EMS - Street Drug Review 2008 1 hour

Slide 1: Street Drug Review 2008 West Valley Hospital May, 2008

Slide 3: Who am I? • Steve Cole • colemedic@hotmail.com • Ada County Paramedics for 10 years • EMS for 17 years.

Slide 4: Rescources • Web sites – www.dancesafe.org – www.erowid.org – DAWN

Slide 5: WWW.EROWID.ORG

Slide 6: • www.dancesafe.org • Non Profit • Drug testing kits • Drug warnings • Drug testing and postings • HARM REDUCTION

Slide 7: • Hundreds of Metropolitan/Suburban Hospitals and Coroners/ME offices across the US. • A DAWN case is any ED visit or death related to recent drug use. The criteria for inclusion in DAWN are intentionally broad and simple, with few exceptions • Thousands of drugs of all types are included in DAWN. These include: – Illegal drugs of abuse; – Prescription and over-the-counter medications; – Dietary supplements; – Non-pharmaceutical inhalants; – Alcohol in combination with other drugs (adults and children) – Alcohol alone (age < 21).

Slide 8: Question: Do we have Raves here??? Then why do we have Rave drugs?

Slide 9: DRUGS CAN BE ANYWHERE

Slide 10: Clues • Light Sticks • Water/Gatorade Bottles for sale • H2O shut off in bathroom • Crash Rooms/Candles/Etc. • Have Dance Breaks/cool down periods • In Idaho we are mainly seeing these in remote locations.

Slide 11: Some risk taking behavior you probably haven't heard of…

Slide 12: Eye Candy • Visual Stimulation up close & personal. Some lights are very bright. • ?? Petite Mall SZ???

Slide 13: AIRWAY PROBLEM??? • Glow sticks of all sizes • Special mouthguards – Protect from swallowing mini glow sticks – Also less visible than the pacifiers – Bruxism

Slide 14: Why Face Masks & Vicks? • The sensation of breathing is intensified by the menthol (eucalyptus) in vapor rub products. This will be slathered on their upper lips or in face masks. Or inhalers will be used. • Remember, many report things like “being burned by a cigarette feels good.” It’s all about sensation

Slide 15: It’s About Sensation Vibration of the music through the balloon feels good too.

Slide 16: Other testing • Dancesafe offers some street level drug testing for MDMA • Only qualifies, not quantifies

Slide 17: The Drugs

Slide 18: Opioids

Slide 19: What are we talking about here? • Illicit • Prescription • Heroin • Vicoden – Black Tar • Norco – China White • Oxycontin • Illicit Fentanyl • Methadone • Opioid/Poly-pharmacy • Duragesic Mixes • Fentanyl • Morphine

Slide 20: So why do people overdose? • IV opioid use • Poly-pharmacy Overdose • Returning to opioid use from abstinence – Jail? – Detox? • The Weekend Warrior • Using opioids alone • New supply of Drug

Slide 21: Opiate Abuse

Slide 22: Methods of use: • Shooting • Skin Popping • Muscle Popping • Chasing the dragon • Freebasing • Dirty Hit • Tea – With Grapefruit Juice • Tincture – Laudanum and Perigoric

Slide 23: Heroin • Black Tar • China White • Speed Ball • Homicide, Buick, super Buick, twilight sleep • Fentanyl??????

Slide 24: Oxycontin / MS Contin • Time released capsules, some may have more than 100 mg • Often crushed and snorted, eliminating the “time release” • May be crushed, diluted, and injected like traditional heroin • Becoming much more common

Slide 25: Methadone • Like other prescription opiates, WIDELY Available • One study showed of 18 methadone related deaths: – Less than ½ were prescribed methadone – Only three were prescribed methadone through a methadone tx program

Slide 26: Duragesic • Fentanyl Citrate • Transdermal Absorbtion • Used in chronic pain patients • 100 times the potency of morphine • Fastest growing method of opiate abuse • Commonly Used for chronic pain • Synthetic opioid • Easily Acquired • Easily abused

Slide 27: Duragesic- methods of abuse • Almost 70 fold increase in use from 1995-2002 (DAWN) • Rate of use is increasing. • Street price between $10-100/PATCH • Methods of abuse – Topical – Injected – Chewed • Oral Conversion – Up to 50% may be lost in conversion, so it is often frozen first. – Preservatives may cause liver problems – 25 ug/hr = 2.5 mg avail – 50 ug/hr = 5 mg avail – 75 ug/hr = 7.5 mg avail – 100 ug/hr = 10 mg avail

Slide 29: Opioid Toxidrome • The Opiate Toxidrome consists of: – Altered mental status – Miosis* – Unresponsiveness – Shallow respirations – Slow respiratory rate – Decreased bowel sounds – Hypothermia – Hypotension* • * these symptoms are very subjective, and may not be present in polypharmacy overdoses. KEY POINT: Miosis and Hypotension are not definitive for ruling in or ruling out a opioid overdose.

Slide 30: BASIC TREATMENT • Ventilation/stimulation first • Slow admin of Narcan, just enough to make them breath • Adult: – IV, SL: 0.1-2 mg PRN to a max of 10 mg. – IN/IM/ETT, IV in cardiac arrest: 2 mg. • Pediatrics: – 0.01-0.05 mg/kg IV, IO, IM, SubQ, ET. Repeat PRN. – MAX 2 mg/dose • High doses may be needed if drug is synthetic • Watch for re-sedation due to Narcan’s short duration (about 20-30 minutes)

Slide 31: Smaller doses of Narcan? • “The short time between naloxone administration and the occurrence of complications, as well as the type of complications, are strong evidence of a causal link. In 1000 clinically diagnosed intoxications with heroin or heroin mixtures, from 4 to 30 serious complications can be expected. “ • “…Development of ventricular tachycardia or fibrillation; atrial fibrillation; asystole; pulmonary edema; convulsions; vomiting; and violent behavior within ten minutes after parenteral administration of naloxone.” • “Such a high incidence of complications is unacceptable and could theoretically be reduced by artificial respiration with a bag valve device (hyperventilation) as well as by administering naloxone in minimal divided doses, injected slowly.” • • Source: – Osterwalder JJ. “Naloxonefor intoxications with intravenous heroin and heroin mixtures: harmless or hazardous? A prospective clinical study.” J Toxicol Clin Toxicol 34 (1996): 409-416 – Cuss FM, Colaço CB, & Baron JH Cardiac arrest after reversal of effects of opiates with naloxone. Br Med J, 288(1984): 363-364

Slide 32: Release Criteria – Criteria: • The patient can mobilize as usual; • The patient has an oxygen saturation on room air of >92%; 3) have a respiratory rate >10 breaths/min and <20 breaths/min; • The patient has a temperature of >35.0°C and <37.5°C; • The patient has a heart rate >50 beats/min and <100 beats/min; and • The patient has a Glasgow Coma Scale score of 15. – Follow up with IM (or SQ) Narcan • References: – Christenson J, Etherington J, Grafstein E, et al. Early discharge of patients with presumed opioid overdose: development of a clinical prediction rule. Acad Emerg Med 2000;7(10);1110-18. – Wanger K, Brough L, MacMillan I, et al. Intravenous vs subcutaneous naloxone for out-of-hospital management of presumed opioid overdose. Acad Emerg Med 1998;5(4);293-9.

Slide 33: Some weird things that have been done with a Opioid ODs • Injected someone with salt water or Milk This is an old junky myth sometimes still used. • Injected someone who overdosed on heroin with cocaine or speed, or vice versa. Another old myth. • Narcan Used PTA of EMS- Narcan is becoming more and more common among junkies for “emergencies” (some trials are being done in Seattle and Europe) • Put ice on their genitals (down their pants) . – Packing • Placed in a cold shower

Slide 34: MDMA and PMA

Slide 35: Introduction • methylenedioxy-n- methylamphetamine (MDMA) – MDMA is *chemically* an amphetamine, but psychologically its what's known as an empathogen-entactogen – Shares similarities to both mescaline (a hallucinogen) and amphetamines • Para-methoxyamphetamine, ( PMA) , 4-METHOXYAMPHETAMINE – Chemically similar to MDMA, first created almost 25 years ago – Since its cheaper to make, and uses non controlled substances, PMA is often misrepresented as MDMA. – At doses considered “safe” for MDMA, PMA is highly toxic.

Slide 36: PMA • Use is identical to MDMA, PMA is more toxic than MDMA • It often appears identical to MDMA, sometimes simply thicker. • Its onset of action is longer (almost 60 minutes) compared to MDMA at 15-30 minutes • Users will re-dose thinking its MDMA and push them selves into the toxic range • Some people think they know their MDMA dose and apply this to PMA, thus going toxic • Substances like Cocaine and Methamphetamine may exacerbate the toxic effects of either PMA or MDMA

Slide 37: PMA and MDMA • Taken in tabs although inhalation and injection have been infrequently reported. • Effects generally appear within 15-30 minutes (MDMA) or almost 60 minutes (PMA). • The usual dose ranges from 100 to 150 mg. Toxicity may be seen at doses as little as 175 mg

Slide 38: What is does… Amphetamine • MDMA is best described as an _____________ Hallucinogenic with _____________ properties. • Many of the effects are dose dependent. – Auditory and/or visual hallucinations are not commonly observed. – Tactile hallucinations and Tactile euphoria more common. – Much of the abuse potential lies in its pleasurable subjective effects (eg, empathy, euphoria, disinhibition, increased sensuality). • AKA: “The Hug Drug”

Slide 39: MDMA/PMA how It Looks • Powder • Pressed pills “Euros” • Capsules (may not be full) • Wide range of logos • Wide variety of colors & shapes • Nicknames reflect logos & colors • Designed to look “innocent” & thus “harmless.” • BRAND MARKETING

Slide 40: MDMA/PMA Packaging • Because of their small size, MDMA pills may be easily hidden. They may simply be mixed in with other candies, such as Skittles, M&Ms, etc. Pez containers are common too.

Slide 41: Patho-Physiology • Onset of action Typically 15-30 minutes – Longer for PMA (60 minutes) • Metabolized In Liver • Excreted via Kidneys • Increased mortality with liver disorders – Specifically Liver Enzyme CYP2D6 deficiency

Slide 42: MDMA Toxidrome • Stimulant like effects with in 1 hour: – Jaw clenching (Lower Jaw)/teeth grinding, and scratching (think Tweekers) – Nystagmus, – Dilated Pupils – Tremors – Tachycardia, increased B/P – Sensation of chills (secondary to elevated temp) • Hallucinogenic effects after 1 hour. Peak at 90 minutes-2 hours, last 4-6 hours. – relaxation, euphoria, and increased empathy and communication – Disinhibition – Auditory Hallucinations (non specific)/sensitivity • Other SE: – Orthostatic s/s, – Hyperthermia – syncope secondary to dehydration

Slide 43: MDMA/PMA Toxicity Major S/S • Serotonin Syndrome • Severe Dehydration with Hyponatremia – Consult re: hypertonic Saline • Autonomic Instability (“Hyper-dynamic Crisis”) – Severe Tachycardia, HTN crisis, CHF • Hyperthermia – Morbidity and Mortality directly linked to duration/severity of hyperthermia • Disseminated Intravascular Coagulation (DIC) (may have rapid onset) • Decreased LOC/Coma • Stroke S/S, Seizures • Kidney Failure

Slide 44: MDMA/PMA Basic Tx • Calm low stimulus environment • VOMIT (standard ALS) • Aggressive Fluid Resuscitation as needed for hypotension, dehydration, and/or orthostatic s/s – Evaluate for electrolyte abnormalities (Hyponatremia) – Evaluate for renal issues – Evaluate for rhabdo – Liver Studies • Active cooling if indicated • Core Temp if unresponsive

Slide 45: MDMA Focused Tx • Benzodiazepines – Ativan 0.5-2 mg, 4 mg for SZ – Valium 2.5-10 mg, may require more for SZ • Beta blockers have fallen out of favor (like Brevibloc), Consider an adrenergic blocker w/ alpha blocker properties as well. – Consult RE: Regitine (A1/A2 blocker) • 1-2 mg IV initial, then 0.05 mg/kg IV; not to exceed 5 mg – Consult RE: Nitrates? • Consider BZD or even Paralytics for extreme hyperthermia and/or serotonin syndrome (risk vs. benefit analysis)

Slide 46: Take Home Information • Core Temp if unresponsive • Fluid Resuscitation • Sedation PRN • Benzo’s are your friend • Watch for DIC, Elctrolyte issues, Rhabdo, and SZ

Slide 47: DXM

Slide 48: DXM- Introduction • Yes, its in cough syrup OR COUGH TABS (CORICIDIN)”TRIPPLE C” • Dextromethorphan acts as a cough suppressant via its agonist (activating) activity at mu-opioid receptors. • In Canada: Contac CoughCaps (30 mg DXM) • Related in effects to Ketamine and PCP

Slide 49: DXM- How is it used? • “Robo-ing” (Old Term from early 90’s) • DXM is available over-the- counter in tablet form in several countries as a cough med. Robitussin Maximum Strength Cough (not Robitussin DM) syrup • Users often refer to DXM in “plateaus” • Dose of Robitussin Maximum Strength Cough syrup is two to five full "shots" using the shot glass that comes with the bottle.

Slide 50: DXM- “Coricidin Toxicity” • Coricidin Cough and Cold Caps, 30 mg DXM and 4 mgs of Chlorphineramine maleate • Chlorphineramine maleate is an anti-cholinergic drug like scopolamine. • Non-Specific reports of “Respiratory Failure” at high doses.

Slide 51: DXM- Coricidin Toxicity • Robo-Walk • Robo-Itch • Robo-Talk • Psychosis • Dialated Pupils

Slide 52: DXM- Treatment • VOMIT • Symptomatic TX. • Be alert for and (Cautiously) treat hypertension or hypotension, and rarely, cardiovascular problems • Restraints (?) • Avoid Chemical Restraint (Haldol, Droperidol),Benzo’s are preferred (Be prepared to manage the airway) • Benadryl may be given for Dystonic reactions, and for s/s of histamine release.

Slide 53: DXM- What does this mean to me? • Be Careful, take the same precautions you would with a PCP patient. • ALS eval is a must ( HTN, Hyperthermia, Respiratory Depression, and self harm) • DXM differs from other drugs. Its presentation of s/s extend well beyond simple CNS depression and hallucinations but into basic cognitive functions as well. • Understanding that DXM effects last well beyond the 4 hours of intoxication , and that side effects may include “Psychotic Breaks” will help determine deposition of patients.

Slide 54: GHB

Slide 55: GHB Analogs- Introduction • Gamma-hydroxybutyrate (GHB) may be made in homes by using recipes with common ingredients. • "Liquid Ecstasy," "Georgia Home Boy," "Grievous Bodily Harm, • “Liquid ecstasy," do not confuse w/ MDMA • GBL, GBH, One 4 B

Slide 56: Recognizing GHB AKA: GHB, G, Jib, Scoop, Liquid E, Liquid X, Woman’s Viagra, Grievous Bodily Harm, Easy Lay, Gamma 10, Salty Water, GH Buddy, Aminos, Blue Nitro, Blue Thunder, Thunder Nectar, Renewtrient, Revivarant, Remforce, Firewater, Invigorate, Xyrem (research product), sodium oxybate, Fantasy & One4B (NZ)

Slide 57: GHB analogs – How are they used? • GHB can be produced in clear liquid, or a white powder, tablet, and capsule forms, and it is often used in combination with alcohol, making it even more dangerous • It is often carried in an eye dropper, or in water/Gatorade bottles and passed around. • Typically measured out in capfuls. • Occasionally blue food coloring is used to identify it at some raves. • It is occasionally used as a body building aid

Slide 58: Other GHB Products

Slide 59: Efforts to Avoid Detection • GHB & its analogs are NOT protected by the Dietary Supplement & Heath Education Act of 1994. • “Misbranded” drugs. • May be listed as “weight belt cleaner” or other solvent use or plant growth formula—trying to avoid detection

Slide 60: Typical Drinks To Hide GHB Any Substance can be used to hide a GHB Analog!

Slide 61: Efforts to Avoid Detection • Acetone free Nail Polish

Slide 62: GHB Test KITS False Security

Slide 63: GHB- No longer Just for Rapists • Recreational Use • Muscle Gain • Those under mandatory drug testing • Elderly

Slide 64: AquaDots??

Slide 65: What To Expect

Slide 66: GHB analogs - What does it do • At lower doses, GHB has sedative effects, but, as the dose increases, GHB effects may result in sleep ,eventual coma, respiratory arrest, or death. • It is these effects that make it both a prime drug at Raves, and for Date Rape

Slide 67: GHB analogs toxicity- mild • Lethargy, easily aroused with repeated stimulation • Drowsiness, somnolence, dizziness, euphoria • Confusion (dazed and confused) • Amnesia, Susceptible to suggestion

Slide 68: GHB analogs Toxicity- Severe • 66% with GCS <9, ½ of these may have GCS at 3! • Frequent Vomiting, • Bradycardia, • Respiratory depression or arrest • Seizures • Sudden onset of coma . Patients often demonstrate extreme SUDDEN combativeness and agitation despite such profound CNS and respiratory depression • Death (usually secondary to respiratory failure or aspiration)

Slide 69: GHB • ALCOHOL IS THE MOST COMMON DRUG CO CONSUMED IN GHB RELATED DEATHS

Slide 70: GHB analogs-Treatment • Primary Supportive • Beware of positional Asphyxia, but soft restraints are a good idea • Due to the risk of sudden airway failure, aspiration, and respiratory collapse, these patients need aggressive airway monitoring by ALS providers

Slide 71: GHB analogs-Treatment • Protect your self • VOMIT • Be cautious using respiratory depressants • Making the decision to tube/not tube is tough, these patients do frequently vomit. • ETT placement is uncommon, but post ETT sedation/paralysis and restraint should be mandatory in the field

Slide 72: Billy Idol: Famous GHB’er Billy almost died in 1993 from (then legal) GHB in front of a L.A. Night club

Slide 73: Nick Nolte

Slide 74: Difficulty in Prosecution • Sort Duration • Amnesia clouds recall • Often pro-sexual appearing behavior • Lack of : – Credible witness – Evidence

Slide 75: GHB analogs- What does this mean to me? • GHB analogs are unpredictable in clinical course, other than duration. • GHB analogs cause a rapid change in mental and respiratory status that makes it difficult to plan treatment and care • GHB’s presentation often mimics ETOH abuse and is often co-imbibed.

Slide 76: GHB- Take Home Information • Most deaths from Hypoxia, Respiratory failure, and aspiration • Expect sudden changes in Mental status • Sedate and restrain post ETT • ETOH + GHB = ↑ Mortality

Slide 77: In closing • Know your drugs • Stay Updated • Use m,ultiple sources for relaibility • Expect the unexpected. • When it comes to drugs, one Tx does not fit all.