Death by NBOMe
By Alan Perry
Introduction
I recently had the opportunity to treat three young women,
in separate events, within a week for some very strange symptoms that were very
concerning. All three refused to (or were unable to) disclose what they had
taken. It seems likely that it must be some variation of a substance known as 25I,
N-Bomb or Smiles. The chemical name is 2-(4-iodo-2,5-dimethoxyphenyl)-N-[(2-methoxyphenyl)methyl]ethanamine.
It can be supplied as a powder or liquid, snorted or applied directly to the
mucous membrane, there are also reports that it is being marketed as legal LSD
and dispensed on blotter paper. There are only a handful of states that have
made this product illegal (Virginia is one of them) but it is still widely
available elsewhere in the U.S. and abroad. It can be purchased online, from “tobacco”
shops and local dealers. Various reports on the drug identify it as a
stimulant, hallucinogenic and serotonergic. Its effects have been documented to
last up to 48 hours.
The Victims
All of these young women presented wit
h a lack of gross
motor coordination, hallucinations, paranoia, dysphasia, tachycardia and
hypertension, one had reported seizure activity. Initial concerns with these patients
where directed toward the cardiac effects of the drug. There had been a
reported case of a young female dying from a cardiac event a week earlier
leading to speculation that this may have been a possible cause. Richmond
Virginia had a rash of similar events in February 2012 with reported brain
injuries and one death associated with the drug. It is extremely potent with
and onset of effects within 5 minutes of ingestion. The effects on the patient
are highly variable, pupil size and response may be unaffected, respiratory
depression or hyperventilation did not occur with any of these patients during
the Prehospital phase, one patient vomited, one had seizure activity, two
presented in SVT, all had hallucinations, two exhibited paranoid behavior. Other
reports have documented violent behavior and multiple deaths since its debut in
2010. This drug is not currently part of routine drug screening therefore its
use will be difficult to confirm.
The Treatment
EMS treatment of drug overdose/effects are typically based
on toxidromes specific to a class of drugs such as narcotics (opiates),
stimulants (cocaine) and muscarinic (organophosphates). The problem with most
designer drugs such as NBOMe is that they produce effects relevant to multiple
toxidromes and therefore do not fit neatly into one class, we are frequently
left to attempt treatment of the most urgent presenting problems with
incomplete or no data on efficacy or untoward interaction with the substance
involved. As an example, many of these patients present with
tachycardia-frequently SVT-if we only treat the sign without considering the
totality of the circumstances we could be led to attempt to cardiovert the
patient. Such an action might prove injurious or fatal to the patient with an
unknown ingestion of 25I-NBOMe. A more reasonable approach might be
consultation with your medical control, and the subsequent administration of a benzodiazepine
to blunt the sympathetic nervous system response to the drug, provided the
patient is otherwise stable. A definitive treatment algorhythm has not been
established and research is very limited and commercialized.
Looking Forward
I am unaware of any free, easily accessible data sharing on
the topic of emergency treatment of any of these new designer drugs. It seems
prudent that the CDC, the American College of Emergency Physicians or the state
departments of health develop a free, easily accessible resource for providers
to access, reference for the purpose of informing providers of the existence, prevalence
and treatment for overdoses/poisoning from these substances. Ideally this could
also be used to identify new substances quickly as they are modified and hit
the street so providers are better prepared to handle them appropriately.
Be Safe,
References:
NBC12 Richmond, VA. News article:
Website marketing this product:
and another:
Severe clinical toxicity associated with analytically
confirmed recreational use of 25I-NBOMe: case series. Hill SL, et al. Medical
Toxicology Centre, Institute of Cellular Medicine, Newcastle University,
Newcastle, UK.
Erowid drug information website:
Mercy Emergency services:
Bartlett Regional Hospital Statement:
Wikipedia:
