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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.

Assessing for Substance Use Disorders

• Individuals predisposed to developing PPD might also have a predisposition to using substances and/or substance use may accelerate the course of an underlying psychotic disorder.
• As hallucinations are the intended toxidrome, these substances cause some psychosis by definition, but symptoms might persist beyond the initial period of intoxication.
• 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.
• According to the National Institute on Drug Abuse, Florida appears to be the nation’s hot spot for reports of Flakka.
• There was no indication of puncture of the left internal carotid artery in these studies.

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.

What are the Long-Term Effects of Flakka?

• In Type 2, the frequency, duration, and intensity can increase over time,23 and it has been suggested that this may convert into persistent psychotic illness.
• 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.
• Occupational therapy and physiotherapy were initiated, and the patient was discharged with only a mild right hemiparesis.
• Flakka 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.

We present a case report of an acute ischemic stroke following the recreational use of α-PVP. The ischemic lesions were located in the middle cerebral artery and deep watershed areas of the left cerebral hemisphere. Occupational therapy and physiotherapy were initiated, and the patient was discharged with only a mild right hemiparesis. 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. During the initial evaluation, the patient was drowsy and not coherent enough to give an accurate history of the events leading up to her current altered state.

Coarse of Hospital Stay

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, flakka-induced prolonged psychosis pmc 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.

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. Insight into SUD severity is often low, so collateral information from family and toxicology screening can be useful. Norepinephrine buildup triggers “fight-or-flight” responses, such as increased heart rate, high blood pressure, and hyper-alertness. Many flakka users become agitated or panicked, sometimes exhibiting violent outbursts. Flakka, sometimes called alpha-pyrrolidinopentiophenone (α-PVP), is a synthetic cathinone known for its stimulant properties and unpredictable potency. Flakka is a synthetic substance that has earned sensational nicknames like the “zombie drug.” However, there’s a lot more to it regarding its chemistry, effects, and impact on the community.

What are the Effects of Flakka?

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.

Cocaine –

Individuals predisposed to developing PPD might also have a predisposition to using substances and/or substance use may accelerate the course of an underlying psychotic disorder. 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. Structurally and pharmacologically synthetic cathinones are similar to amphetamine, and physiological changes include hypertension, arrythmia, and vasoconstriction, which are known to cause strokes 5. Transthoracic and transesophageal echocardiography showed no evidence of endocarditis or intracardial thrombi.

Substance-specific considerations

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.

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.

Manufacturers frequently mix α-PVP with cheap fillers such as caffeine or sugar to alter appearance and maximize profit. These additives rarely affect the psychoactive strength of the drug but can further complicate health risks. In the emergency room, Kevin told staff that he was afraid of “shadow government agents.” He described that they had been observing him through electronic devices for several weeks, and this evening he had seen shadowy figures in his home out of the corner of his eye.

His parents agree to engage in parent guidance at the nearby adolescent SUD clinic to learn more about SUD and psychosis, as well as ways they can support Kevin’s engagement in treatment. After a few more meetings with you and encouragement from his parents, Kevin agrees to attend individual and group sessions at the adolescent SUD clinic, as well. Effective integrated treatment programs for adults with schizophrenia and SUD highlight the importance of social support.45 Leveraging pro-social connections may also be of benefit for youth with SIP and SUD. Identifying a relationship with an adult trusted by the adolescent such as a teacher, coach, or work supervisor might be helpful in monitoring the youth’s symptoms, substance use, and functioning.

In Type 2, the frequency, duration, and intensity can increase over time,23 and it has been suggested that this may convert into persistent psychotic illness. A systematic review found very few well-designed studies examining hallucinogen persisting perception disorder,22 making it difficult to summarize effective approaches for managing this condition. His medical workup was unremarkable except for a urine toxicology screen, which was positive for amphetamines and cannabinoids. He also reported that over the summer he was not taking the mixed amphetamine extended release since he often woke up late in the day. Instead he took the immediate release medication and would occasionally take three to four times the prescribed dose when he was tired.

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.

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