update on drugs of abuse (“some club-drug stuff”)
TRANSCRIPT
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Update on Drugs of Update on Drugs of AbuseAbuse (“some club-drug stuff”)(“some club-drug stuff”)
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Overview of TopicsOverview of Topics
Gamma hydroxybutyrate (GHB)Gamma hydroxybutyrate (GHB)– GHBGHB– GHB AnalogsGHB Analogs– GHB / Analog WithdrawalGHB / Analog Withdrawal
Ecstasy : MDMA (Methylene Ecstasy : MDMA (Methylene dioxymethamphetamine)dioxymethamphetamine)
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Overview of TopicsOverview of Topics
MethamphetamineMethamphetamine
Dextromethorphan (DM)Dextromethorphan (DM)
KetamineKetamine
FlunitrazepamFlunitrazepam
MescalineMescaline
InhalantsInhalants
AnticholinergicsAnticholinergics
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GHBGHB((GGamma-amma-
hhydroxyydroxybbutyrate)utyrate)
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What is GHB?What is GHB?Gamma hydroxybutyrateGamma hydroxybutyrateNaturally occurring in brain tissueNaturally occurring in brain tissue– neurotransmitter-like substanceneurotransmitter-like substance– dopamine release in substantia nigradopamine release in substantia nigra
Similar structure to GABASimilar structure to GABAGABA-B agonist effectsGABA-B agonist effectsApproved for narcolepsy 2002Approved for narcolepsy 2002– Sodium oxybate (Xyrem) Orphan MedicalSodium oxybate (Xyrem) Orphan Medical– 4.5 gms a night AWP $739 / month limited 4.5 gms a night AWP $739 / month limited
to certain pharmacies and physiciansto certain pharmacies and physicians
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GHBGHBInvestigated as an anesthetic agent : Investigated as an anesthetic agent : caused myoclonus and delirium ; current caused myoclonus and delirium ; current IND for sleep apneaIND for sleep apneaCrystalline saltCrystalline saltSoluble in water and methanolSoluble in water and methanolTastelessTastelessGBL-gamma-butyrolactone & BD-1,4 GBL-gamma-butyrolactone & BD-1,4 butanediol precursor molecules convert to butanediol precursor molecules convert to GHB in-vivoGHB in-vivo
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Structure Activity Structure Activity RelationshipRelationship
COOH
CH2
CH2
CH2
OH
COOH
CH2
CH2
CH2
NH2
gamma hydroxybutyrate
gamma amino butyric acid
GHB GABA
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History of GHBHistory of GHB
1960’s1960’s France - Synthesized as an AnestheticFrance - Synthesized as an Anesthetic19871987 Orphan Drug (IND-narcolepsy) ; USFDAOrphan Drug (IND-narcolepsy) ; USFDA1990-11990-1 Body Builders “Undetectable steroid”Body Builders “Undetectable steroid”
Growth hormone stimulatorGrowth hormone stimulator 1992-51992-5 Sleep aid, Rave party, Popularity risesSleep aid, Rave party, Popularity rises19961996 Sexual enhancer, “Date-Rape” DrugSexual enhancer, “Date-Rape” Drug19971997 Emergence of GHB AnalogsEmergence of GHB Analogs
Emergence of Withdrawal CasesEmergence of Withdrawal Cases20002000 Federal Schedule I statusFederal Schedule I status2002 2002 FDA approval for Narcolepsy : XyremFDA approval for Narcolepsy : Xyrem
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Slang Names : Slang Names : Gamma HydroxybutyrateGamma Hydroxybutyrate
Cherry methCherry meth
Easy layEasy lay
G, G capsG, G caps
Gamma hydrateGamma hydrate
Georgia home boyGeorgia home boy
GHBGHB
GH BeersGH Beers
Liquid ELiquid E
Liquid XLiquid X
Liquid ecstasyLiquid ecstasy
Natural sleep 500Natural sleep 500
Organic QuaaludeOrganic Quaalude
Oxy sleepOxy sleep
ScoopScoop
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What are GHB Analogs?What are GHB Analogs?
Organic solvents Organic solvents – √√-Butyrolactone, 2(3) Dihydrofuranone,-Butyrolactone, 2(3) Dihydrofuranone,– 1,4-Butanediol, Tetramethylene Glycol1,4-Butanediol, Tetramethylene Glycol
Converted to GHB Converted to GHB in vitroin vitro or or in vivoin vivo– In vitro using NaOH, heatIn vitro using NaOH, heat– In vivo (Lactonase enzymes) : GBLIn vivo (Lactonase enzymes) : GBL– In vivo (alcohol / aldehyde In vivo (alcohol / aldehyde
dehydrogenase)dehydrogenase)
Identical clinical effects to GHBIdentical clinical effects to GHB
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Conversion : Conversion : Gamma Butyrolactone (GBL)Gamma Butyrolactone (GBL)
O
=O
NaOH + H2O
Lactonasein vitro
In vivo
C OOHCH2
CH2
CH2 OH
GBL GHB
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Gamma Butyrolactone Gamma Butyrolactone (GBL)(GBL)
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Slang Names :Slang Names : Gamma Butyrolactone or Dihydro Gamma Butyrolactone or Dihydro
FuranoneFuranone
Blue NitroBlue Nitro
FirewaterFirewater
Furanone ExtremeFuranone Extreme
Gamma GGamma G
GBLGBL
GH ReleaseGH Release
Insom-XInsom-X
InvigorateInvigorate
JoltJolt
Liquid LibidoLiquid Libido
RegenerizeRegenerize
ReneTrientReneTrient
RevivarantRevivarant
Revivarant-GRevivarant-G
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Slang Terms : Slang Terms : 1,4 Butanediol or Tetramethylene 1,4 Butanediol or Tetramethylene
glycolglycol
Biocopia PMBiocopia PM
BorametzBorametz
BVMBVM
EnlivenEnliven
FXFX
NRG3NRG3
Inner GInner G
Thunder NectarThunder Nectar
Pro GPro G
PromusolPromusol
Rest-ezeRest-eze
Revitalize PlusRevitalize Plus
SerenitySerenity
SomatoProSomatoPro
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Incidence : GHB and Incidence : GHB and PrecursorsPrecursors
18 10 934
1937
89105
199
232
356
0
50
100
150
200
250
300
350
400
CASES
1990 1991 1992 1993 1994 1995 1996 1997 1997 1998 1999
SF POISON CONTROL CA POISON CONTROL
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PathologyPathology
Structurally similar to GABAStructurally similar to GABA
Stimulates GABAStimulates GABABB receptors receptors
Influences dopamine release from Influences dopamine release from substantia nigrasubstantia nigra
Readily crosses the BB barrierReadily crosses the BB barrier
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GHB / Analogs : GHB / Analogs : Clinical PresentationClinical Presentation
Vomiting, Coma, BradycardiaVomiting, Coma, Bradycardia
Myoclonic jerkingMyoclonic jerking
Loss of protective airway reflexesLoss of protective airway reflexes– Aspiration riskAspiration risk
Hypothermia, Mild respiratory acidosisHypothermia, Mild respiratory acidosis
HOTN when combined with ethanolHOTN when combined with ethanol
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EffectsEffects
““DESIRED”DESIRED”
EuphoriaEuphoriaMood elevationMood elevationHallucinationsHallucinationsGH-Muscle GH-Muscle growth?growth?AmnesiaAmnesia
UNDESIREDUNDESIRED
Decreased HR, Decreased HR, RRRR
ComaComa
Excessive Excessive salivationsalivation
Absence-like sz’sAbsence-like sz’s
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Emergency Department (ED) Course of Emergency Department (ED) Course of Gamma Hydroxybutyric Acid (GHB) Gamma Hydroxybutyric Acid (GHB)
Intoxication Study Intoxication Study Acad Emerg MedAcad Emerg Med 2002 Jul;9(7):730-9 Mason 2002 Jul;9(7):730-9 Mason
StudyStudy IntubatedIntubated Duration Duration of of
IntubationIntubation
Time in Time in ED if Not ED if Not AdmittedAdmitted
Number Number AdmittedAdmitted
Chin et al. Chin et al.
( n = 88)( n = 88)13 %13 % 179 min179 min NRNR 11 %11 %
Mahon et Mahon et al. ( n = 8)al. ( n = 8)
50 %50 % 80 min80 min NRNR 0 %0 %
Li et al.Li et al.
( n = 7)( n = 7)57 %57 % 210 min210 min 360 min360 min 43 %43 %
Garrison & Garrison & Mueller ( n Mueller ( n = 78)= 78)
10 %10 % NRNR 180 min180 min 4 %4 %
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Case Study …..Case Study …..
26 y/o F with chronic insomnia doubled 26 y/o F with chronic insomnia doubled her dose of Blue Nitro (GBL) : 3 oz.her dose of Blue Nitro (GBL) : 3 oz.
– Vomiting within 15 minutesVomiting within 15 minutes
– Pt was unresponsive within 30 minutesPt was unresponsive within 30 minutes
– Myoclonic jerkingMyoclonic jerking
– EMS was calledEMS was called
– VS: BP 120 / 70, HR 50, RR 22, T 35VS: BP 120 / 70, HR 50, RR 22, T 35
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Case Study continued ….Case Study continued ….
Unresponsive to pain, GCS 3.Unresponsive to pain, GCS 3.
CT scan normal, glucose 125CT scan normal, glucose 125
No response to naloxone or flumazenilNo response to naloxone or flumazenil
Woke up within 4 hoursWoke up within 4 hours
Discharged Discharged
Urine Toxicology screen negativeUrine Toxicology screen negative
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GHB / Analogs : KineticsGHB / Analogs : Kinetics
OnsetOnset 15 minutes15 minutes– Immediate conversion of analogs to GHBImmediate conversion of analogs to GHB
ComaComa within 30 minuteswithin 30 minutes
PeakPeak 1 hour1 hour
T 1/2T 1/2 ShortShort
DurationDuration 1 to 6 hours (1 to 6 hours (Average 2.5 hr)Average 2.5 hr)
Most patients require < 5 hr observationMost patients require < 5 hr observation
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Emergence DeliriumEmergence Delirium
Myoclonic jerking motionsMyoclonic jerking motions
Confusion, agitation, combativenessConfusion, agitation, combativeness– Transient symptoms (< 30 minutes)Transient symptoms (< 30 minutes)– Symptoms worsen with stimulationSymptoms worsen with stimulation
TreatmentTreatment– Supportive CareSupportive Care– Minimize stimulation. “Back off”Minimize stimulation. “Back off”
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GHB / Analogs : DiagnosisGHB / Analogs : Diagnosis
History of use and circumstancesHistory of use and circumstances
Clinical PresentationClinical Presentation
Short Duration Short Duration
Role of LaboratoryRole of Laboratory– Suspected assaultSuspected assault– Obtain sample within 12 hoursObtain sample within 12 hours– National Medical LaboratoriesNational Medical Laboratories
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GHB / Analogs : TreatmentGHB / Analogs : Treatment
Supportive CareSupportive Care– Approximately 35 % patients require Approximately 35 % patients require
airway protectionairway protection
Gastrointestinal DecontaminationGastrointestinal Decontamination– Limited ValueLimited Value– Consider Charcoal in massive ingestionsConsider Charcoal in massive ingestions
Education regarding DependenceEducation regarding Dependence
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GHB Dependence : Case StudyGHB Dependence : Case Study
29 year old male started taking GHB for 29 year old male started taking GHB for the “anabolic effects” 2 yrs agothe “anabolic effects” 2 yrs ago
Gradually increased dose to 4 to 6 Gradually increased dose to 4 to 6 “capfuls” every 4 hours “capfuls” every 4 hours
Discontinued the GHB cold turkeyDiscontinued the GHB cold turkey
Arrived in ED 24 hr after his last dose Arrived in ED 24 hr after his last dose
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Case Study continued ….Case Study continued ….
– Patient was highly agitatedPatient was highly agitated
– Visual and auditory hallucinationsVisual and auditory hallucinations
– Delusional, paranoid Delusional, paranoid
– Tremulous, diaphoreticTremulous, diaphoretic
– VS: HR 110, BP 160 / 112, T 99.1VS: HR 110, BP 160 / 112, T 99.1
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Case Study continued ...Case Study continued ...
Patient received :Patient received :– Ativan : 90 mg in the first 24 hoursAtivan : 90 mg in the first 24 hours– Phenobarbital, HaloperidolPhenobarbital, Haloperidol
10 day withdrawal course 10 day withdrawal course
Discharged symptom and drug freeDischarged symptom and drug free
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GHB WithdrawalGHB Withdrawal
Similar to ETOH and sedative-hypnotic Similar to ETOH and sedative-hypnotic withdrawal.withdrawal.
Symptoms start within a few hours of Symptoms start within a few hours of discontinuation. discontinuation.
Seen with long-term use or daily use.Seen with long-term use or daily use.
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GHB Withdrawal : Clinical GHB Withdrawal : Clinical PresentationPresentation
Onset :Onset : 1 to 6 hours1 to 6 hours
Progression of sxs over 1 to 3 daysProgression of sxs over 1 to 3 days
Symptoms Symptoms – Agitation, hallucinations, paranoiaAgitation, hallucinations, paranoia– Tremulous, diaphoreticTremulous, diaphoretic– Tachycardic, hypertensiveTachycardic, hypertensive– Hyperthermia, Rhabdomyolysis possibleHyperthermia, Rhabdomyolysis possible
Duration :Duration : 5 to 15 days5 to 15 days
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GHB Withdrawal : GHB Withdrawal : ManagementManagement
AGGRESSIVE TREATMENT EARLYAGGRESSIVE TREATMENT EARLY
BenzodiazepinesBenzodiazepinesHigh doses may be requiredHigh doses may be required
BarbituratesBarbiturates
AntipsychoticsAntipsychotics
Unproven TherapyUnproven Therapy– Baclofen (GABA-B agonist)Baclofen (GABA-B agonist)
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Stimulants of AbuseStimulants of AbuseMethamphetamineMethamphetamineMethylene dioxymethamphetamine : Methylene dioxymethamphetamine : MDMA (Ecstasy)MDMA (Ecstasy)
CocaineCocaine
Ketamine / PCP (phencyclidine)Ketamine / PCP (phencyclidine)
DextromethorphanDextromethorphan
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Rave Party : Case Study ...Rave Party : Case Study ...
18 year old F was at a Rave party with a 18 year old F was at a Rave party with a friend. She was drinking ethanol and friend. She was drinking ethanol and using the following:using the following:– MidnightMidnight 1 tablet of Ecstasy1 tablet of Ecstasy– 3 am3 am Snorted 1 line of KetamineSnorted 1 line of Ketamine– 5 am5 am Drank a “capful” of GHBDrank a “capful” of GHB
At 6:30 am patient found slumped in At 6:30 am patient found slumped in bathroom, cyanotic. EMS called.bathroom, cyanotic. EMS called.
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Case Study continued ….Case Study continued ….
In ED, comatose but not cyanotic. In ED, comatose but not cyanotic. Intubated for airway protection. Intubated for airway protection. No response to flumazenil or narcanNo response to flumazenil or narcanVS: HR 58, BP 110 / 60, RR 16, p VS: HR 58, BP 110 / 60, RR 16, p 5mm, T 375mm, T 37
ICU admission. Woke up at 12 hoursICU admission. Woke up at 12 hoursExtubated, dischargedExtubated, discharged
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Ketamine : Clinical Ketamine : Clinical PresentationPresentation
Dissociative anestheticDissociative anesthetic
Clinical PresentationClinical Presentation– Separation of perception and sensationSeparation of perception and sensation– Nystagmus, hallucinations, lethargy, szNystagmus, hallucinations, lethargy, sz– tachycardia, HTN, RR depressiontachycardia, HTN, RR depression– hyperthermiahyperthermia
DurationDuration– 2 to 4 hours2 to 4 hours
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Ketamine TreatmentKetamine Treatment
SupportiveSupportive
SedationSedation
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Phencyclidine EffectsPhencyclidine Effects
Tremors, agitation, hallucinations : Tremors, agitation, hallucinations : visual and auditory.visual and auditory.
Tachycardia, HTN.Tachycardia, HTN.
Wernicke-Korsakoff syndrome.Wernicke-Korsakoff syndrome.
Treatment is same as for ketamine
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MethamphetamineMethamphetamine
First synthesized by a Japanese First synthesized by a Japanese pharmacologist in 1893pharmacologist in 1893Ephedrine most common precursorEphedrine most common precursorRed phosphorus-hydriotic acid most Red phosphorus-hydriotic acid most common reduction method.common reduction method.D-isomer : CNS stimulant effects.D-isomer : CNS stimulant effects.L-isomer : peripheral sympathomimetic L-isomer : peripheral sympathomimetic activity.activity.
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StructuresStructures
PhenethylaminePhenethylamine
AmphetamineAmphetamine
MethamphetamineMethamphetamine
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ProductionProduction
EphedrineEphedrine
MethamphetamineMethamphetamine
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PathologyPathologyIncrease release of Increase release of neurotransmitters from nerve neurotransmitters from nerve terminals.terminals.Serotinergic and dopaminergic ATP Serotinergic and dopaminergic ATP decrease.decrease.5HT and D2 depletion.5HT and D2 depletion.ApoptosisApoptosisEndothelial injury.Endothelial injury. Reactive oxygen species.Reactive oxygen species.
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Signs and SymptomsSigns and Symptoms
Action phaseAction phase
Skin pickingSkin picking
Head bangingHead banging
PacingPacing
Paranoid psychosisParanoid psychosis
Extreme Extreme suspiciousnesssuspiciousness
Resolution phaseResolution phase
ExhaustionExhaustion
FatigueFatigue
SleepSleep
DepressionDepression
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Other Signs and SymptomsOther Signs and Symptoms
Pulmonary hypertensionPulmonary hypertension
DyspneaDyspnea
Pleuritic chest painPleuritic chest pain
Anorexia/weight lossAnorexia/weight loss
UlcersUlcers
RhabdomyolysisRhabdomyolysis
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TESS DATATESS DATAMethamphetamine Exposures Without Concomitants, 2001
(Cardiovascular Effects)
0
50
100
150
200
250
300
350
400
Fig 3 American Association of Poison Control Centers Toxic Exposure Surveillance System, 2001
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Methamphetamine and the EDMethamphetamine and the ED
6 months UCDMC ED ending February 19976 months UCDMC ED ending February 1997461 methamphetamine (+) patients461 methamphetamine (+) patientsCaucasian males without health insuranceCaucasian males without health insuranceIncrease use of ambulances and acute Increase use of ambulances and acute hospitalizationhospitalizationSignificant association with trauma : blunt Significant association with trauma : blunt 33 % and penetrating 4 %33 % and penetrating 4 %Altered LOC (23 %), Abd pain (13 %), suicide Altered LOC (23 %), Abd pain (13 %), suicide (8 %), chest pain (8 %), skin infections (6 %)(8 %), chest pain (8 %), skin infections (6 %)Richards, et al., Richards, et al., West J MedWest J Med 1999 ; 170:198- 1999 ; 170:198-202202
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Methamphetamine and Methamphetamine and TraumaTrauma
UCDMC Level 1 Trauma CenterUCDMC Level 1 Trauma Center
Retrospective Study 1989 to 1994Retrospective Study 1989 to 1994
Results :Results :– 18,004 pts ; 3.1 / 1000 population per year18,004 pts ; 3.1 / 1000 population per year– + methamphetamine defined as urine > + methamphetamine defined as urine >
1000 ng / ml1000 ng / ml– Rates increased from 7.4 to 13.4 %Rates increased from 7.4 to 13.4 %– Cocaine rates 5.8 to 6.2 %Cocaine rates 5.8 to 6.2 %
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Methamphetamine and Methamphetamine and TraumaTrauma
Decrease in ethanol from 43 % to 35 %Decrease in ethanol from 43 % to 35 %Meth (+) most common in Caucasian or Meth (+) most common in Caucasian or HispanicHispanicCocaine (+) most common African AmericanCocaine (+) most common African AmericanMeth (+) in MVA or MCA’sMeth (+) in MVA or MCA’sCocaine (+) in assaults, GSW’s or stab Cocaine (+) in assaults, GSW’s or stab woundswounds
Schermer and Wisner, Schermer and Wisner, J Am Coll SurgJ Am Coll Surg 1999; 189: 1999; 189: 442-449442-449
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TreatmentTreatment Don’t forget to r/o other causes :Don’t forget to r/o other causes :– Look-alike diseases : e.g. Pheo, scorpion Look-alike diseases : e.g. Pheo, scorpion
bites.bites.– Drugs : e.g. LSD, psilocybin-hallucinations, Drugs : e.g. LSD, psilocybin-hallucinations,
etc.etc.– Elevated temperature : e.g. malignant Elevated temperature : e.g. malignant
hyperthermia, NMS, anticholinergic hyperthermia, NMS, anticholinergic syndrome.syndrome.
– Seizures : e.g. cocaine, ETOH withdrawal.Seizures : e.g. cocaine, ETOH withdrawal.– CVS : e.g. GHB withdrawal.CVS : e.g. GHB withdrawal.
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Treatment (cont.)Treatment (cont.)
Control stimulant effectsControl stimulant effects
DecontaminationDecontamination
Control hyperthermia : how ?Control hyperthermia : how ?
Control seizures : how ?Control seizures : how ?
Be careful of physical restraints.Be careful of physical restraints.
Treat psychiatric conditions.Treat psychiatric conditions.
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What is Ecstasy (MDMA) ?What is Ecstasy (MDMA) ?
3,4-Methylenedioxymethamphetamine3,4-Methylenedioxymethamphetamine
Sympathetic effects mild in low dosesSympathetic effects mild in low doses
Potent releaser of serotoninPotent releaser of serotonin
OverdoseOverdose– Symptoms similar to amphetaminesSymptoms similar to amphetamines– Risk of serotonin syndromeRisk of serotonin syndrome– Risk of hyponatremia Risk of hyponatremia
SIADH and / or increased water intakeSIADH and / or increased water intake
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MDMAMDMA
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History of EcstasyHistory of Ecstasy
19141914 Patented as Appetite suppressantPatented as Appetite suppressant
Never MarketedNever Marketed
1970’s1970’s Use by psychiatristsUse by psychiatrists
1980’s1980’s “LSD of the 60’s” “LSD of the 60’s”
1990’s1990’s Increasing abuse, Rave party useIncreasing abuse, Rave party use
20002000 Continuing abuseContinuing abuse
Illicit adulterants commonIllicit adulterants common
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Illicit Ecstasy TabletsIllicit Ecstasy Tablets
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PathologyPathology
Similar to other amphetamines in Similar to other amphetamines in causing release of catecholamines.causing release of catecholamines.
Alpha and beta-adrenergic agonist.Alpha and beta-adrenergic agonist.
Can cause SIADH by an unclear Can cause SIADH by an unclear mechanism.mechanism.
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EffectsEffects
DESIREDDESIRED
Increased energyIncreased energy
EuphoriaEuphoria
EmpathyEmpathy
Visual Visual hallucinationshallucinations
UNDESIREDUNDESIRED
Jaw clenchingJaw clenching
ParanoiaParanoia
Hot / cold flashesHot / cold flashes
HyperpyrexiaHyperpyrexia
SeizuresSeizures
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Clinical Signs and SymptomsClinical Signs and Symptoms
RhabdomyolysisRhabdomyolysis
HyponatremiaHyponatremia
DICDIC
Renal failureRenal failure
HepatotoxicityHepatotoxicity
Aplastic anemia : rareAplastic anemia : rare
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Illicit MDMA AdulterantsIllicit MDMA Adulterants
Assayed tablets have contained :Assayed tablets have contained :– MDMAMDMA– MDMA with CaffeineMDMA with Caffeine– Dextromethorphan 122 to 143 mg / tabletDextromethorphan 122 to 143 mg / tablet– CaffeineCaffeine– Ephedrine, Pseudoephedrine, PPAEphedrine, Pseudoephedrine, PPA– PlaceboPlacebo
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TreatmentTreatment
Similar to amphetamines and Similar to amphetamines and derivativesderivatives
Controlling cerebral edema from Controlling cerebral edema from hyponatremia important.hyponatremia important.
Pneumomediastinum also an issuePneumomediastinum also an issue
Controlling hyperthermia predicts Controlling hyperthermia predicts survival in several studiessurvival in several studies
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Dextromethorphan : Case Dextromethorphan : Case Study …..Study …..
14 year old M ingested 30 Coricidin 14 year old M ingested 30 Coricidin tablets to get high. At 2.5 hours : tablets to get high. At 2.5 hours : – Lethargic, slurred speechLethargic, slurred speech, , hallucinatinghallucinating
– Flushed , tremulousFlushed , tremulous
– Nystagmus presentNystagmus present
– VS : HR 114, BP 170 / 100, T 97.8, p 7mmVS : HR 114, BP 170 / 100, T 97.8, p 7mm
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Dextromethorphan (DXMF) Dextromethorphan (DXMF) AbuseAbuse
Many DXMF containing OTC productsMany DXMF containing OTC products
Coricidin : many combinationsCoricidin : many combinations– DXMF 30 mg, CTM, APAP, PPA, etc.DXMF 30 mg, CTM, APAP, PPA, etc.
Teenage DXMF abuse is rising Teenage DXMF abuse is rising
Easy OTC availability Easy OTC availability
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DextromethorphanDextromethorphan
Therapeutic doses : mild CNS effectsTherapeutic doses : mild CNS effects
High doses : significant CNS effectsHigh doses : significant CNS effectsSpecific DXMF receptors (opiate - sigma)Specific DXMF receptors (opiate - sigma)
Anticholinergic-like symptomsAnticholinergic-like symptoms
Hallucinations, delusion, dysphoriaHallucinations, delusion, dysphoria
Opiate kappa and mu receptorsOpiate kappa and mu receptorsOpiate effectsOpiate effects
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Dextromethorphan : Dextromethorphan : TreatmentTreatment
Gastrointestinal decontaminationGastrointestinal decontamination
Narcan may be usefulNarcan may be useful
Supportive CareSupportive Care
LaboratoryLaboratory– Rule out aspirin and acetaminophenRule out aspirin and acetaminophen
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MescalineMescaline
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CharacteristicsCharacteristics
Derived from peyote cactus.Derived from peyote cactus.
Hallucinogen.Hallucinogen.
Can mimic an acute gastroenteritisCan mimic an acute gastroenteritis
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Mescaline TreatmentMescaline Treatment
SupportiveSupportive
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FlunitrazepamFlunitrazepam
Used throughout Europe.Used throughout Europe.
Not approved in the US.Not approved in the US.
One of the “date-rape” drugs.One of the “date-rape” drugs.
By weight 10x more potent than By weight 10x more potent than diazepam.diazepam.
Produces effects within 15 mins.Produces effects within 15 mins.
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Flunitrazepam tabletsFlunitrazepam tablets
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PathologyPathology
A benzodiazapine working on the A benzodiazapine working on the GABAGABAAA receptor. receptor.
Lipid soluble rapidly crossing the BB Lipid soluble rapidly crossing the BB barrier.barrier.
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EffectsEffects
““DESIRED”DESIRED”
EuphoriaEuphoriaHallucinationsHallucinationsDisinhibitionDisinhibitionSM relaxationSM relaxationSedationSedationMemory impairmentMemory impairment
UNDESIREDUNDESIRED
HypotensionHypotension
DrowsinessDrowsiness
ApneaApnea
Urinary retentionUrinary retention
TremorsTremors
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TreatmentTreatment
Supportive care.Supportive care.
AC, lavage (use with caution, may be AC, lavage (use with caution, may be contraindicated)contraindicated)
Benzodiazepine antagonists Benzodiazepine antagonists (flumazenil) :(flumazenil) :
NONO!!!! (very few indications). (very few indications).
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Inhalant AbuseInhalant Abuse
Freon PropellantsFreon Propellants
Xylene, TolueneXylene, Toluene
Gasoline FumesGasoline Fumes
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Anticholinergic AbuseAnticholinergic Abuse
AntihistaminesAntihistaminesJimson WeedJimson WeedAnticholinergic Syndrome:Anticholinergic Syndrome:– Mad as a hatterMad as a hatter– Blind as a batBlind as a bat– Hot as HadesHot as Hades– Dry as a boneDry as a bone– Red as a beetRed as a beet
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SummarySummary
GHB / GHB AnalogsGHB / GHB Analogs– Classic Symptoms in OverdoseClassic Symptoms in Overdose– Withdrawal SymptomsWithdrawal Symptoms
Rave PartiesRave Parties– Multiple drugs commonly usedMultiple drugs commonly used
Rising OTC Dextromethorphan UseRising OTC Dextromethorphan Use– Rule out aspirin and acetaminophenRule out aspirin and acetaminophen
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SummarySummary
Methamphetamine is a major problemMethamphetamine is a major problemOlder drugs of abuse have not gone Older drugs of abuse have not gone awayaway– PCPPCP– LSDLSD– HeroinHeroin– CocaineCocaine– EthanolEthanol– MarijuanaMarijuana
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Questions?
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