Case report Two psychiatric presentations linked with ‘head shop’ products Chimdi Uhoegbu, Eric Kolshus, Izu Nwachukwu, Allys Guerandel, Caroline Maher Ir J Psych Med 2011; 28(1): S8-S10 Abstract We report two cases of acute onset and rapid resolution of psychotic symptoms, the first following oral inges- tion and the second following intravenous injection of some head shop products (HSPs). Both were associated with autonomic instability and negative results on urine toxicology screening using standard techniques. They highlight the potential dangers of managing such cases in acute stand-alone psychiatric units. Recent advance in characterising some HSPs by toxicology screening is also discussed Key words: Head shops; Cathinone; Delusions; Maculo- papular; Eruptions; Autonomic, ‘Mint Mania’, ‘Snow’. Background ‘Legal highs’ and ‘herbal highs’ are legal alternatives to illegal drugs 1 that are sold online or in retail outlets called ‘Head Shops’, which originated in the United States as ‘drug paraphernalia stores’ including marijuana-inhaling devices. 2 The mental health dangers posed by the operation of these ‘Head Shops’ as legal enterprises have increased dramati- cally since 2000 when the first shop opened in Ireland. In 2005, “legal highs” began to attract media attention when a young man died after jumping from a fourth floor balcony after taking alcohol, cannabis and psilocybin mushroom. 3,4 Some of the chemical compounds commonly seen in HSPs, in Ireland include: 5 • Cathinones–agroupofdrugsrelatedtoamphetamines. Mephedrone, methedrone, flephedrone, methylone, buty- lone, and methylenedioxypyruvalenone (MDPV), belong to this family, and are marketed online and in ‘Head Shops’ under the names ‘MCAT’, ‘Snow’, ‘Charge’. • Spiceproducts–originallyamixofinnocuousherbs,but have been found in some cases to be mixed with synthetic cannabinoids. • Piperazine – synthetic drugs with psychoactive properties. They include 1-benzylpiperazine (BZP), methyl- benzylpiperazine, meta-chlorophenylpiperazine (mCPP), and 1-(4-fluorophenyl) piperazine. They are sold as components of ‘party pills’. They were banned in Europe in March 2008, and in Ireland, March 2009. • Salviadivonorum(divinemint)–containschemicalswith potency similar to LSD. Its use may result in euphoria, out- of-body experience, and at high doses, delirium. Early in 2010, Dr Bobby Smyth, a consultant child and adolescent psychiatrist in Dublin, with expertise in youth drug and alcohol problems, stated that of the 130 adolescents aged between 13 and 18 years who attended his service in 2009, for drug and addiction problems, 80% (104), were new clients, with ‘Head Shops’ playing increasing role in their drug habits. 6 In a recent survey of ‘Head Shops’ in Dublin, Pillay and Kelly found that in all the shops surveyed, sales attendants recommended specific substances to their clients and described all their products as “legal and safe”. 7 In the light of these findings, the recent ban effective from June 2010 by the Irish Government 8 on some products of HSPs is welcome. Case A A 30-year-old single unemployed woman with no past psychiatric history presented to our hospital Emergency Department (ED) with 24 hours history of psychomotor agitation, irritability, paranoid delusions and maculo-papular eruptions in the distal third of her right thigh and on proximal third of both legs. On assessment, she was grossly disorganised in her speech and behaviour and expressed paranoid delusions. She claimed to have overheard staff telling her family and friends that she had developed “brain cell death”, with a remote chance of survival. Physical examination revealed raised and fluctuating blood pressure and pulse rates with peaks of 160/100mmHg and 120bpm respectively. Computed tomography (CT) brain scan and lumbar punc- ture were normal. Urine toxicology screen was negative for ‘common’ illicit substances. She settled transiently with parenteral administration of lorazepam and haloperidol but was observed overnight at the ED due to ongoing autonomic instability. While settled, she gave a six to eight month history of regular use of products called ‘Mint Mania’ and ‘Lime Fantasy’ which she procured from ‘Head Shops’, with rapid dose escalation in the 48 hours prior to presentation. She described the usual intoxicant effects from these products as “(being) very alert, hyperac- tive, not feeling any pain, you forget everything, impulsive and (have) increased libido”. In the context of this intoxication (which was usually potentiated by alcohol), she has shop- lifted “a few times” and has had casual sex with strangers. Collateral history from a close former colleague confirmed that she had not been known to have any mental health diffi- culties in the past. She had been regarded by colleagues to have an alcohol misuse problem, but not known to be abus- ing psychoactive drugs. While maculo-papular skin eruptions have been S8 *Chimdi Uhoegbu, Registrar in Psychiatry, Eric Kolshus, Registrar in Psychiatry, Izu Nwachukwu, Senior Registrar in Psychiatry, Allys Guerandel, Consultant Psychiatrist, Caroline Maher, Consultant Psychiatrist, St Vincent’s University Hospital, Elm Park, Dublin 4, Ireland. Email: tendeze@yahoo.com *Correspondence SUBMITTED: APRIL 19, 2010. ACCEPTED: OCTOBER 1, 2010.