Veterans’ Use of Designer Cathinones and Cannabinoids

Although the elevated risks and rates of veterans’ substance abuse patterns are well documented, little has been written about veterans’ use of designer drugs.^1-6 In recent months throughout Europe and the U.S., there has been a flurry of media attention for 2 classes of designer drugs: synthetic cathinones and synthetic cannabinoids.^7,8 In the U.S., the popularity of these drugs has surged, and a disproportionate amount of use of these 2 drug classes is coming from locations near military instillations.^9,10

The purpose of this article is to raise awareness regarding these 2 burgeoning designer drug classes and their impact on veterans. Designer drugs affecting vulnerable populations are not a new phenomenon, yet many providers are unfamiliar with the effects of these unique drugs of abuse on their veteran populations.^11-13

Many designer drugs begin their existence as variations of other addictive or psychoactive drugs. Others begin in laboratories as investigative research compounds that end up on the street, often promising a novel mind-altering experience as a “legal high.”^14-18 The Designer Drug Enforcement Act of 1986 was an initial attempt in the U.S. to define and control the early rise of copycat drugs that appeared on the streets and mimicked the effects of other illicit substances. More recent legislation enacted in the U.S. has imposed Schedule I controls on the manufacture, distribution, possession, importation, and exportation of these types of drugs, including both synthetic cathinones and synthetic cannabinoids. State laws are perennially in flux trying to keep up with the latest drug trends.^19-21

Similar efforts have been made by the European Union to control mephedrone, a synthetic cathinone, citing multiple fatalities, seizures, related crime, lack of medical use, and risk of dependence.²² Although uniform levels of control do not exist in Europe for synthetic cannabinoids, many countries have independently acted to limit their use.²³

In its recent World Drug Report 2013, the United Nations Office on Drugs and Crime documents its growing concern about the “new psychoactive substances” category of illicit recreational substances (in which synthetic cannabinoids and cathinones are included) that has increased by 50% since 2009.²⁴ Alone, this category now outnumbers the total number of substances controlled by international drug conventions.

The novelty and variability of designer drugs causes difficulties with detection and regulation. Innovative chemists can legally manufacture new versions of known molecules intended for illicit use with a rapidity that outpaces bureaucratic control. Local law enforcement officials may be unaware of the latest designer drug trends, stifling efforts at public education or restriction. Designer drugs are often deceptively packaged and are available in convenience stores, tobacco outlets, gas stations, pawnshops, tattoo parlors, and truck stops.^25-28 The Internet may be the singular reason, however, that designer drugs continue to be widely available to veterans.^11,18

Innumerable websites discuss, promote, and sell designer drugs or deceitfully market them as safe, legitimate household products (“not for human consumption”), which can be ordered online and shipped by commercial carriers.¹² Little accurate information is known about their effects or about the specific compounds they contain. When the recreational nature of the drugs is actually acknowledged, information on how the buyer can evade prosecution is often provided in tandem. The suppliers’ inventory of the drugs has been shown to be variable and inconsistent, and the product ingredients can be similarly unpredictable despite comparatively more stable naming and labeling.^14,29

In the clinical setting, a reliable patient drug history may not be available. This ensures that the diagnosis of designer drug use will be an exclusionary process involving routine laboratory work, physical examination, and at times electroencephalogram and/or neuroimaging. Psychiatric consultation is often useful in this setting. Routine immunoassay tests do not detect either synthetic cathinones or synthetic cannabinoids.³⁰

Both cannabinoids and cathinones can be identified using gas chromatography-mass spectroscopy (GC-MS) or liquid chromatography-mass spectroscopy (LC-MS). However, this technology is limited to specialized laboratories.^31,32 The laboratory results often are not immediately available, potentially limiting the tests’ use in emergency or inpatient settings, as the patient may have left the hospital by the time the results are available. Additionally, these drugs’ prevalence of use, while increasing, often does not justify the cost of these tests.

The inability to routinely detect metabolites in urine may increase the enticement of these drugs given the likelihood that active-duty personnel could use them surreptitiously. Further, these compounds are evolving and seemingly limitless in their variability, and there is often a paucity of pure reference materials. As such, it is impossible to guarantee reliable test results.

The following profiles of each of these drug classes will be accompanied by clinical cases depicting the drugs’ effects and how an affected veteran might present clinically. The severe effects of these novel agents illustrate the value in maintaining a functional knowledge base about emerging drug trends. The accuracy of diagnosis as well as the outcome of a veteran’s treatment may depend on the provider’s ability to identify the presence of a drug and manage its effects.