National Association of Attorneys General
Education and Prevention Initiatives as Necessary Tools to Combat Synthetic Drug Abuse
This article is the second half of a two-part NAAGazette series that examines the prevalence of, dangers associated with, and actions taken to combat synthetic drug abuse. The first half of the series, which was published in the February 2014 NAAGazette, provided the reader with a brief history of the development of synthetic cannabinoids and cathinones, and described the efforts taken by law enforcement and state and federal legislators to reduce the synthetic drug supply in our marketplace through criminal and civil proceedings. This article discusses the importance of education, prevention and treatment in decreasing the use of these substances. The article also details efforts taken at the federal, state and local levels to increase public awareness and provides the reader with educational and prevention resources.
Effectively reducing synthetic drug abuse requires a multipronged approach. Synthetic drug abuse is different than that of cocaine or heroin. First, these substances are sold openly and often legally in convenience stores, head shops, and on the Internet. Because of the mainstream nature of this market, individuals often assume that the substances are safe for consumption when in reality the manufacture and sale of these substances is unregulated. In 2013, a retailer who was interviewed by BusinessWeek claimed that he sold most of his product to members of the military, soccer moms, teachers and firefighters. Commenting on the �not for human consumption� labeling that manufacturers and retailers often use to evade responsibility for overdoses, he stated, �I don�t tell people what to do with it�this is a marketer�s dream. I underpromise and it overdelivers.�
Second, while the federal, state and local governments have taken quick and decisive action to ban synthetic drugs, the chemical makeup of the drugs can be easily altered to create new compounds not covered by the ban. Manufacturers and retailers have a financial incentive to continue developing and marketing these substances. Alan G. Santos, associate deputy assistant administrator for the U.S. Drug Enforcement Administration (DEA), Office of Diversion Control, stated that the synthetic drug market is �conservatively�a multibillion-dollar-a-year industry.� It is therefore no surprise that the National Drug Threat Assessment Summary published by the U.S. Department of Justice and the DEA in 2013 predicted that the threat posed by the availability of synthetic cannabinoids and synthetic cathinones will most likely continue to increase.
Third, since new compounds emerge monthly, we do not know much about the long-term health effects of the use of these substances and in particular, the effect on the developing adolescent brain. However, what we do know is extremely troubling. Early studies and anecdotal evidence have shown that synthetic cannabinoids and cathinones are addictive. Moreover, not only is synthetic marijuana about 10 times more potent than the THC "contained in" natural marijuana, but also research has shown that users of synthetic marijuana are more likely to experience psychotic symptoms and more likely to overdose than if they had ingested natural marijuana. There are two reasons for this phenomenon. First, synthetic marijuana does not contain cannabidol, the chemical in natural marijuana that is �linked to sedative, anxiety relieving and antipsychotic properties.� Second, natural marijuana is a partial agonist, meaning that it only partially stimulates the brain�s cannabinoid receptors, while synthetic cannabinoids bind to all cannabinoid receptors in the brain, fully stimulating them, leading to overdose potential. The use of synthetic drugs has also recently been associated with kidney damage.
We are therefore presented with a dangerous collection of addictive substances that are readily available and an industry that is highly motivated to continue to evade the law. It is almost universally agreed that we cannot incarcerate our way out of the drug problem in this country. Nowhere is this truer than in the area of synthetic drugs. While law enforcement and scheduling legislation play a huge role in addressing this scourge, the complexities of the problem make prevention, education and treatment invaluable. Particular care must be taken to educate young adults, parents, first responders, healthcare workers, and retailers.
Educating the Public
In June 2012, a report issued by the U.S. Senate Caucus on International Narcotics Control stated that according to the DEA, teenagers and young adults are the most frequent users of synthetic substances which are often marketed to them as being the �legal� alternative to methamphetamine, marijuana and cocaine. Young adults can not only purchase the substances online but also can use the Internet to learn how to achieve the �best� high or even how to manufacture synthetic drugs on their own. Between March 2012 and August 2013, at least 19 young adults were reported to have died as the result of ingesting N-Bomb, a synthetic phenethylamine psychedelic. In 2010, there were 11,406 emergency room visits related to synthetic drug exposure. Seventy-five percent of the patients were between 12 and 29 years of age. In 2011�s Monitoring the Future Survey, one in nine high school seniors reported using synthetic marijuana. Parents must be made aware of the prevalence and widespread availability of these drugs and must have the ability to identify both the products and the symptoms associated with their use.
Recognizing the importance of prevention and education, the federal government and the states have developed prevention initiatives geared specifically towards the use of synthetics. Through the White House Office of National Drug Control Policy (ONDCP)�s Drug Free Communities grant program, which provides drug prevention funding based on specific community needs, many organizations have been able to develop prevention efforts tailored to their communities. For example, Oceanside, California�s North Coastal Prevention Coalition has used the federal grant money to directly confront stores selling synthetic drugs and to collaborate with stakeholders in order to pass local ordinances classifying head shops as adult businesses and limiting the areas where they can operate.
The ONDCP has endeavored to assist states and localities with educating parents and families by developing a synthetic drugs information kit, which was launched with The Partnership at DrugFree.org. The kit includes a slide cast, podcast and video that helps the public learn more about the effects of the drugs. The information kit also includes a guide for parents that identifies the street names of the drugs and describes the warning signs of drug use, as well as a tip sheet that details how parents can communicate with and monitor their children. These materials are available for free download on the Partnership website.
In March 2014, the U.S. Senate passed a resolution which designated the week of March 9 through March 15 as National Youth Synthetic Drug Awareness Week. The resolution cites a lack of public understanding of the potential harm of synthetic drugs and explains the necessity of raising public awareness as to the dangers of such drugs and the deceptive marketing by online and brick and mortar retailers. The resolution also urges communities to carry out appropriate programs and activities to educate parents and youth about the dangers associated with synthetic drug abuse.
States have also taken action to prevent additional addiction through collaboration and public education initiatives. In June 2012, Illinois Attorney General Lisa Madigan and Indiana Attorney General Greg Zoeller held an interstate summit to address both synthetic drug and small-batch methamphetamine production and use. The summit was also attended by poison control agencies, law enforcement, state representatives and representatives from the pharmaceutical industry. Ohio Attorney General Mike DeWine has organized training for law enforcement officers, so that the officers can learn about the identification of and dangers involved with these drugs and has also participated in county-level synthetic drug symposiums.
The members of the NAAG Substance Abuse Committee, including Florida Attorney General Pam Bondi and Kentucky Attorney General Jack Conway, committee co-chairs, and members Attorney General Sam Olens of Georgia, Attorney General Patrick Morrisey of West Virginia, and Attorney General Janet Mills of Maine have all acted as leaders in the development of education and prevention efforts in their states as well. For example, Attorney General Bondi worked with the Florida Department of Law Enforcement to develop a synthetic drug informational pamphlet, which helps to educate the public about synthetic drugs and the current state of the law in Florida.
Grassroots organizations and community groups have also acted to combat synthetic drug use through education and awareness. Two of the many notable efforts are the K2drugfacts.com website and the To the Maximus Foundation. The K2drugfacts.com website was established by the family of David Rozga, who smoked K2, a synthetic cathinone, and then committed suicide. The family works to increase public knowledge of the dangers of these drugs because they strongly believe that had David known the effects of these drugs, he would never have smoked K2. The website provides facts and resources as well as updates regarding new legislation. The To the Maximus Foundation was also founded by the family of a young adult who died after ingesting a synthetic drug. Max Dobner was 19 when he smoked synthetic marijuana in 2011, drove his car and was involved in a fatal car accident. At the time Mr. Dobner purchased the substance, he remarked to a friend that �it must be safe because it was legal and marijuana was illegal�it must be safer than marijuana.� The Foundation has worked with the media to educate and inform the public and has advocated for legislation that would outlaw synthetic drugs. Over the past three years, members of the Foundation have picketed stores selling the substances and successfully advocated for a ban on the drugs in Chicago, Ill.
Educating the Medical Community
Education and public awareness efforts must go beyond parents and young adults and extend to first responders and emergency room personnel, who must be able to identify the symptoms of synthetic drug use in order to provide appropriate and effective care. According to the National Council on Alcoholism and Drug Dependence, only half of emergency room doctors had even heard of synthetic drugs in 2010, and many had misconceptions relating to treatment. Additionally, due to the often violent nature of an individual overdosing on a synthetic substance, clinicians also must establish plans for securing the safety of their hospitals and personnel.
Emergency room and urgent care clinicians should be educated on the signs and symptoms of intoxication and be urged to reach out to toxicologists, poison control centers and other drug experts whenever necessary. Doctors who are unfamiliar with synthetic drugs and their effects run the risk of misdiagnosis. For example, women who use synthetic marijuana during pregnancy may develop symptoms similar to those of eclampsia and preeclampsia. A doctor treating a pregnant woman who is exhibiting these symptoms without considering synthetic drug intoxication may misdiagnose the patient and induce labor.
Even doctors familiar with synthetic drugs often find it difficult to develop appropriate treatment plans due to the unregulated manufacturing of the substances and the variety of possible effects. Treatment for individuals exposed to synthetic drugs is different than treatment for exposure to other illicit substances, as certain synthetic cathinones do not follow a normal �dose-response pattern.� In the normal pattern, drugs like cocaine or amphetamine enter the patient�s system and begin to wear off within a few hours. However, the effects of synthetic drugs, such as paranoia or delusions, often last for many days. Moreover, many of the synthetic substances do not appear on routine urinalysis, so doctors may have to send out blood tests and await lab results.
The Eastern Maine Medical Center is an example of a hospital that has developed detailed procedures and treatment techniques particularly geared to synthetic ingestion and overdose. Because synthetic drug users can be paranoid and delusional, a special room has been set up which contains almost no furniture, and health care personnel are aware of these symptoms and on guard. These treatment protocols were developed after a patient on bath salts demolished a special care room at a nearby hospital, destroying more than $30,000 worth of medical equipment. After treating many synthetic cathinones overdoses using medications used for psychotic patients, the doctors found that they were �under-prescribing and not using the right medicines.� The providers now have fast-working sedatives on hand, such as midazolam, to administer to those patients who seem to possess superhuman strength and exhibit no pain threshold. For patients who are delirious, the doctors place them in a medically induced sleep.
Clinicians and social workers can also download a helpful training package, developed by Jane Maxwell, PhD, a senior research scientist with the University of Texas at Austin�s School of Social Work�s Addiction and Research Institute, which includes a PowerPoint presentation entitled, �Synthetic Drugs � Will They Turn You Into a Zombie?� It is an introductory training package for clinicians and gives a detailed synopsis of the types of synthetics, defines key terms, provides information regarding the identification of and assessment of patients who have ingested these drugs.
Last, retailers must be made aware of the dangerous and often illegal nature of these substances. Not only will this reduce the number of drugs in the supply chain, but proof that a retailer was warned and continued to sell the substances is also helpful for a prosecutor working to establish intent at that retailer�s trial. Over the past two years, both states and the federal government have taken many efforts to put the retailers on notice. Initially, retailers were not very responsive. For example, in 2011, instead of advocating for a ban on the sale of these drugs, the Retail Compliance Association asked Congress to consider a federal licensing system to track the number of manufacturers and distributors selling the drugs and suggested the enactment of a tax, similar to that which applies to cigarettes, to help address potential health problems related to the use of these drugs.
However, as the problems associated with these substances have become worse, retail associations have become more cooperative. In June 2012, the Michigan Food and Beverage Association adopted a �no sale� policy for synthetic marijuana and supported state legislation that banned the products. During that same year, the Georgia Association of Convenience Stores supported Georgia�s anti-synthetics legislation and asked their stores not to sell synthetic drug products.
Moreover, in 2013, the DEA sent a letter to the top 100 retail convenience stores and gas stations, informing them of the existence of synthetic drugs �masquerading as over-the-counter household items� and explaining the potential for abuse and the health risks associated with the drugs. The letter also asked the corporations to stop the sale of these substances. The vast majority of the retailers who were contacted banned the sale of the substances after receiving this letter. The DEA also held a seminar for corporations in August 2013 which focused on the dangers of synthetic drugs. While only four corporations attended the seminar, each of the corporate attendees has a great number of individual outlets throughout the country.
BP and Citgo have warned their individual branded stores against the sale of the drugs and introduced a broad prohibition. A letter sent to BP marketers stated that all BP-branded stores are prohibited from �displaying, using, storing, offering or selling illegal drugs or synthetic drugs produced to mimic illegal drugs, or items that are intended or designed for use in ingesting, inhaling or otherwise consuming an illegal drug.�
While retail associations have been responsive, many individual stores have continued to market these drugs, sometimes even after the substances are banned. Attorneys general have reached out to individual retailers in an attempt to end these activities. In September 2012, Indiana Attorney General Greg Zoeller sent retailers a formal notice and warning, hand-delivered by police officers, and collaborated with a local prosecutor to ensure that retailers who continued to sell the substances would face substantial penalties, including the loss of their retail merchant certificate of business for one year. Attorney General Zoeller also requested that retailers sign a �Synthetic Drug Community Protection Agreement,� in which the retailer pledged to no longer sell the substances and to relinquish any remaining inventory.
As part of Illinois Attorney General Lisa Madigan�s Operation Smoked Out Initiative, investigators from her office worked with local police officers in 24 counties to convince synthetic cannabinoid and cathinone retailers to hand over their stock of synthetic drugs, including compounds that were not yet banned. By June 2013, Illinois retailers had voluntarily turned over tens of thousands worth of drugs with a street value of over $650,000.
Individual counties have followed suit. For example, in 2013, a task force that included the sheriff of San Bernardino County, Calif., sent a letter to businesses informing them that certain synthetic drugs, sold as bath salts or �spice� were no longer legal. The letter summarized the laws pertaining to the substances and offered to help the retailers discard the products through a voluntary take back day. In October 2013, Pawtucket, R.I. police contacted stores in their jurisdiction and provided them with a short window of time in which to relinquish any remaining stock before facing prosecution.
The efforts of the federal, state and local stakeholders in reducing the supply and demand of synthetic drugs have garnered results. The combination of legislation, law enforcement activity and prevention and treatment efforts have reduced the use of synthetic drugs by young adults over the past two years. However, recent headlines have shown that the problem is far from solved. A recent article published in May 2014 reported that Dallas, Texas area hospitals had seen 40 overdoses over two days, all tied to the use of synthetic drugs. On May 7, the execution of Project Synergy, Part II, the culmination of a DEA investigation, led to the arrest of 150 people, the seizure of hundreds of thousands of individual doses of synthetic drugs, hundreds of kilos of raw synthetic products and over $20 million in cash and assets. This investigation targeted retailers, wholesalers and manufacturers and also uncovered a massive flow of drug-related proceeds to countries in the Middle East. This investigation makes clear that the synthetic drug trade is still very robust and we must remain vigilant in our efforts to combat the availability of and market for these drugs.
 A head shop is a shop specializing in articles of interest to drug users. �Head shop.� Merriam-Online Dictionary, 2014. Available at http://www.merriam-webster.com/dictionary/head%20shop(last visited May 12, 2014).
 Drug Known as Smiles and N-Bomb Gaining in Popularity Among Teens, http://www.cadca.org/resources/detail/drug-known-smiles-and-n-bomb-gaining-popularity-among-teens (last visited May 12, 2014).
 The Department of Defense has a �zero-tolerance� policy for the use of illicit drugs. however, the random urinalysis used by the DOD did not detect synthetics, until recently. The DOD is working to expand its urinalysis drug testing to include synthetics. Spice: Zero Tolerance, All the Time, http://www.malmstrom.af.mil/news/story.asp?id=123402604(last visited May 12, 2014).
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 Drug Enforcement Administration, 2013 National Drug Threat Assessment Summary, p. 14, available at http://www.justice.gov/dea/resource-center/DIR-017-13%20NDTA%20Summary%20final.pdf (last visited May 12, 2014).
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 Synthetic Drugs � Fake Substances, Real Dangers, http://www.socialworktoday.com/archive/070212p12.shtml (last visited May 12, 2014). One public health concern is that there may be harmful heavy metal residues in mixtures.
 Synthetic Marijuana More Dangerous Than the Real Thing?, http://addiction-dirkh.blogspot.com/2012/06/new-highs-are-bath-salts-addictive.html (last visited May 12, 2014).
 Synthetic Drugs � Fake Substances, Real Dangers, supra n.8.
 Acute Kidney Injury Linked With Synthetic Marijuana, http://www.ncadd.org/index.php/in-the-news/626-acute-kidney-injury-linked-with-synthetic-marijuana (last visited May 12, 2014).
 United States Senate Caucus on International Narcotics Control, Reducing the U.S. Demand for Illegal Drugs, p. 5, available at http://www.feinstein.senate.gov/public/index.cfm/files/serve/?File_id=81b53476-64a3-4088-9bae-254a84b95ddb (last visited May 12, 2014).
 Synthetic Drugs � Fake Substances, Real Dangers, supra n.8.
 Drug Known as Smiles and N-Bomb Gaining in Popularity Among Teens, supra n.1.
 First-of-its-kind Report Finds That Street Forms of �Synthetic Marijuana� Products Linked to Thousands of Hospital Emergency Departments Visits Each Year, http://www.samhsa.gov/newsroom/advisories/1212040915.aspx (last visited May 12, 2014).
 The Partnership at Drugfree.org Responds to 2011 Monitoring the Future Study Results, http://www.drugfree.org/newsroom/the-partnership-at-drugfree-org-responds-to-2011-monitoring-the-future-study-results (last visited May 12, 2014).
 Reducing the U.S. Demand for Illegal Drugs, supra n. 13 at 32. An independent evaluation of drug free community (DFC) programs has shown their effectiveness, through significant declines of substance abuse in DFC communities. See National Evaluation Finds Drug Free Communities Program Effective at Reducing Drug Abuse, http://www.cadca.org/resources/detail/national-evaluation-finds-drug-free-communities-program-effective-reducing-drug-abu (last visited May 12, 2014).
 Reducing the U.S. Demand for Illegal Drugs, supra n. 13 at 33.
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 Synthetic Drugs FAQS, http://www.ohioattorneygeneral.gov/FAQ/Synthetic-Drug-FAQs (last visited May 12, 2014).
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 Use of Synthetic Drugs Causes Symptoms Similar to Eclampsia, http://www.isaude.net/en/noticia/34853/general/use-of-synthetic-drugs-on-pregnancy-causes-symptoms-similar-to-eclampsia (last visited May 12, 2014).
 Synthetic Drug Users Should Seek Treatment for Addiction, http://www.oneidadispatch.com/general-news/20120816/synthetic-drug-users-should-seek-treatment-for-addiction (last visited May 12, 2014). By �unregulated manufacturing,� I am referring to the fact that different packages of the same product may contain different dosages of that product, meaning that some people will react more strongly than others.
 Bath Salts The Drug That Never Lets Go,� http://www.pbs.org/newshour/spc/multimedia/bath-salts/ (last visited May 12, 2014).
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 This package can be accessed at the following website:http://www.uclaisap.org/slides/synthetic-drug-training-package.html.
 The Big Business of Synthetic Highs, supra n. 3.
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 Dangerous Synthetic Drugs: Testimony Before the Caucus on International Narcotics Control, United States Senate (September 25, 2013) (Testimony of Joseph T. Rannazzisi, p. 5).
 Id. at 27.
 Fight to Eliminate Synthetic Marijuana Spreading Across Country, supra n.47.
 For example, as described in the February 2014 article, a Duluth, Minnesota retailer continued to sell synthetic substances. The City of Duluth eventually brought a successful public nuisance action against the retailer. See City of Duluth v. 120 East Superior Street, 2013 Minn. App. Unpub. LEXIS 881 (Minn. Ct. App. Sept. 16, 2013). The owner of the store was later convicted in federal court of over 51 charges relating to the sale of synthetic drugs. Guilty Verdict in Minn. Synthetic Case, http://www.mprnews.org/story/2013/10/07/last-place-on-earth-convicted (last visited February 3, 2014).
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 Attorneys General Madigan, Zoeller Convene Inter-State Summit on Meth, Synthetic Drug Abuse, http://www.ag.state.il.us/pressroom/2012_06/20120619.html (last visited May 12, 2014).
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 Sheriffs Issue Warning on Synthetic Drug Sales, http://www.myfoxla.com/story/23773534/sheriffs-issue-warnings-on-synthetic-drugs-sales (last visited May 12, 2014).
Pawtucket Asks Stores to Surrender Bath Salts, http://www.630wpro.com/common/page.php?feed=2&pt=NEWS%3A+Pawtucket+asks+stores+to+surrender+bath+salts&id=24813&is_corp=0 (last visited May 12, 2014).
 The results of the most recently released University of Michigan�s Monitoring the Future Study showed that the use of synthetic marijuana decreased substantially and also showed that the number of teens who believe that the use of bath salts involves great risk has �increased sharply.� American Teens More Cautious About Using Synthetic Drugs, http://www.monitoringthefuture.org/pressreleases/13drugpr_complete.pdf (last visited May 12, 2014).
 Doctors Suspect Synthetic Drugs in About 40 Overdoses at Area Hospitals, http://crimeblog.dallasnews.com/2014/05/30-people-treated-at-local-hospitals-for-possible-synthetic-marijuana-overdoses.html/ (last visited May 12, 2014).
 DEA and Other Federal and State Agencies Announce Major Nationwide Synthetic Drug Takedown, http://www.cadca.org/resources/detail/dea-and-other-federal-and-state-agencies-announce-major-nationwide-synthetic-drug-t (last visited May 12, 2014).