Alpha-PVP (alpha-pyrrolidinovalerophenone), known on the streets as “Flakka,” is a new synthetic drug that has become an epidemic in South Florida. Flakka is the latest in a series of synthetic drugs that have become popular in the United States; included on this list are Ecstasy and Bath Salts. It is chemically similar to MDPV, also known as Bath Salts, which was blamed for a surge of bizarre cases of intoxication and agitation throughout the US a few years ago 1. In discussions with Kevin and his parents, everyone agrees to a trial of an antipsychotic medication to reduce his symptoms and optimize his functioning. His parents wonder if this means he has schizophrenia, or if he will have to be on medications for the rest of his life.
- His parents agree to engage in parent guidance at the nearby adolescent SUD clinic to learn more about SUD and psychosis, as well as ways they can support Kevin’s engagement in treatment.
- In place of the prior discrete categories of “abuse” and “dependence, SUD is now classified by severity.
- Similar symptoms continued to be apparent on the third hospital day, where the patient remained bizarre, disorganized, and psychotic, repeating the phrase “Thank you, thank you Jesus.” She again mentioned that she might have taken Flakka but remains vague about the incident.
- During the initial evaluation, the patient was drowsy and not coherent enough to give an accurate history of the events leading up to her current altered state.
- The following article will review substance induced psychosis (SIP) including the definition, epidemiology, causes, treatment, and prognosis.
This influx in dopamine causes an intense feeling of euphoria but also leads a person to the possibility of agitated delirium and thus psychiatric hospitalizations 4. The street drug known as “Flakka” has been the latest plague of the synthetic substances causing havoc on the streets and in hospitals. South Florida is the epicenter of multiple Flakka episodes, with users displaying bizarre and psychotic behaviors 1.
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This complex presentation illustrates several of the ambiguities of these symptoms that cross diagnostic categories. Removing agents that are likely to contribute to psychosis, such as cannabis, stimulants, and hallucinogens is important, but this can be clinically difficult, and in some cases symptoms might persist for months. He has attention deficit hyperactivity disorder (ADHD) which has been effectively treated by his pediatrician since the age of 7. Over the past 3 years he has taken mixed amphetamine salts extended release 25 mg in the morning and an additional 7.5mg of immediate release after school. He has no other psychiatric history; neither his parents nor his pediatrician have ever been concerned about symptoms of a mood, anxiety, psychotic, or substance use disorder.
Types
Flakka is also known to provoke a condition called agitated delirium, when there is an excessive influx of sympathetic activation. This condition causes alterations in the mental status and can include bizarre behaviors, anxiety, agitation, violent outbursts, confusion, myoclonus, and rare cases of seizures. Clinical symptoms of agitated delirium involve tachycardia, hypertension, hyperthermia, diaphoresis, and mydriasis 3. The normal urine drug screen used at the emergency departments in Finland does not demonstrate the use of synthetic drugs.
Is Weed a Depressant, Stimulant, or Hallucinogen?
She remained somewhat constricted and at times required redirection and instructions to complete tasks. When asked about her symptoms for the past week, she described an incident that happened at school the day before being admitted to the hospital. She claims that a group of her “friends” were pressuring her to try Flakka with them. Although she refused, she believes that they put some on the food she was eating because she claimed it tasted funny and felt weird ever since. She also denies any recent major stressors or traumatic events that could have led to her behaviors.
Alpha-pyrrolidinovalerophenone (α-PVP), or “flakka” by its street name, is a synthetic stimulant used recreationally. Α-PVP is related to other cathinone derivates often commonly referred to as “bath salts,” and the mechanism of action resembles that of cocaine and amphetamine by inhibiting dopamine and norepinephrine reuptake 1. Unlike older drugs, the adverse effects of newer designer drugs are not as well known. The previously reported serious adverse effects of α-PVP included psychosis and catatonia 2, myocardial infarction 3, and Stevens-Johnson syndrome 4, but not stroke. Here we present a case report of an acute ischemic stroke following injection of α-PVP. Since the patient has never experienced any symptoms of this nature in the past, she was admitted on day one for observation and symptomatic treatment without any routine psychotropic medications being started.
As a prophylactic dose against deep vein thrombosis were administered, and the patient was admitted to the neurology ward. Further investigations included a neck ultrasound, which ruled out thrombosis of the jugular vein. Head MRI showed multiple new ischemic lesions in the left cerebral hemisphere (Fig. 1). MRA of the carotid and cerebral arteries did not show vasospasm or clinically relevant atherosclerotic stenosis. There was no indication of puncture of the left internal carotid artery in these studies. In the meantime, you offer to continue to see Kevin regularly to try to minimize symptoms of psychosis and continue to address his substance use using MI.
Research Chemicals and “Club Drugs”
Kevin declines to engage in these services, as he feels sufficiently motivated to stop using cannabis. Despite the recognized importance of screening for and evaluating youth for SUD, there are few standards for how to do so in psychiatric settings. In particular, Screening to Brief Intervention (S2BI); Brief Screener for Tobacco, Alcohol, and Other Drugs (BSTAD) for adolescents; and the Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) tool for young adults. As outlined above, the prevalence of heavy substance use is high in adolescents with psychosis, whether the psychosis is primary or substance-induced. Although the focus of this chapter is on the psychosis, it is important to evaluate and treat any comorbid substance use disorder (SUD).
- In the meantime, you offer to continue to see Kevin regularly to try to minimize symptoms of psychosis and continue to address his substance use using MI.
- Clinical symptoms of agitated delirium involve tachycardia, hypertension, hyperthermia, diaphoresis, and mydriasis 3.
- Until we can stop the import of the synthetic substance from international sources, the epidemic is likely to persist.
- You continue to meet with him at short intervals for the rest of the summer to assess his symptoms of psychosis and his response to atomoxetine.
- Over the past 3 years he has taken mixed amphetamine salts extended release 25 mg in the morning and an additional 7.5mg of immediate release after school.
Commonly prescribed medications
He was also able to hear them speaking to one another, and although he could not make out specific words, he felt certain they were conspiring to capture or kill him. Flakka, though not as widespread as often portrayed in sensationalized media reports, poses real dangers to users and communities. By staying informed and advocating for empathetic responses, we can help reduce the harm caused by flakka.
After multiple days of symptomatic treatment with benzodiazepines and antipsychotics, the patient became coherent enough to give a history of a “friend” putting Flakka in her food at school as a joke. Although she continues to have residual symptoms including psychomotor agitation and slowing of cognition, she was alert, oriented, and able to be discharged home with proper follow-up. According to the flakka-induced prolonged psychosis pmc National Institute on Drug Abuse, Florida appears to be the nation’s hot spot for reports of Flakka. After multiple days of symptomatic treatment with benzodiazepines and antipsychotics, the patient became coherent enough to give a history of a “friend” putting Flakka in her food at school as a joke.
A comprehensive approach is the best management for SIP, ideally including 1) medication management, 2) psychosocial treatment (individual and/or group therapy), and 3) engagement of family (and possibly other important social connections). This combination of highly specific treatment can be difficult to find even in relatively resource-rich locations. Except in cases where all symptoms of psychosis clearly resolve in the absence of the offending agent, treating psychosis and SUD simultaneously is more effective than trying to address these challenges sequentially. Despite its street-level reputation as a “zombie drug,” it’s primarily a chemical cousin of other stimulants like amphetamines and “bath salts,” with a high risk of severe side effects. Alpha-pyrrolidinovalerophenone (α-PVP) is a designer drug, the mechanism of action of which resembles that of cocaine and amphetamine.
Substance-Induced Psychosis in Youth
Depending on his response to treatment and the amount of cannabis he continues to use, it is reasonable to try without medication in the future. You continue to meet with him at short intervals for the rest of the summer to assess his symptoms of psychosis and his response to atomoxetine. Kevin appears to be doing well and by the beginning of his senior year he is feeling healthy and confident. He denies symptoms of psychosis as well as cannabis use, which is corroborated by urine toxicology screens that are negative for THC. Hallucinogens describes a diverse group of both naturally occurring substances (such as psilocybin and mescaline) as well as synthetic lysergic acid diethylamide (LSD) and LSD-like substances. As hallucinations are the intended toxidrome, these substances cause some psychosis by definition, but symptoms might persist beyond the initial period of intoxication.
What are the Effects of Flakka?
Because of this affordability, the drug is appealing to economically vulnerable groups, contributing to pockets of higher usage despite overall modest national prevalence. Florida, especially Broward County, once experienced a spike in flakka-related emergencies. Reports show this synthetic drug traveling to states like Georgia, Kentucky, Tennessee, and Ohio. Because flakka’s potency can spark life-threatening complications (high fever, heart issues), using this drug can lead to emergency room overcrowding.
