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.