DESCRIPTION
SUBSTANCE CLASS
Psychoactive Central Stimulant
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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.  |
INTERVENTION CRITERIA
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. |
Appropriate medical assessment and observation is recommended for: - Any exposure to a piperazine based hallucinogenic stimulant |
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 |
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 |
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) |
Heart rate Blood pressure Body temperature 12 lead ECG Blood glucose Serum sodium
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Serum concentrations do not aid management. |
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.  |
EMERGENCY STABILIZATION
Ensure Adequate Cardiopulmonary Function |
Ensure the airway is protected if compromised (intubation may be necessary). |
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. |
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. |
Most toxic seizures are short-lived and often do not require intervention.  Administer a benzodiazepine as first-line treatment to patients with seizure activity.  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). |
Respiratory rate Heart rate Blood pressure State of hydration 12 lead ECG Serum electrolytes - especially sodium Blood glucose Neurological status |
DECONTAMINATION
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.  Piperazine toxicity commonly causes tachycardia, hypertension, palpitations, gastrointestinal upset (nausea, abdominal pain, vomiting), dehydration, headache, anxiety, fever, and agitation.     Mydriasis, blurred vision, sweating, tremor, and confusion are relatively common. Trismus and paresthesia may uncommonly occur,  while hallucinations, hyperventilation, shortness of breath, and flushed skin are rare.  In more severe cases, seizures, collapse, myoclonic jerking, and extrapyramidal features (choreoathetoid movements, dystonic reactions) may occur.  Serotonin syndrome has also been reported.  Hypertension can be severe.  If prolonged or severe, fever and excessive motor activity may lead to hyperthermia, metabolic acidosis, disseminated intravascular coagulation, and acute kidney injury.  Psychosis has been reported.  Given piperazine's mechanism of action, theoretical concerns are cardiac dysrhythmia, acute hepatitis/liver failure, and death.  Hypersensitivity reactions, such as bronchospasm, Stevens-Johnson syndrome, acute hepatitis, thrombocytopenia, hemolytic anemia and angioedema have occurred in individuals taking piperazine therapeutically. |
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.   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.  |
Onset/Duration of Symptoms |
Onset of affect is usually delayed about 2 hours post-ingestion.   Effects generally persist for about 12 to 24 hours, but may occur for up to 72 hours following use.  There may be a role for monoamine depletion/withdrawal in prolonged toxicity.
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Mild Piperazine Toxicity | Moderate Piperazine Toxicity | Severe 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 |
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CHRONIC EFFECTS
Hypersensitivity reactions, such as bronchospasm, Stevens-Johnson syndrome, acute hepatitis, thrombocytopenia, hemolytic anemia and angioedema have occurred in individuals taking piperazine therapeutically.  Given their mechanism of action, theoretical concerns following chronic us/abuse of piperazines would be similar to hallucinogenic amphetamines. |
Chronic oral amphetamine abuse has been associated with:   Cardiomyopathy (non-ischemic) Vascular spasm Aortic dissection Congestive heart failure   Pulmonary hypertension  Chronic intravenous abuse with:  Widespread necrotising angiitis Aneurysm Sacculations Segmental stenosis Vascular rupture Thrombosis Hypertension Pulmonary edema Renal failure |
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 Hallucinations Visual Tactile Olfactory Auditory (less common) A lasting paranoid psychotic reaction may develop, 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.  Single re-exposures may produce acute exacerbations even after long periods of abstinence. |
Ischemic colitis can occur following long-term use of amphetamines.  |
Diffuse hair loss has been associated with long-term amphetamine use.   Amphetamine and amphetamine-like compounds have rarely produced aplastic anemia and a fatal pancytopenia after prolonged use.  Infections such as hepatitis B and C and HIV are possible complications of intravenous use of amphetamine and amphetamine-like compounds.  |
Acute withdrawal may precipitate severe depression and suicidal thoughts. Symptoms usually peak after 2 to 3 days and are seldom directly life-threatening. Abdominal cramps Anxiety Craving Moderate to severe depression Diaphoresis Dyspnea Exhaustion Gastroenteritis Headache Increased appetite Irritability Insomnia Lethargy Mental confusion Psychotic reaction Restlessness |
Tolerance can develop to the anorectic and various autonomic effects including body temperature, blood pressure, heart rate and respirations.  |
Do Not Archive. This document is current on day of issue,
NZ: 21.Apr.2018 |