Summer is peak concert season, a time when illicit drug use tends to spike. Professor C. Michael White, head of the Department of Pharmacy Practice in the UConn School of Pharmacy, has his eye on a relative newcomer to the scene: synthetic cathinones. In 2015, one in 100 12th graders nationwide tried some version of the drug, which is viewed as a cheap substitute for other stimulants such as heroin, crack, and methamphetamine. Labeled with the warning “not for human consumption,” synthetic cathinones remained in the shadows of the drug abuse world for years, sold as “bath salts,” “plant food,” or “jewelry cleaner” in some convenience stores, gas stations, and other venues. White, who recently published a comprehensive review of the drug in the Journal of Clinical Pharmacology, discussed the substance with UConn Today.
Q: What are synthetic cathinones and how do they work?
A: Cathinone is derived from the Khatt plant, which is commonly used in Africa and the Arabian Peninsula. In Somalia and Yemen, over one-third of the population use the product every week. But synthetic cathinones are made in the laboratory and chemically altered to heighten the effects of the drug, making it more potent and more dangerous. First made in Russia as an appetite suppressor but removed from the market due to abuse, it spread across Europe before ending up here in 2008. The most common synthetic cathinones are mephedrone, MDPV, and flakka, which is chemically called alpha-PVP. They are structurally very similar to methamphetamine, and people use them for increased energy and a feeling of euphoria. It causes this feeling by increasing serotonin, dopamine, and norepinephrine in the brain, and it’s the intense release of these brain chemicals that also causes adverse effects.
Q: What effect does the drug have on users?
A: People take drugs like these during raves, parties, or concerts to give themselves energy, and to make themselves feel happy and up for the long haul. They like these drugs versus marijuana because it is much harder to detect by the smell it leaves behind, and is harder to detect by laboratory testing as well. However, any time you buy an illegal drug, you have no idea how much active ingredient is in it, whether it has other drugs in it to enhance the effects, and how you in particular will react to it versus your friends. In addition, these drugs are broken down by liver enzymes, and there are important potential drug interactions that can occur. So you can’t say that since you tried it before taking the same amount this time will give the same effect, or because your friend tried it before that your experience will be the same. These drugs are also addictive, and there are many reports of people being hospitalized or undergoing treatment and then relapsing. Like with crack, trying it a time or two for a high can result in addiction that is incredibly hard to break.
Q: News stories chronicle deaths from synthetic cathinone use. What causes death?
A: The most common adverse effects associated with synthetic cathinones include mental issues such as agitation, hallucinations, delusions, or psychosis; heart effects like racing heartbeat, elevated blood pressure, and arrhythmias; severe muscle damage leading to kidney damage; and seizures. The mental effects can be very pronounced, with several people fleeing imaginary monsters, scorpions, or people; stripping off their clothes; jumping off bridges; drowning; and other self-inflicted harm. These hallucinations and delusions make the heart risks even higher, as the panic they induce drives adrenaline concentrations up.
Q: How does research help healthcare practitioners on the front lines?
A: I got interested in the illicit use of drugs when Molly (chemical name MDMA) was introduced and high school and college age people were being injured due to its use. I did not see a high quality assessment of MDMA in the medical literature, and was concerned that physicians, nurses, and pharmacists would not recognize the signs of abuse, the risks of use, and the treatments that are needed to prevent patient harm. I was also alarmed when I found that the lack of pharmacologic understanding of why MDMA was causing adverse events, and how that led to recommendations being espoused that traded one adverse effect for another. For example, MDMA raises body temperature and can damage muscles through that mechanism, so people were being told at concerts and raves to drink lots of water. However, MDMA also causes increases in other hormones that make people retain fluid, so with the addition of water, they were more likely to dilute the sodium in their blood stream and be harmed from that. Drinking electrolyte-enhanced beverages and staying away from products with caffeine was a much better recommendation, once you understood exactly how the drug caused its desired and harmful effects. When the article came out, I was contacted by a medical professional who coordinates emergency medical services at raves who told me how helpful it was to have concise information to share with his paramedics, who do their best to keep attendees safe.
Q: How important is the role of the pharmacist in public health efforts in general?
A: We have faculty and students volunteering at migrant farm worker clinics providing care to those with no health coverage. We have faculty supporting Khmer Health Associates, which provides care for Cambodian refugees who emigrated in the United States and experienced genocide and torture under the Khmer Rouge. We have faculty, staff, and students doing missions of mercy to Haiti, Cambodia, and Thailand, and others doing health fairs and providing care in clinics that serve predominantly Medicaid and uninsured patients.
A few years ago, we coalesced our work with underserved patients through the creation of the PeRformance Improvement for Safe Medication Management (PRISM) Collaborative, which is conducting research across Connecticut on how best to utilize the pharmacist to meet the needs of the most underserved sectors of our society. Pharmacists are known for their caring, and this initiative helps us understand and train students in how to care for people with cultural, economic, and social barriers to better health. We have already found ways that pharmacists can improve the care of these patients in a cost-neutral or cost-lowering environment, and are working aggressively to investigate new models of care like this that can pay immediate benefits to patients’ well-being and help solve one of the greatest challenges we have – how to expand coverage without bankrupting our healthcare system.