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.
Alpha-PVP (alpha-pyrrolidinovalerophenone), known on the streets as “Flakka,” is a new synthetic drug that has become an epidemic in South Florida. Flakka flakka-induced prolonged psychosis pmc 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.
- 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.
- Many flakka users become agitated or panicked, sometimes exhibiting violent outbursts.
- This complex presentation illustrates several of the ambiguities of these symptoms that cross diagnostic categories.
- She remained somewhat constricted and at times required redirection and instructions to complete tasks.
- We did not find previous reports of ischemic strokes caused by α-PVP, although cardiovascular events such as myocardial infarction had been previously reported 3.
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.
Research Chemicals and “Club Drugs”
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.
Is Weed a Depressant, Stimulant, or Hallucinogen?
After one more day of observation, the patient did not display any more overt psychotic symptoms and was discharged home with the appropriate scheduled outpatient appointments. Psychostimulants (often simply called stimulants) are commonly prescribed to treat ADHD, and are commonly misused by youth (i.e. taken at higher doses than prescribed, using stimulants that were prescribed to someone else, or crushing and insufflating these medications). Although the exact mechanism of action is unclear, why it has been causing this alteration in a person’s functions, it is known that Flakka is designed to cause the brain to become flooded with dopamine.
One approach is referred to as “parallel treatment,” and involves simultaneous treatment for both disorders, but by different agencies or providers with expertise in their specific area. An alternative approach is “sequential treatment,” where a patient receives either psychosis or substance-use focused treatment first, in isolation, based on the idea that resolving one problem allows the other to be more effectively treated. After his initial presentation to the emergency room, Kevin stopped smoking cannabis because he was worried about his symptoms and concerned that cannabis may be playing a role. He seems to have improved insight into some of his symptoms, and no longer believes that there are intruders in his home. He has continued to largely isolate in his room, however, and while he has been using his phone and computer, he acknowledges avoiding certain sites because he “can’t shake the feeling” that he, specifically, is being monitored in a nefarious way.
Commonly prescribed medications
The emergency room staff recommended voluntary hospitalization which he and his parents declined. He was instructed to not use cannabis and to not take medication for his ADHD until he was evaluated further. The mother further denies any past history of any mood or psychotic disorders and believes that her daughter is just overwhelmed with stress due to multiple factors including school-related pressures and a long-distance relationship. The patient’s laboratory values obtained at the Emergency Department were within normal limits besides her urine drug screen showing tricyclic antidepressants, which the mother explained that it could be due to a cream being used to treat the patient’s migraines for many years. The patient’s laboratory values obtained at the Emergency Department were within normal limits besides her urine drug screen showing tricyclic antidepressants, which the mother explained that it could be due to a cream being used to treat the patient’s migraines for many years.
What are the Long-Term Effects of Flakka?
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.
- According to the National Institute on Drug Abuse, Florida appears to be the nation’s hot spot for reports of Flakka.
- 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.
- He has continued to largely isolate in his room, however, and while he has been using his phone and computer, he acknowledges avoiding certain sites because he “can’t shake the feeling” that he, specifically, is being monitored in a nefarious way.
- Alpha-pyrrolidinovalerophenone (α-PVP), or “flakka” by its street name, is a synthetic stimulant used recreationally.
- 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.
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.
Who is at Risk of Using Flakka?
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).
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 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.
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.