorphine should not be taken with full agonist opioids, such as oxycodone, hydrocodone, and morphine.4 Buprenorphine is metabolized by CYP3A4.

Dose adjustments and monitoring are needed when administered with CYP450 inducers and/or CYP450 inhibitors.4

Monitoring/Drug Screens: • While buprenorphine is an opioid, it doesn’t show up in most common drug tests. It is a synthetic opioid, so a specific drug test that tests for its chemical structure may be required. Therefore, it will not show up on a routine opiate test, which reliably detects morphine, codeine, and heroin.9 • Buprenorphine will not cause false positives for other opioids.9

Laws •

•

COVID-19 Telemedicine Flexibilities for Prescribing Controlled Medications: In March 2020, the DEA permitted controlled substances, including buprenorphine, to be prescribed via telemedicine.8 Consolidated Appropriations Act of 2023: Section 1262 of the CAA removed the requirement that a healthcare practitioner must apply for a waiver from the DEA to dispense Schedule III, IV, or V medications for the treatment of substance use disorder. Additionally, there is no longer a federal limit on the number of patients a prescriber may treat for opioid use disorder with buprenorphine.8

Buprenorphine Drug Test.

POCTestSupply. Accessed November 16, 2023. https://www.poctestsupply .com/store/p/41Buprenorphine-DrugTest.aspx

Professional Opinion: I believe buprenorphine is a safe option for medication-assisted treatment as compared to its alternatives. However, just like other opioids, it requires strict monitoring when prescribing and dispensing. I hope to help patients with substance use disorder in my future career, and I hope that there will one day be a drug for the treatment of SUD and OUD that will have little to no potential for abuse.

-E Frey

References: 1. Slang Terms and Code Words: A Reference for Law Enforcement Personnel DEA Intelligence Report.; 2018. https://www.dea.gov/sites/default/files/2018-07/DIR022-18.pdf 2. Shulman M, Wai JM, Nunes EV. Buprenorphine Treatment for Opioid Use Disorder: An Overview. CNS drugs. 2019;33(6):567-580. doi:https://doi.org/10.1007/s40263-019-00637-z 3. Sivils A, Lyell P, Wang JQ, Chu XP. Suboxone: History, controversy, and open questions. Frontiers in Psychiatry. 2022;13. doi:https://doi.org/10.3389/fpsyt.2022.1046648 4. Information NC for B, Pike USNL of M 8600 R, MD B, Usa 20894. Drug Interactions Involving Methadone and Buprenorphine. World Health Organization; 2009. https://www.ncbi.nlm.nih.gov/books/NBK143177/ 5. Kumar R, Viswanath O, Saadabadi A. Buprenorphine. PubMed. Published 2023. https://www.ncbi.nlm.nih.gov/books/NBK459126/#:~:text=Buprenorphine%20is%20also%20not%20a 6. Select Federal Policies Governing Methadone and Buprenorphine for Opioid Use Disorder. Default. Accessed October 2, 2023. https://www.asam.org/advocacy/practice-resources/regulatory-resources/select-federal-policies-addiction-medications 7. Pope C. Does Suboxone show up on a drug test? Drugs.com. Published March 21, 2023. Accessed October 2, 2023. https://www.drugs.com/medicalanswers/suboxone-show-drug-test-3535355/ 8. How is Suboxone Abused? Signs and Symptoms of Addiction and Abuse. Mission Harbor Behavioral Health. https://sbtreatment.com/suboxone/

CANNABIDIOL/THC/HASHISH History and Background: -First discovered near the Altai Mountains 12,000 years ago in Central Asia.

-Nomandic people brought cannabis seeds with them as they migrated.

-Cannabis was used medicinally before the Common Era in Egypt, China, and Greece. It then made its way to Europe.

-Some people used cannabis for ropes, food, seeds for oil, or to make nets.

-Other people realized the structure of cannabis and cultivated it for the THC content.

-Cannabis was utilized to reduce anxiety, relax muscles, decrease appetite, provide a euphoric feeling, or aid with nausea.

-The common name in China is Má which refers to numbness/anesthesia.

-2 main cannabinoids: THC and CBD

Slang Terms: Weed, pot, Mary Jane, bud, ganga, joint, dope, dab

Ashton CH. Pharmacology and effects of cannabis: A brief review. The British Journal of Psychiatry. 2001;178(2):101106. doi:10.1192/bjp.178.2.101

Pharmacology/drug effects: -THC is an agonist for CB1 and CB2 of the cannabinoid receptor.

-These receptors are in the central nervous system and on some peripheral tissues such as the spleen, urinary tract, GI tract and leukocytes.

-Herbal cannabis contains over 400 compounds and 60 cannabinoids. Many of the compounds are unknown, but THC is the most potent component.

-Relatively water insoluble so it cannot be used intravenously.

-THC has less oral bioavailability, so people who use it orally will only get 25-30% of what the smokers would get with the same amount of THC. -By smoking cannabis, 50% will be absorbed in the lungs and get into the blood stream and cross the blood brain barrier.

-THC is lipid soluble and accumulates in fatty tissue.

-Elimination half-life of THC in tissues is ~ 7 days, but it takes ~30 days to eliminate a single dose.

-THC is metabolized by the liver.

-The use of THC can result in spontaneous laughter, happiness, euphoria, reflective mood, quiet, sedation, increased heart rate, facial flushing, dry mouth, dizziness, coughing, or bloodshot eyes.

Meghan Collins, Student Pharmacist, Fall 2023

Drug Interactions and Toxicology: -THC increases the impact of alcohol.

-THC may impact the way the body processes herbs, anticoagulants, anti-platelets, and supplements.

-Increases the sedative impact of antidepressants.

-Potentially reduces the effect of protease inhibitors.

-Mania may be induced if marijuana is taken with a selective serotonin reuptake inhibitor (SSRI).

Monitoring and drug screening: -Urine test -Cannabinoid immunoassay -Test blood, saliva, or hair -High pressure liquid chromatography

Laws: -In Indiana, a person carrying marijuana can be charged with a class B misdemeanor which results in 180 days of jail time or a maximum fine of $1000.

-Possession of THC is illegal at the federal level.

-States are adopting their own policies and some have made THC legal to possess.

-THC is considered a schedule 1 controlled substance.

Ashton CH. Pharmacology and effects of cannabis: A brief review. The British Journal of Psychiatry.

2001;178(2):101-106. doi:10.1192/bjp.178.2.101

Professional opinion: In my opinion, I do not think that marijuana should be considered a schedule 1 controlled drug because there are benefits for people to improve their quality of life and is has medical benefits. In addition, I think marijuana legalization would boost the economy and provide more jobs. -M Collins

References: 1. Testing THC Levels in Edibles – Modern Canna Science. Modern Canna | MCS. Accessed September 28, 2023. https://moderncanna.com/testing-thc-levels/edibles/ 2. Cannabinoids - Alcohol and Drug Foundation. Accessed September 28, 2023. https://adf.org.au/drug-facts/cannabinoids/ 3. Staff NA. Common Street Names for Marijuana. Newport Academy. Published February 28, 2020. Accessed September 28, 2023. https://www.newportacademy.com/resources/substance-abuse/street-names/ 4. Crocq MA. History of cannabis and the endocannabinoid system. Dialogues Clin Neurosci. 2020;22(3):223-228. doi:10.31887/DCNS.2020.22.3/mcrocq 5. In the Weeds. Accessed September 28, 2023. https://rockinst.org/intheweeds/ 6. admin. Indiana Marijuana Laws: Crossing the (State) Line. Keffer Hirschauer LLP. Published July 14, 2023. Accessed September 28, 2023. https://www.indyjustice.com/blog/criminal-defense/indiana-marijuana-laws/ 7. Marijuana. Mayo Clinic. Accessed September 28, 2023. https://www.mayoclinic.org/drugs-supplements-marijuana/art20364974 8. Marijuana (THC) Testing. Testing.com. Published June 17, 2021. Accessed September 28, 2023. https://www.testing.com/tests/marijuana-thc-testing/ 9. Ashton CH. Pharmacology and effects of cannabis: A brief review. The British Journal of Psychiatry. 2001;178(2):101-106. doi:10.1192/bjp.178.2.101 10. Grotenhermen F. Pharmacology of cannabinoids. Neuro Endocrinol Lett. 2004;25(1-2):14-23.

11. Sacco LN, Lampe JR, Sheikh HZ. The Federal Status of Marijuana and the Expanding Policy Gap with States.

12. Education MCL. Weeding Through the Information: Interpreting Laboratory Tests to Determine New vs. Residual Use of Marijuana. Insights. Published March 7, 2022. Accessed September 28, 2023. https://news.mayocliniclabs.com/2022/03/07/weeding-through-the-information-interpreting-laboratory-tests-todetermine-new-vs-residual-use-of-marijuana/

Cocaine, Chioma Olumba Student Pharmacist, Fall 2023 History/Background of cocaine use: ❖ Indigenous peoples in South America have used coca leaves for thousands of years for medicinal, religious, and stimulant purposes. ❖ In the late 19th and early 20th centuries, cocaine gained popularity in tonics, elixirs, and even beverages like Coca-Cola. However, as its addictive properties became evident, regulatory measures were introduced. ❖ In the 1980s, cocaine abuse soared, leading to a public health crisis in the United States and other countries. ❖ Since then, efforts have been made to curb cocaine production and trafficking globally. However, cocaine abuse remains a significant problem in various parts of the world.

Slang terms for cocaine: Coke, flake, Snow, Big C, Coca, White Horse, Nose Candy, Coca Cola, Blow, Rock Pharmacology/Drug effects: ❖ Cocaine is a reuptake inhibitor, meaning it blocks the reuptake transporters for neurotransmitters such as dopamine, serotonin, and norepinephrine. By blocking the reuptake process, cocaine increases the concentration of these neurotransmitters in the synaptic cleft, leading to prolonged neurotransmitter activity and intensifying the signaling between neurons. Some effects of cocaine include headaches, seizures, heart attack, stroke, mood problems, lung damage, loss of smell, trouble swallowing, and HIV.

Drug Interactions/Toxicology: ❖ Alcohol ❖ Amphetamines ❖ Opioids ❖ Benzodiazepines ❖ Monoamine oxidase inhibitors (MAOIs)

Laws: ❖ Schedule II controlled substance under the Controlled Substances Act. This classification indicates that it is considered to have a high potential for abuse, has currently accepted medical uses with severe restrictions, and can lead to severe psychological or physical dependence. ❖ The possession, distribution, and trafficking of cocaine are federal offenses and are punishable under federal law.

Monitoring/drug screens: ❖ Urine drug testing, blood drug testing, hair drug testing and saliva drug testing. Drug screens are required for pre-Employment testing, probation and parole, sports, and substance abuse treatments.

Professional opinion: ❖ Cocaine use is strongly discouraged due to its severe health risks, including heart problems, addiction, and mental health disorders. It can lead to dangerous behaviors and long-term health issues. Treatment and support from healthcare providers are important for individuals struggling with cocaine addiction.

Prevention efforts and education about the dangers of cocaine use are vital in promoting public health.

References 1. Cocaine: Short and long-term side-effects & treatment of addiction. WebMD. 2018. Accessed November 17, 2023. https://www.webmd.com/mental-health/addiction/cocaine-use-and-its-effects.

2. Ciccarone D. Stimulant abuse: Pharmacology, cocaine, methamphetamine, treatment, attempts at pharmacotherapy.

Primary Care: Clinics in Office Practice. 2011;38(1):41-58. doi:10.1016/j.pop.2010.11.004 3. Richards J. Cocaine National Library of Medicine. Accessed November 18, 2023. https://www.ncbi.nlm.nih.gov/books/NBK430769/.

4. 1. Editor L. Cocaine Possession: Federal laws, penalties and punishments. Lawteryx. February 13, 2023. Accessed November 17, 2023. https://www.lawteryx.com/blog/criminal-law/cocaine-laws-punishments/.

5. Cocaine- molecule in 3D using JMOL. Accessed November 17, 2023. https://www.edinformatics.com/interactive_molecules/3D/cocaine_molecule.htm.

6. 1. Download Pills clipart HQ PNG image. FreePNGImg. Accessed November 17, 2023. https://www.freepngimg.com/png/27363-pills-clipart.

“Devil’s Breath”

CLAIRE REYES

(Scopolamin e, Angel’s Trumpet, Burandanga )

PHARMACY STUDENT FALL 2023

History/Background First synthesized in 1959 derived from plants in the Solanacae family Medically used for nausea, motion sickness, or anasthesia Has been used for many years in spiritual rituals in South America Can be used to take advantage of people and put them into a dazed state Devil's Breath, also known as yellow datura flowers, pictured in Vancouver, British Columbia. https://www.insider.com/a-tiktoker-accidentally-drugged-herself-sniffing-devils-breath-flower-2021-7

Pharmacology “Devil’s breath” acts as a competitive inhibitor for the muscarinic receptors in the body. The normal substrate is acetylcholine which affects the central nervous system.

Drug Effects: Restlessness Hallucinations Agitation Memory loss Delirium Seizures Coma Devil’s breath, used to hypnotize, rob victims. https://www.thestar.co.ke/sasa/lifestyle/2019-06-08-devils-breath-used-to-hypnotise-robvictims/

Toxicology

Drug Interactions

In large doses, devil’s breath

Anticholenergic drugs

can cause:

Drugs that cause central

lethargy

nervous system adverse effects

hallucinations

Oral drugs absorbed in the

dry, flushed skin and dry

stomach

mouth increased heart rate increased blood pressure

Laws/Monitoring and Drug Screens Currently, there are no laws regulating scopolamine. The plant it derives from can be grown legally in the United States.

Scopolamine powder. https://www.standardmedia.co.ke/entertainment/news/article/2001403892/for get-mchele-why-you-should-be-wary-of-devils-breath-in-night-clubs

Professional Opinion “As a pharmacy student, devil’s breath is incredibly potent and can be dangerous when in the wrong hands. I believe there needs to be more regulations around this drug. ~C. Reyes References 1. Brugmansia. The Vaults of Erowid. Accessed October 14, 2023. https://www.erowid.org/plants/brugmansia/brugmansia.shtml 2. Scopolamine: The Blowing Powder. Northpoint Recovery. Accessed October 14, 2023. https://www.northpointrecovery.com/blog/scopolamine-blowing-powder/ 3. Scopolamine. Drug Bank Online. Accesed October 14, 2023. https://go.drugbank.com/drugs/DB00747 4. Devil’s Breath: Urban Legend or the World’s Most Scary Drug? Drugs.com. Accessed October 14, 2023. https://www.drugs.com/illicit/devils-breath.html 5. Transderm Scop. Package Insert. ALZA Corporation. 2013.

6. What is Devil’s Breath (Scopolamine)? WebMD. Accessed October 14, 2023. https://www.webmd.com/drug-medication/what-is-devils-breath 7. Devil’s Breath in the United States. Narconon Arrowhead. Accessed October 14, 2023. https://www.narcononarrowhead.org/blog/devils-breath-in-the-united-states.html

DEXTROMETHORPHAN Naomi Davis | Student Pharmacist 2023

Fall 2023

DXM

RoboTablets cough suppressant, 100 doses, dextromethorphan 30 mg 100 tablets, 5 mm diameter tablets. Gosupps.com.

Accessed October 20, 2023.

HISTORY OF DXM 1 DXM was introduced by the FDA in 1958 for coughs. In 1962, the first documentation of using DXM for fun was reported. In the 1970s, it was then sold as a tablet form over the counter. In 1973, the brand ‘Romilar’ was removed from the market because of ABC Action News. Father says son abused over-the-counter medicine. YouTube. March 5, 2014. Accessed October 23, 2023. https://youtube.com

2

increased sales in recreational use.

SLANG TERMS

DXM, Robo, Tussin, Robo-tripping, Tussing, Dexing, Robodosing, robofizzing, skittling

PHARMACOLOGY AND DRUG EFFECTS3 Dextromethorphan (DXM), which is found in cough medicines, goes through a process in the body called "first-pass metabolism" and turns into "dextrophan." Dextrophan has two effects: it can help suppress coughs, but it can also make the user feel detached from reality by affecting NMDA brain receptors.

DXM interacts with different parts of the brain and body, which are usually targeted when treating brain and mental health problems. It's important to note that it doesn't work on the same receptors as opioids. When DXM is metabolized, it becomes dextrophan, which can't easily get past the blood-brain-barrier. Even though there might be a lot of dextrophan in the blood stream, it doesn't usually have an effect in the brain, unless taken in extremely high doses. Taking too much DXM can cause serious problems like such as behaving strangely, having a high body temperature, and even seizures.

RoboTablets cough suppressant, 100 doses, dextromethorphan 30 mg 100 tablets, 5 mm diameter tablets.

Gosupps.com. Accessed October 20, 2023.

DEXTROMETHORPHAN Rbitussin. Robitussin Adult Maximum Strength Cough + Chest Congestion DM Max (8 fl. oz Bottle), Non-Drowsy Suppressant & Expactorant, Raspbrry Flavor. Amazon. Accessed October 18, 2023. https://amazon.com

Fall 2023

DXM DRUG INTERACTIONS 4 Using dextromethorphan (DXM) isn't physically addictive, but heavy users might develop a rare psychological addiction. Regular use can lead to tolerance, and it can potentially cause small brain abnormalities known as Olney's Lesions. DXM is not recommended, when taking MAO inhibitors or when there's a risk of serotonin syndrome.

LAWS

5

MONITORING

6

DXM is a legally sold cough

DXM has a relatively short half-life of about 3-4

suppressant, it is neither a controlled

hours, meaning it can remain in a user's system

substance or a regulated chemical. It

for approximately 6-8 hours after use. It can be

is restricted from purchasers under

detected in urine for up to 2 days, in blood for

the age of 18 years old with out

3-24 hours, and in hair for as long as 90 days

prescription.

after the last dose. Despite its relatively short

PROFESSIONAL OPINION

duration of action, DXM misuse remains a

Dextromethorphan is a great therapeutic option for treating cough and congestion at recommended doses. When abused at higher doses, it can get into the CNS and cause unpredictable neurological disorders.

REFERENCES

1. Erowid. DXM Timeline. The Vaults of Erowid. February 10, 2015. Accessed October 10, 2023. https://www.erowid.org/chemicals/dxm/dxm_timelin e.php 2. May ME. Dextromethorphan Abuse. Poison Control.

Accessed October 25, 2023. https://https://www.poison.org/articles/dextrometh orphan

concern, with a 5% prevalence among 12th graders in 2013, and an estimated annual usage by over 1 million people in preparations containing DXM. 3. Taylor, C. P., Traynelis, S. F., Siffert, J., Pope, L. E., & Matsumoto, R. R. (2016). Pharmacology of dextromethorphan: Relevance to dextromethorphan/quinidine (Nuedexta®) clinical use.

Pharmacology & Therapeutics (Oxford), 164, 170–182. https://doi.org/10.1016/j.pharmthera.2016.04.010 4. Erowid. DXM Basics. The Vaults of Erowid. February 10, 2015.

Accessed October 10, 2023 5. Drug Fact Sheet: DXM. Department of Justice/Drug Enforcement Administration. Accessed October 15, 2023. https://www.dea.gov/sites/default/files/2020-06/DXM-2020.pdf 6. How long does dextromethorphan stay in your system? Banyan Treatment Centers. Accessed October 15, 2023. https://www.banyantreatmentcenter.com/2021/09/07/dextrometh orphan-and-how-long-it-stays-in-your-system/

DHEA By: Emily Byford Fall 2023 Student Pharmacist

1. HISTORY/ BACKGROUND

DHEA was first discovered as a urine metabolite in 1934 by Adolf Buteiiandt and Hans Dannenbaum from Germany, reaffirmed as a urinary metabolite in 1943 and isolated from serum in 1954. DHEA, is the second most abundant circulating steroid in humans and serves as the substrate (precursor) for other androgens As a synthetic supplement, it is aimed towards alleviating symptoms associated with a decreased DHEA pool and sometimes it is used when the user wants to increase the DHEA pool and downstream metabolites, such as testosterone, for a short period of time. People use DHEA as an anti-aging therapy and to improve physical performance. DHEA is also used to treat depression and symptoms of menopause.

2. SLANG TERMS Dehydroepiandrosterone Intrarosa Prasterone Mother of all hormones 3b-hydroxyandrost-5-en17-one 3β-hydroxy-5-androsten17-one Androstenolone

3. PHARMACOLOGY/ DRUG EFFECTS DHEA is a hormone. Use of this supplement might increase levels of androgen and have a steroid effect. DHEA also might increase the risk of hormone-sensitive cancers, including prostate, breast and ovarian cancers. If you have any form of cancer or are at risk of cancer, don't use DHEA. Don't use DHEA if you're pregnant or breastfeeding. Consider avoiding use of DHEA if you have high cholesterol or a condition that affects the supply of blood to the heart (ischemic heart disease). DHEA might reduce high-density lipoprotein (HDL), or "good," cholesterol levels. Use of DHEA also might worsen psychiatric disorders and increase the risk of mania in people who have mood disorders. It also might cause oily skin, acne and unwanted, male-pattern hair growth in women (hirsutism).

4. DRUG INTERACTIONS/ TOXICOLOGY There are many interactions with DHEA with other hormones and how it can cause excess hormones or cause many severe effects with testosterone.

Another thing that DHEA can do with drugs is decrease the effectiveness with antipsych, seizure, and reuptake of serotinin inhibitor medicaitons.

5. LAWS 1. DHEA is a “legal” dietary supplement ingredient and not a controlled substance. Despite this, the World AntiDoping Agency (WADA) prohibits its use in sport.

2. DHEA is banned by the National Collegiate Athletic Association (NCAA), the International Olympic Committee, and the World Anti-Doping Agency (WADA)

6.MONITORING/ DRUG SCREEN No, DHEA will not show up on a routine drug test.

Can be tested through blood If you feel you have taken to much hormone, watch for signs of blurred vision, extreme headache, vomiting, high fever, and serious heart issues

7. PROFESSIONAL OPINION In my professional opinion, there is not enough clinical evidence about DHEA’s efficacy and safety that would allow me to feel comfortable recommending this to a patient as treatment. Since this is a steroid, there are many interactions and we already have hormones in our body so adding more would most likely cause adverse effects. Until more data is out there through clinical trials I would not recommend this to my patients as it could increase the risk of hormone-sensitive cancers as well.

-E. Byford, PharmD Student

8. References 1. NYCE J. ALERT TO US PHYSICIANS: DHEA, WIDELY USED AS AN OTC ANDROGEN SUPPLEMENT, MAY EXACERBATE COVID-19. ERC. FEBRUARY 1, 2021. ACCESSED SEPTEMBER 24, 2023.

HTTPS://ERC.BIOSCIENTIFICA.COM/VIEW/JOURNALS/ERC/28/2/ERC-200439.XML. 2. MILAZZO N, SICART P-A. DHEA. EXAMINE. JULY 17, 2023. ACCESSED SEPTEMBER 24, 2023.

HTTPS://EXAMINE.COM/SUPPLEMENTS/DHEA/RESEARCH/.

3. DHEA SULFATE TEST: MEDLINEPLUS MEDICAL TEST. MEDLINEPLUS. NOVEMBER 12, 2021. ACCESSED SEPTEMBER 24, 2023.

HTTPS://MEDLINEPLUS.GOV/LAB-TESTS/DHEA-SULFATETEST/#:~:TEXT=A%20HEALTH%20CARE%20PROFESSIONAL%20WILL,TAKES %20LESS%20THAN%20FIVE%20MINUTES. 4. DHEA: OVERVIEW, USES, SIDE EFFECTS, PRECAUTIONS, INTERACTIONS, DOSING AND REVIEWS. WEBMD. 2020. ACCESSED SEPTEMBER 24, 2023.

HTTPS://WWW.WEBMD.COM/VITAMINS/AI/INGREDIENTMONO-331/DHEA. 5. DHEA: CAN I USE IT? OPSS. MAY 7, 2020. ACCESSED SEPTEMBER 24, 2023. HTTPS://WWW.OPSS.ORG/ARTICLE/DHEA-CAN-I-USEIT#:~:TEXT=DHEA%20IS%20A%20%E2%80%9CLEGAL%E2%80%9D%20DIETA RY,PROHIBITS%20ITS%20USE%20IN%20SPORT. 6. COUCH J. 9 FACTS YOU DIDN’T KNOW ABOUT DHEA, THE “MOTHER OF ALL HORMONES.” YOUR WELLNESS CENTER. SEPTEMBER 9, 2021. ACCESSED SEPTEMBER 24, 2023. HTTPS://YOURWELLNESSCENTER.COM/BLOG/9FACTS-YOU-DIDNT-KNOW-ABOUT-DHEA-THE-MOTHER-OF-ALLHORMONES/#:~:TEXT=WHEREAS%20PROGESTERONE%20RECEIVED%20ITS %20NICKNAME,ABUNDANT%20HORMONE%20IN%20YOUR%20BODY.

9. Article

ANDROGENS PLAY A FUNDAMENTAL ROLE IN THE MORBIDITY AND MORTALITY OF COVID-19, INDUCING BOTH THE ACE-2 RECEPTOR TO WHICH SARS-COV-2 BINDS TO GAIN ENTRY INTO THE CELL, AND THE TRANSMEMBRANE PROTEASE THAT PRIMES THE VIRAL SPIKE PROTEIN FOR EFFICIENT INFECTION. THE UNITED STATES STANDS ALONE AMONG DEVELOPED NATIONS IN PERMITTING ONE ANDROGEN, ORAL DHEA, TO BE FREELY AVAILABLE OTC AND ONLINE AS A ‘DIETARY SUPPLEMENT’. DHEA IS WIDELY USED BY MALES IN THE US TO OFFSET THE AGE-RELATED DECLINE IN CIRCULATING ANDROGENS. EVERY OTHER DEVELOPED NATION REGULATES DHEA AS A CONTROLLED SUBSTANCE. DHEA IS AN EXTREMELY POTENT INHIBITOR OF GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD), WITH UNIQUELY UNSTABLE UNCOMPETITIVE INHIBITION KINETICS. BECAUSE DHEA IS LIPOPHILIC AND FREELY PASSES INTO CELLS, ORAL DHEA BYPASSES THE NORMAL CONTROLS REGULATING ANDROGEN BIOLOGY AND UNCOMPETITIVE G6PD INHIBITION. DHEA’S STATUS AS A ‘DIETARY SUPPLEMENT’ MEANS THAT NO CLINICAL TRIALS DEMONSTRATING SAFETY HAVE BEEN PERFORMED, AND, IN THE ABSENCE OF PHYSICIAN SUPERVISION, NO DATA ON ADVERSE EVENTS HAVE BEEN COLLECTED. DURING THE CURRENT PANDEMIC, THE UNRESTRICTED AVAILABILITY OF ORAL DHEA AS A ‘DIETARY SUPPLEMENT’ CANNOT BE CONSIDERED SAFE WITHOUT PROOF FROM PLACEBO-CONTROLLED CLINICAL TRIALS THAT IT IS NOT CONTRIBUTING TO THE SEVERITY OF COVID-19.

diphenhydramine Grace Garland, Student Pharmacist, Fall 2023

Drug Effects Used to relieve symptoms of allergies, hay fever, and the common cold.1 Symptoms occurring from these include rash, itching, watery eyes, cough, runny nose, and sneezing.1

https://www.drugs.com/imprints/ap-20-20626.html

Monitoring When taking diphenhydramine, monitor for the relief of symptoms that are being experienced.3 Also monitor for mental alertness.3

Drug Interactions

Check the labels on all medications as some may contain diphenhydramine in them already.

Diphenhydramine is also referred to as drill, benadryled, diph, pink dreamz, and benny tripping.2

Used to prevent and treat nausea, vomiting, and dizziness occurring from motion sickness.1 Used to help relax and fall asleep.1

Some products that may interact with this drug include topical antihistamines, products causing drowsiness, alcohol, marijuana, drugs for sleep or anxiety, and muscle relaxants.1

Slang Terms

https://thedrugclassroom.com/video/diphenhydramine-dphbenadryl/

Drug Screens Diphenhydramine may interfere with urine detection and lead to false positives of methadone, phencyclidine, and TCA.3

Pharmacology Diphenhydramine is an antihistamine with drying and sedative effects.1 Maximum activity occurs about one hour after taking the medication and the duration of activity ranges from four to six hours.1

History of Use/Abuse

Law

Diphenhydramine is a first generation histamine receptor blocker.4 Given its multiple potential mechanisms of action, situations of misuse and abuse have been reported.4 Cases of abuse are mostly due to behavioral effects like elevated mood, increased energy levels, and mild euphoria.4

In the United States, diphenhydramine is unscheduled.5 It is sold over the counter as an approved drug.5 It is legal to buy, possess, and ingest without a prescription or license.5 It is regulated by the FDA concerning the sales for human consumption.5 All formulations require their own specific FDA approval.5

Toxicology

Professional Opinion Diphenhydramine should only be used as an antihistamine for the treatment of allergies, motion sickness, falling asleep, and to relieve symptoms of Parkinson’s Disease. Diphenhydramine is not a scheduled drug in the United States, but it can be abused to the point where toxic levels are reached. When toxic levels are reached, various signs, symptoms or fatalities can occur. ~ G. Garland

Diphenhydramine overdose can cause significant toxicity.6 This toxicity can range from agitation to cardiac arrhythmias.6 Signs of toxicity include confusion, flushed skin, high temperature, blurry vision, and increased heart rate.6

References 1. WebMD. Diphenhydramine oral: Uses, side effects, interactions, pictures, warnings & dosing.

WebMD. Accessed September 24, 2023. https://www.webmd.com/drugs/2/drug1428/diphenhydramine-oral/details 2. Partnership to End Addiction. Diphenhydramine. Partnership to End Addiction. Published March 2021. Accessed September 24, 2023. https://drugfree.org/drugs/diphenhydramine/ 3. Diphenhydramine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed September 24, 2023. http://online.lexi.com 4. Saran JS, Barbano RL, Schult R, Wiegand TJ, Selioutski O. Chronic diphenhydramine abuse and withdrawal. NLM. 2017;7(5):439-441. doi:10.1212/CPJ.0000000000000304 5. Erowind. Diphenhydramine (Benadryl) Legal Status. Erowind. Published June 20, 2004.

Updated May 10, 2016. Accessed September 24, 2023. https://www.erowid.org/pharms/diphenhydramine/diphenhydramine_law.shtml 6. Sicari V, Zabbo CP. Diphenhydramine. National Library of Medicine. Updated July 10, 2023.

Accessed September 24, 2023. https://www.ncbi.nlm.nih.gov/books/NBK526010/

Disulfiram

Written by Faiz Inamdar | Student Pharmacist | October 1st, Fall 2023

Slang Terms: Trade names: Antabuse/Antabus (no reports of other slang used for disulfiram)

History: Disulfiram was first synthesized as tetraethylthiuram disulfide, reported in 1881. About 20 years down the road, it became a big deal for sulfur vulcanization of rubber used in the industrial process.

During this time its effects were beginning to get figured out after workers in the industry started to get sick after drinking alcohol. It wasn’t until 1947 where a study was conducted to confirm if there was a relationship between disulfiram and alcohol, and if this caused the illness that was found. Shortly after, the FDA approved this drug to treat alcohol dependence in the United States, and ever since then this drug has continued to be explored in the clinical setting. ¹

Pharmacology/Drug Effects: Other drugs approved to treat alcohol dependence usually affect brain opiate γaminobutyric acid or glutamate receptors directly, but disulfiram is unique in this case because it does not affect them. It inhibits enzyme dopamine-β-hydroxylase and impacts serotonergic function, indicating that it has some CNS effects. This in turn, causes a severe reaction to alcohol when it is consumed on this drug, helping increase patient motivation to stay abstinent from alcohol. The disulfiram-alcohol reaction increases acetaldehyde concentration in blood from 5x-10x due to this drug blocking oxidation by inhibiting ALDH, so this is what explains why someone can get so ill when they take disulfiram and alcohol together. ¹

Figure 1¹

Disulfiram Drug Interactions/Toxicology: Drug interactions include alcohol-containing products (cough/cold syrups), amitriptyline, benznidazole, warfarin and other blood thinners, and phenytoin/fosphenytoin. ² Signs and symptoms of disulfiram overdose include hypotension, tachycardia, and dyspnea. Other side effects include abdominal pain, nausea, vomiting, sulfur/garlic odor on breath. ³

Figure 2² Laws: Disulfiram is one of three drugs approved by the FDA for alcohol dependence. It is the 2nd line option with 1st line being acamprosate or naltrexone.

This drug should never be taken while intoxicated, and not to be taken for at least 12 hours after drinking alcohol. ³ Teva started to discontinue this disulfiram in late 2020 and Mylan also followed in their footsteps. This is due to high concentrations of nitrosamine being found in these drugs, and prolonged exposure to this substance

Monitoring/Drug Screens: Monitoring parameters for signs and symptoms of hepatitis are required for patients on disulfiram and these include fatigue, weakness anorexia, nausea, vomiting, jaundice, malaise, and dark urine. Baseline and follow up liver function tests should also be conducted. ³

Professional Opinion: I think that disulfiram started out to be a promising drug at first, but at the end of the day it got taken off the market due to stock shortages and nitrosamine. I feel like the first line therapies for alcohol dependence should be suffice until further medications like disulfiram are discovered. In my clinical setting, I wouldn’t recommend using this drug because of the lack of access as well as adverse events that could happen if someone is careless with their alcohol use while on this drug (F. Inamdar).

References:

1.

Chapter 3—Disulfiram - Incorporating Alcohol Pharmacotherapies Into ...

https://www.ncbi.nlm.nih.gov/books/NBK64036/ Accessed 1 Oct. 2023.

2.

“Disulfiram Oral: Uses, Side Effects, Interactions.” WebMD

www.webmd.com/drugs/2/drug-1446/disulfiram-oral/details#:~:text=Some%20products%20that%20may%20interact,%2C%20fezolinetant%2C%20isoniazid%2C%20metronidazole%2C. Accessed 1 Oct. 2023.

3.

Samara Soghoian, MD. “Disulfiram Toxicity Clinical Presentation.” Medscape

emedicine.medscape.com/article/814525- clinical#: ~:text=Signs%20and%20symptoms%20of%20acute,%2C%20chorea%2C%20hallucinations%2C%20and%20lethargy. Accessed 1 Oct. 2023.

4.

ASHP; Disulfiram Tablets, Current Drug Shortages

https://www.ashp.org/drug-shortages/current-shortages/drug-shortage-detail.aspx?id=601#:~:text=Teva%20discontinued%20disulfiram%20tablets%20in,Mylan%20discontinued%20disulfiram%20tablets. Accessed 1 Oct. 2023.

-T. Lengerich

Ethylene Glycol

Zayaan Habib October 1, 2023

History/Background

The actual use of ethylene glycol is primarily as an anti-freeze or de icer. It can also be found in the chemical synthesis of plastics, brake fluid, and solvents. However, ethylene glycol is also known to be consumed by alcoholics due to it being a cheaper and more accessible alternative to purchasing alcoholic beverages. It is more commonly seen in poorer populations.

Slang Terms

Because ethylene glycol when used for consumption is mostly seen with antifreeze, most “slang” terms for ethylene glycol are brand names for common antifreezes, such as: Fridex Tescol Norkool Zerex

Pharmacology/Drug Effects Ethylene glycol is consumed by alcoholics because of its potential to give them that “buzz” effect. However, ethylene glycol is highly toxic and not safe for human consumption. Consuming it can cause nausea, vomiting, metabolic acidosis, and severe damage to the heart, brain, and kidneys. Severe cases can be fatal if left untreated.

Toxicology

In the CNS, ethylene glycol can cause similar intoxicating effects as ethanol (alcohol), such as the “buzzed” feeling. Higher doses lead to worsening CNS effects, ranging from nausea/vomiting to coma and death. Another main toxic effect from ethylene glycol consumption is renal failure. Metabolites from ethylene glycol consumption leads to nephrotoxicity, resulting in tubular necrosis, focual tubular degeneration, atrophy, and kidney failure.

Laws

Ethylene glycol is classified as a hazardous air pollutant by the Environmental Protection Agency under the Clean Air Act (EPA 2007).

The EPA recommends that children are not exposed to more than 20 mg/L of ethylene glycol in drinking water per day, and that adults should not be exposed to more than 7 mg/L per day of ethylene glycol in their lifetime.

Monitoring/Drug Screens

In patients who have consumed ethylene glycol, significant toxicity of ethylene glycol is listed as a serum level of 25 mg/dL or greater. In a urine test, patients will likely have detected calcium oxalate or hippurate crystals and an elevated anion or osmolal gap.

Professional Opinion

Overall, it is quite difficult to legally deal with ethylene glycol consumption, as the primary source for using it as a “street drug” comes from consuming it in the form of lifestyle products such as antifreeze. A solution to help reduce the amount of incidents relating to ethylene glycol consumption, public education about alcoholism and advertising the serious health risks that result from using lifestyle products such as antifreeze. to get high or buzzed.

References

1. Ethylene Glycol | Medical Management Guidelines | Toxic Substance Portal | ATSDR. wwwn.cdc.gov. https://wwwn.cdc.gov/TSP/MMG/MMGDetails.aspx? mmgid=82&toxid=21

2. ETHYLENE GLYCOL | CAMEO Chemicals | NOAA. m.cameochemicals.noaa.gov.

Accessed October 1, 2023. https://m.cameochemicals.noaa.gov/chemical/8660

3. Alyssa. Why Do Alcoholics Drink Antifreeze? | Banyan Pompano. Banyan Treatment Center. Published October 28, 2021. https://www.banyantreatmentcenter.com/2021/10/28/alcoholics-drinking-antifreezepompano/

4. Wu X, Lu G, Qi B, Wang R, Guo D, Liu X. Antifreeze poisoning: A case report.

Experimental and Therapeutic Medicine. 2017;13(2):701-704. doi:https://doi.org/10.3892/etm.2016.3976

5. What Are U.S. Regulations and Guidelines for Ethylene Glycol Exposure? www.atsdr.cdc.gov. Published October 6, 2022. Accessed October 1, 2023. https://www.atsdr.cdc.gov/csem/ethylene-propyleneglycol/regulations_guidelines.html#:~:text=The%20National%20Institute%20for%20Occu pational%20Safety%20and%20Health

6. Ethylene Glycol and Propylene Glycol Toxicity: What Laboratory Tests Can Help in Evaluating Patients Exposed to Ethylene Glycol? | Environmental Medicine | ATSDR. www.atsdr.cdc.gov. Published October 6, 2022. Accessed October 1, 2023. https://www.atsdr.cdc.gov/csem/ethylene-propyleneglycol/laboratory_tests.html#:~:text=All%20patients%20with%20known%20or%20suspect ed%20ethylene%20glycol

FENTANYL AND CARFENTANIL Abby Hamilton | Student Pharmacist Fall 2023 Eucalyp, Amethyststudio. Atom Gradient Icon, Canva.com. Accessed March 30, 2023. https://www.canva.com

HISTORY/BACKGROUND Fentanyl was first synthesized in the 1960s and became used as an IV anasthetic medication. Fentanyl is a synthetic opioid that works like morphine but is up to 100 times more potent than morphine. It can be used to treat very severe pain after surgeries or in end-of-life care.

Carfentanil is another synthetic opioid. It is used as a tranquilizer for very large animals like rhinos and elephants. Opioid overdoses are on the rise.

Fentanyl and carfentanil may be deadly if they are injected. They are so strong that even touching or inhaling them can be lethal.

SLANG TERMS

PHARMACOLOGY/DRUG EFFECTS Fentanyl works by binding to the body's opioid receptors, which are found in areas of the brain that control pain and emotions.Some side effects include extreme happiness, confusion, constipation, nausea, drowsiness, sedation, tolerance, and addiction. Fentanyl can also cause respiratory depression and cardiac arrest, as well as comas, unconsciousness and death. The effects of euphoria make it extremely addictive and dangerous to use Fentanyl is a powerful synthetic opioid analgesic that is similar to morphine but is 50 to 100 times more potent. The high potency of fentanyl increases the risk of overdose, a lot of times people are unaware that their drugs have fentanyl in them and because of its potency very small amounts can cause overdoses and death

Slang terms are used by people who use and manufacture illicit drugs fentanyl and other drugs. They do this to communicate in secret and avoid law enforcement.

Slang terms are used by people who use and manufacture illicit drugs fentanyl and other drugs. They do this to communicate in secret and avoid law enforcement.

Jones C. Education on fentanyl, other drugs often optional in California schools, if offered at all.

EdSource. Published October 5, 2022. Accessed October 1, 2023. https://edsource.org/2022/educati on-on-fentanyl-other-drugs-oftenoptional-in-school-if-offered-atall/67'216.

DRUG INTERACTIONS/ TOXICOLOGY There are many contraindications/interactions for the use of Fentanyl and it’s opioid analogs.

Patients with liver failure Patients with respiratory diseases including COPD Patients with biliary problems that interfere with the elimination of opioids Patients using CYP3A4 inhibitors and protease inhibitors The main concern with taking Fentanyl is the risk for overdosing. This typically manifests as opioid-induced respiratory depression. Oxygen should be administered and naloxone, an opioid antagonist, should be administered to reverse the effects of Fentanyl.

LAWS FENTANYL IS A SCHEDULE II NARCOTIC UNDER THE UNITED STATES CONTROLLED SUBSTANCES ACT OF 1970.

WHY IS FENTANYL SO DANGEROUS? BRIGHTVIEW. UPDATED SEPTEMBER 11, 2023. ACCESSED OCTOBER 1, 2023.

HTTPS://WWW.BR IGHTVIEWHEALTH .COM/LATESTUPDATES/WHYIS-FENTANYL-SODANGEROUS/

MONITORING AND DRUG SCREENS Fentanyl test strips are an affordable way to reduce harm for people using drugs. The strips can be used with other substances to detect the presence of fentanyl.

Standard drug tests do not account for fentanyl. Other screenings specifically for synthetic opioids are required.

For monitoring, patients/doctors will need to monitor very closely how a person is responding and their side effects to fentanyl.

PROFESSIONAL OPINION Fentanyl is a very potent synthetic opioid. It should be used with caution because of its addictive characteristics. A lot of danger surrounds the use of the drug and over 70 thousand people died from synthetic opioid drug overdose in 2021. It is an odorless and tasteless substance which adds to its danger. I think the use of illicit fentanyl is terrible and is only used because it is cheaper than other drugs. Unfortunately, I don’t think its use will subside until we as a society work to improve peoples lives so that they don’t fell the need to turn to using drugs for happiness. ~A. Hamilton

References: NIDA. Fentanyl DrugFacts. National Institute on Drug Abuse website. https://nida.nih.gov/publications/drugfacts/fentanyl. June 1, 2021 Accessed October 1, 2023.

Fentanyl. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 1, 2023. http://online.lexi.com Ramos-Matos CF, Bistas KG, Lopez-Ojeda W. Fentanyl. [Updated 2023 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459275/ Fentanyl Test Strips: A Harm Reduction Strategy. Centers for Disease Control. Updated September 30, 2022. Accessed October 1, 2023. https://www.cdc.gov/stopoverdose/fentanyl/fentanyl-test-strips.html Drug Overdose Death Rates. National Institute on Drug Abuse. Updated June 30 ,2023. Accessed October 1, 2023. https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates Slang Terms and Code Words: A Reference for Law Enforcement Personnel. United States Drug Enforcement Administration. Intelligence Report. Accessed October 1 ,2023. https://www.dea.gov/sites/default/files/2018-07/DIR-022-18.pdf

https://www.beachesrecovery.com/florida-addiction-treatment-center-programs/substance-abuse-treatment-center-fl/flakka-drug/flakka-drug-facts/

Flakka (alpha-PVP) PURDUE UNIVERSITY COLLEGE OF PHARMACY

BACKGROUND

DATE: Fall 2023

NAME: Sarah Hauser, Student Pharmacist

Flakka is a dangerous and highly addictive designer drug that is typically light pink/white in color and presents in the form of a crystal.

It is a derivative of the khat plant from the Middle East and Somalia. In these areas, the leaves are commonly consumed for a euphoric buzz.

Flakka can be eaten, snorted, injected, or inhaled via e-cigarettes or other vaporizing devices.

Drug users take Flakka to get a feeling of euphoria, a heightened sense of awareness, stimulation, and energy.

Flakka is very inexpensive, costing as little as $5 for a dose.

Synthetic cathinones like Flakka were first synthesized in the 1920s, originating in

HISTORY

Great Britain and Europe, and eventually spreading to the United States.

The label “cathinone” only appeared about 40 years ago. Its use and synthesis hit a decline until about 10 years ago when underground chemists started synthesizing what we know today as designer drugs.

Since 2010, the reported crises involving cathinones has been dramatically increasing. Despite legal action against designer drugs, newly synthesized derivatives have become popular in an attempt to find legal loopholes.

PHARMACOLOGY

1. Flakka is structurally similar to ephedrine and other phenylethylamines. The results of taking Flakka are similar to those of other stimulants and amphetamines.

2. Flakka is highly lipophilic and is therefore able to easily cross the blood brain barrier.

3. After administration of Flakka, the extracellular concentration of dopamine and norepinephrine increases because the synthetic compound inhibits the neurotransmitter reuptake. a. Flakka acts on the CNS via D1 and D2 receptors to stimulate euphoria and delirium. These feelings may escalate to paranoia, psychosis, or extreme agitation.

Chemcial name: alpha-pyrrolidinopentiophenone (Alpha-PVP).

SLANG

1. Gravel 2. Flocka

https://www.biorxiv.org/content/10.1101/191155v3.full

3. Bath Salts 4. The Zombie Drug Flakka belongs to a group of substances known as synthetic cathinones. Related compounds include Bliss, Vanilla Sky, Lunar Wave, Cloud Nine, and White Lightning.

DRUG INTERACTIONS AND TOXICOLOGY

There’s an enormous lack of information regarding long term Flakka use and the consequences on a user’s health There are no known drug interactions for Flakka From the minimal studies that have been conducted, Flakka has been shown to be toxic to the kidneys and cause renal failure Flakka has been determined to be as addictive

DRUG TESTING

LAWS

as methamphetamines

https://time.com/3768667/flakka-drug-florida/

α-PVP is a strictly controlled substance The use of Flakka and many of its derivatives have been banned in the United States and most of the world.

Currently, Flakka is listed as a Schedule 1 drug, just like cocaine, which means it has no therapeutic indication or medical value.

Flakka and other bath salt designer drug derivatives are essentially loophole drugs.

Each time one type is made illegal, the drug labs change the chemical structure slightly and a new drug that is technically not illegal is synthesized.

Flakka can be detected in urine with The NarcoCheck® Alpha-PVP This test can detect any use of Flakka up to 48-72h after previous consumption This test is specific to Alpha-PVP. It will not detect similar derivatives like methamphetamine or MDMA.

REFERENCES

PROFESSIONAL OPINION

https://www.narcocheck.com/en/urine-drug-tests

Flakka is an extremely addictive drug with nothing but unhealthy consequences for its users. While Flakka itself is illegal, there needs to be stricter laws regarding derivatives of this drug otherwise cathinone misuse will continue. However, I’m not sure that this should be a primary concern of lawmakers because Flakka use seems to have been a fad from 2014-2016 and there may be other substances that are more important to regulate. This drug should remain a Schedule 1 drug, there’s simply no medical use for it. - S. Hauser 1. Patocka J, Zhao B, Wu W, et al. Flakka: new dangerous synthetic cathinone on the drug scene.

International Journal of Molecular Sciences. 2020;21(21):8185. Published 2020 Oct 31. doi:10.3390/ijms21218185 2. What is Flakka? Partnership to End Addiction. September 25, 2023. Accessed September 28, 2023. https://drugfree.org/drugs/what-is-flakka/.

3. Ayer U. Flakka effects: short-term, long-term, & side effects. DrugAbuse.com. June 1, 2023. Accessed September 28, 2023. https://drugabuse.com/drugs/flakka/effects-use/.

4. Cunha JP. Flakka drug signs & symptoms, side effects, complications. MedicineNet. August 10, 2023.

Accessed September 28, 2023. https://www.medicinenet.com/flakka/article.htm.

5. Alpha-PVP (Flakka) rapid screening test. PharmaDrugTest.com. Accessed September 28, 2023. https://www.pharmadrugtest.com/urine-drug-tests/109-flakka-alpha-pvp-urine-test.html.

Bethany Hayden Student Pharmacist Fall 2023

GAMMA HYDROXYBUTYRATE Stephanie Hessong, Student Pharmacist

https://commons.wikimedia.org/wiki/ File:GHB-3Dballs.png

History 1960s Synthesized as an anesthetic to aid in surgery from its ability to induce sleep and 1 reversible coma 1980s Sold in the health food industry as a growth hormone stimulator to promote muscle mass and as an over the counter sedative 1 agent 1991 Drug banned by the FDA after multiple adverse reaction 1 reports

Fall 2023

https://cdn.dev.glasspress.io/info/ghb-gamma-hydroxybutyric-acid-drugtest-image-info-hero-800.jpg

Background Gamma hydroxybutyrate (GHB) is a central nervous system depressant used to treat daytime sleepiness and muscle weakness with narcolepsy. It is a colorless liquid or white powder. GHB has a high potential for abuse due to its euphoric and calming effects. It is a popular date rape drug, put into a person’s drink without 2 them knowing.

Pharmacology Gamma hydroxybutyrate is a central nervous system depressant. It works by inhibiting dopamine release at low doses and promoting 3 dopamine release at high doses.

Slang Terms GHB Goop Grievous Bodily Harm

Liquid Ecstasy Liquid X Scoop

Toxicology GHB can cause harmful effects such as respiratory depression, bradycardia, apnea, vertigo, weakness, dizziness, sedation, confusion, hallucinations, coma, 1 respiratory acidosis, and seizures.

GHB should not be mixed with drugs such as alcohol, benzodiazepines, and hypnotics because they will enhance the 4 CNS depressant effect of GHB.

Laws GHB : Schedule 1 controlled substance, high potential for abuse, no current accepted 2 medical use in the United States Xyrem : FDA approved GHB product Schedule 3 controlled substance, with moderate to low potential for physical and psychological dependence2

Drug Interactions AVOID combination with GHB:

Alcohol Alprazolam Azelastine Bromperidol Clonazepam Diazepam Eszopiclone Lorazepam

Midazolam Orphenadrine Ramelteon Temazepam Thalidomide Zolpidem Zopiclone

Monitoring GHB stays in the body for up to 12 hours.5 GHB can be detected in the body by serum screening, urine screening, and whole 4 blood screening

Professional Opinion Gamma Hydroxybutyrate has numerous harmful effects and interactions with other drugs. Its history of use as a “date rape” drug highlights the consequences of misuse. I think gamma hydroxybutyrate should stay a schedule 1 substance because of its addiction potential and harmful effects. It is also crucial to raise awareness about the harmful effects of this drug to safegard the well-being of young adults. - S.Hessong References 1. O'Connell T, Kaye L, Plosay JJ 3rd. Gamma-hydroxybutyrate (GHB): a newer drug of abuse. Am Fam Physician.

2000;62(11):2478-2483.

2. Drug Enforcement Administration. GHB – Gamma-Hydroxybutyric Acid. Accessed, September 20, 2023. https://www.dea.gov/factsheets/ghb-gamma-hydroxybutyric-acid 3. Oliveto A, Gentry WB, Pruzinsky R, et al. Behavioral effects of gamma-hydroxybutyrate in humans. Behav Pharmacol.

2010;21(4):332-342. doi:10.1097/FBP.0b013e32833b3397 4. .Sodium Oxybate. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed September 30, 2023. http://online.lexi.com 5. .American Addiction Centers. How Long Does GHB Stay in Your System?. Updated June 29, 2023. Accessed September 30, 2023.https://americanaddictioncenters.org/ghb-abused/how-long-in-system

GRAY DEATH HISTORY:

By: Isabella Eichmann Student Pharmacist Fall 2023

Definition: : “a street name or a slang term that is frequently used to describe a mixture of illegal l drugs - mainly synthetic opioids and other systemic narcotics” Psychoactive components like heroin, fentanyl, and/or U-47700 are usually found in drug cocktails In combination with cocaine, amphetamines, and other synthetic designer drugs Contains extremely potent and addictive doses Mixture looks like “concrete powder” or “tiny rocks” Can be injected via IV, made into a powder to snort, inhale, smoke, or take by mouth as a tablet First appeared in the South in early 2017, Alabama and Georgia first, spread to Ohio and Pennsylvania From January 2017 - April 2017, gray death was a part of at least 50 incidents and 17 overdoses in Georgia Sometimes contains carfentanil, that is 100x stronger than fentanyl and 10,000x stronger than morphine

SLANG TERMS: There are no alternative names because the mixtures vary from batch to batch and are known as “gray death”

PHARMACOLOGY/DRUG EFFECTS: Hard to be specific because there are many different combinations of it, so side effects can be mild to server Major side effects include confusion, difficulty moving, tiredness, tremors, balance loss, seizures, mental fog, nausea/vomiting, myosis, spasms or generalized convulsions, and hypoventilation Overdose symptoms include: faded or sweaty face, languid body, grunting noises, blueish lips, shallow breathing, irregular pulse, and speech difficulties Gray death overdose is arguably the scariest because of the combination and strength of drugs In the event of an overdose, naloxone may or may not be effective (may take 5-10 doses)

DRUG INTERACTION/TOXICOLOGY: With every batch being different, hard to say specific interactions Drug interactions between the more common drugs found in gray death Heroin Very many interactions, risk levels range from “avoid combination” to “monitor therapy” Fentanyl Very many interactions, most include enhancing the CNS depressant effects Carfentanil and U-47700 No Lexi-Comp entries, says to refer to “opioids” section Toxicology of opioids includes xylazine exposure

https://www.dea.gov/sites/ default/files/2018-11/DIR-03218%202018%20NDTA%20final %20low%20resolution.pdf

DRUG INTERACTION/TOXICOLOGY CONT: Toxicology of opioids “Opioids bind to opioid receptors in the CNS and produce generalized CNS depression and excitation of the parasympathetic nervous system resulting in bradycardia, hypotension, and pupil constriction” “Some opioids exhibit significant serotonergic activity (fentanyl, meperidine, tramadol) and have been associated with the development of serotonin syndrome/serotonin toxicity, especially when used in combination with other serotonergic agents”

LAWS: No specific laws over gray death itself, but laws over the possible ingredients exist In November 2017 the US DOJ decided to temporarily schedule all substances chemically related to fentanyl as schedule 1 drugs under the Controlled Substance Act (CSA) Went into effect February 2018 Anyone who possesses, imports, distributes, or manufactures any fentanyl-related substance (FRS) would receive criminal prosecution in the same way as fentanyl and other controlled substances Carfentanil is an FRS Heroin is a schedule 1 substance under the CSA and is illegal U-47700 is a schedule 1 substance under the CSA and is illegal

MONITORING/DRUG SCREENS: No current drug screens for gray death Monitoring for gray death’s possible ingredients are tracked in many ways, like in airports and mailing facilities

PROFESSIONAL OPINION:

I. Eichmann

https://www.dea.gov/sites/de fault/files/2018-11/DIR-03218%202018%20NDTA%20fi nal%20low%20resolution.pdf

After researching gray death, I believe that it is a very frightening drug combination that is roaming the streets. The fact that it includes a combination of already very harmful drugs is a very big concern. It is also shocking that the batches are never the same, and that it may include “whatever the drug dealer has on hand.” This gives power to the drug dealers in that they can give the buyer whatever their gray death includes, which may include drugs that the user has never had before, and the user would be deceived. I also believe that is it hard to monitor and regulate this drug because to do that, the following of at least 3 drugs is needed. With this, the drugs acquired to make gray death could all have been retrieved from different sources. I personally promote the laws and regulations that keep the harmful drugs off the street and criminally prosecute those who possess, distribute, and/or manufacture it.

REFERENCES: Hasan T, Sami SA, Barmon J, Hossain MK, Emran TB. Gray death: a powerful opioid combination leading to rapid fatality correspondence. Ann Med Surg (Lond). 2023;85(4):1308-1309. Published 2023 Mar 14. doi:10.1097/MS9.0000000000000310 Gray Death Drug Facts: Effects, hazards & warnings. Drugs.com. Accessed November 15, 2023. https://www.drugs.com/illicit/graydeath.html Gray death crisis: New Killer Heroin Drug Cocktail. DrugAbuse.com. October 19, 2023. Accessed November 15, 2023. https://drugabuse.com/drugs/heroin/gray-death-crisis/ Heroin. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed November 15th, 2023. http://online.lexi.com Fentanyl. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed November 15th, 2023. http://online.lexi.com Lexi-Tox Opioids. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed November 15th, 2023. http://online.lexi.com

Heroin (Diacetylmorphine) Jake Bra ain, Student Pharmacist, Fall 2023

Pharmacology/Drug Effects

Heroin Withdrawal Symptoms and Timeline - Pinelands Recovery Center. Pinelands Recovery Center of

Medford. Published April 26, 2019. h ps://www.pinelandsrecovery.com/heroin-withdrawalsymptoms-and- meline/

History & Background Heroin is a schedule I opioid drug derived from morphine, which originates from the seed of an opium poppy plant. The schedule I designation refers to its incredibly addictive properties while providing no beneficial medical use. The Bayer Company, the same developers of aspirin, first developed heroin through acetylation of morphine, which proved more beneficial than morphine or codeine in suppressing cough in patients with respiratory illnesses. However, studies soon showed that patients using heroin developed a tolerance to the drug, leading to higher subsequent doses and eventual addiction to the euphoric effects of the drug. While commercial production of the drug eventually stopped, the illicit production and distribution of the drug continues today and is a major public health crisis across the world.

Heroin is a potent derivative or morphine that increases smooth muscle tone, exhibits central nervous system depressant effects, and acts as an analgesic.

When administered intravenously, the onset of action can be less than a minute.1 Street Names4

 Black tar  Dope  Hero  Capital H  H Caps  Smack  Beast  Snow  Junk  China White  H  Diesel  White Stuff  Brown Crystal  Black Sheep

Drug Interactions/Toxicology

Monitoring/Drug Screening

Ethanol – enhances CNS depressant effect1

A standard five-panel urine test will detect the presence of opiates in the urine but will not distinguish between the different types of opiates. To identify heroin in someone’s system, an immunoassay blood test can be completed to detect the primary metabolite of heroin: 6monoacetylmorphine. The reference range for morphine detection in the bloodstream is 21-65 ng/ml.3

Amphetamines – enhance analgesic effect1 Anticholinergics – heightened effects of constipation and urinary retention when combined1 Antiplatelets – may diminish effects of antiplatelet agents1 Opioids – enhance effects of CNS depressant effects (avoid concurrent use if possible)1 Serotonergic Agents – concurrent use with opioids can lead to serotonin syndrome1 Federal Laws

Professional Opinion

 5-year minimum/40-year maximum*: 100g or more of heroin in possession5  10 year minimum/life maximum*: ≥ 1 kg5

Based on federal laws and the reported medical usage of the drug, it is not recommended from a professional standpoint for any therapeutic use in any population due to its extremely addictive properties and alternative available options.

*20 years mandatory if death or serious injury results from drug use *Harsher punishment for distribution based on age and location *Penalties can be increased based on criminal history of the offender

References: 1. Diamorphine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed Septebmer 30, 2023. http://online.lexi.com 2. Hosztafi S. [The history of heroin]. Acta Pharm Hung. 2001;71(2):233-242.

3. Abuse NI on D. Heroin drug facts | national institute on drug abuse (Nida). Published December 16, 2022. Accessed September 30, 2023. https://nida.nih.gov/publications/drugfacts/heroin 4. Heroin street names, nicknames & slang terms. American Addiction Centers. Accessed October 31, 2023. https://americanaddictioncenters.org/heroin-treatment/slang-names 5. Federal drug laws. Accessed October 31, 2023. https://www.iwu.edu/counseling/Federal_Drug_Laws.htm

K2/Spice Drug Monograph Jonah Lenters Student Pharmacist Purdue University, Fall 2023 History “K2” and “Spice” are synthe c THCs which is the psychoac ve ingredient in marijuana. “Spice” and “K2” are the trade names for these synthe c THCs. The U.S. became aware of synthe c opioids in 2008 when they were found by customs under the brand name “spice”. JWH-018 was the first synthe c THC. It was synthesized to aid in studying the cannabinoid system. Many more synthe c THCs followed and were scheduled temporarily before permanently being placed in schedule 1. In 2013 it was also found that people who used synthe c THCs also managed to pass tradi onal drug tests cleanly but failed tests designed to detect synthe c cannabinoids.1 Synthe c cannabinoids are currently marketed towards youth and adolescents using colorful packaging that o en also says “not for human consump on” and “fragrance purposes only”. While the government has made it illegal to use and have these substances, these laws are being sidestepped by changing up the chemical formula ever so slightly to avoid being illegal on a technicality.2 Slang Terms Synthe c THCs are sold under hundreds of different trade names. Some of the most common are “Spice,” “K2,” “Blaze,” “Red X Dawn,” “Paradise,” “Demon,” “Black Magic,” “Spike,” “Mr. Nice Guy,” “Ninja,” “Zohai,” “Dream,” “Genie,” “Sence,” “Smoke,” “Skunk,” “Serenity,” “Yucatan,” “Fire,” and “Crazy Clown.”1 Pharmacology Synthe c THCs interact with the CB1 and CB2 receptors in the brain. It has been shown to have a lower K i compared to THC.3 Both the CB1 and CB2 receptors are G-protein coupled receptors predominately located in the brain. The CB1 receptor is shown to cause the psychoac ve effects of synthe c THC while the CB2 receptor is shown to play a role in inflamma on.4The pharmacologic effect of taking synthe c THC includes elevated mood, relaxa on, and altered percep on. Pa ents also experienced psycho c effects including extreme anxiety, confusion, paranoia, and hallucina ons. People who found themselves in the emergency room had severe side effects such as rapid heart rate, vomi ng, violent behavior, and suicidal thoughts.5

Toxicology and Drug Interac ons Mild toxici es include xerostomia, reddened conjunc va, and increased heart rate. Pa ents also experience hyperemesis. Some mes, however, pa ents do not show toxici es matching natural THC including hypertension, agita on, tremors, paranoia, hallucina ons, and hypokalemia. Pa ents with more severe toxic side effects experience severe agita on, hyperthermia, recurrent seizures, supraventricular tachycardia, and rhabdomyolysis. Pa ents experiencing hyperemesis may also experience acute renal injuries.6 Laws Under Indiana state law, marijuana is illegal as well as synthe c cannabinoids are schedule 1 substances.7 Synthe c cannabinoids are also illegal under na onal law.2 Monitoring and Drug Screens Current drug screening includes a urine test for synthe c THCs. It is not an all-inclusive list but includes the most found synthe c THCs. It is listed with the synonyms “K2” and “Spice” on the labcorp website to order the test.8 Professional Opinion Synthe c cannabinoids like “K2” and “Spice” are dangerous substances. Many states have begun to legalize marijuana, and its side effect profile is known. The side effect profile of synthe c THCs has been shown to be more dangerous than that of natural marijuana. They lead to more complica ons and more dangerous side effects than marijuana. Marijuana does s ll have dangerous toxici es, but synthe c THCs are showing more different toxici es likely due to the lack of regula on of their produc on. In professional opinion, I recommend against inges on of this subclass of drugs. If you absolutely have to try it, use the natural stuff instead.

References: 1.

2.

3.

4.

5.

6.

7.

8.

Drug Enforcement Administration, Department of Justice. Schedules of controlled substances: temporary placement of four synthetic cannabinoids into Schedule I. Final order. Fed Regist. 2014;79(27):7577-7582.

Drug fact sheet: K2/spice - dea.gov. dea.gov. Accessed September 29, 2023. https://www.dea.gov/sites/default/files/2020-06/K2-spice-2020.pdf.

Tai S, Fantegrossi WE. Synthetic Cannabinoids: Pharmacology, Behavioral Effects, and Abuse Potential. Curr Addict Rep. 2014;1(2):129-136. doi:10.1007/s40429-014-0014-y Howlett AC, Abood ME. CB1 and CB2 Receptor Pharmacology. Adv Pharmacol. 2017;80:169-206. doi:10.1016/bs.apha.2017.03.007 Synthetic cannabinoids (K2/spice) DrugFacts. National Institutes of Health. March 22, 2022. Accessed September 29, 2023. https://nida.nih.gov/publications/drugfacts/synthetic-cannabinoids-k2spice.

Synthetic Cannabinioids. Micromedex Solutions. Greenwood Village, CO: Truven Health Analytics. http://micromedex.com/. May 25, 2023. September 29, 2023.

Rokita T. Official Opinion 2023-1. in.gov. January 12, 2023. Accessed September 29, 2023. https://www.in.gov/attorneygeneral/files/Official-Opinion-2023-1.pdf.

Synthetic Cannabinoids (K2, Spice), Screen with Reflexed Confirmation, Qualitative, Urine. labcorp.com.

Accessed September 29, 2023. https://www.labcorp.com/tests/701106/synthetic-cannabinoids-k2-spicescreen-with-reflexed-confirmation-qualitative-urine.

KAVA KAVA By: Conner Lubbehusen Fall 2023 Pharmacy Student

History/Background

Piper Methysticum, or kava, is an indigenous to the Pacific Islands that was first discovered by Captain James Cook while on his second voyage. He noted that his crew experienced symptoms that were similar to opium when consuming1 what the natives called “kava”. The crew members later states that it was an ‘intoxicating pepper’ .

Furthermore, Kava is consumed in many ways by chewing, grinding, or 2 even pounding the roots releasing the kavalactones, causing the effects of euphoria, muscle relaxation, sedation and analgesia.

Traditionally, the plants are harvested at around four years of age; as 1 the older the plant, the higher concentrations of kavalactone that are released . By the 1990s, extracts of Kava were being marketed as a dietary supplement in many parts of the world for anxiety disorder.

However, many incidents of hepatoxicty caused these Kava extracts to be withdrawn from some countries, in the early twenty-first century.

Slang Terms

3

Kava Kava

Yaqona

Kawa

Gorg [Fiji]

Waka

‘awa [Hawaii & Samoa]

Lewena

Wait [New Guinea]

Pharmacology/Drug Effects Chewing on kava can causes numbness in the month due to the local anesthetic action due to the kavalactones release. This kalavalctone action is very similar to that produced by cocaine and lasts longer than that of benzocaine. Additionally, Kava is able to produces a mild euphoria feeling, able to enhance sight, smell and sounds. Furthermore, higher doses are able to lead toward muscle weakness, mainly in the legs, which is related to sitting for long periods of time. Also, a very high dose of Kava 4 can induce deep sleep, so it can be sedative.

Drug Interaction/Toxicities Kava may rarely causes serious (possibly fatal) liver diseases. If you develop any signs and symptoms of Liver injury; this includes nausea that persists, stomach or abdominal pain, dark urine and yellowing of eyes/skin be sure to consult your doctor immediately. Furthermore, some 5 of the drug interactions with Kava are the drugs that interact with the liver possibly causing harm, these includes; acetaminophen, amiodarone, methotrexate, “statins”, and warfarin.

Laws In the United States, Kava is sold as a dietary supplement that promoted as an alternative to anti-anxiety medications and sleeping pills. The FDA has not made a determination about Kava’s efficacy for the use for anxiety or sleep.

6 So, by the law it is fully legal but that doesn't mean it is 100% safe.

In a more Illegal use, Kava is being used recreationally to help relax the body and help achieve mild euphoria making it not a controlled substance within 6 the United States.

Monitoring/Drug Screens Monitoring for Kava will be for that liver function as it does play a role in 5 liver toxicity.

Kava CANNOT be tested for through a drug test or screen as there really is not a need to as it is a legal dietary supplement and the United States do not consider it an addictive drug. 7

Professional Opinion

In my professional opinion, I feel that Kava, at least in smaller doses, would be great to use for patients that have anxiety. My reason behind this is that it is used as a dietary supplement for this. My only thing is that, the FDA hasn't fully approved the use of Kava to be used due to the severe hepatic toxicities that can arise. So, I personally would not recommend this to patients due to that toxicity, unless they know that they have great liver function.

- C. Lubbehusen PharmD Student

References

1) Piper Methysticum. University of Oxford. 2023. Accessed on September 25, 2023, https://herbaria.plants.ox.ac.uk/bol/plants400/Profiles/op/piperm#:~:text=Piper%20methysticu m%20is%20indigenous%20to,the%20beverage%20and%20the%20plant.

2) Kava. Streetdrugs. Accessed on September 25, 2023. https://streetdrugs.org/865-2/ 3) What is Kava. Kava - Alcohol and Drug Foundation. (n.d.). Accessed on September 25, 2023, https://adf.org.au/drug-facts/kava/ 4) Kava. Lexi-Drugs. Lexi-Comp. Wolters Kluwer Health, Inc. Hudson, Ohio. 2022. Acessed on September 27, 2023. https://online.lexi.com/lco/action/doc/retrieve/docid/fc_rnp2/3750215? cesid=aRu9SjnmlP7&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3Dkava%26t%3Dname%26acs %3Dtrue%26acq%3Dkava# 5) Kava (Piper Methysticum) Capsule - Uses, SIde Effects, and More. WebMD. 2020. Accessed on September 27, 2023. https://www.webmd.com/drugs/2/drug-17314/kava-piper-methysticumoral/details 6) Kava - DEA Diversion Control Division. DEA. September 2019. Accessed on September 27, 2023. https://www.deadiversion.usdoj.gov/drug_chem_info/kava.pdf 7) Does Kava Show up on a Drug Test. Botanic Tonics. 2023. Accessed on September 27, 2023. https://botanictonics.com/blogs/botanic-secrets/does-kava-show-up-on-a-drug-testbotanictonics#:~:text=Generally%2C%20though%2C%20kava%20is%20not,valid%20reason%20to%20do% 20so.

8) Savage, K. M., Stough, C. K., Byrne, G. J., Scholey, A., Bousman, C., Murphy, J., Macdonald, P., Suo, C., Hughes, M., Thomas, S., Teschke, R., Xing, C., & Sarris, J. (2015). Kava for the treatment of generalized anxiety disorder (K-GAD): study protocol for a randomised controlled trial. Trials, 16, 493. https://doi.org/10.1186/s13063-015-0986-5

Article

Generalized anxity disorder, or known as GAD, is a chronic condition that creates a high level of strees that can be very diffeicult to treat. The current treatment options for GAD are mostly moderative effective and has a long list of side effects that are undesirable.

Through the targeted actions that are geared toward the gamma-aminobutyric acid [GABA] pathway, Kava is able to potentially treat GAD via a non-addicitive, non-hypnotic way. With these recent clinical trails, research has also shown a number of satfey concerns related to hepatotoxicity making the German Court ban Kava (possibly influences the rest of the European Union). In summary, the traditional extract of kava is confirmed to be safe and as effective as a ‘level 1’ therapy associated with anxiety.

Furthermore, it is able to 8 provide a significant support to use within a clinical setting, allowing it to ease any of the concerns about the potential restricted markets along with providing a socioeconomic Benefit toward the poorer Pacific Islands.

Ketamine

https://www.erowid.org/chemicals/show_image.php?i=ketamine/ ketamine10.jpg

John Ton Student Pharmacist Fall 2023

History •

1962: first developed by Calvin Stevens to replace phencyclidine (PCP).

1963: Belgium patented Ketamine as veterinary anesthetic 1965: determined that Ketamine could be a safe anesthetic in humans; also found be a potent psychedelic drug from recreational use 1969: Ketamine HCl becomes available by prescription as ‘Ketalar’ Late 1970s, early 1980s: ketamine abuse across the US 1999: FDA classifies ketamine a Schedule III drug

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Pharmacology https://go.drugbank.com/drugs/DB0122 1

Slang terms • • • • • • • • •

K Special K Cat Tranquilizer Cat Valium Super Acid Special La Coke Purple Jet Vitamin K

Ketamine is an anesthetic for human and veterinary use by acting as an NMDA receptor antagonist. It is similar to PCP, an intravenous anesthetic for surgery and other procedures. It is deemed a dissociative anesthetic because it creates the sensation of having the mind “separated” from the body. This separation of mind from body usually results in hallucinations. o o o o o

lasts 30 to 60 minutes sedation immobility amnesia analgesia

Drug Screening

Laws

• Not one of the SAMHSA-5 standardly tested in a typical drug test, so it isn’t typically tested for • It is possible to test for in urine, blood, and hair • It is detectable in both blood and urine for 7 to 14 days as it is broken down to norketamine in the body

Ketamine is a Schedule III controlled substance as part of the Controlled Substances Act.

https://www.erowid.org/chemicals/keta mine/

Toxicology Can cause increased blood pressure, tachycardia, difficulty urinating, blood in urine, hallucinations, and delirium.

Drug interactions • Taking Ketamine with other drugs that make you sleepy or slow down breathing, such as alcohol, opioids, medications for mood, and sleeping pills, makes it more difficult to wake up from anesthesia • 1,315 drugs have been found to interact with ketamine, so all medications, prescribed and overthe-counter medications have to be disclosed before use

Professional Opinion I think that ketamine, like many drugs has its medical uses, but it should have just stayed as a veterinary anesthetic. As an anesthetic for humans, our ingenuity in biochemistry can create better anesthetics that have lower risk for dependency and abuse. ~J. Ton

References Ketamine. DEA. Accessed October 1, 2023. https://www.deadiversion.usdoj.gov/drug_chem_info/ketamine.pdf Ketamine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 1, 2023. http://online.lexi.com Ketamine: Peril and Promise. MAPS. Published 2007. Accessed October 1, 2023. https://maps.org/news-letters/v17n1html/ketamine-peril_and_promise.html Ketamine. Streetdrugs. Accessed October 1, 2023. https://streetdrugs.org/ketamine/ Ketamine Timeline. Erowid. Accessed October 1, 2023. https://www.erowid.org/chemicals/ketamine/

Khat Dillon Kish, Student Pharmacist, Fall 2023

History/background of use/abuse: • • • • • •

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Stimulant plant Khat is chewed then held in between the teeth and gums Only fresh Khat is used Evergreen shrub with two active ingredients, cathinone and cathine Used throughout East Africa and the South-West Arabian Peninsula Some indigenous people in East Africa use Khat medicinally to elevate mood and combat fatigue Was first introduced to Yemen between the first and sixth centuries Used frequently during celebrations and marriages due to the euphoric effects

htps://www.dea.gov/factsheets/khat

Pharmacology/drug effects: •

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Adverse effects include grandiose delusions, paranoia, nightmares, hallucinations, hyperactivity, increased blood pressure and heart rate, and brown staining on the teeth.

Possibility of causing manic behavior Said to have similar effects to amphetamine.

Cathinone and cathine are both central nervous system stimulants.

Creates a euphoric feeling with increase alertness and arousal.

Begin to feel affects after one hour of chewing

Slang terms: • • • • • • •

https://www.bbc.com/news/uk-27921832

Abyssinian Tea African Salad Catha Kat Miraa Oat Quaadka

Drug Interactions/Toxicology: • • •

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Laws:

Amount to cause an overdose is unknown Possibility of liver damage and myocardial infarctions Linked to causing oral and gastric cancer, cerebral hemorrhage, and severe headaches Khat interferes with the absorption of amoxicillin and ampicillin Use of nicotine and caffeine will increase the stimulatory effects of khat

Professional Opinion: As a student pharmacist, I believe that Khat is an addictive drug that should be avoided. The prevalence of khat was once only in Eastern Africa, has rapidly been spreading throughout the world. It is now estimated that there are 10 million Khat chewers around the world.

Approximately 80% of adults in Somalia and Yemen routinely use Khat. In my opinion, the use Khat has been normalized by its frequent use in celebrations.

Long term use of Khat, can lead to life altering side effects and should be avoided.-DKish

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Monitoring/Drug Screens: •

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Urine tests that test for the active substance of cathine are available Typical drug tests will not detect Khat

Summary of Article: From April to June 2015 a study was conducted to assess the factors determining khat chewers in high school. The study observed outside socioeconomic factors that seem to be common among khat chewers.

Students from different high schools within the Khat growing capital were examined. Out of the 1,655 students the majority of 54.6% reported chewing on the regular basis. The studies also looked at sexual activity related to khat use and found that 24.4% of sexually active participants also chewed khat.

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Chemicals in Khat are controlled under the Controlled Substances Act Cathine is a schedule IV stimulant, which means it is a low risk for both abuse and addiction Cathinone is a schedule I, which means it is a highly addictive substance with no medical purposes Legal is some countries in Africa and Europe

References: Khat - an overview | ScienceDirect Topics. www.sciencedirect.com. Accessed October 2, 2023. https://www.sciencedirect.com/topics/agriculturalandbiological-sciences/khat Khat Uses, Benefits & Dosage - Drugs.com Herbal Database. Drugs.com. Accessed October 2, 2023. https://www.drugs.com/npp/khat.html#:~:text=It%2 0has%20traditionally%20been%20used Khat drug profile | www.emcdda.europa.eu. www.emcdda.europa.eu. https://www.emcdda.europa.eu/publications/drugprofiles/kh at_en Erowid Khat (Catha edulis) Vault. www.erowid.org.

Accessed October 2, 2023. https://www.erowid.org/plants/khat/khat.shtml Khat. Dea.gov. Published 2019. https://www.dea.gov/factsheets/khat

By: Karen Robles-Garcia Student Pharmacist Purdue University College of Pharmacy

Kratom (Mitragyna speciosa Korth)

What is it?

Fall 2023

Street Names  Thang  Kakuam  Thom  Ketum  Biak / Biak-Biak  Herbal speedball

Kratom (2020).Photograph. Parkridge Health System. https://parkridgehealth.com/blog/entry/kratom-the-risky-newsubstance-you-need-to-know-about

History & Background  Indigenous plant to Thailand, Myanmar, Malaysia, and 

Professional Opinion Based on the lack of scientific evidence for the efficacy and safety of Kratom, as well as no support from the FDA or DEA, Kratom should not be used as a medical remedy for symptoms of opioid withdrawal, as an opioid alternative, pain reliever, and/or recreational use.

K.Robles-Garcia

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areas of Southeast Asia - chewed by native laborers as an herbal drug to get energy and muscle pain relief The leaves are smoked, brewed in tea, or placed in gel capsules The leaves are also used as an opiate substitute or for opioid withdrawal symptoms (documented since 1836) New current use for psychoactive and euphoric effects Used in doses of 2 to 5 grams Consumption can lead to addiction

Pharmacological Profile Pharmacology & Drug Effects  

Contains mitragynine and 7-hydroxumitragynine – both have mu-opioid receptor agonist activity Produces both stimulant (at low doses) and sedative effects (at high doses)

Toxicity  

No current scientific literature on intoxications Has been associated with cases of overdose and fatalities

Drug Interactions References: •

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Kratom. U.S. Department of Health and Human Services.

National Institute on Drug Abuse. Updated April 24, 2023.

Accessed October 1, 2023. https://nida.nih.gov/researchtopics/kratom Drugs.com. (n.d.) Kratom uses, benefits & dosage. Updated November 24, 2022. Accessed October 1, 2023. https://www.drugs.com/npp/krat om.html Kratom. ). NatMed. trchealthcare. Uploaded August 2022. Accessed October 1, 2023.

11https://naturalmedicinestherapeuticresearchcom.eu1.proxy.openathens.net/d atabases/food,-herbssupplements/professional.aspx?p roductid=828 Drug fact sheet: Kratom.

Department of Justice/Drug Enforcement Administration.

Published April 2022. Accessed October 1, 2023. https://www.dea.gov/sites/defaul t/files/2020-06/Kratom2020_0.pdf Is kratom legal? Kratom legality

by State. Sprout Health Group.

Uploaded October 29, 2022.

Accessed October 1, 2023. https://www.sprouthealthgroup.c om/substances/is-kratom-legalby-state/ Does Kratom show up on a drug test?. Keystone Lab, Inc. Uploaded November 25, 2022.

Accessed October 1, 2023. https://keystonelab.com/uncateg orized/kratom/

Causes mild to severe itching, nausea, drowsiness, constipation, dry mouth, and dizziness

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Modafinil (Provigil) – increase seizure risk Medications changed by the liver –changes how quickly liver breaks down medications Quetiapine (Seroquel) – increases side effects Sedative medications – increase sleepiness Naltrexone (Vivitrol) – may lead to withdrawal Venlafaxine (Effexor) – increases effects

Legal Status  

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In the U.S, Kratom is not federally regulated Kratom Consumer Protection Act (KCPA) – protection for consumers who use unregulated products. States that passed this bill include Nevada, Utah, Arizona, and Georgia Kratom is illegal to buy, sell, possess, or use in: Alabama, Arkansas, Indiana, Rhode Island, Vermont, and Wisconsin All other states, it is legal, but may be regulated No FDA approval On the DEA list for Drug and Chemicals of Concern

Monitoring & Drug Screens   

Not detectable in many routine drug tests like the SAMHSA-5 Can be detected in a 10-panel drug test for up to 7 days after consumption Need specialized tests for the blood and urine

Bunloet, S. (2023). Kratom Leaves. Photograph. Getty Images. https://www.nbcnews.com/health/health-news/11-million-awardedfamily-woman-died-taking-kratom-opioid-herb-rcna97293

Krokodil////Desomorphone Desomorphine Krokodil nd Khoa Thai Thai //// 22nd Year Professional Year Student Student //// Fall Fall 2023 2023 Khoa Professional Terminology Slang Terms: Krokodil or Crocodil1 Proper Name: Desomorphine1 History – The Rise of Krokodil Krokodil first appeared on the streets in 2002. Known for its opioid-like potent effects (10x stronger than morphine); it spread like wildfire internationally.1 As a cheap alternative to heroin, its popularity grew dramatically within the Russian young adult community.1 The name Krokodil came to be as chronic users were seen with scaly, greenish skin due to thrombosis, damaged blood vessels, and soft tissues.1 This appearance resembles that of a crocodile.1

Toxicology & Interactions Krokodil has multiple drug interactions, especially those of the benzodiazepines class such as: lorazepam, alprazolam, temazepam, and diazepam.2,3 Other classes include selective serotonin reuptake inhibitors (SSRIs), as Krokodil enhances the effect of SSRIs leading to serotonin syndrome.2,3 Other drug class that enhances the effect of Krokodil includes stimulants such as amphetamines, methylphenidate, methamphetamine, and cocaine.2 Krokodil overdose leads to opioid-like overdose symptoms including extreme drowsiness, difficulty breathing, impaired motor skills, and in severe cases, coma.2

Pharmacology & Effects Desomorphine emits a very potent opioid analgesic effect like that of morphine, oxycodone, hydrocodone…etc.2 Desomorphine has a very fast onset of around 30 minutes and a short serum half-life of approximately 1 hour.2

Desomorphine: Pharmaceutical Mode of Action, Illicit Use, and Future Prospects. www.linkedin.com. Accessed November 16, 2023. https://www.linkedin.com/pulse/desomorphinepharmaceutical-mode-action-illicit-use-future-aggarwal

Laws There is no current medical use for Krokodil.4 The Drug Enforcement Administration (DEA) has classified Krokodil as a Schedule 1 drug, indicating that there is no medical use and a high potential for abuse.5 The only legal use of Krokodil is currently in Switzerland, where it is marketed under the name Permonid.4 The indication for Permonid is like that of morphine, where it is shown to have a shorter onset and duration.4

Professional Opinion I believe that there can be a use for Desomorphine given the time and research. With a quick onset, this could be a very novel and potent analgesic for patients. Furthermore, this could act as a short-term analgesic due to the short serum half-life. On the contrary, this could also contribute to abuse due to the high potential for addiction like that of opioids. If the legalization of this drug goes through, I believe there will be even greater monitoring of it compared to regular opioids. - K. Thai

Shuster S. The World’s Deadliest Drug: Inside a Krokodil Cookhouse. Time.com.

Published December 5, 2013. https://time.com/3398086/the-worlds-deadliestdrug-inside-a-krokodil-cookhouse/

Wikipedia Contributors. Desomorphine. Wikipedia. Published November 26, 2019. https://en.wikipedia.org/wiki/Desomorphine

Monitoring & Screening There are currently no monitoring guidelines for the use of Krokodil due to the lack of medicinal use.6 Krokodil can be screened using opioid test assays such as ELISA.6 Due to the similar structure to morphine, many screening assays that detect morphine will emit a positive result for Krokodil due to cross reactivity.6 References 1. DEA Office of Diversion Control. DESOMORPHINE (Dihydrodesoxymorphine; Dihydrodesoxymorphine-D; Street Name: Krokodil, Crocodil).; 2013. https://www.deadiversion.usdoj.gov/drug_chem_info/desomorphine.pdf 2. Desomorphine. go.drugbank.com. Accessed November 16, 2023. https://go.drugbank.com/drugs/DB01531 3. Krokodil Drug Facts. Drugs.com. Published July 2014. https://www.drugs.com/illicit/krokodil.html 4. Villa L, February 24 Mphl updated on, 2021. Krokodil the Zombie Drug | Desomorphin Effects & Symptoms. DrugAbuse.com. https://drugabuse.com/drugs/krokodil/ 5. RECENT STATISTICS and TREND ANALYSIS of ILLICIT DRUG MARKETS the Global Picture.; 2012. https://www.unodc.org/documents/data-andanalysis/WDR2012/WDR_2012_Chapter1.pdf 6. Winborn J, Kerrigan S. Desomorphine Screening Using Commercial EnzymeLinked Immunosorbent Assays. Journal of Analytical Toxicology.

2017;41(5):455-460. doi:https://doi.org/10.1093/jat/bkx024

Lauren Mikell, Student Pharmacist

LAXATIVES Fall 2023

HISTORY/BACKGROUND The word “laxative” is derived from the Latin word laxus, which means loose. In the early 19th century, the use of laxatives became prevalent as a way to clear the body of ailments and return its systems back to equilibrium. At this time, a cathartic medication called calomel also called mercurous chloride became the most used while having toxic effects such as hair loss, teeth loss, and mercury intoxication. Other kind of laxatives that were popular at the time were aloe, jalap, senna, and castor oil.

Towards the early the 1900s, the idea of autointoxication came into play implying that intestinal waste products can poison the body and are a major contributor to numerous diseases. This sent the populations into a frenzy as it caused them to look for agents that would help clear the system. The public fell prey to anti-constipation agents thus the rise of laxatives and the golden age of purgation in the 20s. Although this theory was torn down eventually as evidence disproved it, laxatives are still used today for regular constipation but also abuse in certain conditions such as anorexia, binge eating, bulimia, etc.

PHARMACOLOGY/DRUG EFFECTS Laxatives work by acting on or altering parts of the digestive system in order to make it easier to empty the bowels.

There are several different types: 1. Bulk-forming laxatives: retain fluid and increase stool weight and consistency 2. Osmotic agents: draws water into the lumen of the bowel 3. Prokinetic agents: work on intrinsic neurons and increase Acetylcholine release and inducing mucosal secretion

4. Lubricants: aid in passage of stool by lubricating action throughout the intestines 5. Stimulants: increase intestinal secretion and motility; decrease absorption of water from the lumen of the bowel 6. Surface active agents: lowers surface tension; leading to water and fats penetrating the stool.

7. Guanylate cyclase agonist: induces cGMP which leads to water and electrolyte secretion into the lumen 8. Chloride channel activator: leads to water and chloride secretion in to the stool and softer stool consistency

Popular Laxatives/Most Abused on the Market SLANG TERMS Cathartics Purgative Aperient Stimulants Emetics Evacuant Eliminatory

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Bisacodyl Senokot Phenolphthalein Castor oil

L A X A T I V E S

DRUG INTERACTIONS/TOXICOLOGY

LAWS

Interactions: 1. Steroids 2. Antacids 3. Mineral oil 4. Fat soluble vitamins 5. Diuretics

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Toxicology: Laxatives work by enhancing fluid retention, decreasing net absorption of fluid, and altering motility. When these mechanisms are increased there are often overdose can involve nausea, vomiting, abdominal cramping, and diarrhea. In more severe case there can be dehydration and electrolyte imbalances. Rebound constipation can also occur from taking laxatives.

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As of now, laxatives can be purchased over the counter without a prescription and with one as well.

It is important that the recommend doses and usage are all followed correctly so that abuse and misuse does not occur.

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Laxative pranks are illegal, one can be charged with a felony for this infraction.

MONITORING/SCREENING -

Monitor for bowel movements and frequency of them.

Monitor for rebound constipation from overuse Trapped gas in the intestines Monitor fecal matter Monitor hydration habits; take lots of water Monitor for fissure and hemorrhoids which can cause chronic constipations Monitor electrolyte level Monitor for abuse in those with bulimia and anorexia as well as the elderly

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Laxatives are not regularly screened for however it can be detected in the urine like many other drugs.

Screening would have to depend solely on circumstance and necessity.

REFERENCES 1. Bashir A. Laxatives. StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK537246/. Published October 13, 2022.

2. Laxative Use and Abuse in the Older Adult: Part I. Consultant360. https://www.consultant360.com/articles/laxative-use-and-abuse-older-adultparti#:~:text=HISTORICAL%20BACKGROUND&text=Laxatives%20were%20used%2 0to%20purge,restore%20the%20body's%20natural%20equilibrium.&text=The %20most%20commonly%20used%20laxative,teeth%20from%20acute%20mer cury%20intoxication.

3. Laxatives, Classification and Properties, Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed November 17, 2023. http://online.lexi.co

PROFESSIONAL OPINION Laxatives can be helpful in many medical situations; however, it is important to use them correctly. Misuse of laxatives can lead to misuse, electrolyte imbalances, and other health issues. If Laxatives are to be used for an extended period of time, it should be under the recommendation and supervision of a healthcare provider. ~ L. Mikell

LSD Lysergic Acid Diethylamide Allison Mack Student Pharmacist Fall 2023

History of Use Mendoza, Mer. “Riso Style Smiley Face.” Canva, Accessed October 19, 2023. https://www.canva.com/design/DAFwCE5iNBE/ItJ7RiBLxyKaE1a1XPIEzA/edit

Developed by Albert Hoffman, while working for Sandoz in 1938.

It was synthesized from a chemical in the ergot fungus that is known to grow on grains.

Its hallucinogenic effects were discovered in 1943 by accidental ingestion.

It was a popular recreational drug in both the 1960s and 1990s.

It was once used to mimic a mental state similar to schizophrenia for experimental medicine.

Slang Terms Acid Microdot Boomers Black Star Cubes Mellow Yellow Tripping- when it is taken LSD Addiction .Oasis Recovery Runcorn. Updated September 5, 2023. Accessed October 19, 2023. https://www.oasisrehab.co.uk/addiction/drug/lsd/

Pharmacology Administered as a tablet/capsule, filter or blotting paper, or as a sugar cube dissolved in the mouth.

Mechanism of action: Blocks the effects of serotonin Overactive neuronal firing which causes changes in perception

Effects: Distorted colors and sounds Increased heart rate, sweating, sleeplessness Kaleidoscope visions Impaired perception of time and depth

Drug Interactions Lithium and tricyclic antidepressants This combo could be lethal Other stimulant drugs: Cocaine Amphetamines

Laws

Monitoring Present in a urine sample 2-4 days after last use Present in a blood sample 6-12 hours after last use Present in the hair Up to 90 days after last use

Toxicology

Schedule I substance Highest potential for abuse No medically accepted use Illegal under U. S Federal law

Longer, more intense trips Depression, anxiety, & paranoia can be long lasting Hallucinations, fear, & tremors Fatality is very rare

Professional Opinion Feminine Inspire For U. “Organic Abstract Swirly Shape.” Canva, Accessed October 19, 2023. https://www.canva.com/design /DAFwCE5iNBE/ItJ7RiBLxyKaE1a 1XPIEzA/edit

In my opinion, as a student pharmacist, there is good reason why LSD is a Schedule I, Federally illegal and controlled substance. From the research done, I agree that it should not be used recreationally due to its severe psychotic and longlasting effects. - A. Mack

References 1. LSD. HISTORY. Accessed October 1, 2023. Published June 14, 2017. Updated August 21, 2018. https://www.history.com/topics/crime/history-of-lsd 2. Mosel, S. History of LSD. American Addiction Centers. Recovery.org. Updated November 15, 2022. Accessed October 1, 2023. https://recovery.org/lsd-addiction/history/ 3. The War on Drugs: History, Policy, and Therapeutics. Dominican University. Accessed October 1, 2023. https://research.dom.edu/the-war-on-drugs--history-policy-therapeutics/LSD 4. A Parent’s Guide: Drug Slang. RI Department of Behavioral Healthcare, Developmental Disabilities and Hospitals.

Accessed October 1, 2023. https://bhddh.ri.gov/sites/g/files/xkgbur411/files/documents/Drug-Slang---guide-FINAL.pdf 5. Drug Fact Sheet: LSD. Department of Justice/Drug Enforcement Administration. Accessed October 1, 2023. https://www.dea.gov/sites/default/files/2023-04/LSD%202022%20Drug%20Fact%20Sheet.pdf 6. Is It Bad to Mix LSD With Other Drugs. Skywood Recovery. Accessed October 1, 2023. https://skywoodrecovery.com/lsdabuse/is-it-bad-to-mix-lsd-with-other-drugs/ 7. Lysergic Acid Diethylamide. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 1, 2023. http://online.lexi.com

Methylenedioxymethamphetamine (MDMA) Blake Mathis, Student Pharmacist, Fall 2023

DEA. Ecstasy Or MDMA (Also Known As Molly). Accessed October 1, 2023. https://www.dea.gov/factsheets/ecstasy-or-mdma-also-known-molly

Background: MDMA was originally synthesized by a pharmacist in Germany in 1912. It was originally made to be used to synthesize medications that can control bleeding although a common myth states that it was used to lower appetite.

Its potent psychoactive nature made it popular among US psychiatrists within the 1970s and 80s because they believed it would allow their patients to be calmer and trusting and thus be able to talk about their problems better. It is also around this time that MDMA began to be abused and thus viewed as a “street drug.”

MDMA was most notably used in nightclubs and raves, where it is still very popular in use today.

Slang terms: MDMA can be identified by a number of slang terms including, but not limited to:  Ecstasy (E, XTC)  Molly  Disco Biscuit

Pharmacology/Drug effects: MDMA has purported benefits for use as a pain reliever in terminally ill patients. It also is commonly thought to ease anxiety and post-traumatic stress disorder (PTSD).

MDMA acts by increasing the activity of three main brain chemicals: dopamine, norepinephrine, and serotonin.  Dopamine: Increases energy and activity  Norepinephrine: Increases heart rate and blood pressures  Serotonin: Affects mood, appetite, and sleep behaviors, as well as triggering hormones that affect sexual arousal and trust MDMA is chemically similar to both stimulants and hallucinogens and affects the user’s sense of time and awareness.

Drug Interactions/Toxicology: The most common adverse effects of MDMA are increased blood pressure, dehydration, nausea, vomiting, muscle twitching, and bruxism (involuntary clenching of teeth).

MDMA has a high potential for addiction, as shown in animal trials wherein they would self-administer the drug.

Symptoms of withdraw include fatigue, loss of appetite, depression, trouble concentration, and decreased interest and enjoyment of sexual activity.

MDMA also has potential to interact with lots of antidepressants such as SSRIs, SNRIs, tricyclic antidepressants (TCAs), Monoamine Oxidase Inhibitors (MAOIs), trazadone, lithium, buspirone, and others.

Professional Opinion (B. Mathis) As a pharmacy student, I would love to see more clinical trials for MDMA before I can have a distinct opinion on the use of MDMA within the medical field. That said, I would say that the adverse reactions and addiction potential of MDMA far outweigh the purported benefits and could not professionally endorse use of MDMA.

Laws: In the United States, MDMA is listed as a C-I scheduled substance, meaning it has no proven therapeutic usage and has high potential for addiction or misuse.

While there is promise as a potential treatment for mood, anxiety, and substance use disorder, there are not enough human clinical trials for the FDA to list MDMA as anything other than a Schedule I illicit substance.

Monitoring/Drug Screens: MDMA will be picked up as an amphetamine in the majority of urine tests. The average time before a negative urine result from the last date of usage is 1 to 2 days.

Resources: 1. DEA. Ecstasy Or MDMA (Also Known As Molly). Accessed October 1, 2023. https://www.dea.gov/factsheets/ecstasy-or-mdma-also-known-molly 2. NIDA. What is the history of MDMA?. National Institute on Drug Abuse website.

April 13, 2021. Accessed October 1, 2023. https://nida.nih.gov/publications/researchreports/mdma-ecstasy-abuse/what-is-the-history-of-mdma 3. NIDA. MDMA (Ecstasy/Molly) DrugFacts. National Institute on Drug Abuse website. https://nida.nih.gov/publications/drugfacts/mdma-ecstasymolly. June 15, 2020 Accessed November 17, 2023.

4. Amphetamine and Related Compounds. Lexi-Tox. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 1, 2023. http://online.lexi.com 5. Sarparast, A, Thomas K, Malcom B, Stauffer CS. Drug-drug interactions between psychiatric medications and MDMCA or psilocybin: a systematic reviex.

Psychopharmacology (Berl). 2022;239(6): 1945-1976. Doi:10.1007/s00213-02206083-y

BATH SALTS MDPV Johnny Tran, PharmD Student, Fall 2023

History and Background Methylenedioxypyrovalerone or MDPV was initially developed by pharmaceutical company Boehringer Ingelheim in the mid-1960s as a CNS stimulant and possible treatment for chronic fatigue syndrome. This has re-emerged 4 decades later as a potential recreational drug. Structurally similar to a cathinone and derived from the Khat plant native to Africa. It has no indicated medical use in the United States and is placed under Schedule 1 due to high potential abuse.

On July 9th, 2012 this control became permanent due to the passage of the Synthetic Drug Abuse Prevention Act of 2012.

Pharmacology and Drug Effects This drug is typically snorted, taken orally, smoked, or injected. Binds to human dopamine, norepinephrine, and serotonin transporters to inhibit reuptake causing a release. These effects are similar to those of amphetamine or MDMA. These studies have been tested on rat brains to show an increase in dopamine levels. It increases heart rate and blood pressure as well. Some behavioral effects of taking bath salts could be panic attacks, anxiety, agitation, and hallucinations.

Toxicology Physical effect can range from many different possibilities. Main ones include things such as tachycardia, hypertension, arrhythmia, sweating, muscle tremors, spasms, and possible coma or death, Do not use with other cathinones and alcohol to avoid risk of overdose or drug interactions. Also, avoid in use with other hypertensive drugs.

Slang terms Monkey Dust Super Coke Vanilla Sky Cosmic Blast

Monitoring and Screening Monitoring people who have taken bath salts and other cathinones can be done often with routine urine and blood drug screens. These are not typically used for bath salts but can be detected for synthetic use of the drug. In 2012, the number of MDPV reports increased slightly from 3,714. The good news is, people are screening and reports are going down as of 2013.

Professional opinion Ken T. Wakabayashi, a doctorate at the University of Nebraska, says it is a “more potent cocaine-like stimulant and shares similar pharmacological and locomotor responses. Mentions how it can involve problems related to addiction and abuse as well as overall mental health. Goes on to speak about how acute cocaine can cause most cardiovascular complications.. It is an enhanced stimulant that can be very dangerous when taken without proper handling. Certain survivors will say its not worth it.

References 1. Shandrow M. A New And Dangerous Drug - “MDPV.” Asana Recovery. Published June 15, 2018. Accessed October 1, 2023. https://asanarecovery.com/a-new-and-dangerousdrug-mdvp/ 2. “Bath salts” drug ingredient to be made illegal | CBC News.

Accessed November 16, 2023. https://www.cbc.ca/news/politics/bath-salts-drugingredient-to-be-made-illegal-1.1247255 3. 1.3,4-Methylenedioxypyrovalerone (MDPV) (Street Names: “bath salts,” “Ivory Wave,” “plant fertilizer,” “Vanilla Sky,” “Energy-1”).

4. Methylenedioxypyrovalerone - an overview | ScienceDirect Topics. Accessed November 16, 2023. https://www.sciencedirect.com/topics/neuroscience/meth ylenedioxypyrovalerone 5.

Wakabayashi K, Ren S, Kiyatkin E. Methylenedioxypyrovalerone (MDPV) mimics cocaine in its physiological and behavioral effects but induces distinct changes in NAc glucose. Frontiers in Neuroscience. 2015;9.

Accessed October 1, 2023. https://www.frontiersin.org/articles/10.3389/fnins.2015.0032 4 6. Online Explore a Career as a Pharmacy Technician Details | Orange Community Education & Recreation. Accessed November 16, 2023. https://www.ed2go.com/orangecommed/onlinecourses/pharmacy-technician-explore-career/?tab=detail 7. Bath Salts | Elkhart County Prosecutors Office. Accessed November 15, 2023. http://www.elkhartcountyprosecutor.com/syntheticdrugs/bath-salts

EMMA RONK

STUDENT PHARMACIST

FALL 2023

MESCALINE WHAT IS MESCALINE? Mescaline, also known as ‘buttons’, ‘mescalito’, or ‘peyoto’, is a naturally occurring hallucinogenic substance found in a species of spineless cacti, called Peyote, that is native to Mexico and the southwestern parts of Texas. While it has been found in a variety of other cacti, it is also synthetically produced and illegally distributed in a colored powder, tablet, or capsule form.

PHARMACOLOGY & DRUG EFFECTS On the top, or the crown, of the Peyote cactus there are small disc-shaped ‘buttons’. These are cut from their roots, dried, and then either directly chewed or left to soak in water to make a hallucinogenic, intoxicating solution that can be consumed. It can also be ground into a fine powder where it can either be smoked or put into an oral tablet or capsule.

Upon ingestion, a person may experience many psychosis-associated effects such alteration of perception, consciousness, and thoughts. It has also been known to induce introspective and self-sentient states that some describe as spiritual or like being in a dream. Just like other hallucinogens, such as LSD, mescaline binds and activates the serotonin 5-HT2A receptor, initiating those central nervous system effects and the euphoric feelings for about 12 hours at a time.

Bender e. Mescaline.Nature. https://www.nature.com. September 28, 2022. October 4, 2022. Accessed October 1, 2023.

HISTORY OF USE Mescaline-containing peyote buttons have been found at numerous archaeological sites in Texas, dating their use all the way back to at least 3000 BC. They were primarily utilized by the natives that resided in Northern Mexico and the southwestern parts of the United States. Traditionally used for ritualistic and healing purposes, it was believed that this substance could be beneficial in the treatment of colds, mild to moderate pain, and rheumatoid induced inflammation. It was even used on those who were blind and struggled with alcoholism.

Mescaline and similar compounds were also utilized and experimented with during the mid-1900s by the military for its potential use within intelligence. It was first tested in the 1940s as a “truth drug” by the Germans for use during interrogations and to control behavior.

DRUG INTERACTIONS & TOXICOLOGY At this point in time here have not been any well-controlled or regulated studies to determine if mescaline has any notable interactions with other drugs or medications. However, since it is serotonin receptor agonist, mescaline may be dangerous if it is taken with other medications that have their affect in the brain and on the level of serotonin such as antidepressants and antipsychotic agents. Similarly, if mescaline is taken with medications that target the heart, circulatory system, or have stimulatory effects could further increase the heart rate and result in other unpredictable consequences.

LAWS

DRUG SCREENS

Mescaline is classified as a Schedule I substance due to its high potential for abuse and its use is currently illegal in the United States. However, it is still utilized within the Native American faith for religious intentions.

There are rapid test strips available for the detection of mescaline in urine following its use. The test only takes about 5 minutes to complete and is relatively simple to utilize. There is also a urine sample that can be taken and evaluated by a lab to detect if there is this hallucinogen is present in someone’s system.

Not only is the use of the substance extracted from Peyote considered illegal, but the growth and cultivation of the cactus is prohibited in the United States. The only exception to this law is if the grower is an active member of the Native American Church and utilizes the plant to carry out a religious ritual.

REFERENCES Grant BL. Peyote Plant Info: What You Should Know About Growing Peyote Cactus. Gardening Know How. Accessed October 1, 2023.

Mescaline. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 1, 2023. http://online.lexi.com Mescaline. StreetDrugs. Accessed October 1, 2023. https://streetdrugs.org/mescaline/ Mescaline Urine Test. PharmaDrugTest.

Accessed October 1, 2023. https://www.pharmadrugtest.com Peyote And Mescaline. U.S. Drug Enforcement Agency (DEA).

Accessed October 1, 2023. https://www.dea.gov/factsheets/peyote-andmescaline

PROFESSIONAL OPINION Since there is so much uncertainty with the use of mescaline and there is no direct evidence proving it to be an effective healing agent, I would not recommend or suggest its use. It is also a very strictly regulated, illegal substance, and there are other options available for the purported benefits it may have to offer.

Jay M. A mind bending history of mescaline. The Economist. https://www.economis t.com. June 29, 2019. Accessed October 1, 2023.

METHAMPHETAMINE Maggie Rose, Student Pharmacist Fall 2023

BACKGROUND Methamphetamine was first synthesized in Japan in 1919 by a scientist.

During World War II, it became increasingly popular as a performance enhancer for American soldiers.

Methamphetamine became a Schedule II drug in 1970.

In the early 2000s, state laws were placed to restrict sales of pseudoephedrine and ephedrine to reduce local methamphetamine production.

SLANG TERMS Meth; Speed; Crank; Crystal meth; Yaba, Shabu Shabu

PHARMACOLOGY/DRUG EFFECTS Methamphetamine is a sympathomimetic that causes the release of dopamine from the brain. It also inhibits the metabolism of dopamine. This medication is a stimulant used to treat attention deficit hyperactivity disorder (ADHD).

An instantaneous dopamine rush is released when smoked or injected, leading to a temporary euphoric feeling.

Long-term use can chemically alter the CNS leading to anxiety, violent behavior, paranoia, reduced motor skills, and many other neurological issues.

It can be used in small amounts to increase wakefulness and physical activity.

At higher doses, methamphetamine induces irregular heartbeat, increases blood pressure and heart rate, and causes convulsions.

TOXICOLOGY A serious drug interaction exists between methamphetamine and monoamine oxidase inhibitors, as there is an increased risk of hypertension.

Methamphetamine is contraindicated in patients with cardiovascular problems such as hypertension, heart failure, or recent MI. This drug should be avoided in patients with preexisting psychosis, as symptoms may be exacerbated.

Patients must also be cautioned about completing tasks that require mental alertness, such as driving, due to CNS effects.

DRUG SCREENS Methamphetamines are included in the 5 drugs tested for in a standard NIDAapproved urine drug test. It is detectable for up to 5 days in the urine.

It is detectable in a standard hair test for about 90 days.

Methamphetamine is detectable in the blood for up to 3 days, and levels above 100ng/mL are considered abuse.

LAWS Methamphetamine is a Schedule II stimulant in America, meaning it has a high potential for abuse. However, it does have an accepted medical use, and it is only accessible with a prescription that cannot be refilled. .A person in possession of methamphetamine without a valid prescription would be charged with a Class A misdemeanor in the state of Indiana.

PROFESSIONAL OPINION Methamphetamine is rarely prescribed and has the potential to be highly addictive. It also has many neurological side effects, some of which are irreversible. In my professional opinion, the risks of prescribing this medication outweigh the benefits. (MRose) It should be dispensed sparingly, if at all, and patients should be monitored closely while taking this drug.

REFERENCES Methamphetamine Basics. Erowid. Modified May 11, 2017. Accessed October 1, 2023. https://www.erowid.org/chemicals/meth/meth_basics.shtml Methamphetamine. Street Drugs. Accessed October 1, 2023. https://streetdrugs.org/methamphetamine/ Methamphetamine Drug Fact Sheet. Drug Enforcement Administration. Published April 2020. Accessed October 1, 2023. https://www.dea.gov/sites/default/files/2020-06/Methamphetamine-2020_0.pdf Methamphetamine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 1, 2023. http://online.lexi.com Indiana General Assembly. https://iga.in.gov/laws/2023/ic/titles/35#35-48-4-6.1. Accessed November 7, 2023.

Morning Glory: Ipomoea Violacea Madeline Russow Student Pharmacist

Morning Glory Seeds: Source 9

Morning Glory: Source 9

Fall 2023

History Ipomoea violacea, a type of morning glory, originates from North & Central America (1).

Cultivation of this plant has spread through the world (1). They were historically used by groups such as the Aztecs In Central America for their hallucinogenic properties (2). This hallucinogenic plant was considered to have both medical and religious uses (1). There Is approximately 500 species In this genus, but Ipomoea violacia Is most known for the hallucinogenic properties (1).

Background

The seeds In morning glory have drug effects similar to LSD, while providing a legal high (3). The seeds contain alkaloids, which are used by people to get high (3). These seeds contain d-lysergic acid amide (LSA), which Is similar to the structure of LSD (3). Morning glory seeds are available for purchase In greeneries and other retail settings, making them easy to obtain (3). The active Ingredient can be extracted and made Into a concentrate which Is Ilegal to possess (4). The seeds are taken orally

by Ingesting whole or taking the concentrate (4).

Slang Terms

5

Tlitliltzin MG seeds Aztec seeds Heavenly blue Badoh negro Flying saucers

Pharmacology The pharmacology of d-lysergic acid amide (LSA) Involves Interactions with serotonin, adrenergic, and dopamine receptors (6). This Is a similar mechanism of action to that of LDS, however, LSA has lower binding affinity and therefore weaker psychotic effects (6). The hallucinogenic effects are due to the activation of the 5-HT2a serotonin receptor (6).

Drug Effects

3

Hallucinations (3) Visual distortions Elevated mood Sense of deep Insight Diarrhea, cramping, gas Nausea, vomiting Rapid heart rate, Increased blood pressure Dilated pupils Anxiety

Drug Interations This drug works by Interacting with the serotonin receptors, so any drugs that also Interact with these receptors will have an effect (7). For example, It Interacts with the same receptors as SSRIs, SNRIs, and MAOI’s which are common antidepressants (7,4). This can lead to a dangerous syndrome known as serotonin syndrome, which can be fatal (7). Lithium, cannabis, stimulants, and tramadol are some other medications that have dangerous interactions with morning glory (8).

Toxicology Morning glory can have intoxicating side effects, however, deaths are rare and those that have been reported are due to self harm (3). Those that consume this drug are more likely to feel sick than have a high (3). Symptoms can Include severe nausea and vomiting that can lead to dehydration, along with the other symptoms noted In drug effects (9). There Is a high variability In those who use this drug, so the effects are unpredictable (9). Eating the seeds however, Is not directly toxic (9).

Laws It is legal to possess morning glory or morning glory seeds (9). In fact, they are commonly sold In many gardening stores, greeneries, and retail stores (9). However, It Is Illegal to extract, buy/sell, or consume the concentrated active Ingredient (LSA) as a drug (9). LSA is considered a schedule III drug (9).

Monitoring/Drug Screen Standard and extended drug screenings do not test for LSA. However, It Is possible to screen for LSA through blood serum and urine If necessary. It Is possible for those who Ingest LSA to test positive for LSD due to the chemical similarity. So a false positive screening for LSD Is possible with this drug (10).

Professional Opinion In my professional opinion, LSA should not be consumed.

The drug Is more likely to make you sick than It Is to give you a legal high, as a large quantity must be consumed. It has mind altering effects which can be dangerous, and It also has many serious side effects. There are many serious drug Interactions that can occur with this drug, some even fatal. There Is also a lack of research, as this Is not commonly considered a drug.

Morning Glory: Source 9

References 1. zoom50. Ipomea/Morning glory/Ipomoea Violacea. Zoom’s Edible Plants. Published December 8, 2011. Accessed October 2, 2023. https://zoom50.wordpress.com/2011/12/08/ipomeamorning-gloryipomoea-violacea-2/ 2. Ipomoea violacea: Basic Info | Psycheplants. ICEERS. Published September 23, 2019. https://www.iceers.org/ipomoea-violacea-basic-info/ ‌3 . H o w S i m i l a r I s L S A ( M o r n i n g G l o r y S e e d s ) t o L S D ? S u n r i s e H o u s e . h t t p s : / / s u n r i s e h o u s e . c o m / h e r b a l - d r u g s / l s a - m o r n i n g - g l o r y - s e e d s / ‌4 . E r o w i d M o r n i n g G l o r y V a u l t : B a s i c s . w w w . e r o w i d . o r g . A c c e s s e d O c t o b e r 2 , 2 0 2 3 . https://www.erowid.org/plants/morning_glory/morning_glory_basics.shtml ‌5 . M o r n i n g g l o r y . T h e M i x . P u b l i s h e d S e p t e m b e r 2 5 , 2 0 1 2 . h t t p s : / / w w w . t h e m i x . o r g . u k / d r i n k - a n d - d r u g s / l e g a l - h i g h s / m o r n i n g - g l o r y - 9 8 5 2 . h t m l ‌6 . P a u l k e A , K r e m e r C , W u n d e r C , e t a l . A r g y r e i a n e r v o s a ( B u r m . f . ) : R e c e p t o r p r o f i l i n g o f l y s e r g i c a c i d a m i d e a n d o t h e r p o t e n t i a l p s y c h e d e l i c L S D - l i k e compounds by computational and binding assay approaches. 2013;148(2):492-497. doi:https://doi.org/10.1016/j.jep.2013.04.044 ‌7 . W h y s o m e t e e n s l a n d e d i n t h e E R a f t e r e a t i n g f l o w e r s e e d s . T O D A Y . c o m . h t t p s : / / w w w . t o d a y . c o m / h e a l t h / t e e n s - t r y i n g - g e t - h i g h - s i c k e n e d - a f t e r - e a t i n g flower-seeds-t91031 ‌8 . L S A . P s y c h o n a u t W i k i . P u b l i s h e d J a n u a r y 1 8 , 2 0 2 0 . A c c e s s e d J a n u a r y 2 4 , 2 0 2 0 . h t t p s : / / p s y c h o n a u t w i k i . o r g / w i k i / L S A ‌9 . L S A D r u g : T h e T r i p p y S t o r y B e h i n d t h e C o m p o u n d i n M o r n i n g G l o r y P l a n t s . D o u b l e B l i n d M a g . P u b l i s h e d J u l y 2 2 , 2 0 2 0 . h t t p s : / / d o u b l e b l i n d m a g . c o m / w h a t is-lsa-drug/ ‌1 0 . E r o w i d L S A ( L y s e r g i c A c i d A m i d e ) V a u l t : D r u g T e s t i n g . e r o w i d . o r g . A c c e s s e d O c t o b e r 2 , 2 0 2 3 . h t t p s : / / e r o w i d . o r g / c h e m i c a l s / l s a / l s a _ t e s t i n g . s h t m l

Muscle Relaxants Cole O’Connor Student Pharmacist Fall 2023

https://www.phillyvoice.com/muscle-relaxants-long-termprescriptions-opioids-risks-penn-medicine/

History Some of the first muscle relaxants were derived from a plant called curare. Curare was a poison used by indigenous people in South America to paralyze the animals they were hunting. Other early muscle relaxants, such as dantrolene, were derived from horse urine. Modern muscle relaxants stray more towards synthetic compounds. For example, baclofen is a similar compound to GABA, which is a neurotransmitter that inhibits muscle activity. In the 1950s-1960s, centrally acting muscle relaxants became increasingly more popular and widely used.

These drugs primarily target the central nervous system and depress it.

Pharmacology There are two major drug classes when talking about muscle relaxants, antispastics and antispasmodics. The class is also broken down into centrally acting skeletal muscle relaxants and directly acting skeletal muscle relaxants. The pharmacology of muscle relaxants is dependent on the type of drug, since there are many different types of them. Centrally acting muscle relaxants bind to GABA receptors in the central nervous system.

When this occurs, there is a decrease in excitatory signals that get sent to muscle, this leads to relaxation. Directly acting muscle relaxants work by blocking calcium ions to stop muscle contraction, which causes relaxation.

https://link.springer.com/referencework entry/10.1007/978-3-319-17900-1_136

Slang terms • • •

Benzos Downers Tranks

https://www.norflexgel.co.za/what-is-a-musclerelaxant-and-how-does-it-work/

Drug Screening • Not tested in a typical drug test • It is possible to test for in urine, blood, and saliva • Detectability in the urine can be anywhere from 10 to 30 days, based on the drug

Laws A couple of muscle relaxants are a Schedule IV controlled substance as part of the Controlled Substances Act. The rest are not controlled substances.

Drug interactions

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

Since muscle relaxants work in the central nervous system, they come with quite a few drug interactions. Since opioids cause sedation and respiratory depression, it is not recommended to combine the two to not overdo it. Combining muscle relaxants with benzodiazepines can also increase the risk of sedation.

Professional Opinion Muscle relaxants are effective medications for treating muscle spasms, but they should be monitored closely and used with caution due to their potential for abuse.

People tend to use muscle relaxants to get high or to reduce anxiety, they are also further abused when combined with other drugs such as alcohol or opioids.

With current trends, muscle relaxants may start to be moved towards schedule III or more being considered schedule IV.

Toxicology Can cause vocalization, salivation, ataxia, tremors, weakness, shaking, vomiting, bradycardia, and hypothermia

References -

Abdel Shaheed C, Maher CG, Williams KA, McLachlan AJ. Efficacy and tolerability of muscle relaxants for low back pain: Systematic review and meta-analysis. Eur J Pain. 2017;21(2):228-237. doi:10.1002/ejp.907 Skeletal muscle relaxants: Nursing Pharmacology - Osmosis Video Library. Osmosis. https://www.osmosis.org/learn/Skeletal_muscle_relaxants:_Nursing_Pharmacology Pharmacology of muscle relaxants and their antagonists. Washington.edu. Accessed October 1, 2023. https://faculty.washington.edu/ramaiahr/3BChapter_13.pdf Malcolm E. Muscle relaxants. SMA News Today. Published October 8, 2018. Accessed October 1, 2023. https://smanewstoday.com/muscle-relaxants/

N,N-DIMETHYLTRYPTAMINE (DMT)

2

ABOUT DMT

SIDE EFFECTS

DMT is a mind-altering drug. The drug occurs naturally and is a fast-acting substance.

DMT can cause rapid heart rate, increased blood pressure, dilated pupils, dizziness, nausea, anxiety, fear, panic attacks, paranoia, hallucinations psychosis, and delusions.

BACKGROUND The DMT molecule is found naturally in plants and animals. It also is found in humans. It can be synthesized in a lab.

Rare side effects include: coma, respiratory arrest, or seizures

With the rise of celebrities talking about and taking the drug it has grown in popularity in recent years.

HISTORY

DMT has been used by indigenous tribes in the Amazon Basin for thousands of years. It is a powerful molecule used for therapeutic or ceremonial events.

It was first synthesized in 1931 by a GermanCanadian scientist

PHARMACOLOGY

DMT is a potent hallucinogenic drug. It is a tryptamine which is a derivative of serotonin. DMT is metabolized by MAO-A, which makes DMT not orally available DMT is typically smoked, vaporized, or injected to achieve effects.

Daniel Fuchs Student Pharmacist Purdue University Fall 2023

SLANG TERMS DIMITRI BUSINESSMAN’S TRIP AYAHUASCA

FANTASIA THE SPIRIT MOLECULE THE ROGAN 45 MINUTE PRESENTATION

DRUG INTERACTIONS DMT should not be taken with various medications.

DMT should not be taken with monoamine oxidase inhibitors, serotonin reuptake inhibitors, SNRIs, antihypertensive medications, stimulants, opioids, alcohol and other psychedelic drugs.

DMT is still being studied and this does not include all potential interactions.

LAWS In the United States, DMT is a schedule 1 drug. It carries fines and potential jail time. The law changes between states and country, please look at your jurisdiction for accurate reflection.

Schedule 1 drugs are considered a high potential of abuse.

MONITORING Standard urine and blood drug tests do not test for DMT. There are special drug tests that can screen for DMT and other rare drugs.

Hair tests may be used as extensive tests. Hair tests can flag DMT in the system for previous use.

PROFESSIONAL OPINION

DMT is an illicit hallucinogenic drug. It can cause serious physical and psychological harm to the user.

With little research on long-term harm and complications, it is not recommended for any individual to take the substance.

There is consistent research on potential benefits.

If you are planning on taking DMT contact a qualified healthcare professional for consultation and personalized guidance

CELEBRITY ENDORSERS AARON RODGERS JOE ROGAN MIKE TYSON CHELSEA HANDLER POST MALONE PAUL MCCARTNEY MILEY CYRUS

AND MANY OTHERS..

Please do not let celebrities influence your decison or influence you to take DMT

References 1. Sreenivas S. DMT: What to know. WebMD. Accessed October 1, 2023. https://www.webmd.com/mentalhealth/addiction/what-is-dmt.

2. DMT effects on the brain. DrugAbuse.com. June 25, 2020. Accessed October 1, 2023. https://drugabuse.com/online/dmt-effects-on-the-brain/.

3. E Jose, Ed, Roe, et al. Tryptamines. streetdrugs. Accessed October 1, 2023. https://streetdrugs.org/tryptamines/.

4. Cowling C. A brief history of DMT. Small Pharma. November 24, 2022. Accessed October 1, 2023. https://smallpharma.com/insights/brief-history-dmt/.

5. Mackenzie RJ. Could DMT-assisted therapy help treat mental health disorders? Neuroscience from Technology Networks. Accessed October 1, 2023. https://www.technologynetworks.com/neuroscience/blog/could-dmtassisted-therapy-help-treat-mental-health-disorders-342892.

Naloxone

Prepared by: Maurine De la Paz, Student Pharmacist Fall 2023 History/Background: In March 1961, Dr. Jack Fisherman and Dr. Moses Lewenstein submitted the initial patent applications for naloxone, a medication subsequently granted approval by the Food and Drug Administration (FDA) in 1971 for the treatment of opioid overdoses.

Significantly, in March 2023, naloxone received FDA authorization for over-the-counter distribution, making it accessible without a prescription.

Brand Names: Narcan and RiVive Slang terms: Terminology associated with the combination drug buprenorphine and naloxone, commonly known as Suboxone, include "boxes," "bupes," "oranges," "sobos," "stop signs," "stops," and "subs."

Pharmacology: Narcan is classified as a pure opioid antagonist that competes with and displaces opioids from their respective receptor sites.

Pharmacokinetics: It exhibits a rapid onset of action within 2-13 minutes, with effects lasting approximately 30-120 minutes.

Adverse Effects: When administered, withdrawal symptoms may manifest, including headaches, rapid heart rate, sweating, nausea, vomiting, and tremors Drug Interactions: Methylnaltrexone, naldemedine, and naloxegol may heighten the risk of opioid withdrawal when used concurrently with Narcan. (Risk X - Avoid Combination) Toxicology: Narcan is considered safe for use, exhibiting no adverse effects on individuals even in the absence of opioids in their system.

Furthermore, it presents no potential for abuse.

Laws: In Indiana, Aaron's Law and the Overdose Good Samaritan Law provide legal protection to those administering Narcan during an overdose, given they act in good faith and without willful misconduct. They are also required to promptly seek EMS assistance, even if the individual does not survive after Narcan administration.

These laws extend protection to individuals in possession of controlled substances like cocaine, methamphetamine, and marijuana. Additionally, Indiana residents can obtain naloxone without a prescription to assist those at risk of opioid overdose.

Monitoring/Drug Screens: When administering naloxone, monitor vital signs (respiratory rate, heart rate, blood pressure, temperature, and consciousness level) and assess oxygenation through arterial blood gas analysis (ABGs) or pulse oximetry. Be alert for signs of acute withdrawal symptoms. Naloxone may be detectable in urine but is not commonly part of routine drug tests.

Professional Opinion: Naloxone is a great drug to keep on hand, and I encourage every pharmacy technician, pharmacist, and/or healthcare professional to have one on them at all times. It is advisable that they undergo training in naloxone administration and maintain this medication readily accessible. Furthermore, I advocate for the extension of training programs to encompass college students, considering they have a higher chance of exposure to opioid overdose. - M De la Paz

References: Bureau of Substance Addiction Services. Naloxone facts and formulations. Mass.gov. Accessed October 1, 2023. https://www.mass.gov/info-details/naloxone-facts-and-formulations#:~:text=Facts%20about%20naloxone&amp;text=Jack %20Fishman%20and%20Dr.,reverse%20opioid%20overdoses%20for%20decades.

Department of Public Health. Over the counter (OTC) naloxone. Over the Counter (OTC) Naloxone. Accessed October 1, 2023. https://www.cdph.ca.gov/Programs/CCDPHP/sapb/Pages/Over-the-Counter-(OTC)-Naloxone.aspx#:~:text=Can%20I%20buy%2 0Narcan%C2%AE,for%20use%20without%20a%20prescription. https://www.dea.gov/sites/default/files/2018-07/DIR-022-18.pdf.

Unclassified slang terms and code words: A reference for law enforcement personnel. DEA Intelligence Report. July 2018.

Accessed October 1, 2023. https://www.dea.gov/sites/default/files/2018-07/DIR-022-18.pdf.

Naloxone. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 1, 2023. http://online.lexi.com Naloxone drugfacts. National Institutes of Health. June 1, 2023. Accessed October 1, 2023. https://nida.nih.gov/publications/drugfacts/naloxone#:~:text=People%20with%20physical%20dependence%20on,is%20us ually%20not%20life%20threatening.

Aaron’s Law & Overdose Good Samaritan Law. IN.gov. Accessed October 1, 2023. https://www.in.gov/health/overdose-prevention/files/Aarons-Law-Primer.pdf.

Aaron’s law. Overdose Lifeline. March 3, 2023. Accessed October 1, 2023. https://www.overdoselifeline.org/aarons-law/.

Pope C. Will naloxone show up on a drug test? Drugs.com. March 30, 2023. Accessed October 1, 2023. https://www.drugs.com/medical-answers/naloxone-show-drug-test-3558341/#:~:text=In%20special%20circumstances%2 C%20but%20not,can%20be%20tested%20in%20urine.

Ingoude

NALTREXONE (VIVITROL) Corey Brend, Student Pharmacist Fall 2023

History/Background Naltrexone is a drug that is indicated for the treatment of alcohol use disorder and opioid use disorder. It is considered a long-acting version of Naloxone as Naltrexone has 13 hours of effect as opposed to Naloxone’s 3 hours. In 1974 the National Institute on Drug Abuse approached DuPony Pharmaceuticals about studying Naltrexone to get FDA approval. Some studies showed promising results, however, most participants in the study showed non-compliance as they would rather take heroin than Naltrexone. Despite this Naltrexone was still approved by the FDA in 1984 for treating Heroin addiction. In 2006, an injectable form of Naltrexone called Vivitrol was approved by the FDA for alcoholuse disorder and in 2010 for opioid-use disorder. This injectable form showed much better compliance than the oral form. An even longer-acting implantable form of Naltrexone is currently still being studied but is not yet approved for clinical use.

Slang Terms There are no slang terms for Naltrexone however its brand names are Vivitrol in the United States and ReVia in Canada.

Pharmacology/Drug Effects Naltrexone is a pure opioid antagonist that has a very similar structure to Naloxone and nalorphine.

Naltrexone is a competitive antagonist at opioid receptor sites, specifically the Mu receptors.

Naltrexone also suppresses alcohol consumption by modifying the hypothalamic-pituitary-adrenal access.

Drug interactions/Toxicology Possible interactions with Naltrexone include: Bremelanotide: May decrease the serum concentration of naltrexone Lofexidine: May decrease the serum concentration of naltrexone Methylnaltrexone: May exacerbate any adverse effects Naldemedine: Adverse effects may worsen if taken with naltrexone Naloxegol: Adverse effects may worsen if taken with naltrexone Opioid Agonists: Naltrexone may decrease the effect of any opioid agonist Sibutramine: Adverse effects may worsen if taken with naltrexone Toxic effects associated with naltrexone: Possible overdose: The risk of overdose on naltrexone is higher than other opioid addiction treatments Risk factors: Naltrexone discontinuation Missed naltrexone doses Near the end of the naltrexone dosing interval Patients metabolism Hepatotoxicity: Mild increases in serum transaminases have been reported to result in hepatitis Risk factors Higher oral doses Concurrent NSAID use Patients over the age of 50 Injection site reactions: typically result in pain or discomfort at the injection site most commonly seen with patients with HIV and also can be caused by improper administration Naltrexone precipitated opioid withdrawal: Naltrexone may precipitate withdrawal symptoms in patients with opioid dependencies

Laws

Naltrexone is not a controlled substance so therefore is not subject to the Controlled Substance Act.

Monitoring/drug screens Some things that you may want to monitor while taking Naltrexone would be liver function, signs of opioid withdrawal, pregnancy tests, and HIV tests.

Professional Opinions In my professional opinion, I feel like Naltrexone could be a great medication to take when trying to recover from an opioid or alcohol addiction. It is long-acting so it could help limit the effects of opioids for people before they take them helping to prevent overdoses. However, this drug is very expensive which makes it not very practical to use for a majority of people who suffer from addiction that are very poor.

References 1. Srivastava AB, Gold MS. Naltrexone: A History and Future Directions. Cerebrum. 2018 Sep 1;2018:cer-13-18. PMID: 30746025; PMCID: PMC6353110.

2. Freed PE, York LN. Naltrexone: a controversial therapy for alcohol dependence. J Psychosoc Nurs Ment Health Serv. 1997 Jul;35(7):24-8. doi: 10.3928/0279-3695-19970701-21.

3. Naltrexone. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed November 17, 2023. http://online.lexi.com 4. OPIOID ADDICTION Laws, Regulations, and Other Factors Can Affect Medication-Assisted Treatment Access. United States Government Accountability Office. Accessed November 17, 2023. https://www.gao.gov/assets/gao-16-833.pdf 5. Naltrexone Oral Tablets. Medline. Accessed November 17, 2023. https://punchout.medline.com/product/Naltrexone-OralTablets/Miscellaneous/Z05-PF167934 6. Naltrexone. Wikipedia. Accessed November 17, 2023. https://en.wikipedia.org/wiki/Naltrexone 7. Drug Overdose Myths. Just Think Twice. Accessed November 17, 2023. https://www.justthinktwice.gov/consequences/drug-overdose-myths-jtt

Madelynn Packer Student Pharmacist Fall 2023

NBO-Me Background 2003: First synthesized as a serotonin 2A agonist receptor

Slang

2010: Shows up on the recreational drug market

2008: Developed for positron emission tomography

N-Bomb Bom-52 Smiles

2013: Added as a Schedule I drug by DEA

What is it?

Class of psychedelics 2C family of phenethylamine Sold as blotter paper, powder, or tablet

Pharmacology ultrapotent & efficacious agonist of serotonin 5-HTa affinity for adrenergic alpha-1 receptors

Drug Effects Hallucinations Distorted reality Euphoria

Panic Nausea Dizziness

Pandora Divination Wizard

Hot/cold flashes Sweating Numbness is arms and legs

Drug Interactions NBOMe + prescription or OTC drugs

Unpredictable & dangerous can increase the risk of anxiety, paranoia, panic attacks and psychosis

NBOMe + Cannabis

Increased stimulation, heart rate, and blood pressure

NBOMe + Cocaine

Toxicology

Monitoring & Drug Screens

Cardiovascular complications Agitation Metabolic acidosis Organ Failure Hypothermia

No rapid immunoassay screenings 10-14 day turnaround from testing Urine 1-5mL Presumptive testing via liquid chromatography/mass spectrometry

Laws All forms of NBO-Me are considered schedule 1 drugs in the US Schedule 1 drugs: no current accepted medical use and high abuse potential NBO-Me is illegal in all states in the US Punishment for having or distributing NBO-Me will vary based off the amount and number of offenses

Article from High Alert High Alert, an online site based out of New Zealand, writes about NBO-Me and warns its readers about the dangers of the drug as it rises on the market. The article discusses how NBO-Me is being sold as LSD quite frequently which presents a danger to users because NBO-Me takes longer to take effect than LSD, so users may take more and increase the risk of overdose. The article highlights the way to reduce risks of NBO-Me misuse such as distinguishing it from LSD by its bitter taste and numbing the mouth/tongue, avoiding snorting the drug, and avoid mixing with other drugs and alcohol

References

Professional Opinion NBO-Me is an unsafe drug and use of it should be avoided. Due to the lack of regulation of the drug, there could be dangerous additives in them and the many interactions in the body & other drugs could be harmful or fatal. Unless under close supervision of a doctor, I strongly recommend against use of the drug.

1.Zawilska JB, Kacela M, Adamowicz P. NBOMes–Highly Potent and Toxic Alternatives of LSD. Frontiers in Neuroscience. 2020;14:78. Doi: 10.3389/fnins.2020.00078.

2.Drug Scheduling. United States Drug Enforcement Administration. Accessed September 30, 2023.

3.NBOMe Hallucinogens, Screen and Confirmation, Urine. Laboratory Corporation of America. Accessed September 30, 2023. Add a little bit of body text 4.Laskowski LK, Elbakoush F, Calvo J, et al. Evolution of the NBOMes: 25 C- and 25B- Sold as 25I-NBOMe. Journal of Medical Toxicology. 2015;11(2);237-241. Doi: 10.1007/s13181-014-0445-9.

5.Merino D. Explainer: what is NBOMe?. The Conversation. Accessed September 30, 2023.

6.NBOMes. Alcohol and Drug Foundation. Accessed September 30, 2023.

7. High Lert. What you need to know about NBO-Me. Accessed November 16, 2023. https://www.highalert.org.nz/articles/what-you-needto-know-about-nbome/ 8. Graphics by Canva.com

NIGHTSHADE (ATROPA BELLADONNA)

By Addison Smith, student Pharmacist Fall 2023

HISTORY Nightshade, also known as Atropa Belladonna, has been used and abused since the mid 1700's.

Atropa Belladonna was originally used by women to dilate their pupils to make them appear more beautiful. The plant also has psychoactive properties and is abused to cause hallucinations.

It has also been used during wars to contaminate enemy’s food to get the upper hand on them.

ALTERNATE SLANG TERMS The drug, Atropa Belladonnna, is often referred to on the street as: deadly nightshade, devil’s cherries, dwale, and poison black cherries.

PHARMACOLOGY & DRUG EFFECT

Quinta dos Ouriques. Atropa belladonna. Image Available at: https://www.quintadosouriques.com/store/. Accessed September 29, 2023

ATROPA BELLADONA TRANSLATES TO “BEAUTIFUL LADY” IN ITALIAN

Mechanism of Action Nightshade acts as a competitive antagonists at muscarinic receptors and block the binding of acetylcholine to the central nervous system. The compounds in Nightshade that cause this are Atropine and Scopolamine. The plant’s pharmacology and effects are produced by these to compounds.

Drug Effect The main desired effects of this drug is to dilate pupils which is caused by the atropine in the plant and is used by ophthalmologists for eyeexams and surgery. The drug is also used to relieve pain, relax muscles, reduce inflammation, and to treat whooping cough and hay fever.

In the past this drug has also been used for its poisonous effects.

NIGHTSHADE WAS THE POISON OF CHOICE FOR ASSASSINS AND CRIMINALS AND WAS RUMORED TO BE USED IN WITCH POTIONS

DRUG INTERACTIONS AND TOXICOLOGY The main drug interaction with Nightshade is Cisapride as the atropine in Nightshade decreases the therapeutic effect of Cisapride. As mentioned before, Nightshade contains both Atropine and Scopolamine (anticholinergic drugs). Therefore it can be unsafe to take other anticholinergic drugs while taking Nightshade because the anticholinergic, drying effects will be elevated possibly leading to dry skin, dizziness, hypotension, and tachycardia. There has also been noted interactions with antihistamines and antidepressants. Nightshade is extremely toxic and has been used to poison people in the past. Signs of toxicity include, tachycardia, delirium, vomiting, and hallucinations.

LAWS Nightshade is a naturally occurring plant around the world and is not regulated. Here in the United States, it is legal to grow, sell, and buy Nightshade. However, if it is sold under a type of food or drug product, it must be regulated by the Food and Drug Association (FDA).

Plantura Magazine. Belladonna fruit. Available at: https://plantura.garden/uk/trees-shrubs/deadly-nightshade/.

Accessed September 29, 2023.

MONITORING / DRUG SCREENS While taking Nightshade, it is best to monitor for the signs and symptoms of toxicity mentioned earlier. This is a dangerous drug, and if not used properly, could lead to serious injury or even death.

The best way to screen for this drug in the body is by doing a urine drug test to screen for the scopolamine that is found in nightshade.

Sean Locke. Medical News Today. Available at: https://www.medicalnewstoday.com/articles/. Accessed September 29, 2023.

PROFESSIONAL OPINION

Nightshade (atropa belladonna) is not a drug that is referred to or spoken about often. Its use has decreased overtime as more and more drugs are being created and discovered that give the same, if not better, effect on the user’s body without having the dangerous toxicities. I see Nightshade as a dangerous plant that when misused or mistaken as a safe food option by hikers, can lead to extremely dangerous side effects and therefore should not be used recreationally or medicinally. In our present day, the world of pharmacy has developed so many effective and safe drugs that Nightshade should never be an option for therapeutic use. Nightshade is a dangerous drug and, due to its numerous toxicities and notorious past, should be avoided at all costs.

NIGHTSHADE WAS THE POISON OF CHOICE FOR ASSASSINS AND Drug Effect R E F E R E N C E S CRIMINALS AND WAS 1. U.SThe Forest Service.

The Powerful Belladonna.

Available at: https://www.fs.usda.gov/wildflowers/. main desired effects of this drugSolanaceae: is to dilate pupils which RUMORED TO BE USED Acessed September 2023. in the plant and is used by is caused by the 26, atropine 2. RxList.

Belladonna. for Available at: https://www.rxlist.com/belladonna/supplements.htm.

Accessed September 26, IN WITCH POTIONS ophthalmologists eye-exams and surgery. The drug is

also used to relieve pain, relax muscles, reduce 2023. inflammation, to bad: treat The whooping cough and hay fever.

3. Ambius.

Botany and gone history of the deadly nightshade plant. Available at: In the past this drug has also been used for its poisoness https://www.ambius.com/resources/blog/plant-profile/.

Accessed September 27, 2023. effects 4. DrugBank. Belladonna. Available at: https://go.drugbank.com/drugs/DB13913. Accessed September 25, 2023.

Spencer Stringham, Student Pharmacist, Fall 2023 History/background of use/abuse It is believed that Peyote usage began around 5700 years ago. Peyote (Lophophora williamsii), is a tough underground cactus about the size of a softball. (1). The drug is less popular by the general public due to the rarity of cactus. It grows in northern Mexico and southern Texas. The active psychedelic in the plant is mescaline. According To psychedelic expert Dr. John Halpern, the effects of mescaline are very comparable to other more well-known psychedelic such as LSD. The real reason Peyote is so heavily grown is the use of Peyote in religious ceremonies. The Navajo Nation in the Southwestern United States have used Peyote for thousands of years to enhance emotions and connection to a higher presence. Dr. John Halpern believes the use of Peyote has decreased the rate of alcoholism and other addictions. There appears to be no mental or physical dependence on the drug.

Despite all of this, Peyote is still considered a class 1 substance in the United States and it illegal for recreational use.

Slang Terms Black Button, Cactus, Seni, Shaman, Hikuli, Half Moon, Hikori, Nubs, Tops, Hyatari (2)

Peyote

Monitoring/Drug Screens Peyote can stay in the urine for 2-3 days on a drug test and 24 hours in the blood, depending on how much is used and how often (3)

Pharmacology

Drug Interactions/Toxicology

Mescaline binds to the 5-HT2A-C serotonin receptor (4). This produces the euphoric effect as well as the hallucinogeniceffects

Avoid Tramadol, Alcohol, immunomodulators, cocaine, amphetamines, and MAO-Inhibitors due to risk of serotonin syndrome and extended and amplified side effects (5)

Professional Opinion

Laws

In my professional opinion, like most natural drugs, there is no pharmaceutical company that could profit from it. In this case, it has never been studied for safe doses, in safe formulations. It has been heavily demonized but cultures have used it for thousands of years.

The 1994 amendment to the American Indian Religious Freedom Act of 1978 provided that “the use, possession, or transportation of peyote by an Indian for bona fide traditional ceremonial purposes in connection with the practice of a traditional Indian religion is lawful, and shall not be prohibited by the United States or by any State.” (5) References

1.

2.

3.

4.

5.

Serena K. A Trippy History Of Peyote — The Mysterious Navajo Hallucinogen. All That’s Interesting. Published May 3, 2018.

Peyote Drug Slang/Code Words. Clinical Pain Advisor. Published August 2, 2017.

Dinis-Oliveira RJ, Pereira CL, Silva DD da. Pharmacokinetic and Pharmacodynamic Aspects of Peyote and Mescaline: Clinical and Forensic Repercussions. Current Molecular Pharmacology. 12(3):184-194. Accessed November 17, 2023.

Peyote Trip: How to Take Peyote, Dosage, & Effects. Third Wave. Accessed November 17, 2023 Dinis-Oliveira RJ, Pereira CL, Dias da Silva D. Pharmacokinetic and Pharmacodynamic Aspects of Peyote and Mescaline: Clinical and Forensic Repercussions. Current Molecular Pharmacology. 2019;12(3):184-194. doi:https://doi.org/10.2174/1874467211666181010154139

Phencyclidine (PCP) Emily Wood, Student Pharmacist, Fall 2023

Slang Terms1,2

PCP, Angel Dust, Boat, Tic Tac, Zoom, Shermans, Sherms, Hog, Love Boat, Wack, Ozone, Dust, Embalming Fluid, Rocket Fuel, Crystal (Mixed w/ Marijuana: Supergrass, Superweed, Whacko Tobacco, Killer Joints, Fry, Lovelies, Wets)

History/Background1,3,4 Phencyclidine was developed in the 1950s for use as an IV anesthetic. It ended up being discontinued in 1965 due to its neurotoxic effects (e.g. agitation, delusion, irrational behaviors). A structurally similar drug called ketamine was developed as an alternative and is still used today. h"ps://addic@onresource.com/wp-content/uploads/2020/12/different-drugs.jpg

Toxicology/Interactions2 •

Neurotoxic effects at high doses (e.g. nausea/vomiting, blurred vision, dizziness, hostility, violent behavior, seizures, coma, death)

•

Interacts with CNS depressants (e.g. alcohol, benzodiazepines, opioids)

h"ps://www.chemspider.com/ImagesHandler.ashx?id=6224&w=250&h=250

Pharmacology2,3,4 Chemical Name: 1-(1-phencyclohexyl)piperidine Drug Class: hallucinogen Mechanism of Action: Unknown, thought to reversibly disrupt neurotransmitter communications that regulate functions such as mood and sensory perception Short-term Effects: hallucinations, delusions, paranoia, mood swings, anxiety, tachypnea, tachycardia, hypertension, flushing, sweating, numbness of extremities, loss of coordination, sense of strength/invulnerability, blank stare Long-term Effects*: memory loss, depression, weight loss, difficulties with speech (may persist up to 1 year after quitting) PCP can cause cravings, compulsive PCP-seeking behavior, and withdrawals. Effects are felt 2-5 minutes after smoking or 30-60 minutes after ingesting. The average dose taken is 5 to 10 mg.

Laws5,6 Phencyclidine is a Schedule II controlled substance. Possession or sale of the drug is charged at a minimum as a level 6 felony in the state of Indiana. The below table lists the specifications of each level of felony, though the amount listed may be bumped up to the next level of felony under “enhancing circumstances,” which includes situations such as prior offenses or concomitant possession of a firearm.

Type of Felony Level 6 Level 5 Level 4 Level 3 Level 2

Possession Less than 5 grams 5-10 grams 10-28 grams 28+ grams N/A

Sale/Intent to Sell Less than 1 gram 1-5 grams 5-10 grams 10-28 grams 28+ grams

Sentence Minimum 6 months 1-6 years 2-12 years 3-16 years 10-30 years

Monitoring/Drug Screens4,7 PCP is included in the SAMHSA-5 panel and expanded drug tests. The least expensive method of testing is with urine, though it can also be done using blood or hair. After a single use, PCP is detectable in urine for 3-7 days, but with regular use it can be detected in the urine for up to 30 days.

Tests for phencyclidine have poor specificity, so false positives are common. These false positive may be triggered by drugs such as venlafaxine, dextromethorphan, ketamine, or tramadol.

h"ps://chambers-law.com/wp-content/uploads/2020/08/Drug-arrest-min.png

Professional Opinion I believe that phencyclidine has absolutely no medical use. It has no benefit over any of the alternative anesthetics that are available, and it also carries more risk than these other options. Quite honestly it is also a bad recreational drug too; there are too many adverse effects and dangers involved with PCP when the same or “better” effects can be experienced with other less dangerous hallucinogens. ~E Wood

h"ps://www.illinoisrecoverycenter.com/wp-content/uploads/2022/12/drug-test.jpg

1.

2.

3.

4.

5.

6.

7.

Works Cited Anderson L. PCP (Phencyclidine). Drugs.com. Published May 18, 2014. https://www.drugs.com/illicit/pcp.html PCP – streetdrugs. https://streetdrugs.org/pcp/ Erowid PCP (Phencyclidine) Vault. www.erowid.org. Published May 21, 2019. Accessed November 19, 2023. https://www.erowid.org/chemicals/pcp/pcp.shtml DEA Office of Diversion Control. PHENCYCLIDINE (Street Names: PCP, Angel Dust, Supergrass, Boat, Tic Tac, Zoom, Shermans).; 2013. https://www.deadiversion.usdoj.gov/drug_chem_info/pcp.pdf Fort Wayne PCP Attorney - Angel Dust Charges in Ft. Wayne. The Law Offices of Ryan E. Lackey. Accessed November 19, 2023. https://www.defendingfortwayne.com/practice-areas/drug-crimes/pcp/ 2022 Indiana Code :: Title 35. Criminal Law and Procedure :: Article 48. Controlled Substances :: Chapter 1. Definitions :: 35-48-1-16.5. “Enhancing Circumstance.” Justia Law. Accessed November 19, 2023. https://law.justia.com/codes/indiana/2022/title-35/article-48/chapter-1/section-35-48-1-165/#:~:text=%22Enhancing%20circumstance%22%20means%20one%20(,in%20possession%20of%20a%20firearm.

Erowid Drug Testing Vaults : The Basics. www.erowid.org. Published February 10, 2015. Accessed November 19, 2023. https://www.erowid.org/psychoactives/testing/testing_info1.shtml#what

PSILOCYBIN

HTTPS://WWW.BANYANTREATMENTCENTER.COM/2021/12/06/O VERDOSING-ON-SHROOMS-TEXAS/

HISTORY/BACKGROUND Psilocybin-containing mushrooms have roots in ancient cultures, where they were revered for their spiritual and therapeutic properties. In the mid-20th century, psilocybin gained prominence in Western societies, leading to its classification as a Schedule I controlled substance due to concerns about abuse and recreational use..

SLANG TERMS -"MAGIC MUSHROOMS," "SHROOMS," AND "PSILO" ARE JUST A FEW EXAMPLES

HTTPS://WWW.NEWSCIENTIST.COM/ARTICLE/MG2363153 0-300-MIND-MENDERS-HOW-PSYCHEDELIC-DRUGSREBUILD-BROKEN-BRAINS/

Sameer VarmaStudent PharmacistFALL 2023

HTTPS://PUBCHEM.NCBI.NLM.NIH.GOV/COMPOUND/PSILOCYBINE#SECTION=2D-STRUCTURE

INTRODUCTION PSILOCYBIN, THE PSYCHOACTIVE COMPOUND FOUND IN CERTAIN MUSHROOMS, HAS CAPTIVATED THE HUMAN IMAGINATION FOR CENTURIES. THIS MONOGRAPH DELVES INTO THE MULTIFACETED WORLD OF PSILOCYBIN, EXPLORING ITS HISTORICAL SIGNIFICANCE, PHARMACOLOGICAL EFFECTS, LEGAL STATUS, AND IMPLICATIONS FOR DRUG SCREENING.

PHARMACOLOGY/DRUG EFFECTS PSILOCYBIN'S PHARMACOLOGICAL ACTIONS STEM FROM ITS INTERACTION WITH SEROTONIN RECEPTORS IN THE BRAIN, LEADING TO ALTERED PERCEPTION, MOOD CHANGES, AND, IN SOME CASES, THERAPEUTIC EFFECTS. THESE PROFOUND ALTERATIONS IN CONSCIOUSNESS ARE ESSENTIAL ASPECTS OF PSILOCYBIN USE, UNDERLINING ITS POTENTIAL FOR BOTH RECREATIONAL AND THERAPEUTIC PURPOSES.

HTTPS://FINANCE.YAHOO.COM/NEWS/HERES-MAGIC-MUSHROOMS-BODY-MIND140727345.HTML?GUCCOUNTER=1

DOSAGE Typical doses of psilocybin mushrooms range from 1 to 2.5 grams for moderate effects, while higher doses of 2.5 to 5 grams or more can induce more intense experiences, including profound alterations in perception and hallucinations

EFFECTIVENESS Research suggests that microdosing psilocybin mushrooms may offer potential benefits for mental health, including reports of improved mood, creativity, and focus in some individuals

HTTPS://NEWSROOM.UW.EDU/POSTSCRIPT/PSYCHIATRIST-LEAD-STATE-MANDATED-PSILOCYBINTRIAL

Laws Under federal law in the United States, psilocybin mushrooms are classified as a Schedule I controlled substance, which means they are illegal to possess, cultivate, distribute, or use for any purpose, including medicinal or recreational use, without authorization from the Drug Enforcement Administration (DEA)

MY OPINION In my professional opinion, shrooms should be legalized or decriminalized in all states as they are now more and more researched studies are showing the benefits of micro-dosing on shrooms for studying intentions.

According to the Article titled, Microdosing with psilocybin mushrooms: a double-blind placebocontrolled study, patients who received microdosing showed increased function in the following, subjective experiences, behavior, creativity (divergent and convergent thinking), perception, cognition, and brain activity. ~S VARMA

INTERACTIONS can potentially interact with various medications, particularly those that affect serotonin levels, such as certain antidepressants (SSRIs), MAOIs, and some migraine medications.

MONITORING/DRUG SCREEN Detecting psilocybin in drug tests poses challenges due to its unique chemical structure. Conventional drug screening methods often struggle to identify psilocybin accurately. The limitations of existing techniques and discussion of potential advancements, such as advanced mass spectrometry, may enhance the accuracy of psilocybin detection in drug screenings.

REFERENCES 1. Psilocybin. Uses, Interactions, Mechanism of Action | DrugBank Online. Accessed October 1, 2023. https://go.drugbank.com/drugs/DB11664.

2. Psilocybin: Overview, uses, side effects, precautions, interactions, dosing and reviews. WebMD. Accessed October 1, 2023. https://www.webmd.com/vitamins/ai/ingredientmono-1654/psilocybin.

3. Peden NR, Bissett AF, Macaulay KE, Crooks J, Pelosi AJ. Clinical toxicology of “Magic mushroom” ingestion. Postgraduate medical journal. September 1981.

Accessed October 1, 2023. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2426147/.

4. Cavanna F, Muller S, de la Fuente LA, et al. Microdosing with psilocybin mushrooms: A double-blind placebo-controlled study. Translational psychiatry. August 2, 2022.

Accessed October 1, 2023. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9346139/.

Salvia Divinorum Drug Monograph William Haines Pharmacy Student Fall 2023 History and Background of Salvia Dinvinorum - Salvia Dinvinorum is a plant-based drug which is mostly found in the Northern region of Mexico specifically in the Sierra Mazateca region.

- This leafy plant has been used buccally, but most recently has become popular through smoking route.

- The full timeline is not completely known but first known date was in 1938 when it was used in tea for spiritual upbringings.

Slang Terms of Salvia Divinorum - Ska Pastora - Shepherdess’s Herb - Maria Pastora - Magic Mint - Sally-D - Diviner’s Sage

Pharmacology/Drug Effects - This drug when smoked is fast acting and has a short duration, usually 30-60 minutes with effects starting to show at 20-60 seconds.

- Although many of these effects can vary from person to person there are positive and negative side effects that can also be experienced.

- The active form of Salvia Divinorum is Salvinorin A (Sal A) which acts as a kappa-opioid receptor agonist which can cause hallucinogenic effects.

Laws -

-

Currently in the United States this herbal drug is an unscheduled medication and isn’t controlled or regulated by the DEA. Although some states have made it controlled and illegal to possess.

The DEA has started a process of recommending the medication becomes scheduled, which was initiated in 2007.

Drug Interactions/Toxicology - This medication hasn’t been studied enough in combination with other drugs to find sustainable interactions that should need to be noted.

- The only disease states that should not take this medication are those with mental diseases like schizophrenia or major depressive disorder.

- No toxic effects have been observed while taking this medication, most users have reported that when using the leaves buccally it takes longer to see the same effects compared to those when smoked through a bong or a pipe.

Monitoring and Drug Screens - The monitoring parameters and drug screens for this drug aren’t well investigated and not much are known.

- Salvia Divinorum is only regulated in some states, but over the past couple of years some countries and more states have recognized this drug as controlled and are making it illegal.

Professional Opinion - This drug should not be used due to its hallucinogenic effects. It has similar effects to a close counterpart LSD. Although it’s not thought to be highly toxic or addictive it can be looked down upon and the long-term adverse effects have not been closely studied.

References: 1. Salvia Divinorum. Erowid. Accessed October 1, 2023. https://www.erowid.org/plants/salvia/ 2. Salvia Timelines. Erowid. Accessed October 1, 2023. https://www.erowid.org/plants/salvia/salvia_timeline.php 3. Salvia divinorum Legal Status. Erowid. Accessed October 1, 2023. https://www.erowid.org/plants/salvia/salvia_law.shtml 4. Salvia divinorum. Drugs.com. Last updated on November 3, 2021. Accessed October 1, 2023. https://www.drugs.com/npp/salvia-divinorum.html 5. Krystal Slagle. 10 Popular Species of Salvia Plants. The Spruce. Updated May 20, 2023.

Accessed October 1, 2023https://www.thespruce.com/common-types-of-salvia-flowers-annualand-perennial-4767399 6. Salvia: What are the effects? Medical News Today. Accessed October 1, 2023. https://www.medicalnewstoday.com/articles/309735#extent-of-use

Alexa Carnahan - Student Pharmacist Fall 2023

Prescription Stimulants History/Background of Use

Prescription stimulants are medicines used to treat attention-deficit hyperactivity disorder (ADHD) and narcolepsy, a sleep disorder of uncontrollable daytime sleepiness. These

medications help to increase energy, alertness, and attention. Common examples include: dextroamphetamine (Dexedrine), dextroamphetamine/amphetamine (Adderall), and methylphenidate (Ritalin, Concerta). When used as drugs of abuse, they are taken to: produce a sense of exhilaration, improve mental/physical performance, extend wakefulness, and “get high.”

Slang Terms Adderall Addys Speed Zing Uppers Ritalin Vitamin R Smarties

Pharmacology/Drug Effects The mechanism of action of stimulants revolves around increased catecholamine levels (dopamine and norepinephrine). Prescription stimulants work by increasing the activity of chemicals in the brain: dopamine and norepinephrine. Dopamine is involved in the reinforcement of rewarding behaviors, while norephinephrine affects blood pressure, heart rate, blood sugar, and breathing.

This leads to a euphoric feeling.

Drug Interactions/Toxicology Contraindications: Severe hypertension - as use of stimulants would increase their existing elevated blood pressure.

Drug Interactions: Monoamine oxidase (MAO) inhibitors and dopaminergic agents.

Options for treating stimulant toxicities include: benzodiazepines, beta-blockers, antihypertensive medications, and antiarrhythmic agents.

Stimulants reverse the effects of fatigue on mental and physical activities. Therapeutic levels can produce exhilaration, extended wakefulness, and loss of appetite.

Taking too large of a dose can lead to dizziness, tremors, headache, chest pain, excessive sweating, vomiting, and abdominal cramps. Paranoia, hallucinations, agitation, and agression are associated with chronic, high-dose use.

Monitoring/Drug Screens There are procedures in place to help prevent the abuse of stimulants. A rigorous clinical assessment makes a clear diagnosis of the disorder being treated and then establishes a clear indication for the prescription. The clinician then assesses risk of drug misuse, obtains informed consent regarding the abuse liability of the substance, and continually re-evaluates treatment effectiveness and patient adherence.

Professional Opinion Personally, I believe prescription stimulants are beneficial for those with ADHD or narcolepsy.

However, I believe other options that are not controlled substances should be explored first for the treatment of ADHD and narcolepsy. Due to the potential for these medications to be highly addictive, patients should try a nonstimulant medication first, and if that does not work, then try the stimulant. ACarnahan

Laws Prescription stimulants are classified as Schedule II drugs under the Controlled Substances Act. A Schedule II medication has a high potential for abuse, with use potentially leading to severe psychological or physical dependence.

References

National Institute on Drug Abuse. Prescription Stimulants. Drug Abuse. Updated June 2018. Accessed September 29, 2023. https://nida.nih.gov/sites/default/files/drugfacts-prescriptionstimulants.pdf Teensavers. Teen Drug Slang 101 - Prescription Stimulants. Published February 26, 2020. Accessed September 29, 2023. https://www.teensavers.com/post/teen-drugslang-101-prescription-stimulants Farzam K, Faizy RM, Saadabadi A. Stimulants. [Updated 2023 Jul 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539896/ Department of Justice/Drug Enforcement Administration. Drug Fact Sheet. Drug Enforcement Administration. Published April 2020. Accessed September 29, 2023. https://www.dea.gov/sites/default/files/2020-06/Stimulants-2020.pdf U.S. Food and Drug Administration. Prescription Stimulant Medications. Accessed September 29, 2023. https://www.fda.gov/drugs/information-drugclass/prescription-stimulant-medications CHADD. Carrying Your Medication. Accessed September 29, 2023. https://chadd.org/about-adhd/carrying-your-medication/ Pylkas AM, Bart G. Prescribing controlled substances during a prescription drug epidemic. Neurol Clin Pract. 2014;4(2):99-105. doi:10.1212/01.CPJ.0000437695.56006.4f Mangini L. CNS Stimulants: Few Interactions, Significant Repercussions. Contemporary Clinic. Published June 2, 2017. Accessed September 29, 2023. https://www.contemporaryclinic.com/view/cns-stimulants-few-interactionssignificant-repercussions

JONGMIN YOU STUDENT PHARMACIST FALL 2023

Toad Venom 5-MeO-DMT Source: CNN¹

HISTORY OF USE

PHARMACOLOGY

5-MeO-DMT is a psychoactive molecule present in certain families of plants, shrubs, and trees as well as in the venom of Bufo alvarius. A more common name for Bufo alvarius is Colorado River toad.

5-MeO-DMT mainly binds to nonselective serotonin (5-HT) receptors acting as an agonist.

It was found that 5-MeO-DMT binds to the 5-HT1A receptor with 3001000x higher affinity compared to the 5-HT2A receptor. Most psychedelics activate the 5-HT2A receptor and produce sympathomimetic effects in the body. Because 5-MeO-DMT stimulates the 5-HT1A receptor, it produces a sympathoinhibition. The serotonin receptor activation can cause hallucinations, visionary and auditory changes, and distortion of one’s perception of time.

It is said to have been used in religious rituals and tribal ceremonies by the indigenous people of South America and the Caribbean.

5-MeO-DMT can be used therapeutically, however, it has become another psychedelic drug used recreationally in recent years.

Due to the increasing demand for toad venom, the users are poaching and overharvesting the toads. This is directly endangering the Colorado River toad populations.

SLANG TERMS Five Bufo God Molecule

Source: Drug Science⁵

TOXICOLOGY

LAW

5-MeO-DMT is mostly inactivated by monoamine oxidase A (MAO-A). When 5-MeODMT is taken with an MAO inhibitor, 5-MeO-DMT will remain in the system for a prolonged period of time and will increase the risks for side effects, such as tachycardia, respiratory failure, and even death.

5-MeO-DMT is a schedule 1 drug which means it is not being used therapeutically in medicine and there is high potential for abuse. It is currently illegal in the United States.

DRUG SCREENS Presence of 5-MeO-DMT can be tested by screening for DMT with various methods, such as blood, urine, saliva, and hair follicle testing. These tests must be done within hours of drug use due to how fast DMT gets metabolized in the body. The only exception is the hair follicle testing as DMT can be detected in the hair for up to 90 days.

PROFESSIONAL OPINION As of Fall 2023, toad venom should not be advised for human use due to insufficient information on the therapeutic benefits and the safety of 5-MeO-DMT. I strongly advise against the use of 5-MeO-DMT for people who are taking MAO inhibitors or those with high risks for cardiovascular diseases. The long-term effects of 5-MeO-DMT are still unknown, so it is best if avoided.

— J. You

REFERENCES 1. Sottile Z. Please don’t lick this psychedelic toad, National Park Service warns. CNN. Published November 6, 2022. Accessed October 1, 2023. https://www.cnn.com/2022/11/06/us/nps-toxic-toad-dontlick-scn-trnd/index.html.

2. Reckweg JT, Uthaug MV, Szabo A, et al. The clinical pharmacology and potential therapeutic applications of 5-methoxy-N,N-dimethyltryptamine (5-MeO-DMT). J Neurochem. 2022;162(1):128-146. doi:10.1111/jnc.15587 3. Shen HW, Jiang XL, Winter JC, Yu AM. Psychedelic 5-methoxy-N,N-dimethyltryptamine: metabolism, pharmacokinetics, drug interactions, and pharmacological actions. Curr Drug Metab. 2010;11(8):659666. doi:10.2174/138920010794233495 4. Romero S. Demand for this toad’s psychedelic toxin is booming. some warn that’s bad for the toad. The New York Times. Published March 20, 2022. Accessed October 1, 2023. https://www.nytimes.com/2022/03/20/us/toad-venom-psychedelic.html.

5. 1. 5-MEO-DMT (BUFO) - everything you need to know: Drug science. Drug Science. Published June 16, 2021. Accessed October 1, 2023. https://www.drugscience.org.uk/drug-information/5-meo-dmt/.

6. Smith L. How long is DMT in your system for? Recovered. Updated September 11, 2023. Accessed October 1, 2023. https://recovered.org/hallucinogens/dmt/how-long-dmt-in-system.

Pharmacology and Drug Effects

VAPES AND E-CIGARETTES

Even though vaping devices are much less harmful than cigarettes when regular smokers switch over to substitutional devices, but nicotine in any form is highly addictive regardless by feeding in the brain’s reward and feel-good system, especially when exposed to the developing adolescent brain. E-cigarettes and vapes expose the lungs to a variety of unknown chemicals, especially during the heating and vaporizing process. Studies have shown that these vapors contain multiple carcinogens and toxic chemicals, along with metal nanoparticles from the structure of the device itself. During pregnancy, nicotine can cross over the placenta and has known affects on fetal and postnatal development, possibly leading to multiple adverse consequences like sudden infant death syndrome, deficits in auditory processing, obesity, and more.1,2

NICOLE PRZYBYCIEN STUDENT PHARMACIST FALL 2023

History and Background Vapes and e-cigarettes are devices containing a cartridge with nicotine, flavoring, and other chemicals that are operated by a battery. They are largely meant to replace traditional tobacco products like pipes, cigars, and cigarettes and can even resemble everyday items like USB drive sticks and pens.1 the first ever innovation of an e-cigarette device was developed in 2003 and was put out into the Chinese market in 2004 through the company Ruyan by Hon Lin, a Chinese pharmacist. By 2010, Ruyan was able to gain a U.S. patent for its product, claiming that its purpose was to help quit smoking and substitute cigarettes. Since this introduction to the U.S. in the late 2000s and early 2010s, the sale of e-cigarettes and vapes in the Unites States has risen rapidly with the help of marketing through social media.Due to this form of advertising, it was estimated that 13.1 million middle school and high school students had become aware of e-cigarettes and vapes in 2013.2

Slang Terms Due to this large influence of unlawful vape and e-cigarette culture to younger generations, teenagers have evolved to include nicknames and lingo for the activity.

For instance, a “hit,” “dab,” and “rip” to name a few refers to a single hit from a vape device; to be a “fiend" or “fiending” is when someone who is constantly searching for nicotine to inhale; to “ghost” indicates when a user holds a pull from their device for an extended amount of time and not exhale the puff to show toughness and the water droplets, which are initially condensed, evaporate and almost disappear into thin air; “nick sick” refers to symptoms of overexposure to nicotine depending on someone’s tolerance; “greening” is the act of being overstimulated and throwing up after a hit, specifically from a THC containing device, and many more.3

https://www.electrictobacconist.com/blog/2020/06/essential-guide-to-vaping-terminology/

Drug Interactions Even though nicotine is still actively being studied, there is data linked to its interaction with multiple diseases and drugs. While the other drug interactions are unknown or minor, the most notable medication is Wellbutrin or bupropion, in which the interaction notes an increase in blood pressure. As for disease interactions, notable interactivity includes CVD/PVD, pheochromocytoma, liver disease, PUD, renal dysfunction, asthma, hyperthyroidism, and diabetes, ranging from moderate to minor interactions. Adverse affects include arrhythmias, heart disease, COPD, and overall enhancement of disease states.4

Monitoring and Drug Screening Drug screening and monitoring with nicotine products is rarely seen but options are still available. Nicotine can stay in the bodily system for 3 to 4 days, and a metabolic of nicotine called cotinine can stay for up to 3 weeks.

Vapes and e-cigarettes can also be detected in hair follicles up to a year after exposure. Testing and monitoring for nicotine can done through urine up to 4 days, saliva up to 4 days, blood up to 3 days, and hair follicle sampling up to 3 months to a year.6

Laws It didn’t take long for the United States and the FDA to catch onto these nicotine products, but many rules and regulations are still unknown for nicotine devices. In the United States, vapes and e-cigarettes can be marketed and regulated as either for therapeutic purposes or tobacco products. Initially in 2009, the Tobacco Control Act gave the FDA authority in the United States to regulate the distribution, marketing, and manufacturing of tobacco products. With the increase in vape and e-cigarette across the United States, the FDA issued a “deeming rule” in May of 2016 that extended its authority out to include e-cigarettes.2 This includes regulating the import, packaging, manufacture, labeling, promotion, advertising, sale and distribution of e-cigarettes.

In more recent years, the United States instigated a law that raised the minimum age of sale of tobacco products from 18 to 21 years old as of December 2019, requiring photo and age verification. There are still numerous gray spaces in-between regulations though, like how there’s few federal restrictions on the marketing, no federal excise tax, and no federal policies restricting indoor use of nicotine products.5

https://vaping360.com/learn/fda-deeming-regulations-timeline/

Professional Opinion Vaping and e-cigarettes are still currently being researched on their effects and new grave information is constantly appearing. Nicotine products initially had good intention in helping the overall smoking population quit their addictions, but the idea instead was flipped and directed towards the wrong audience, which in turn has been largely hurting the teenage population. It's unfortunate to see, but its very important to input more regulation and restriction to try and maneuver the intentions back in place to help treat the correct population. But in the meantime, e-cigarettes and vapes have been causing more harm than good and need to be restrained.

References 1. Vaping devices (electronic cigarettes) DrugFacts. National Institutes of Health. July 28, 2023. Accessed October 1, 2023. https://nida.nih.gov/publications/drugfacts/vaping-deviceselectronic- cigarettes.

2. E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General. Chapter 1 Introduction, Conclusions, and Historical Background Relative to ECigarettes . 2016. Accessed October 1, 2023. https://www.ncbi.nlm.nih.gov/books/NBK538684/.

3. Vaping Lingo Dictionary - Truth initiative. Accessed October 1, 2023. https://truthinitiative.org/sites/ default/files/media/files/2020/05/Vaping%20Lingo%20Di ctionary_5.21_Final.pdf.

4. Nicotine interactions. Drugs.com. Accessed October 1, 2023. https://www.drugs.com/druginteractions/nicotine.html.

5. E-cigarettes: Facts, stats and regulations. Truth Initiative.

June 15, 2021. Accessed October 1, 2023. https://truthinitiative.org/research-resources/emergingtobacco-products/e-cigarettes-facts-stats-andregulations.

6. Staff RV. How long does nicotine stay in your body? (Vape Levels Testing). Rosedalekb Vape. August 31, 2023.

Accessed October 1, 2023. https://rosedalekb.com/howlong-does-nicotine-stay-in-yourbody/#:~:text=If%20your%20employer%20or%20health,to %203%20weeks%20after%20exposure.

Xylazine • • • •

• •

Sabrina Zheng Student Pharmacist Fall 2023

History 1962: First synthesized by Bayer HealthCare Pharmaceuticals.1 1972: Approved by the FDA for veterinary use as a sedative and muscle relaxant for animals and gained popularity.1 1980s: Nonmedical use was sporadically reported in literature.3 2001: First reported illicit use in Puerto Rico, where it was mixed with a stimulant (cocaine or amphetamine) and an opioid (heroin, morphine, or fentanyl) to make speedballs.8 2021: Found in over than 90% of illicit drug samples tested in Philadelphia.5 2022: FDA warned healthcare providers about the risk of xylazine exposure in humans.7 DEA has seized xylazine mixed with fentanyl in 48 of 50 states.6

• • • • •

Slang Terms Tranq2 Zombie Drug2 Tranq dope2 Sleep cut2 Speedball 8

https://go.drugbank.com/drugs/DB11477

Pharmacology Xylazine is an alpha-2 adrenergic agonist that is used in veterinary medicine with analgesic and muscle relaxant properties. When xylazine binds to alpha-2 receptors in the brain and spinal cord, norepinephrine, a neurotransmitter that plays a role in the “fight or flight” response, is inhibited; thus, decreasing the sympathetic nervous system’s activity.9

https://thehill.com/policy/healthcare/4089988-white-house-launchesnational-response-plan-for-combatting-tranq-drug-deaths/

Journal Article Summary Gupta R, Holtgrave DR, Ashburn MA. Xylazine - Medical and Public Health Imperatives. N Engl J Med.

2023;388(24):2209-2212. doi:10.1056/NEJMp2303120 The article discusses the increasing threat to public health in the United States posed by the growing use of xylazine combined with other drugs like fentanyl. Although xylazine is FDA approved for veterinary sedation, it is not authorized by the CSA for human use due to severe adverse effects. The study highlights the emergence of xylazine use, its adverse effects, and the challenges associated with its treatment and withdrawal. The article addresses the challenges clinicians face in recognizing xylazine-associated symptoms, especially respiratory depression, and emphasizes the lack of reversal agents. The number of deaths caused by overdose with xylazine is increasing in the United States each year and concurrent xylazine and opioid use complicates addiction treatment, demanding for intensive care. The White House Office of National Drug Control Policy declared xylazine, particularly fentanyl laced with xylazine, as an emerging threat, which triggered the development of a comprehensive response plan to address the escalating harm. The article concludes by stressing the need for effective strategies to address the xylazine threat before it worsens and undermines efforts to combat illicit fentanyl use in the United States.

Toxicology

•

In humans, xylazine can cause hypotension, bradycardia, central nervous system depression, and skin ulcers.2 Tranq can last up to 3 days (8-72 hours) in the human body.2 Unlike mainstream opioids, Xylazine does not respond well to opioid reversal agents like naloxone (Narcan); thus, breathing or heart issues caused by tranq will persist.2 Tranq is not FDA-approved for use in humans and there are no human antidotes.2 o In animals, atipamezole and yohimbine are antidotes for xylazine.2

• https://d-scholarship.pitt.edu/45422/

•

Laws Although Tranq is not federally a controlled substance, some states passed a bill designating xylazine as a controlled substance that is illegal to use or sell.2

•

Professional Opinion Xylazine should be classified as a Schedule 1 controlled substance due to its potential to induce severe side effects and because it has no accepted medical use in humans.

Xylazine abuse is increasing in the United States and the co-administration of xylazine with other opioids such as fentanyl and heroin is life-threatening, especially when there are no reversal agents for xylazine.

- S. Zheng

•

•

Drug Screening Standard drug test typically does not screen for xylazine because it is not intended for human use. o Tranq is undetectable in toxicology screens and routine drug tests used to detect opioids and other street drugs.2 Test that may detect tranq are thin layer chromatography and gas chromatography-mass spectrometry.2 o Xylazine test strips can be used to detect the presence of xylazine in drug samples but not quantity or potency of the drug.4

https://www.cnn.com/2023/03/28/health/xylazine-test-strips/ index.html

References 1.

2.

3.

4.

5.

6.

7.

8.

9.

Xylazine. Drugs.com. Available at: https://www.drugs.com/illicit/xylazine.html. Accessed October 1, 2023.

What is Tranq. WebMD. Accessed October 1, 2023. https://www.webmd.com/mental-health/addiction/what-is-tranqxylazine Holt AC, Schwope DM, Le K, Schrecker JP, Heltsley R. Widespread Distribution of Xylazine Detected Throughout the United States in Healthcare Patient Samples. J Addict Med. 2023;17(4):468-470. doi:10.1097/ADM.0000000000001132 Kounang N. Xylazine test strips available to help users check for animal sedative in drugs. Published March, 2023.

Accessed November 9, 2023. https://www.cnn.com/2023/03/28/health/xylazine-test-strips/index.html Xylazine. Substance Use Prevention & Harm Reduction. Accessed November 9, 2023. https://www.substanceusephilly.com/tranq DEA Reports Widespread Threat of Fentanyl Mixed with Xylazine. Drug Enforcement Administration. Accessed November 9, 2023. https://www.dea.gov/alert/dea-reports-widespread-threat-fentanyl-mixed-xylazine FDA alerts heath care professionals of risk to patients exposed to xylazine in illicit drugs. Food and Drug Administration.

Updated November 8, 2022. Assessed November 9, 2023. https://www.fda.gov/drugs/drug-safety-and-availability/fdaalerts-health-care-professionals-risks-patients-exposed-xylazine-illicit-drugs Gupta R, Holtgrave DR, Ashburn MA. Xylazine - Medical and Public Health Imperatives. N Engl J Med. 2023;388(24):2209-2212. doi:10.1056/NEJMp2303120 Debnath R, Chawla P. Xylazine addiction turning Humans to zombies: Fact or Myth? Health Sciences Review. Published October 20, 2023. Accessed November 9, 2023. https://doi.org/10.1016/j.hsr.2023.100132

Yohimbe/Yohimbine hydrochloride Hunter Craig, Student Pharmacist, Fall 2023 Background Yohimbine is a naturally occurring supplement derived from the bark of the West African yohimbe tree and it has historically been used as an aphrodisiac. The bark of the tree has also been smoked as a hallucinogen and used to treat both angina and hypertension. More recently, its effectiveness has been investigated for the treatment of erectile dysfunction.

Supplements containing yohimbine/yohimbe bark are available to purchase in the U.S and are usually marketed as having various health benefits such as treating erectile dysfunction, aiding in weight loss, or boosting athletic performance. There is still not enough research, however, to say if yohimbe as a dietary supplement is helpful in these cases.

Slang Terms ● “Yo-yo” Pharmacology Yohimbine acts on both the central and peripheral nervous symptoms by selectively antagonizing a2 adrenergic receptors. It is also capable of binding to norepinephrine, serotonin, and dopamine receptors as well.

Erectile dysfunction: In studies exploring the effect of yohimbine in the treatment of erectile dysfunction it was shown to possibly act as an adrenergic blockade of a2 adrenergic receptors in the corpus cavernosum and in the serotonergic system. This may increase the release of nitric oxide from endothelial cells in target tissue, therefore promoting the relaxation of smooth muscle and erection.

Orthostatic hypotension: Yohimbine’s use in the treatment of orthostatic hypotension has not been conclusively established as of yet. It is theorized to have beneficial effects in the treatment of hypertension due to its known effects on lowering blood pressure, however, its use as an antihypertensive agent has been widely abandoned.

Drug Interactions/Toxicology Interactions: ● Yohimbe bark has the potential to potentiate the effect of monoamine oxidase inhibitors.

● ● ●

Yohimbine has been shown to increase the risk of hypertension when given with tricyclic antidepressants.

Yohimbine may diminish the effect of antianxiety agents.

Avoid combination with iobenguane radiopharmaceutical products as yohimbine may diminish the effects of these products.

Adverse Reactions: Most clinical trials show few serious adverse reactions with the use of yohimbe, however there do exist several case reported incidents of adverse reactions which include: Rash, lupus-like syndrome, bronchospasm, arrhythmias, increased anxiety, irritability, excitability, tremors, insomnia, flushing, nausea, vomiting, hypertension, palpitations, angina, tachycardia, and atrial fibrillation.

Toxicology: The reproductive toxicology of yohimbine has been studied in rats and has shown increases in weight of seminal vesicles, decreased sperm count and motility, and increases in sperm abnormalities.

Laws Yohimbine hydrochloride is available to be sold as a prescription drug in the U.S. for the treatment of erectile dysfunction, however supplements or other products containing yohimbe bark or yohimbine cannot be legally sold over-the-counter.

Monitoring/Drug Screening Yohimbine does not have a specific drug screen associated with it currently.

Professional Opinion -H. Craig: As a prescription medication, I believe that yohimbine hydrochloride is an okay option for the treatment of erectile dysfunction. While it has been approved by the FDA for this indication, its use for any condition has been controversial with little evidence showing it to have a substantial benefit compared to other agents on the market. As a street drug/supplement, however, I do not believe one should use yohimbe bark or its derivative yohimbine as it has been shown to have some serious adverse effects and does not seem to have any clinically significant benefit to outweigh these adverse reactions.

References: 1. Yohimbe. Lexi-Drug. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed October 1st, 2023. http://online.lexi.com 2. Colin Anderson, Dan Anderson, Nicole Harre, Norman Wade, Case Study: Two Fatal Case Reports of Acute Yohimbine Intoxication, Journal of Analytical Toxicology, Volume 37, Issue 8, October 2013, Pages 611–614, https://doi.org/10.1093/jat/bkt057 3. National Center for Complementary and Integrative Health. Yohimbe. Available at: https://www.nccih.nih.gov/health/yohimbe#:~:text=Yohimbe%20caused%20stomach%20problems%2C%2 0tachycardia,System%20between%202000%20and%202006. Accessed October 1st, 2023 4. Christopher H Linden, W Peter Vellman, Barry Rumack, Yohimbine: A new street drug, Annals of Emergency Medicine, Volume 14, Issue 10, 1985, Pages 1002-1004, ISSN 0196-0644, https://doi.org/10.1016/S0196-0644(85)80249-3 5. Pausinystalia johimbe-Yohimbe Bark Structure. Accessed November 16, 2023. https://theherbshoppepdx.com/products/pausinystalia-johimbe-yohimbe-tincture 6. Yohimbe Bark Capsules. Accessed November 16, 2023. https://www.natrol.com/products/yohimbe-bark-mens-health-capsules 7. Compound Summary: Yohimbine. Accessed November 17, 2023. https://pubchem.ncbi.nlm.nih.gov/compound/Yohimbine