Widespread publicity about the dangers of designer drugs has raised awareness of illegal substances like bath salts, spice, and research chemicals. But the term flakka is still unfamiliar to many Americans outside of Florida’s drug scene, where this cheap synthetic product has become the latest emerging substance abuse trend. In Florida’s Broward County alone, the drug known as “$5 insanity” was associated with 29 fatalities in 2014, according to The Wall Street Journal.  In addition to these deaths, hundreds of incidents have been reported involving violent and bizarre encounters with users under the influence of flakka, which has been called a bigger threat to public health and safety in Florida than crack cocaine.
In spite of the deadly effects of the drug, flakka use has spread rapidly through Florida, with southern regions like Broward County hit especially hard. The Tampa Tribune reports that drug enforcement agencies have seized multiple shipments of flakka, which is synthesized in laboratories overseas, including 12 kilos from a single dealer who had purchased the drug online from a Chinese distributor.  In 2014, flakka was classified by the U.S. Drug Enforcement Administration (DEA) as a Schedule I controlled substance, meaning that it has no accepted medical use, and that it is illegal to distribute, possess, or use the drug. 
Flakka and other designer drugs in the class of synthetic cathinones are considered to be such a serious public health threat that the DEA imposed an emergency ban on 10 drugs in this category in 2014, including flakka, or alpha-PVP. In a Notice of Intent announcing the ban, the DEA stated: “Available evidence on the overall public health risks associated with the use of synthetic cathinones indicates that … alpha-PVP … can cause acute health problems leading to emergency department admissions, violent behaviors causing harm to self or others, or death. In addition, products containing these synthetic cathinone substances often do not bear labeling information regarding their ingredients, and, if they do, they may not list the active synthetic ingredients or identify the health risks and potential hazards associated with these products.” 
Delirium, aggression, fevers, high blood pressure, and paranoid hallucinations are the most obvious immediate effects of flakka, an illegally manufactured drug whose chemical name is alpha-pyrrolidinopentiophenone, or alpha-PVP. The high internal body temperatures caused by alpha-PVP can lead to severe kidney, liver, and brain damage, eventually resulting in multi-organ system failure.  Users claim that the stimulant gives them a sense of supernatural strength, invincibility, and euphoria that are comparable to crack or meth. But crimes and fatalities involving flakka indicate that this rush is a high price to pay for its physical and psychological side effects.
The Rise of a New Drug
What is flakka, and why are drug enforcement officials and public safety officers so concerned about its growing popularity? Derived from a Spanish slang term for “skinny girl” (la flaca), flakka is a stimulant that is highly potent, widely available, and cheap. Flakka is also known on the streets as “gravel” because of the appearance of its granular, gray crystals. The low cost of flakka — the drug sells for as little as $5 per dose, according to WebMD contributor Matt McMillen — makes it highly accessible to young adults and popular on the club scene. 
Florida has been hit especially hard by the emergence of flakka. The Sunshine State’s coastal location has made it an easy access point for distributors from South America, China, and other parts of the world. Drug enforcement agents and customs officials have been fighting the influx of designer substances like flakka, but this effort hasn’t been easy. In Broward County, Florida — the second most populous county in the state and the site of major transportation hubs like the Fort Lauderdale Hollywood International Airport — seizures of the synthetic drug surpassed cocaine in 2014. 
Detective William Schwarz, a narcotics officer with the Broward County Sheriff’s Office, stated in an interview with Reuters that nearly 35 percent of his department’s crime lab reports from that year concerned flakka, while only 30 percent involved cocaine.  Because flakka is classified as a legal “research chemical” in China, the drug can be sold through the mail via online distributors. Although China has stepped up its efforts to control the manufacture and distribution of designer drugs, the country’s sheer size and the number of international ports present serious challenges to law enforcement. India and Pakistan are two of the other primary suppliers of flakka.
Like methamphetamine and cocaine, flakka is a highly addictive stimulant. Poison control centers in Florida and other states report that the majority of users are teens and young adults — a group that is prone to experimentation and risk-taking behavior. But as the drug spreads across the country, flakka use is no longer limited to a youthful party crowd. The SunSentinal states that in Broward County, which leads the country in flakka-related deaths, 29 fatalities occurred within a matter of months in 2014, and victims were as young as 21 and as old as 58.  James Hall,
an epidemiologist from Florida’s Nova Southeastern University, has called flakka “the most intense, rapidly emerging drug problem since the 1980s with the emergence of crack cocaine.” 
Robert Glatter, MD, a Forbes contributor, writes that incidents involving flakka have increased dramatically since 2012, when the DEA reported 85 cases of flakka use or drug seizures, to 2014, when over 670 cases were reported. . In Broward County, crime labs reported over 300 flakka-related cases in the first three months of the year, compared to only 200 cases for all of 2014.  Although medical experts know that the initial effects of flakka can last for 3-4 hours, very little is known about how this substance will affect the user physically or psychologically over time. The lack of clinical data on the long-term impact of flakka makes its rapid spread across the country even more troubling.
Origins of Flakka
Synthetic cathinones — the class of chemicals that includes flakka — are nothing new on the underground drug scene. These designer stimulants have been produced illegally in laboratories since the 1960s and grown in popularity in the 21st century, especially among teens and young adults. Cathinones are derived from an amphetamine compound that occurs naturally in the Catha edulis plant, an evergreen shrub native to Africa.  The leaves of the Catha edulis, or khat, are chewed for their stimulant properties. Toxic effects of the stimulant in khat include elevated delirium, aggressive behavior, hypertension, rapid heart rate, urinary retention, constipation, and sexual dysfunction. Khat is potentially habit-forming, causing tolerance, dependency, and addiction in individuals who abuse the substance. 
Researchers have not determined exactly how flakka affects the brain, but it is believed that the drug is similar to cocaine and meth in its effects on the brain. These stimulants alter the way the brain processes the neurotransmitters dopamine and norepinephrine. These naturally produced chemicals help regulate moods, energy levels, and sensations of pain or pleasure. By raising levels of these brain chemicals, flakka can produce sensations of euphoria and a rush of energy, but it can also cause a state of agitation, disorientation, and delusional thinking known as “excited delirium.” The surge of norepinephrine, a brain chemical related to adrenaline, triggered by flakka has caused some users to display superhuman strength and violence, requiring multiple law enforcement officers to restrain them.  As the brain builds a tolerance to the chemical effects of flakka, tolerance, dependency, and addiction can develop, causing cravings and withdrawal symptoms if the drug is suddenly stopped.
Synthetic cathinones are sold under a variety of names to pique the interest of potential buyers and to keep law enforcement agencies guessing about the origins of these drugs:
- Bath salts
- Plant food
- Synthetic marijuana
- Research chemicals
Produced in unregulated laboratories, mostly overseas, synthetic cathinones are hard to trace, and the distributors use a variety of methods to cover their steps and circumvent the law. These drugs are marketed as “legal highs” and may be disguised as plant fertilizer, incense, jewelry cleaner, stain remover, insect repellant, and other common household products. To circumvent regulations, the drugs are often sold with the warning label: “Not for human consumption.”
The unreliable chemical content of these drugs has made it difficult to detect them in the user’s system and for effective medical treatment to be provided in the event of an overdose. Some of the hallmark signs of flakka intoxication seen in emergency departments include:
- Severe confusion and disorientation
- Abnormal muscle movements (twisting, writhing, convulsions)
- Paranoid delusions
- Psychotic episodes
- Violent outbursts
- Self-destructive behavior
- Rapid heart rate
- High blood pressure
One of the most common side effects of flakka use is sudden fevers, or hyperthermia. In Deerfield Beach, Florida, a 43-year-old man became hot, sweaty, and paranoid after taking flakka along with several other drugs. Stripping off his clothes, the father of five went outside to the patio, where he lay down, fell unconscious, and later died.  Dangerously elevated body temperatures caused by flakka can lead to internal bleeding, major organ failure, and death. Even after coming down from a flakka high, users may experience lingering suicidal thoughts, depression, or despair.
To add to the dangers of flakka, users can never be sure of the contents of this substance. Synthesized illegally in overseas labs, designer drugs like flakka can be mixed or “cut” with any number of potentially toxic ingredients, including cannabis, heroin, or cocaine. DEA Special Agent in Charge A.D. Wright was quoted on the U.S. Immigration and Customs Enforcement website as saying, “Synthetic drugs are the most lethal drugs out there today no matter what trendy names these drug dealers attach to them. Last year it was molly, now it’s flakka, and who knows what it will be called next … the users are allowing themselves to be utilized as guinea pigs. They have no idea what they are putting into their bodies.” 
Profiles of Flakka Abuse and Recovery
Cheap and readily available, flakka has become one of the most widely used drugs in South Florida, not just among the club scene, but among inexperienced users. The drug can be swallowed in capsule form, snorted as a powder, vaporized in electronic cigarettes, or injected. Customs agents have even seized bags of candy sprinkled with finely ground flakka powder. The DEA states that many users combine synthetic drugs with other substances, such as alcohol, cocaine, meth, and heroin. A large number of flakka-related deaths have occurred among individuals taking several drugs at the same time. In one tragic example, a 29-year-old Florida woman accidentally overdosed and died from a combination of flakka and the prescription drugs Dilaudid (a potent painkiller) and Xanax (a popular anti-anxiety medication). 
Accounts from flakka users tell the story of a drug whose scope and impact are still largely unknown. Users have described terrifying hallucinations, violent rage, and suicidal impulses. Stories of individuals from Florida and other states show that while most people who experiment with this drug are young and male, there is no “typical” flakka user. The drug has affected college students, single adults, parents, and middle-aged professionals from a wide range of socioeconomic backgrounds.
For a Broward County woman featured on NBC Miami, flakka abuse led to paranoia, delusional thinking, and finally to a leap off a bridge in Fort Lauderdale.  Intensive recovery and therapy have helped “Stephanie” and other flakka users restore their physical health and recover from the effects of the “insanity drug.” After a long struggle with addiction to alcohol, street drugs, and finally a destructive episode with flakka, Stephanie considers herself a substance abuse survivor thanks to the help of recovery services like equine therapy.  Other therapeutic interventions include Cognitive Behavioral Therapy, Motivational Interviewing, family and couples counseling, and trauma therapy.
With synthetic drug abuse surpassing street drugs like cocaine or heroin, recovery centers are now admitting more clients who are chemically dependent on these substances. Experimental and recreational users of designer drugs like flakka should be aware that the availability of these products through online suppliers does not make them safer or less addictive than drugs sold on the streets. Individuals who find themselves using flakka compulsively in spite of its health risks could be chemically dependent on the drug. Because withdrawal from flakka can cause serious side effects, including seizures, depression, and suicidal behavior, the safest way to recover from flakka abuse is to enter a medically supervised detox program, where clients can be monitored and kept comfortable while they prepare for the next phase of the recovery process.