CATR: Such as?
Dr. Weaver: One clue would be red, bloodshot eyes if someone is using synthetic cannabinoids. You typically don’t see that in an acute psychotic break. You might also get a history of recent use, or they may have a package on their person or a chemical smell on their breath from recent smoking. You could also look for injection marks, although a lot of these drugs are snorted or smoked. If someone has a history of drug use, but the clinical picture isn’t consistent with that particular drug, then you should suspect synthetic. Keep in mind that patients who are concerned about legal consequences may not be quite as forthcoming as those that are just scared.
CATR: Has it been established if these drugs are addictive? Can people become dependent on them?
Dr. Weaver: Yes. There have been several cases of dependence. You can see cross-tolerance with marijuana among the synthetic cannabinoids. People can develop withdrawal, or they can be used to ameliorate the symptoms of withdrawal. With the bath salts or stimulants, people can have cravings for those on a regular basis. The synthetic hallucinogens are a little bit different in that respect, but people have used them enough to meet the criteria for substance use disorder and obviously have consequences as a result.
CATR: What can we do to help patients who come to us saying they want to get off these drugs?
Dr. Weaver: The treatments for designer drugs are similar to those for other substances in the young adult population. Unfortunately, there is not a substitution therapy like there is methadone or buprenorphine for the opioids, nicotine replacement for tobacco, or other treatments such as naltrexone for alcohol. Cognitive behavioral therapy or other types of therapeutic groups, such as 12-step programs, can help patients make positive environmental changes in order to reduce access and use. These standard treatments can be successful, although young adults are a challenging population because of the developing mind and mindset, “Well, that stuff won’t happen to me.” Family involvement can be very important in order to have an adequate support system and accountability.
CATR: Cannabinoids are now legal recreationally in a couple of states and certainly “medicinally” legal in many states. Would it be more reasonable for patients that are hell-bent on using synthetic cannabinoids like K2 or Spice to use regulated sources of standard cannabis?
CATR: Maybe this isn’t so relevant clinically, but more from the systems’ perspective, what is it about synthetic drugs that makes them so hard to stay on top of in terms of law enforcement?
Dr. Weaver: The reason they were called designer drugs in the first place is because they were designed to evade authorities. You might be able to arrest someone on suspicion of these drugs, but you wouldn’t be able to prosecute someone successfully because the product in possession is not strictly illegal—it’s the specific compounds within the drugs that are illegal.
Young adults are a challenging population because of the developing mind and mindset, “Well, that stuff won’t happen to me.” One of the ways I talk to my patients about [designer drugs] is “buyer beware.” You don’t always know what you’re getting. At best they may get a very bad scare and at worst a life-changing event that could impair their ability to finish school or get a job.
~ Michael Weaver, MD, FASAM
CATR: You would think that, with the techniques we have now, we could quickly determine their chemical makeup and say, “Okay this is a problem, we need to make this illegal.” Why isn’t that happening?
Dr. Weaver: The folks who make these drugs have access to chemical laboratories and the Internet. They know when the net is starting to close on particular substances, and they will quickly jump ahead to a similar sort of designer compound that is just different enough to evade detection. Currently, we are several generations into the different types of synthetic cannabinoids and bath salts in terms of the evolution of the chemical compound families that the clandestine manufacturers are producing. A number of states have started putting specific wording into the legislation to identify specific chemical compounds. But then you run into problems with things like dronabinol, which is a purified form of TCH that is available by prescription, and so it has legal protection and FDA-approval. You don’t necessarily want—from a legal standpoint—to tie the hands of people who have appropriate use of these other compounds for medicinal use.
CATR: In addition to Internet sales, are there also sales from legal stores, such as liquor stores or corner stores?
Dr. Weaver: They are commonly sold at convenience stores and head shops.
CATR: So if I own a head shop and I’m selling something and then I find out that my state has made it illegal (that chemical compound), do I then call my distributor and say, “Okay, do you have something with an extra hydrogen atom on it,” so it’s now the next generation?
Dr. Weaver: Yes, the distributors are usually ahead of the curve on this. They’ve already got the next couple of compounds in the pipeline and start moving updated products with new packaging so that people will continue using similar products.
CATR: I guess the bottom line is that there is a whole world of new compounds out there that we need to educate ourselves about, and we need to have some knowledge as we talk to our patients about them so we can have that suspicion, ask them about specific compounds, and be able to talk to them about the dangerous side effects that they may be oblivious to.
Dr. Weaver: Absolutely, and the good news is that treatment can certainly be successful.
CATR: Thank you, Dr. Weaver.