Per the National Institute on Drug Abuse (NIDA), synthetic cannabinoids are manmade drugs that are commonly used as alternatives to cannabis products where these drugs cannot be purchased legally or by individuals who cannot purchase them where they are legally available (e.g., individuals without a prescription for cannabis products or younger individuals under the age of 18). Phenethylamines are hallucinogenic stimulant drugs that include well-known drugs like amphetamines and ecstasy (MDMA). These drugs also show up as synthetic cannabinoids.
Synthetic cathinones remain some of the most commonly available phenethylamines. These drugs are synthetic forms of the khat plant that is used in Africa and the Middle East for its stimulant properties. There are numerous synthetic cathinones, and one of the most common of these is the drug flakka.
Flakka (alpha-pyrrolidinopentiophenone [alpha-PVP]) is a synthetic cathinone that has achieved significant popularity among younger individuals in Florida and other states. Flakka and similar drugs are often referred to by the collective name of bath salts, but flakka is generally viewed as a more potent form of bath salts.
These drugs are classified as Schedule I controlled substances by the United States Drug Enforcement Administration (DEA). All drugs in this classification are denoted as having no significant medicinal uses and extremely serious potential for abuse and the development of physiological dependence in individuals who use them. Drugs in this classification cannot be purchased legally in the United States except with special permissions from the federal government.
NIDA offers numerous reports of fatalities associated with the use of flakka, ranging from suicide to myocardial infarction. In addition, the drug can produce severe cognitive dysfunction and emotional and psychological distress when used.
The Use of Flakka
According to the DEA and NIDA, synthetic cannabinoids like flakka are most often manufactured overseas, particularly in countries like China and Pakistan, although when the drug was at its height in popularity, it was also made in local laboratories in states like Florida, where it was exceedingly popular for a short period. Because flakka is manufactured overseas or by those working in local private laboratories, there are no restrictions on the ingredients that can be used in the development and manufacture of the drug, and there is no authoritative body that inspects and regulates its manufacture and distribution. Thus, drugs labeled as flakka may have entirely different ingredients added in them from manufacturer to manufacturer and even from batch to batch produced by the same source. Consumers of these drugs have no idea if they are getting what they are paying for it, and there is no guarantee that the drug is actually what it is advertised to be.
Flakka and similar drugs often have extremely potent stimulant and hallucinogenic effects. The drug is typically purchased as pinkish or white crystals that can be ground up, snorted, injected, smoked in an e-cigarette, or taken orally. The drugs have a mechanism of action that blocks the reuptake of the neurotransmitters dopamine and norepinephrine in the brain, and they most likely affect numerous other neurotransmitters.
Effects of Flakka
The research on flakka indicates that the immediate effects include:
- A loss of inhibitions
- Feelings of invulnerability
- Significant psychostimulant and stimulant effects
In addition, the research also indicates that the use of flakka is associated with:
- Irregular or increased heart rate
- Increased blood pressure
- Increases in body temperature (hyperthermia)
- Increased perspiration
- Increased potential for dehydration
- Increased potential for cardiovascular issues (e.g., heart attack)
- Increased potential for respiratory distress
- Increased potential for renal failure
- Increased risk for stroke
- Increased risk for swelling of the brain
- Increased risk for the development of seizures
Psychological effects of using flakka can include:
- Panic attack
- Loss of appetite
- Psychotic behavior (hallucinations and/or delusional behaviors)
- Delirium (severe confusion, disorientation, and/or psychosis)
The occurrence of delirium in individuals often represents the effects of some form of a metabolic imbalance. Individuals with delirium can display variable symptoms that can include combinations of paranoia, hallucinations, severe delusions, hyperactivity, lethargy, hypoactivity, apathy, and severe depressive-type behavior. Delirium is nearly always associated with severe disorientation (e.g., not knowing where one is, the date, or the time; being unable to recognize familiar people, places, etc.), severe confusion, and a significant loss of rational thinking and rational behavior. Individuals who display a hyperactive type of delirium may become aggressive and may be a danger to themselves or others (often due to their hallucinations or paranoia delusions), whereas individuals with a hypoactive delirium may not respond to the environment and are at risk for significant harm due to an inability to attend to their basic needs.
Flakka abuse will most often result in individuals initially expressing a hyperactive or excited delirium state that consists of psychosis, feelings of invulnerability, agitation, aggression, significant disorientation, etc.; however, a hypoactive delirium may follow or occur in individuals who have overdosed on the drug.
Delirium often remits when the cause of the delirium can be reversed, such as the drug in the system being eliminated by the normal process of metabolism or treatment targeted at reducing the effects of the drug; however, extended periods of delirium can be associated with significant and permanent damage to the brain. NIDA offers reports of individuals using flakka who express significant symptoms associated with delirium.
Using flakka can result in significant damage to the brain from other mechanisms as well. Individuals developing seizures, significant respiratory suppression, brain swelling, stroke, etc., as a result of use of the drug are at risk for significant damage to the brain associated with these conditions. In addition, individuals on the drug often become so psychotic that they become suicidal or believe that they are invulnerable, and these states of mind are significant factors associated with the risk for self-harm.
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Extent of Use
Flakka is primarily sold online or in local head shops and other outlets. The increase in the abuse of flakka occurred rapidly in states like Florida, and the severe effects associated with abuse of the drug drew national attention. The data provided by the American Association of Poison Control Centersdocumented a significant rising trend of ER visits/calls associated with the use of the synthetic cathinones between 2009 and 2012, and then a marked decline in their use thereafter. The efforts of local and national government agencies as well as the crackdown on imports of the drug are believed to be associated with the decline in its use and abuse. The state that received the most attention regarding flakka abuse, Florida, reported a dramatic decline in documented cases of abuse of the drug during this period. Nonetheless, national organizations, such as NIDA and the DEA, continue to warn against abuse of the drug and recommend that individuals be on the lookout for potential use and abuse of the drug.
Some signs associated with use of flakka include:
- Hyperactivity (e.g., uncharacteristic talkativeness, sociability, pressured speech, jitteriness, etc.)
- Excessive overheating (e.g., excessive sweating, appearing flushed, etc.)
- Physiological changes, such as a dramatic increase in blood pressure or heart rate
- Severe grandiosity
- A sudden onset of psychotic-type behavior in an individual without any history of psychosis
- Dilated pupils, agitated motor movements, shaking, twitching, and even seizure-like movements
- An alternating pattern of excessive energy, sociability, and heightened mood followed by alternating patterns of apathy, lethargy, depression, etc.
Physical Dependence and Flakka
Research studies using animals and the observational research literature on the use of the drug in humansindicates that chronic use of the drug is associated with compulsive cravings, behaviors that suggests the significant alteration of neurobiological pathways (e.g., the development of tolerance), and the development of a withdrawal syndrome when the drug is discontinued abruptly.
While there are no medications that are specifically designed to address the withdrawal symptoms that occur when individuals discontinue flakka, benzodiazepine drugs would address many of the issues that occur during the withdrawal process.
The withdrawal syndrome appears to be associated with primarily emotional symptoms that include:
- A significant “crash” shortly after the drug is discontinued that includes issues with severe depression, apathy, and a loss of motivation (except the motivation to get more of the drug)
- Severe cravings
- Issues with anxiety
- Issues with sleep that can vary from insomnia to hypersomnia (excessive sleeping)
- Autonomic nervous system symptoms, such as increased heartbeat, increased perspiration, and the development of tremors or shakiness
- Psychotic issues, such as the development of paranoia, hallucinations, delusions, etc.
Comprehensive Treatment for Flakka Abuse and Addiction
Treatment for flakka abuse should be initiated as soon as it is discovered that the individual is taking the drug. This is because chronic use of the drug is associated with the potential for severe consequences.
A well-rounded treatment program for an individual that abuses flakka should include:
- A full assessment of the individual that includes a physical examination by a physician, psychological examination, and an assessment of their living conditions and social situations
- Probable enrollment in a physician-assisted withdrawal management program
- Immediate enrollment in substance use disorder therapy, the cornerstone in any treatment approach for any type of substance abuse or addictive behavior
- Comprehensive psychoeducation regarding substance abuse in general, substance use disorders, and the physical and emotional effects associated with all drugs of abuse as well as their particular substance of choice
- Enrollment in social support group activities, like family therapy, group therapy, or participation in social support groups, such as 12-Step groups
- Medical management of any associated or co-occurring conditions as appropriate in the individual case
- Long-term participation in therapy and social support groups
- Any specific interventions that are germane to the individual case
Individuals who simply complete a withdrawal management program and do not become involved in long-term aftercare treatment will inevitably relapse, as relapse rates in these cases are near 100 percent. It is important to keep the individual engaged in treatment following the completion of any withdrawal management or acute treatment for their substance abuse. Often, individuals need to remain in treatment for years following discontinuation and need to maintain abstinence for at least 5-7 years before they can consider their treatment to be successful.