Since ancient times, humans have been fascinated with ways to alter consciousness, and have gone to great lengths to reach a "higher" ground. From naturally occurring substances such as opium and betel nuts, to synthetic drugs like LSD, people have long experimented with mind-altering substances. This long history of experimentation with psychoactive substances even pre-dates the existence of the word "drug." For example, Native Americans' use of mescaline, extracted from peyote cacti, began as long as 5,700 years ago. Use of the Betel nut - the seed of a palm tree fruit - to alter consciousness may not be well-known in the U.S., but this practice has existed for thousands of years. In fact, it is estimated that among intoxicants, only nicotine, alcohol and caffeine are more popular globally than chewing Betel nut extract. But the latest wave of man-made drugs, or "designer drugs," carries new and very real dangers. For both the individuals using them and the general public, so-called designer drugs like "bath salts," "K2" or "spice" quickly have become a public health crisis, and their use is on the rise. Their danger is related to the potent effect these drugs can have on the human nervous system. For example, "bath salts" (chemically known as synthetic cathinones) combine the dangerous properties of both a potent stimulant and a hallucinogen. "K2" is a type of synthetic marijuana (the active compound is THC) and is dangerous because it can be more potent than the naturally occurring plant. These new designer drugs are proliferating because in many states they are sold "legally." This is possible because they are deliberately designed with an alteration to the molecular structure of an existing drug -- to avoid classification as an illicit drug. Despite their recent proliferation, "designer drugs" are not really new - the term was coined by law enforcement in the 1980s, and widely recognized drugs like LSD, ecstasy and methamphetamines fall into this category. The latest generation of designer drugs includes synthetic cathinones (commonly labeled with harmless-sounding monikers like "bath salts" or "plant food"), which are structurally and pharmacologically similar to cocaine, methamphetamines and ecstasy (MDMA). Synthetic cannabinoids, often branded as "Spice" or "K2," are chemically engineered to mimic marijuana. There are many other potent designer drugs with names like Europa and Smiles that are increasing in use. Many of these designer drugs are available legally in drug paraphernalia stores, convenience stores or even via the Internet. That's right, legally. Like many cyber sales, delivered to your door with free shipping. Law enforcement officials are increasing efforts to monitor for and curtail the use of these dangerous drugs. For example, the Drug Enforcement Administration (DEA) now includes three synthetic cathinones on its Schedule 1 list of controlled substances and several of the chemicals found in synthetic cannabinoids are banned under the Food and Drug Administration Safety and Innovation Act of 2012. But many similar compounds are not yet classified as illegal and in some cases they have not even been identified. This is because the "chemists" who produce designer drugs make incremental alterations to the drugs' chemical make-up, dodging Schedule 1 or illegal classification on a technicality, and thereby claiming to provide a "legal" high. For law enforcement officials and regulators, keeping up with these chemists is a game of cat-and-mouse, with potentially deadly consequences. Bath salts carry a high risk of overdose and addiction, chest pains, increased blood pressure, increased heart rate, agitation, hallucinations, extreme paranoia, and delusions1. Reported side effects of K2 and Spice include paranoia, panic attacks, giddiness and psychotic episodes.2 Despite these risks, their use is on the rise at an alarming rate. In 2011, the National Poison Control Centers received more than 6,000 calls about synthetic cathinones (including bath salts), compared to only 300 in 20103. The American Association of Poison Control Calls reported a 58 percent increase in the number of calls related to synthetic marijuana and/or K2/Spice in just one year - from 2,906 calls in 2010 to 6,959 calls in 2011.4 To make matters worse, the popularity of these drugs is fueled by the frequent claim that standard urine drug screens will not detect their presence. Luckily, there is a new solution that can detect these substances. Sophisticated laboratory technologies using mass spectrometry assays of urine specimens can identify the vast majority of legal and illegal drugs ingested, since most small molecules have metabolites (i.e., break down products) that are excreted by the kidneys and into the urine. Mass spectrometry assays currently used to detect and monitor use of powerful pain medications (e.g. opioids) can be mobilized to help physicians and regulators, such as the DEA, detect these new designer drugs. Specialty laboratories are using these advanced technologies to anticipate new chemical formulations and launch new tests to detect dangerous substances. For example, long before bath salts were a problem in the U.S., the United Kingdom was struggling with increasing rates of overdose and death due to synthetic cathinones. Reports from British physicians, and the laboratory scientists, prompted U.S.-based scientists to develop new tests that would detect multiple synthetic cathinones - even variations that were not yet classified by DEA as Schedule 1 substances. Because physicians are on the front lines - typically seeing the effects of designer drugs in the emergency room, office examination room, or hospital - drug monitoring using mass spectrometry is a critical tool to identify and prevent the use of designer drugs. Consequently, physicians are increasingly relying on specialty laboratories to help identify the compounds present in patients who are taking controlled medications who are at risk for drug misuse or abuse. Tackling the threat to public health posed by the proliferation of designer drugs will require efforts from multiple stakeholders. Policymakers are beginning to take important action. In addition to the national ban on several types of synthetic drugs signed this summer by President Obama, both New Jersey and Washington, D.C., have enacted similar bans in recent weeks.5,6 But the new laws will not save lives without additional action and support. Regulators and the DEA could make better use of advanced drug detection technologies to more quickly classify new designer drugs as illegal. Insurance companies must be encouraged to support these efforts by ensuring reimbursement for specialty labs, so that doctors have access to the best technology available to detect and identify designer drug compounds. Data about drug use trends must be provided to the DEA and physicians to educate clinicians on any new dangerous drugs - and physicians must be vigilant in testing patients who are at risk for drug abuse and misuse. Finally, the public must be educated about this dangerous category of drugs - especially because users commonly assume that if a drug is not technically "illegal," it is safe to use. In summary, we have a new major public health threat that represents just the latest step in man's creative pursuit of new ways to get high. History tells us that we can't completely eliminate this threat, but by pooling our knowledge and streamlining legal and regulatory processes, we can succeed in reducing the threat of designer drugs and enhancing public safety. It is the collective responsibility of public agencies, specialty labs, physicians, regulators, and health insurers to pool their knowledge and resources to help improve individuals' safety and the safety of the communities they live in. ~~~ 1 2 FLASHCARD: National Institute of Health, National Institute of Drug Abuse (2012, May). DrugFacts: Spice (Synthetic Marijuana). 3 American Association of Poison Control Centers, Synthetic Drugs Data and Fact Sheets, Bath Salts and Synthetic Marijuana (September 2012). 4 SLIDE DECK: 5 Howell T. D.C. joins states on synthetic drug ban. Washington Times. Nov 29, 2012. 6 Queally J. N.J. permanently bans synthetic marijuana. The Star-Ledger. Nov 26, 2012. Images: Ameritox