The Pulse

Substance Use Alerts from Gallus Medical Detox

Gallus Medical Detox Centers, a nationally recognized Center of Excellence for inpatient medical detox, is launching a new substance use alert to inform providers of new and potentially dangerous trends happening across the country. With ten years of experience treating SUD patients, we have a unique front-line perspective in providing the medical assistance needed to help patients overcome addiction. We’re providing “The Pulse” to alert you to the use of new substances, legal and illegal, increasing severity within opioid, benzodiazepine, and stimulant epidemics, and complications brought on by increasing polysubstance use. We hope you find this information informative and useful in our fight against the growing problem of substance use disorders.

Latest Alerts

GHB

Gamma Hydroxybutyrate or GHB, also known as the “date rape” drug. It’s a central nervous system depressant and at low doses it can produce effects of euphoria. High doses of this drug can cause blackouts and amnesia. Medically, it’s used to treat sleep disorders like insomnia and narcolepsy. In 1990, the FDA issued an advisory declaring GHB use unsafe and illegal except under FDA approved, physician-supervised protocols. In March 2000, GHB was placed in Schedule I of the Controlled Substances Act. However, the sodium salt of GHB is used as a prescription drug known as Xyrem (sodium oxybate). In 2002, the FDA approved Xyrem for the treatment of narcolepsy. It is a highly regulated prescription medicine classified as a Schedule III controlled substance and requires patient enrollment in a restricted access program.

 

Other names: Scoop, liquid E, liquid X, Georgia Home Boy

Read More

How do people get it?

GHB can be bought on the streets or on the internet.

How is it dangerous?

When GHB is mixed with alcohol it causes faster intoxication, loss of control movements and coordination, vomiting, and more. Withdrawal from GHB can be severe and should be monitored by a medical professional.

Long Term Benzodiazepine Use for Anxiety

Benzodiazepines are a class of drugs that induce a sedative effects. They work in much the same way as alcohol in how they interact with the Gaba receptor complex. Because of the close similarity of effects benzodiazepines are the Gold Standard for medical detox. 

Other Names: Benzos, downers, candy, chill pills, Z bars

Read More

How do people get it?

Benzodiazepines are most commonly prescribed by doctors and other clinicians treating anxiety. It is widely researched and known that daily use beyond two months worsens anxiety and leads to diminished returns, however, prescribers often continue to prescribe them despite this fact. 

How is it dangerous?

Perhaps the biggest risk is withdrawals from benzodiazepines when someone is severely dependent are life threatening. Physical dependence happens rapidly with this class of drugs and it is notoriously challenging and consequential to quit. Studies have shown that even a month long taper leads to worsening panic attacks, permanent deficits in cognitive functioning, and “significant new somatic symptoms such as malaise, weakness, insomnia, tachycardia, and dizziness, after alprazolam (Xanax) discontinuation.” In short, once people become dependent on this substance, it can be extraordinarily challenging to detox off of it.

Psychiatrically speaking, there is no doubt that the consequences outweigh the benefits. There is no doubt that benzodiazepines will stop a panic attack but long term daily prescriptions would be akin to a doctor recommending you drink alcohol every night to manage that panic or anxiety. The most compelling evidence for these drugs worsening mental health is that they increase risk for suicide 3 fold.

Cannabis Induced Psychosis

Cannabis concentrates are oils, budder, wax, and dabs that contain unnatural levels of THC (anywhere from 25 – 75%). The THC is typically extracted with a Butane solvent.

Increased concentrations of THC are leading to higher rates of Cannabis Induced Psychosis.

Read More

Other Names: Wax, dabs, honey oil, black glass

 

How do people get it?

It is extracted from marijuana.

 

How is it dangerous?

It is a common misconception that cannabis does not cause withdrawal. It is true that in the vast majority of the people that use cannabis will have little to no issue stopping. However, for those using concentrates multiple times per day there can be many uncomfortable withdrawal symptoms. At Gallus we have treated patients using 1000mg or more per day (standard dose is 5 to 10mg). At that level of use people can experience hyperemesis (uncontrollable vomiting), hypertension, psychosis, irritability, trouble sleeping, difficulty concentrating, trouble regulating body temperature, etc. The psychosis and metal health disturbance can become quite significant and treatment usually involves short term use of sedatives or antipsychotics to stabilize patients. Those experiencing hyperemesis may also require IV fluids.

In addition to concentrates, casual marijuana users also risk acute mental health episodes when using edibles. Because edibles act more slowly than smoking cannabis, people have been found to eat copious amounts when “I can’t feel anything.” A 5 to 10mg dose is enough to produce the desired high and when users ingest 5 or 10 times that dose paranoia, psychosis, and hypertension can lead to emergency room visits.

Soma

Soma is a muscle relaxer, and its generic name is carisoprodol. It’s used to treat muscle pain, and usually used with rest and physical therapy. It typically is prescribed in 350mg pills and a typical prescription is one pill 3-4 times per day.

Read More

How do people get it?

It’s prescribed for muscle pain and relaxation.

 

How is it dangerous?

There are risks for withdrawals from the substance and at high doses there is a risk of withdrawal seizures. Similarly to Benzodiazepines, Soma is a schedule IV substance by the Federal government. This designates it as low risk of abuse and that it does have verifiable medical benefits. When combined with opiates or benzodiazepines there is an increased risk for abuse. There has been a rise in use and abuse of Soma over the past decade.

“Moreover, while the number of reports regarding carisoprodol abuse continues to increase, there has been little progress in the treatment of carisoprodol dependence and withdrawal. At present, treatment consists of brief courses with benzodiazepines or phenobarbital to combat anxiety and insomnia. Furthermore, treatment of carisoprodol overdose is complicated as it is often characterized by agitation and seizures, and the administration of anticonvulsants and sedatives exacerbates CNS depression, leaving supportive therapy as a preferred course of action.”

Kratom

According to the National Institute on Drug Abuse, kratom is a tropical tree native to Southeast Asia and its leaves contain compounds that can have stimulant and opium-like effects. Traditionally, kratom leaves have been used by Thai and Malaysian natives for centuries. It’s a member of the coffee family, and it’s been utilized to enhance work productivity, cultural ceremonies, and for medicinal purposes.

Other names? Biak, ketum, kakuam, ithang, thom.

Read More

How do people get it?

Kratom, as of recently, is illegal in Thailand, but currently legal in the United States except Wisconsin, Arkansas, Indiana, Alabama, Vermont, and Rhode Island. It can be ordered on the internet and bought in smoke shops. It’s sold in pill, capsule, gum, or extract form.

How is it dangerous?

Kratom causes effects similar to opioids and stimulants. The compounds mitragynine and 7-a-hydroxymitragynine found in kratom leaves interact with opioid receptors in the brain, which produces sedation, pleasure, and decreased pain. Mitragynine also interacts with other receptors in the brain to create stimulant-like effects. When taken in small amounts, users of kratom report increased energy, sociability, and alertness. But Kratom can cause uncomfortable and potentially dangerous side effects. 

There are now some products out there that are adulterating the substance by adding the ingredient 7-hydroxymitragynine, which increases side effects. “We have found multiple packaged commercial Kratom products to contain artificially elevated concentrations of 7-hydroxymitragynine, the alkaloid responsible for M. speciosa’s concerning mechanistic and side effect profile [2022]. The amount of 7-hydroxymitragynine exceeded that found in naturally occurring material by up to 500%.”

In our centers, we are seeing that Kratom is not coming off patient’s receptors quickly. This causes the risk of increased precipitated withdrawal when starting Buprenorphine to ease withdrawal symptoms. We are having to allow more time between the patient’s last Kratom use and beginning a Buprenorphine taper, which extends the patients length of stay in detox. The withdrawal symptoms from Kratom have also increased in severity from what we used to see.

“We have cared for patients in severe withdrawals from Kratom and are seeing an uptick in cases. This is likely due to the way they are altering Kratom with presumably more potent intoxicating additives. The withdrawals we observe from Kratom are identical to what you would experience withdrawing from Heroin or other prescription opiates.” Steve Carleton LCSW, CACIII

Nitrous Oxide

Medical nitrous oxide is used for sedation and pain relief and is classified as a dissociative anesthetic. It is also used as a propellant for whipped cream and in the automotive industry to enhance engine performance. Sold as cartridges that can be discharged into another object such as a balloon or directly into the mouth and inhaled. They provide a brief, rapid euphoric high and feeling of floating or excitement. They also can cause sudden death do to profound hypoxia.

Other names: Whippits, NOS, nangs, hippy crack, buzz bomb, balloons or laughing gas

Read More

Where do people get them?

It can be purchased on Amazon and restaurant supply stores.

 

How are they dangerous?

When used frequently or long term, they can cause memory loss, vitamin B12 deficiency (causing brain, spinal cord, and nerve damage), incontinence, depression, dependence, psychosis, as well as other side effects. When inhaling directly from tanks or whippets, it can cause frostbite to the nose, lips and throat, including the vocal cords. Because of the high pressure, it can also cause ruptures in the lung tissue when inhaled directly from the containers. The neurological symptoms can be severe, resembling Guillain-Barre Syndrome, affecting the ability to walk and causing profound weakness of the extremities. Abstinence and supplementation with injectable B12 is the only treatment for the neurological side effects and can sometimes take months to completely reverse the damage, sometimes the damage is not completely reversible.

Gabapentin

Gabapentin, approved in 2004, was originally prescribed for neuropathic pain, it is now also prescribed for a variety of things, including mood disorders, anxiety, and seizure disorders. 

Other names: Gabbies

Read More

Where do people get them?

They are prescribed, also sold from drug dealers.

 

How are they dangerous?

Gabapentin is now a prevalent drug of abuse, causing euphoria, improved sociability, relaxation, and a sense of calm. Evidence supports that patients with opioid use disorder are at higher risk of abusing Gabapentin. The withdrawal symptoms include mental status changes, chest pain, high blood pressure, restlessness, agitation, anxiety, insomnia, and seizures.

M-30's

M-30 is the common, or street name, for oxycodone IR 30 mg pills, called that because the pill has a ‘30’ on one side and an ‘M’ on the other. These have long been very popular with opiate users.

Read More

Where do people get them?

Off the street, purchased online or through friends.

How are they dangerous?

Several years ago, dealers started to press pills to look identical to the pharmaceutical M-30s, but they actually made them with Fentanyl, due to the cheaper cost and easier availability of Fentanyl vs pharmaceutical oxycodone. This caused a huge spike in overdose deaths, because people did not know they were getting Fentanyl. Now, at least in most metropolitan areas, most opiate addicts know they are getting Fentanyl when they buy M-30’s off the street.

Now we assume anyone buying M-30s that aren’t prescribed is actually getting Fentanyl. At Gallus we did a review of all of our opiate admissions from November through the end of February, 88% were positive for Fentanyl – that accounted for 100% of the Colorado opiate admissions, and only 2 of the Scottsdale admissions were actually getting oxycodone – they were purchased from friends who were selling their prescriptions. Prior to a few years ago, we never saw Fentanyl unless it was prescribed.

Dangers of Pill Presses

Pill presses are devices that produce counterfeit pills. Pressed pills are commonly produced with fentanyl because it’s cheaply imported. The biggest risk and danger is that people are not getting what they think they are getting. It is common that people are seeking benzodiazepines, MDMA, or other prescription opiates but it’s more often than not Fentanyl. When substances are mixed and pressed with these devices they are not balanced effectively. The pills end up with varied strength, resulting in higher risk for overdose and death.

Read More

​Where do people get them?

The internet.

 

How are they dangerous?

There is a risk of hot shots, dealers at times will intentionally press pills with higher potency leading to overdose. When people seeking drugs hear about an overdose there is often an assumption that the supplier has higher quality product which leads to an uptick in sales for the supplier. Another concern is that there is no manufacturing control or protocol when making these counterfeit products. Pharmacies and legal drug manufactures ensure that when drugs are mixed they are balanced and there is a guarantee of consistency that pills of the same variety are identical. The strength of illegally manufactured drugs sold on the street can be extremely varied leading to risk of overdose. Finally, this growing trend is dangerous because people are completely unaware that they are buying Fentanyl when seeking out drugs. The might be searching for sedatives, stimulants, or some other type of opiate and end up with Fentanyl. 

Mephentermine

Mephentermine was originally approved by the FDA in 1951 as a vasopressor (used to increase blood pressure) and a nasal decongestant. It’s banned in the United States, but still used in other countries. It is structurally similar to methamphetamine. It’s prohibited by the World Anti-Doping Agency – used by young athletes for its stimulant effect and improved physical performance.

Other Names?
None found.
Read More

How do people get it?

Online from other countries.

How is it dangerous?

It can cause psychotic symptoms with misuse, and chronic psychosis with dependency; cardiac disorders and rhythm disturbances. It can also cause hallucinations, seizures, slow heart rate, confusion, irritability. Fatal side effects include severe heart block, cerebral (brain) hemorrhage, pulmonary edema (fluid in the lungs), and fatal heart rhythm disturbances. This is not super commonly seen in the US, but Brazil and India are experiencing a huge increase in issues from this drug. ​

Phenibut

A central nervous system depressant with anxiolytic properties. A GABA-b receptor agonist similar to Baclofen and GHB. With higher doses is a GABA-agonist, much like benzos. Developed in the Soviet Union in the 1960’s and currently the only area of the world that uses it for medical purposes. Not approved for medical use in the US. Used for insomnia, anxiety, and as a nootropic for focus and concentration.

Other names? Fenibut, Anvifen, Noofen

Read More

How do people get it?

GNC, and health or nutritional supplement store, online.

 

How is it dangerous?

Very – intoxication has been known to cause decreased level of conscious, stupor, decreased muscle tone, decreased respiratory drive temperature dysregulation and high or low blood pressure; also can cause severe agitation, hallucinations, seizures and delirium, to the point of requiring so much sedation that the person gets intubated and put on mechanical ventilation. Withdrawal is very dangerous, commonly ending up in the ICU on mechanical ventilation due to severe agitation, seizures, unstable heart rate and blood pressure.

2c-b

2c-b is classified as a novel psychoactive drug from the phenethylamine class of drugs, similar to mescaline. Its effects vary depending on dosage, but is classified as a stimulant and hallucinogenic. It is a club drug, commonly found as an adulterant in MDMA or Ecstasy. It can also be taken alone. It comes in powder or tablet form and can be snorted, taken by mouth, or taken rectally. It causes feelings of pleasure, hallucinations. Side effects can include tremors, muscle spasms, diarrhea of other GI distress, tachycardia, hypertension, and elevated body temperature.

Other names: Nexus, Bees, Tu Si

Read More

Where do people get it?
 
It can be purchased on the internet, but more commonly mixed in other drugs or bought off the street.
 
How is it dangerous?
 
It can cause serotonin syndrome, leading to severe cerebral edema (brain swelling), seizures, and long term neurological damage.

Tianeptine

An atypical antidepressant and neurorestorative agent. It is also a mu-opioid receptor agonist, which at high doses works just like any other opioid. It has a long half life and is very addictive. It is not FDA approved in the US. It was scheduled in Michigan as a schedule 2 narcotic, and Alabama is currently working through doing the same thing. The CDC has identified it as an emerging public health risk, as its use is becoming popular, and there are being more and more deaths reported as being directly related to Tianeptine. Particularly when also being taken with Phenibut. Appears to be very hepatotoxic (liver toxic) at higher doses, but not well studied. It can be reversed by Naloxone, but is not always recognized as an opioid overdose. Interestingly enough, it wasn’t until recently it has been seen as an addictive substance, in fact there are many research articles from 2017 and prior that state it is not addictive and works well as an antidepressant.

Other names: Tia, ZaZa Reds, ZaZa Whites

Read More

Where do people get it?
 
Gas stations, online.
 
How is it dangerous?
 
It has a long half-life, not detectable in normal urine drug screens, and from anecdotal reports does not always respond well to Sub.

Fentanyl

It’s a synthetic opioid pain reliever that is 80 – 100 times more powerful than morphine. There is pharmaceutical fentanyl and illicitly manufactured fentanyl. Pharmaceutical fentanyl is used to treat severe pain, most commonly advanced cancer symptoms. Illicitly manufactured fentanyl is placed in eye droppers or nasal sprays, made into pills, dropped onto blotter paper and made into a powder. Chemically-similar analogs of fentanyl are also being created, and these include carfentanil, acetylfentanyl, butyrfentanyl, and furanyl fentanyl.

 

Other names: Apace, China Girl, China Town, Dance Fever, Goodfellas

Read More

Where do people get it?

Online and through illegal drug markets. Many people purchase heroin, not knowing it is mixed with fentanyl, resulting in overdose deaths. Counterfeit OxyIR 30mg tabs (M-30s) bought off the street are usually Fentanyl pressed into a pill and made to look like OxyIRs.

How is it dangerous?

It has a heroin-like effect and is highly addictive. Heroin or cocaine have the highest likelihood of being mixed with fentanyl. Fentanyl has become a popular additive due to its easiness in creating a high, making it a cheaper option. Fentanyl has a long half-life, causing many patients to have precipitated withdrawal when being switched over to substances too soon. As a company (both our Colorado and Arizona centers) we are seeing 88% of our opiate patients testing positive for Fentanyl, and many patients are unaware they were being given fentanyl.

Clonazolam

It’s a triazolobenzodiazepine, it was prescribed for veterinary practices in some regions of Africa, but is now sold online as a designer drug. It’s considered Schedule 1 in Virginia and Louisiana, but in all the other states it’s classified as research. It has similar effects as a benzodiazepine but is much much stronger. It is also sold in blotters.

Other names? Clam, c-lam

Read More

Where do people get it?

It’s not prescribed in the U.S. People are buying it online.

How it is dangerous?

It’s highly addictive, and when taken it can cause a large increase in seizures. The effects last longer than 24 hours. Research shows that people think they’re buying valium or Xanax but it’s Clonazolam. Gallus’ experience has been that the withdrawal is much longer and has significantly more detox symptoms than regular benzos.

U-47700

A synthetic opioid 7.5-8 times more potent than Morphine. In 2016, DEA classified it as a Schedule 1 narcotic. It has had no medical use in the United States. Originally developed by the pharmaceutical company Upjohn in the 1970s. It started emerging in 2014.

Other Names: Pink, pinky, pink heroin

Read More

Where Do People Get It?It’s sold on the internet as a research chemical, it’s also sold on the street. It’s often pressed into pills and made to look like prescription Oxy IR, often combined with Heroin or Fentanyl.

How It Is Dangerous?Research suggests it has enhanced brain penetration, it’s more attracted to lipids than Morphine, which makes for longer half-life (researchers think around 6.5 hours). There have been many overdose fatalities, contributed to Prince’s overdose and subsequent death. It’s unable to be detected on most UDS screens, but Lab Corp does have a test for it.