ATrain Education

 

Continuing Education for Health Professionals

Designer Drugs: Bath Salts, Synthetic Cannabinoids, and Synthetic Hallucinogens

Module 6

Designer Drug Management and Treatment

Management of acute intoxication from designer drugs is especially difficult because no antidotes are available. Acute and long-term treatment is also a challenge and must rely heavily on counseling while encouraging young, impulsive patients to change their behavior.

Management of Acute Intoxication

No specific antidotes are available for designer drug toxicity. Activated charcoal is not useful unless there has been significant oral ingestion. Most non-psychiatric symptoms appear self-limited and resolve within one to several days with supportive treatment. Unpleasant psychological effects of acute intoxication, such as anxiety, agitation, or paranoia, may be managed with supportive treatment. Placing the distraught user in a quiet environment and maintaining gentle contact is often sufficient until the acute effects subside (Weaver et al., 2015).

Psychosis due to synthetic cannabinoid and 25I-NBOMe intoxication has been managed with monitored observation. For psychopathologic clinical features, benzodiazepines have been used to treat anxiety, agitation, and seizures. Antipsychotics are second-line agents for agitation, due to the lowered seizure threshold with use of cathinone and phenethylamine designer drugs. Sedation may be required if the patient is markedly agitated and at risk for harm to self or healthcare staff. Since some designer drug-associated psychosis may be severe and require prolonged inpatient treatment, psychiatric consultation is indicated, in particular for those with persistent symptoms (Weaver et al., 2015).

Abrupt discontinuation of stimulants or hallucinogens does not cause gross physiologic sequelae, so they are not tapered off or replaced with a cross-tolerant drug during medically supervised withdrawal. Abrupt discontinuation of synthetic cannabinoids could result in withdrawal symptoms such as nausea and irritability, similar to that with cannabis cessation: however, there is no indication for pharmacologic replacement (eg, dronabinol), since synthetic cannabinoid withdrawal is not life-threatening (Weaver et al., 2015).

Patients can be treated with supportive care by intravenous fluids and antiemetics if necessary. If marked psychiatric symptoms persist longer than one or more weeks after discontinuation, the patient should be evaluated carefully to determine whether there is a co-occurring primary psychiatric disorder, which then should be treated with specific therapy. Treatment of prolonged anxiety, depression, or psychosis is the same as when these conditions are not associated with recent designer drug use (Weaver et al., 2015).

For a significant number of patients, the high level of illness severity warrants admission to critical care. Intoxicated patients should be placed initially on continuous cardiac monitoring with pulse oximetry and frequent neurologic assessments. Adequate administration of intravenous fluids is encouraged to ensure good urine output, as these patients often are dehydrated. Fluid administration in the presence of rhabdomyolysis can help prevent acute renal failure. Intensive monitoring allows for early detection and intervention for serious consequences such as myocardial infarction (Weaver et al., 2015).

Patients may present with concurrent ingestion of drugs with different pharmacologic profiles, including both stimulant and depressant drugs. Clinicians should be alert for an unexpected response to a therapeutic intervention or to a change in patient presentation as one type of designer drug wears off and ongoing intoxication with another class of designer drug is revealed. This may require some flexibility in treatment due to changes in mental or cardiovascular status (Weaver et al., 2015).

Treatment of Designer Drug Addiction

Hospitalization for the adverse effects of designer drugs affords an excellent opportunity for advising patients to decrease their substance use and for engaging them in treatment. Healthcare provider awareness and patient education are cornerstones of public health initiatives to confront new challenges presented by designer drugs. Simple admonitions to stop are sometimes helpful if the diagnosis is made early, but in most cases are insufficient. Many patients who use designer drugs may be ambivalent about changing behavior, so the clinician should express empathy without confrontation, which shows respect for the patient’s autonomy (Weaver et al., 2015).

Providing appropriate, accurate information about the potential risks of designer drugs and encouraging healthy choices can help patients make the best informed decision about changing behavior. Physicians should involve the patient proactively in the process of problem-solving, while reminding the patient of responsibility for all actions. The responsibility of the practitioner is to motivate the patient to seek recovery from designer drug use instead of blaming the patient for being unmotivated to change. Accurate information about the relative risks and unknown harms of these products helps a patient make an informed choice about continuing to use particular products, to make a quit attempt, or to seek more specific addiction treatment (Weaver et al., 2015).

Although prospective treatment data are limited, once a designer drug use disorder diagnosis is made, acute and long-term treatment is likely necessary. Recovery from substance use disorder in general is possible, and those who are treated have less disability than those who remain untreated. Long-term treatment of designer drug use disorders likely involves similar components to that of other types of addiction treatment, including behavioral components such as individual and group counseling with cognitive-behavioral therapy, motivational enhancement therapy, and 12-step self-help group facilitation. Family members should be considered as part of the treatment program, in particular when treating adolescents or young adults. Unfortunately, pharmacologic treatment data to guide management of those with designer drug use disorders are unavailable (Weaver et al., 2015).

Patients identified with substance use disorders in the ED or hospital inpatient setting should be provided with information linking them to local community addiction treatment resources. In the United States, physicians certified in the treatment of addictive disorders can be found through the American Society of Addiction Medicine or the American Academy of Addiction Psychiatry. At times, it may be more expedient and cost effective to refer the patient to a non-physician counselor, who can be found through the National Association for Alcohol and Drug Abuse Counselors’ website. Substance abuse treatment services in the United States can also be located via the Substance Abuse and Mental Health Services Administration Behavioral Health Services Treatment Locator (Weaver et al., 2015).

Treatment of designer drug substance use disorders is challenging for several reasons. Designer drugs consist of several classes of substances, which vary in their psychological and physiologic effects. Treatment is often difficult due to the young age of most users and the possibility of concurrent polysubstance use. The pattern of use is usually intermittent in social settings, so it may be perceived as less of a problem. Clinicians should be knowledgeable and prepared to provide treatment for very different combinations, such as occurs with club drug use. A treatment environment with a supportive structure can be helpful. Addiction treatment is cost effective, and even multiple episodes of treatment are worthwhile. It can be rewarding for any healthcare practitioner to assist a patient who was impaired by addiction return to normal functioning in society (Weaver et al., 2015).

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