Flakka: A Deadly High

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COMMENTARY

The abuse of a dangerous designer drug known as “flakka” is rapidly on the rise in the US.¹ Despite growing efforts to ban this substance by drug enforcement agencies, flakka has infiltrated the youth population. It is sold in combination with other recreational drugs (eg, MDMA), and it is generally distributed in sealed bags marked “not for human consumption” or “for research use only.”

The primary ingredient of is pyrrolidinopentiophenone (alpha-PVP), a synthetic cathinone that is chemically related to pyrovalerone. It is the ketone analog of prolintane,² which inhibits norepinephrine-dopamine reuptake and thus acts as a central nervous system stimulant.³

These man-made products are easily obtained over the Internet at a very low cost. Flakka is reported to be 10 to 20 times more potent than cocaine and methylenedioxypyrovalerone (or MDPV, an ingredient in bath salts).³ It is introduced in the body by smoking, snorting, placing under the tongue, injecting, or vaping (in e-cigarette-type devices).

Users tend to be young, economically disadvantaged adults. The risk of overdose is high, especially because larger amounts can be purchased and consumed at once and in quick succession, either accidently or on purpose. The effects occur within 30 to 45 minutes of administration with a peak rush at 1.5 hours and the total “desirable” experience continuing from 6 to 8 hours. Adverse effects can continue for days.³

The National Institute on Drug Abuse has warned that because flakka enters the bloodstream very quickly, there is a very real risk of overdose.⁴ The drug is reported to be stronger and more dangerous than other synthetic cathinones, so health care workers, parents, and adolescents need to be aware of the potentially catastrophic outcomes concerning fatalities and intoxications caused by its use.

Many cases-both fatal and non-fatal-have been reported worldwide with acute intoxications of alpha-PVP for which hospitalizations were required.⁵ There were 6 fatal cases related to this drug which have been reported in Ohio.⁶

Patients who use flakka present with symptoms such as excited delirium and agitation; violent and aggressive behavior; and paranoia and hallucinations. Self-injurious behaviors and suicidal tendencies have been reported.³ Eventually, hyperthermia can result in dehydration, rhabdomyolysis, and eventual kidney failure.

Like other street drugs, flakka tends to produce “super human strength.” Although drug effects last one to several hours (or days), neurological damage is long lasting, and serious behavioral manifestations have been reported as “Zombie-like.”

Routine drug screens cannot detect flakka. However, liquid chromatography-mass spectrometry (LC-MS/MS) can measure flakka levels with accuracy and confirm overdose in hospitalized patients or provide evidence in medicolegal death investigations.^2,3 Illicit use of the substance has been blamed for 18 deaths in a single south Florida county.⁷

Flakka use is on the increase. In 2010, there were no reported cases; 85 cases in 2012; and under just over a thousand in 2014. According to the DEA, alpha- PVP is a listed schedule 1 drug along with other synthetic cathinones.⁸More recently, however, in New York City alone, 150 hospital admissions per week were related to flakka usage.⁹ In 2015, there was a sharp rise in the number of overdoses.⁵

Users often think they are purchasing a capsule of MDMA (aka molly or ecstasy), but instead they end up with flakka. This adds to the dangerous nature of the drug and serious consequences that ensue. Its low cost, easy availability, confusion with other drugs, and widespread use-these make for a lethal combination that is quickly spreading among users of illicit drugs and young “partiers” alike.

Treatment of acute intoxication is mainly supportive. It includes providing hydration by intravenous fluids, benzodiazepines to counteract agitation, and low-dose norepinephrine to normalize heart rate and blood pressure. Like treatment for other addictions, treatment for flakka abuse should address medical and psychiatric problems, along with psychosocial education, counseling, and participation in peer groups.

Further reading“Designer Drug” Use and Abuse: Implications for PsychiatristsFlakka-Induced Prolonged PsychosisThe Backstory You Really Need to Know About Flakka And Other Synthetic DrugsSynthetic Cathinones: Signs, Symptoms, and Treatment

Disclosures:

Dr Anjum is a Research Associate and Dr Aggarwal is Associate Professor in the department of psychiatry at Rutgers New Jersey Medical School, Newark, New Jersey. The authors report no conflicts of interest concerning the subject matter of this article.

References:

1. New synthetic drug ‘flakka’ triggers crazed behaviors. Drugs.com. April 16, 2015. http://www.drugs.com/news/new-synthetic-flakka-triggers-crazed-behaviors-56432.html. Accessed August 3, 2016.
2. Wood MR, Bernal I, Lalancette RA. The dangerous new synthetic drug α-PVP as the hydrated chloride salt α-pyrrolidinopentiophenone hydrochloride 0.786-hydrate. Acta Crystallogr C Struct Chem. 2016;72(Pt 1):48-51.
3. Katselou M, Papoutsis I, Nikolaou P, et al. a-PVP (‘‘flakka’’): a new synthetic cathinone invades the drug arena. Forensic Toxicol. 2016;34(1):41-50.
4. “Flakka” (alpha-pvp). National Institute on Drug Abuse. https://www.drugabuse.gov/emerging-trends/flakka-alpha-pvp. Accessed August 3, 2016.
5. World Health Organization. Expert Peer Review No. 1. Expert Committee on Drug Dependence 37th Meeting; November 16-20, 2015; Geneva, Switzerland. http://www.who.int/medicines/access/controlled-substances/5.3_aPVP_PR1.pdf. Accessed August 3, 2016.
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7. Robles F. Police in Florida grapple with a cheap and dangerous new drug. New York Times. May 24, 2015. http://www.nytimes.com/2015/05/25/us/police-in-florida-grapple-with-flakka-a-cheap-and-dangerous-new-drug.html. Accessed August 3, 2016.
8. Drug Enforcement Administration. Schedules of Controlled Substances: Temporary Placement of 10 Synthetic Cathinones Into Schedule I. Regist 79:129 38- 129 93. http://www.deadiversion.usdoj.gov/fed_regs/rules/2014/fr0307_2.htm. Accessed August 3, 2016.
9. Steinberg J. Flakka: The new illegal drug you need to know about. Inc. November 8, 2015. http://www.inc.com/joseph-steinberg/flakka-the-new-illegal-drug-you-need-to-know-about.html. Accessed August 3, 2016.