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Charge (BZP)

Charge (BZP)
25.Sep.2017-Expires: 7 days - Do not archive

DESCRIPTION

SUBSTANCE NAME

Benzylpiperazine (BZP)
 

SUBSTANCE CLASS

Psychoactive Central Stimulant

Piperazine-Based Hallucinogenic Stimulant
 

ACTIVE INGREDIENT

Charge Capsule
105 mg Benzylpiperazine (BZP)
 
Recommended dose is 1 to 2 capsules, then another 1 to 2 after 2 hours. Maximum dose 3 capsules. Available in packets of 6 or 18.
 
Warning: Tablets claim to contain "500 mg". However, this refers to total mg of all ingredients, not active ingredients, and is effectively a meaningless statement.
 

USES

While piperazine-based hallucinogenics or stimulants are not currently used therapeutically, they are misused. It is believed to have a similar action as the hallucinogenic-amphetamines, explaining the reason for its abuse. It is less potent than methamphetamine or MDMA, but is being sold in continuously increasing doses, making the effects more consistent with these more potent drugs.[1]
 

INTERVENTION CRITERIA

Intervention Level

The correct identification of the substance is important. If the symptoms are inconsistent with those described in the literature, or the history is considered unreliable, other substances may need to be considered.
 

Acute

Child

Appropriate medical assessment and observation is recommended for:
- Any exposure to a piperazine based hallucinogenic stimulant
 

Adult

Appropriate medical assessment and observation is recommended:
- If > 400 mg of a piperazine-based hallucinogenic stimulant is ingested
- Symptomatic patients (other than mild)
- Exposures with intent to self-harm
 

Observation Period

Observation at Home

If the patient does not require medical observation they can be monitored at home for 4 hours in the care of a reliable observer.
 
Medical attention should be sought if ANY symptoms occur, including:
Euphoria
Confusion/agitation
Anxiety
Increased heart rate
Palpitations
Chest pain
Gastrointestinal upset
Fever
Tremor
 

Medical Observation

If medical observation is required the patient must be monitored for 4 hours following exposure for onset or worsening of symptoms.
 
Those with mild signs and symptoms (e.g. euphoria, increased alertness, altered mental status, tachycardia) should be closely observed until symptoms abate.
 
If the patient is asymptomatic at the end of the observation period (there is no agitation or serotonergic signs, and pulse, BP, temperature are normal), and provided that appropriate assessment and investigations have been carried out, they may be:
Discharged into the care of a reliable observer, or
Referred for psychological assessment (if the overdose or exposure was intentional)
 

Investigations

Monitoring

Heart rate
Blood pressure
Body temperature
12 lead ECG
Blood glucose
Serum sodium

Levels

Serum concentrations do not aid management.
 

Admission Criteria

Admission to an intensive care environment is recommended for:
Severe hypertension
Cardiac ischemia
Significant cardiac dysrhythmias, including supraventricular tachycardias
Cerebral hemorrhage
Intractable seizures
Agitated delirium with fever
Multisystem organ failure
 

TREATMENT

TREATMENT SUMMARY

Piperazine based hallucinogenic stimulants are considered to possess an hallucinogenic-amphetamine-like effect.
 
in the majority of cases gastrointestinal decontamination is unlikely to be beneficial. There is no antidote for intoxication and no methods for enhancing elimination can be recommended.
 
The majority of presentations will recover with a period of observation, calming environment and, if required, administration of a benzodiazepine. Patients may become dehydrated and require significant volume replacement, however, it is imperative to recognize those suffering hyponatremia as administration of fluids may prove fatal. Serum sodium must be measured, and CT brain scan undertaken to exclude cerebral edema in those with CNS signs.
 
The severely toxic may suffer seizure or cardiovascular abnormality. Persistent seizures require treatment with a benzodiazepine or if refractory, a barbiturate. Chest pain may indicate an acute coronary syndrome (arteriospasm) which will likely settle if the patient is calmed with a benzodiazepine, nitrate, or in severe cases a vasodilator such as phentolamine. Hyperthermia should be immediately and actively managed, and the patient carefully monitored for further complications including rhabdomyolysis, DIC, and renal failure. Serotonin syndrome should be considered, especially in those using other serotonergic compounds either therapeutically or recreationally.[2]
 
Stimulant abuse may be via intravenous injection of ground tablets. Pulmonary granuloma formation in chronic abusers predisposes to reduced pulmonary function,[3] vascular obliteration, pulmonary hypertension, and cor pulmonale.[4][5]
 
Emergency Stabilization
Decontamination
Ingestion
Antidote(s)
Enhanced Elimination
Supportive Care
Neurologic
Cardiovascular
Metabolic
Musculoskeletal
Respiratory
Renal
Fluid and electrolytes
Hepatic
Other
Ocular
Dermatologic
 

EMERGENCY STABILIZATION

Ensure Adequate Cardiopulmonary Function

Airway

Ensure the airway is protected if compromised (intubation may be necessary).
 

Cardiovascular

Immediately establish secure intravenous access.
 
A range of acute cardiovascular emergencies may occur due to vasospasm or vascular rupture. Such events include hemorrhagic or ischemic stroke, cardiac dysrhythmia/arrest, and dissection of large vessels including the aorta.
 
A range of acute cardiovascular emergencies may occur due to vasospasm or vascular rupture. Such events include hemorrhagic or ischemic stroke, cardiac dysrhythmia/arrest, dissection of large vessels including the aorta.
 

Cardiac Arrest

Prolonged cardiac resuscitation following standard ACLS protocols is warranted as recovery with a good neurological outcome is reported in poisoned patients receiving CPR for periods of 3 to 5 hours.[6]
 

Seizure

Most toxic seizures are short-lived and often do not require intervention.[7]
 
Administer a benzodiazepine as first-line treatment to patients with seizure activity.[7]
 
Blood glucose concentration should be promptly determined. If the result indicates hypoglycemia, or is unobtainable, 50% dextrose should be administered IV (preceded by thiamine in adults).
 

Emergency Monitoring

Respiratory rate
Heart rate
Blood pressure
State of hydration
12 lead ECG
Serum electrolytes - especially sodium
Blood glucose
Neurological status
 

DECONTAMINATION

Ingestion

Decontamination Not Recommended

Efficacy of gastrointestinal decontamination is questionable as these compounds are rapidly absorbed and the patient is likely a late presenter and less than co-operative. As the risks likely outweigh benefit, activated charcoal is not recommended.
 

ANTIDOTE(S)

There Are No Antidotes For This Substance

There is no specific antidote for the treatment of this poisoning. Treatment is based on symptomatic and supportive care.
 

SIGNS AND SYMPTOMS

The correct identification of the substance is important. If the symptoms are inconsistent with those described in the literature, or the history is considered unreliable, other substances may need to be considered.
 
Piperazines have a stimulant effect resulting from increased monoamine (dopamine, serotonin, norepinephrine (noradrenaline)) availability.[8]
 
Piperazine toxicity commonly causes tachycardia, hypertension, palpitations, gastrointestinal upset (nausea, abdominal pain, vomiting), dehydration, headache, anxiety, fever, and agitation.[9][10][11][2] Mydriasis, blurred vision, sweating, tremor, and confusion are relatively common. Trismus and paresthesia may uncommonly occur,[9] while hallucinations, hyperventilation, shortness of breath, and flushed skin are rare.[2]
 
In more severe cases, seizures, collapse, myoclonic jerking, and extrapyramidal features (choreoathetoid movements, dystonic reactions) may occur.[9] Serotonin syndrome has also been reported.[12] Hypertension can be severe.[9] If prolonged or severe, fever and excessive motor activity may lead to hyperthermia, metabolic acidosis, disseminated intravascular coagulation, and acute kidney injury.[13] Psychosis has been reported.[14] Given piperazine's mechanism of action, theoretical concerns are cardiac dysrhythmia, acute hepatitis/liver failure, and death.[15]
 
Hypersensitivity reactions, such as bronchospasm, Stevens-Johnson syndrome, acute hepatitis, thrombocytopenia, hemolytic anemia and angioedema have occurred in individuals taking piperazine therapeutically.
 

Routes of Exposure

Benzylpiperazine (BZP) liquid and dust is known to be corrosive. This may cause burns to the gastrointestinal tract if swallowed or to the eye or skin if these areas are contaminated. Piperazine based hallucinogenic stimulants are also smoked by some individuals and there is also the potential for effects similar to inhalation of a corrosive (or acid) gas to manifest.
 
Tablets are often dissolved and directly injected. Due to the bulk of these tablets being composed of non-water soluble agents such as talc there is a high rate of complications following granuloma formation and vascular obliteration.[5][4] While the lung is a particular target with resultant pulmonary hypertension/cor pulmonale, other organs can be affected. Infection following such abuse is also a concern.[3]
 

Onset/Duration of Symptoms

Onset of affect is usually delayed about 2 hours post-ingestion.[1][16] Effects generally persist for about 12 to 24 hours, but may occur for up to 72 hours following use.[9] There may be a role for monoamine depletion/withdrawal in prolonged toxicity.

Severity of Poisoning

Mild Piperazine ToxicityModerate Piperazine ToxicitySevere Piperazine Toxicity
Increased alertness
Mydriasis
Bruxism (grinding of teeth)
Altered mental status
Tachycardia
Hypertension
Agitation
Paranoia
Hallucinations
Diaphoresis
Vomiting
Abdominal pain
Palpitations
Chest pain
Hyperthermia
Hyponatremia
Metabolic acidosis
Rhabdomyolysis
DIC (disseminated intravascular coagulation)
Acute renal failure
 

CHRONIC EFFECTS

Hypersensitivity reactions, such as bronchospasm, Stevens-Johnson syndrome, acute hepatitis, thrombocytopenia, hemolytic anemia and angioedema have occurred in individuals taking piperazine therapeutically.[17]
 
Given their mechanism of action, theoretical concerns following chronic us/abuse of piperazines would be similar to hallucinogenic amphetamines.
 

Cardiovascular

Chronic oral amphetamine abuse has been associated with:[18][19]
Cardiomyopathy (non-ischemic)
Vascular spasm
Aortic dissection
Congestive heart failure[5][20]
Pulmonary hypertension[5]
 
Chronic intravenous abuse with:[21]
Widespread necrotising angiitis
Aneurysm
Sacculations
Segmental stenosis
Vascular rupture
Thrombosis
Hypertension
Pulmonary edema
Renal failure
 

Neurologic

If large amounts of amphetamine or amphetamine-like compounds are consumed over a long period of time, amphetamine psychosis can develop, which is similar to paranoid schizophrenia. The psychosis is manifested by hallucinations, delusions and paranoia. Symptoms usually disappear within a few weeks after drug use stops.
 
A range of sequelae have been noted following chronic human abuse including:
Choreoathetoid movements[22]
Hallucinations[23]
Visual
Tactile
Olfactory
Auditory (less common)
 
A lasting paranoid psychotic reaction may develop,[24] and behavior can become destructive and violent. While the majority of patients recover within 10 days, effects persist for more than 6 months in 10% of cases.[25][26][27] Single re-exposures may produce acute exacerbations even after long periods of abstinence.
 

Gastrointestinal

Ischemic colitis can occur following long-term use of amphetamines.[28]
 

Other

Diffuse hair loss has been associated with long-term amphetamine use.[29][30]
 
Amphetamine and amphetamine-like compounds have rarely produced aplastic anemia and a fatal pancytopenia after prolonged use.[31]
 
Infections such as hepatitis B and C and HIV are possible complications of intravenous use of amphetamine and amphetamine-like compounds.[31]
 

Withdrawal Syndrome

Acute withdrawal may precipitate severe depression and suicidal thoughts. Symptoms usually peak after 2 to 3 days and are seldom directly life-threatening.
 
Physical symptoms associated with withdrawal are:[32][33][34]
Abdominal cramps
Anxiety
Craving
Moderate to severe depression
Diaphoresis
Dyspnea
Exhaustion
Gastroenteritis
Headache
Increased appetite
Irritability
Insomnia
Lethargy
Mental confusion
Psychotic reaction
Restlessness
 

Tolerance

Tolerance can develop to the anorectic and various autonomic effects including body temperature, blood pressure, heart rate and respirations.[35]
 

REFERENCES

 
[1] Bye C, Munro-Faure AD, Peck AW, Young PA. A comparison of the effects of 1-benzylpiperazine and dexamphetamine on human performance tests. Eur J Clin Pharmacol 1973 Oct; 6 (3): 163-9.
[2] Schep LJ, Slaughter RJ, Vale JA, Beasley DM, Gee P. The clinical toxicology of the designer "party pills" benzylpiperazine and trifluoromethylphenylpiperazine. Clin Toxicol (Phila) 2011 Mar; 49 (3): 131-41.
[3] Parran TV Jr, Jasinski DR. Intravenous methylphenidate abuse. Prototype for prescription drug abuse. Arch Intern Med 1991 Apr; 151 (4): 781-3.
[4] Hahn HH, Schweid AI, Beaty HN. Complications of injecting dissolved methylphenidate tablets. Arch Intern Med 1969 Jun; 123 (6): 656-9.
[5] Lewman LV. Fatal pulmonary hypertension from intravenous injection of methylphenidate (Ritalin) tablets. Hum Pathol 1972 Mar; 3 (1): 67-70.
[6] Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 8: advanced challenges in resuscitation: section 2: toxicology in ECC. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Circulation 2000 Aug 22; 102 (8 Suppl): I223-8.
[7] Chen HY, Albertson TE, Olson KR. Treatment of drug-induced seizures. Br J Clin Pharmacol 2016 Mar; 81 (3): 412-9.
[8] Baumann MH, Clark RD, Budzynski AG, Partilla JS, Blough BE, Rothman RB. N-substituted piperazines abused by humans mimic the molecular mechanism of 3,4-methylenedioxymethamphetamine (MDMA, or 'Ecstasy'). Neuropsychopharmacology 2005 Mar; 30 (3): 550-60.
[9] Gee P, Richardson S, Woltersdorf W, Moore G. Toxic effects of BZP-based herbal party pills in humans: a prospective study in Christchurch, New Zealand. N Z Med J 2005 Dec 16; 118 (1227): U1784.
[10] Theron L, Jansen K, Miles J. Benzylpiperizine-based party pills' impact on the Auckland City Hospital Emergency Department Overdose Database (2002-2004) compared with ecstasy (MDMA or methylene dioxymethamphetamine), gamma hydroxybutyrate (GHB), amphetamines, cocaine, and alcohol. N Z Med J 2007 Feb 16; 120 (1249): U2416.
[11] Gee P, Gilbert M, Richardson S, Moore G, Paterson S, Graham P. Toxicity from the recreational use of 1-benzylpiperazine. Clin Toxicol (Phila) 2008 Nov; 46 (9): 802-7.
[12] Klaassen T, Ho Pian KL, Westenberg HG, den Boer JA, van Praag HM. Serotonin syndrome after challenge with the 5-HT agonist meta-chlorophenylpiperazine. Psychiatry Res 1998 Jul 13; 79 (3): 207-12.
[13] Gee P, Jerram T, Bowie D. Multiorgan failure from 1-benzylpiperazine ingestion--legal high or lethal high? Clin Toxicol (Phila) 2010 Mar; 48 (3): 230-3.
[14] Austin H, Monasterio E. Acute psychosis following ingestion of 'Rapture'. Australas Psychiatry 2004 Dec; 12 (4): 406-8.
[15] Greene SL, Dargan PI, O'connor N, Jones AL, Kerins M. Multiple toxicity from 3,4-methylenedioxymethamphetamine ("ecstasy"). Am J Emerg Med 2003 Mar; 21 (2): 121-4.
[16] Campbell H, Cline W, Evans M, Lloyd J, Peck AW. Comparison of the effects of dexamphetamine and 1-benzylpiperazine in former addicts. Eur J Clin Pharmacol 1973 Oct; 6 (3): 170-6.
[17] Sweetman SC, editor. Martindale. The complete drug reference. 33rd ed. London: Pharmaceutical Press; 2002. p. 105-6.
[18] Davis GG, Swalwell CI. Acute aortic dissections and ruptured berry aneurysms associated with methamphetamine abuse. J Forensic Sci 1994 Nov; 39 (6): 1481-5.
[19] Wijetunga M, Seto T, Lindsay J, Schatz I. Crystal methamphetamine-associated cardiomyopathy: tip of the iceberg? J Toxicol Clin Toxicol 2003; 41 (7): 981-6.
[20] Haning W, Goebert D. Electrocardiographic abnormalities in methamphetamine abusers. Addiction 2007 Apr; 102 Suppl 1 (): 70-5.
[21] Citron BP, Halpern M, McCarron M, Lundberg GD, McCormick R, Pincus IJ, Tatter D, Haverback BJ. Necrotizing angiitis associated with drug abuse. N Engl J Med 1970 Nov 5; 283 (19): 1003-11.
[22] Lundh H, Tunving K. An extrapyramidal choreiform syndrome caused by amphetamine addiction. J Neurol Neurosurg Psychiatry 1981 Aug; 44 (8): 728-30.
[23] Jackson JG. The hazards of smokable methamphetamine. [Letter] N Engl J Med 1989 Sep 28; 321 (13): 907.
[24] Sato M. A lasting vulnerability to psychosis in patients with previous methamphetamine psychosis. Ann N Y Acad Sci 1992 Jun 28; 654 (): 160-70.
[25] Schaffer CB, Pauli MW. Psychotic reaction caused by proprietary oral diet agents. Am J Psychiatry 1980 Oct; 137 (10): 1256-7.
[26] Ando K, Hironaka N, Yanagita T. Psychotic manifestations in amphetamine abuse--experimental study on the mechanism of psychotic recurrence. Psychopharmacol Bull 1986; 22 (3): 763-7.
[27] Iwanami A, Kato N, Nakatani Y. P300 in methamphetamine psychosis. Biol Psychiatry 1991 Oct 1; 30 (7): 726-30.
[28] Dirkx CA, Gerscovich EO. Sonographic findings in methamphetamine-induced ischemic colitis. J Clin Ultrasound 1998 Nov-Dec; 26 (9): 479-82.
[29] Eckert J, Church RE, Ebling FJ, Munro DS. Hair loss in women. Br J Dermatol 1967 Oct; 79 (10): 543-8.
[30] Alexander S. Diffuse alopecia in women. Trans St Johns Hosp Dermatol Soc 1965; 51 (1): 99-102.
[31] McEvoy GK, editor. AHFS drug information. Bethesda (MD): American Society of Health-System Pharmacists; 1997. p. 1764-6.
[32] Schep LJ, Slaughter RJ, Beasley DM. The clinical toxicology of metamfetamine. Clin Toxicol (Phila) 2010 Aug; 48 (7): 675-94.
[33] OSWALD I, THACORE VR. Amphetamine and phenmetrazine addiction. Physiological abnormalities in the abstinence syndrome. Br Med J 1963 Aug 17; 5354 (): 427-31.
[34] Meredith CW, Jaffe C, Ang-Lee K, Saxon AJ. Implications of chronic methamphetamine use: a literature review. Harv Rev Psychiatry 2005 May-Jun; 13 (3): 141-54.
[35] Robinson TE, Becker JB. Enduring changes in brain and behavior produced by chronic amphetamine administration: a review and evaluation of animal models of amphetamine psychosis. Brain Res 1986 Jun; 396 (2): 157-98.

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