Friday, August 23, 2013

Death by NBOMe

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:

No comments:

Post a Comment