On the following day, the patient needed full assistance from the staff with her activities of daily living and continued to act bizarre and illogical. Although unable to fully communicate due to her altered thought process, she mentioned that she might have been given Flakka by a “friend.” A noncontrast CT scan of the head was ordered to rule out any organic causes, which came back negative. 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. Since the patient received intramuscular Olanzapine and Lorazepam multiple times since being admitted, it was deemed appropriate to start the patient on scheduled Olanzapine to target her symptoms. By the fifth hospital day, the patient was taking Olanzapine 10 mg twice a day routinely with Lorazepam every four hours as needed for agitation. Finally, on day six, the patient became coherent, alert and oriented to person, place, time, and situation, and capable of completing her activities of daily living.
As this case demonstrates, patients seeking medical aid sometimes willingly share information about illicit drug use, if only they are asked. We strongly suspect that the patient’s stroke was caused by the use of α-PVP, although the exact mechanism remains unknown. The patient used a clean needle with a microfilter, which lowers the risk of embolic adulterants to be the direct cause of the ischemic stroke. The comprehensive evaluation ruled out other major causes of stroke, and the onset of the stroke was immediately after the α-PVP injection. The urine drug screen was only positive for benzodiazepines, which rules out other confounding substances. Different approaches have been developed for the treatment of patients with a SUD and a psychotic disorder.
A Case of Alpha-Pyrrolidinopentiophenone (Flakka)-Induced Ischemic Stroke
- Alpha-PVP (alpha-pyrrolidinovalerophenone), known on the streets as “Flakka,” is a new synthetic drug that has become an epidemic in South Florida.
- Head MRI showed multiple new ischemic lesions in the left cerebral hemisphere (Fig. 1).
- 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.
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.
Treatment Options for Flakka Addiction
The intended injection site was the left external jugular vein, since the peripheral veins were damaged due to numerous injections. Before the injection, the drug had been mixed with tap water and injected using a clean needle and a microfilter provided by a nonprofit organization aimed at diminishing health complications from drug use. The major challenges facing the clinicians managing a person with cathinone intoxication are control of agitation and other signs of sympathetic excess and acute decompensation can occur if immediate measures are not taken. Although most respond to aggressive treatment, the course is usually prolonged and many never return back to baseline. Until we can stop the import of the synthetic substance from international sources, the epidemic is likely to persist.
At discharge, the patient had a mild right-sided hemiparesis but could walk with the aid of forearm crutches he had already been using because of osteoarthrosis. Prescriptions of aspirin 100 mg and atorvastatin 10 mg once per day were given, and the patient was advised to continue occupational therapy at the local healthcare center to rehabilitate right arm functions. The clinical neurological evaluation at the emergency department showed right-sided hemiparesis, no visual deficits, and no aphasia or dysarthria. Only a small puncture wound without surrounding hematoma was found on the patient’s neck. From medically assisted interventions to harm reduction policies, a multi-layered approach can help individuals and communities manage and prevent this dangerous drug. By preventing cells from reabsorbing dopamine and norepinephrine, flakka prolongs the “rush” effect.
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.
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The norepinephrine buildup also drives rapid heart rate and elevated blood pressure, causing dangerous overstimulation. The patient was evaluated, and rehabilitation was initiated by an occupational therapist. However, the patient left the hospital on the fifth day of his own will before a complete physiotherapy evaluation.
According to her mother, the patient was at home when she began yelling and screaming “go away! The patient claimed that it was just a nightmare but the mother refutes that claim, saying that she was not sleeping and has no history of nightmares or sleep terrors. The patient was originally brought to the hospital at the request of the patient’s mother who noticed an acute onset of these bizarre behaviors.
Research Chemicals and “Club Drugs”
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.
- By the fifth hospital day, the patient was taking Olanzapine 10 mg twice a day routinely with Lorazepam every four hours as needed for agitation.
- Insight into SUD severity is often low, so collateral information from family and toxicology screening can be useful.
- Patients who screen positive for at-risk substance use should be further evaluated for a SUD—which assesses how the substance is affecting the patient’s functioning—for each substance they are using since polysubstance use is common in youth.
- South Florida is the epicenter of multiple Flakka episodes, with users displaying bizarre and psychotic behaviors 1.
- Because of this affordability, the drug is appealing to economically vulnerable groups, contributing to pockets of higher usage despite overall modest national prevalence.
Is Weed a Depressant, Stimulant, or Hallucinogen?
In South Florida, there has been a highly addictive new synthetic drug flooding the streets for people looking for a cheap high. Alpha-PVP, better known as Flakka, is an illegal substance that sells on the streets for as little as $5 a hit and delivers an instant high that can last from hours to days with lingering effects for weeks after it has been ingested. Although people use Flakka for its potential euphoric high, symptoms are known to easily escalate into frightening delusions, paranoid psychosis, extreme agitation, and a multitude of other altered mental states. According to the National Institute on Drug Abuse, Florida appears to be the nation’s hot spot for reports of Flakka. In this case report, a 17-year-old female with no prior psychiatric diagnosis presents to the hospital under a 72-hour involuntary placement for altered mental status with agitation and psychotic behaviors.
Kevin returns to your office in the early fall and is very upset to have failed the first quiz of the year. You assess further and learn that he missed some classes because he believes that a government organization has infiltrated his school in an to attempt to monitor and target him. When comparing this to his recent period without these beliefs, he reluctantly admits that he never stopped worrying about being monitored by the agency but did not want to admit this to you. He is also hesitant to provide a urine sample for toxicology testing, and when he does, acknowledges, “It’s going to show weed. You also assess his substance use further and determine Kevin meets criteria for cannabis use disorder, moderate. You refer him to a colleague for SUD therapy and find a local resource that provides both group therapy and parent guidance for guardians of youth with SUD.
A part of the cathinone class, Flakka is a very addictive substance created in laboratories in order to produce euphoric symptoms in people trying to obtain a cheap, quick high. Cathinones have been found to stimulate the release of dopamine and inhibit the reuptake of epinephrine, norepinephrine, and serotonin in the central nervous system. Since cathinones are hydrophobic molecules, they can easily cross cell membranes and the blood brain barrier, allowing them to heavily interact with the monoamine transporters in the synaptic cleft between neurons 2.
A urine drug screen was positive for benzodiazepines, and the patient reported occasional use of benzodiazepines. A full thrombophilia workup was negative and along with a normal complete blood count ruled out most common thrombophilias and hematological disorders. A Finnish male patient in his sixties with hepatitis C and osteoarthrosis of both knees was admitted to the emergency department because of acute right-sided hemiparesis that had started a day before the admission. Prior to the onset of hemiparesis, the patient’s friend had injected a dose of α-PVP into the patient’s neck.
In this case report, the patient’s baseline mental status changed abruptly and drastically from only one use of Flakka. Even with the use of benzodiazepines and antipsychotics, the patient became alert and oriented but never returned back to her normal functioning. 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. In this case report, the patient’s baseline mental status changed abruptly and drastically from only one use of Flakka. Symptoms related to hallucinogen persisting perception disorder usually include afterimages, halos, trails, or visual snows, without affecting other modalities (e.g., flakka-induced prolonged psychosis pmc auditory hallucinations). Type 1 episodes tend to occur less frequently, with shorter duration or intensity, following onset.