street drug od
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Street Drug OD. Nathanael Wood, MD May 9, 2006. Street Drug Overdoses. Overdoses in General Rock Smack XTC PCP. What is an Overdose?. Not based on dose. Based on Clinical Picture An “Overdose” is any clinically relevant instability from drug ingestion. . - PowerPoint PPT PresentationTRANSCRIPT
Street Drug OD
Nathanael Wood, MDMay 9, 2006
Street Drug Overdoses
• Overdoses in General• Rock• Smack• XTC• PCP
What is an Overdose?
• Not based on dose.• Based on Clinical Picture• An “Overdose” is any clinically relevant
instability from drug ingestion.
Recreational Drugs Popular in the Capital Region
Most common in the Emergency Department:• Alcohol• Cocaine and Crack• Heroin and Opioids• Marijuana
Case Study
• 24 year old female found seizing.• No medical problems• Vitals: HR 153, BP 205/122, O2 sat 85%,
RR 22• Continues to seize after valium
Cocaine• Andes, Mexico,
West Indies, and Indonesia.
• Erythroxylon coca • Diminish fatigue at
altitude.
Cocaine
• Sigmund Freud• 1884: “Über Coca”• “Wonder drug”• Depression• Alcohol dependence
Freud became severely addicted.
Cocaine
• Most popular street drug • Water-soluble HCl salt
– IV– Snorted
• Also SC or IM– Slow absorption – Less “rush”
Crack• How to make Crack
– Cocaine– Baking soda and water – Boil– Separate
• Late 1980s • Smoke vapors• Popping sound • “Rock”
Cocaine: Pathophysiology• CNS Stimulant• Blocks reuptake of
norepinephrine and dopamine.
Cocaine: Pathophysiology• Norepenepherine• Sympathetic stimulation• “Fight or Flight”
– Pupil dilation– Elevated blood pressure– Tachycardia– Hyperglycemia– Hyperthermia– Cardiac arrhythmias– Seizures
Cocaine: Pathophysiology• Dopamine
– Pleasure response – Euphoria– Addiction
Assessment
• ABC• If decreased mental status:
– Narcan– Finger stick glucose or D50
Cocaine Overdose
• Convulsions• Stroke• Chest Pain• Hyperthermia• Hypertension
Cocaine Overdose
• Convulsions– Any route– Dose dependent– Usually benign
Can be caused by more serious complications like stroke or intracranial hemorrhage.
Cocaine Overdose
• Convulsions– ABC– Benzodiazepines
• Valium• Midazolam
– Avoid restraints*
Cocaine Overdose• Stroke
– Bleed or Ischemia– Seconds to 12 hrs
Cocaine Overdose• Stroke
– ABC– Rapid transport – Neurosurgery
Cocaine Overdose
• Chest Pain– Vasoconstriction– Cardiac ischemia– Angina– MI
Cocaine Chest Pain
• Treat them as real– O2, aspirin, nitrates, EKG– NO BETA-BLOCKERS
• NO LOPRESSOR (metoprolol)
– Benzodiazepines
Cocaine Overdose
• Hyperthermia– 114° F– Deadly– Avoid coverings– Avoid restraints– Cooling can be life-saving
Treat shivering and psychomotor agitation with benzodiazepines to reduce heat production.
Cocaine Overdose
• Hypertension– Alpha-mediated vasoconstriction – DO NOT USE BETA-BLOCKERS
• Unopposed alpha stimulation• WORSENS HYPERTENSION!
– Use Benzodiazepines– Consider Nitro with medical direction.
Cocaine Overdose
• Body Packers– Mules– Transport drugs– Ingested packages– International flights– Well contained packages
Breakage of packages can cause severe OD.
Cocaine Overdose
• Body stuffers– Ingest drugs they have on them – Concealment– Packages not well made– Rupture easily– Can cause severe overdoses
Be suspicious of symptomatic patients in police custody.
Cocaine Overdose
• Packers and Stuffers– Treat as OD– ER: bowel decontamination– Surgery
Cocaine Overdose - Overview• ABC• O2, IV, cardiac monitor• Detailed history:
– What and how much– Co-ingestions
• Fingerstick• Narcan• NO BETA BLOCKERS• Treat chest pain like it’s real
– NO BETA BLOCKERS
Cocaine Overdose - Overview
• Cooling• Avoid restraints if possible• Use Benzodiazepines
– Agitation– Seizure– Hypertension– Shivering when hyperthermic
Heroin
• Semisynthetic • Derived from morphine• Opiates / Narcotics family
– Opium – Methadone– Hydrocodone– Oxycontin
Heroin
• 1874• Safer, non-addictive substitute to morphine • 1920: Dangerous Drugs Act
– Drove it underground
• Most frequently abused narcotic in US – Followed by codeine and methadone
Heroin
• Pure form– White powder – Bitter taste
• Street form– Frequently mixed / cut– Maximize profits– Variety of colors– White to dark brown
Heroin
• Impure heroin – Slower absorption– Limits rush when
sniffed or snorted
• IV injection
Heroin
• 100-mg bag in 1980– 3.6% pure – $3.90
• 100-mg bag in 1999 – 38.2% pure – $0.80
South American samples have highest purity, reaching the 90% range.
Snorting and smoking are slowly becoming the methods of choice and are especially by the younger users.
Heroin
Pathophysiology• CNS effects
– Analgesia– Sedation– Euphoria– Respiratory
depression
Heroin
Pathophysiology• CNS effects
– Pupil constriction– Nausea / Vomiting– Cough suppression– Physical
dependence
Heroin
Pathophysiology• Peripheral
effects– Histamine
release– Bradycardia– Constipation
Heroin
Pathophysiology• Antidote
– Narcan
Heroin
• IV use:– Onset: 1 minute– Rush: few minutes– Sedation: 1 hour– Half life: 15 to 30 min
Heroin
• IM / SC / snorted:– Not common– Slower onset– Less rush
Heroin Overdose
• Fatal overdoses– Respiratory depression– Co-ingestion
• Alcohol• Cocaine• Antidepressants
Heroin Overdose
• Nonfatal complications– Pulmonary edema
• Up to 24 hrs after use
– Prolonged coma• Rhabdomyolisis • Compartment syndrome
Heroin Overdose
• Should be easy to recognize1. Coma 2. Respiratory depression or apnea3. Pupil constriction
Heroin Overdose
• Can be mimicked– Stroke– ICH (pontine hemorrhage)– Hypoglycemia– Hypoxia
Heroin Overdose
• Clinical picture can be confused– Co-ingestions– Adulterants– Preexisting medical conditions
Heroin Overdose
• Injection of a highly concentrated sample by an unsuspecting client
• Suicide attempt• Co-ingestion
As with cocaine, can have body stuffers and body packers, leading to severe overdoses.
Heroin Overdose - Overview
• ABC’s• O2, IV, cardiac monitor• Detailed history
– What and how much– Co-ingestions– Consider impurities
• Fingerstick• Narcan
Cocaine vs. Heroin
Cocaine• Sympathetic response• “Fight or Flight”• “Upper”
– Dilated pupils– Agitation– Tachycardia– Hypertension
Heroin• Parasympathetic response• “Feed or Breed”• “Downer”
– Constricted pupils– Sedation– Bradycardia – Respiratory depression
3,4-methylenedioxymethamphetamine
• MDMA • Ecstasy• XTC• Adam
• E• X• Clarity• Stacy
MDMA
• Amphetamine derivative • 1914: synthesized by Merck
and Company• 1950’s: US military
– possible brainwashing agent
• 1970’s: Psychiatry– psychotherapy – marital counseling
MDMA
• 1980’s: Recreational use spread– Raves– Major cities, US and Europe
MDMA - Effects
• Hallucinogenic amphetamine• Amphetamine (speed) + LSD (acid)
– Empathy– Euphoria– Disinhibition– Increased sensuality
MDMA• Forms
– Capsule– Powder– Liquid– Tablets
• Doves• Blue elephants• 8 ½• Bugs Bunny• Ferraris
MDMA
• Long acting– Duration of action: 8-24 hrs– Half-life:12-34 hrs.
• Metabolized in the liver and excreted renally. • Small subset of the population is missing the
liver enzyme that metabolizes MDMA– Can be fatal
MDMA
• One tablet – 50-100 mg – $20-25.
• Initial effects occur in 30-60 minutes. • Peak effects occur at 90 min
– May persist 4-8 hrs.
• Tolerance develops rapidly
MDMA
• Often impure• Substances mixed with MDMA
– Heroin– Ketamine– Ephedrine (herbal ecstasy).
MDMA - Effects• Initial 30 minutes
– Anxiety – Tachycardia– Elevated BP– Diaphoresis– Jaw clenching– Paresthesias– Dry mouth– Increased psychomotor
activity– Blurred vision
• Within 1 hour – Relaxation– Euphoria– Empathy – Increased communication. – Increased sensory tactile
enhancement– Mild visual distortions,
such as halos.
MDMA - Effects• If too much MDMA is consumed in a single session,
– Restlessness– Paranoia– Anxiety
• Following the acute effects of MDMA, “Blues.” – 24- to 48-hrs– Lethargy– Anorexia– Dysphoria. – Users often co-ingest to help ease the “Blues"
MDMA - Toxicity
• “Seratonin Syndrome”– Exacerbated by dancing in hot clubs– Hyperthermia– Dehydration– Muscle breakdown – Liver toxicity– Renal Failure
MDMA - Toxicity
• Hyponatremia – Hyperthermia– Seratonin syndrome, – Increased water intake– Excessive sweating with physical exertion
• Altered mental status• Seizure• Coma
MDMA - Toxicity
• Cardiovascular– Hypertension– Dysrhythmias
• Stroke and Intracranial bleeds– Rare
MDMA - Overview
• ABC’s.• Prehospital care is supportive.• IV, O2, Frequent vital sign check, fingerstick
glucose.• Most frequent morbidity/mortality is from
hyperthermia and electrolyte abnormalities.• Consider benzo’s for anxiety, agitation, panic
reactions, and seizures.
Phencyclidine
• PCP• Angle Dust
PCP
• 1950’s: Developed for use as a general anesthetic for surgery.
• 1965: Discontinued because of side effects of psychotic features, dysphoria, and extreme agitation.
• 1960’s: Maufactured illegally. • 1970’s: Popular street drug.
PCP
• White crystalline powder available in liquid, tablet, or powder forms.
• It can be snorted, ingested orally, injected, or smoked.
PCP
• Dissociative anesthetic.• Effects occur in minutes. • Lasts several hours. • May last up to 48 hrs with overdose.
PCP - Effects• Nystagmus (horizontal, vertical, or rotary).• Hypertension.• Acute brain syndrome involving confusion, amnesia,
disorientation, and violence.• Agitation and violent behavior.• Tachycardia.• Bizarre behavior including public nudity.• Hallucinations and delusions.• Miosis - Often reported with a blank stare
PCP - Rare Effects– Seizures – Dystonia– Ataxia– Apnea (often seen with co-ingestants)– Catatonia– Coma– Hypertensive crisis– Intracranial and subarachnoid hemorrhage
PCP – Prehospital Care
• ABC’s• Supportive care.• Fingerstick glucose.• Physical restraints may be required to prevent self-
injury and to protect the medical staff. • Narcan for depressed mental status (for possible
co-ingestion)• Benzo’s for severe agitation.