• Generally speaking, “Rave” applies not just The Rave Culture to the parties but to an entire subculture• Not just “Night time” Parties at clubs• Can extend into multi- day events (Burning Man)• Hallmarked by techno/new age music and Psychedelic visual displays.
Anatomy of a RAVE • Day or Night • Tend to be “Sponsored” (A.K.A. “Promoters”), limits liability on both sides • Sometimes marketed as “Drug Free Teen Dance Parties” • If not at a formal club, they tend to be located in remote locations to limit outside interference. • Often will have a DJ instead of a band. Some DJ’s are celebrities, called the “A-List”, traveling a “Circuit” ($1000-5000/hr)
Anatomy of a Rave• Remember, the overall event doesnt have to be a rave to have a strong Raver presence…..
Anatomy of a Rave- 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.
Lights are Captivating• Three or more work on one X user’s eyes, up close & personal. Some lights are very bright.• It’s called “Eye Candy”
More “Eye Candy”• Glow sticks of all sizes• Special mouthguards – Protect from swallowing mini glow sticks – Also less visible than the pacifiers
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
It’s About Sensation • Many carry personal vibrators. Notice the “x” & “e” & butterfly beads. Butterfly is a common emblem for Ecstasy.Vibration of the music through • Every touch feels good.the balloon feels good too. • They may rub each other with things like Tiger Balm or with hair brushes or gloves with the “gripper dots” to intensify touch.
Drug Paraphernalia• MDMA causes “bruxism”—teeth grinding & involuntary jaw locking; damages teeth.• Pacifiers, lollipops, mouthguards & other things to suck help reduce this.• Hidden compartments
Anatomy of a Rave-Common Medicalconcerns • Severe Dehydration and Hyperthermia • Poly-Pharm involvement • Date Rape • Multiple Patients (approach with a plan) • Volatile Crowds
Interacting with Ravers• Remember there is a cultural distrust• Don’t be afraid to ask for interpretation of slang• Generally not overtly violent singularly, but beware of crowds• Our attitude and interaction may have a positive or negative impact on the crowd.• Check for a “Trip Sitter”
Safety• Hazards: Uncontrolled Scenes – Patients – Environment – Bystanders – Weapons – CLAN LABS• Tactics learned from law enforcement community – Staging – Isolation and Control – Scoop and swoop – Travel in Packs
SAFETY for the PT.• Pt safety poses an extreme challenge for EMS – Drug Interactions – Rapid Changes – Restraint
Heroin• Black Tar• China White• Speed Ball• Homicide, Buick, super Buick, twilight sleep
Methods of use:• Shooting:• Skin Popping:• Muscle Popping:• Chasing the dragon: Smoking• Freebasing• Dirty Hit:
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
Methadone • Reportedly Harder to “kick” than Heroin • 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
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
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
S/S OF AN OPIATE OVERDOSE• Pin Point Pupils • Dirty Needles• Hypotension (“Diabetics”)• N/V • Cotton balls, Cig• Respiratory/CNS Filters depression • Spoons w/ residue or• Aspiration and Hypoxia similar improvised• Hallucinations device• Other s/s? Think poly- pharm involvement
BASIC TREATMENT• Ventilation/stimulation first• Slow admin of Narcan, just enough to make them breath – Narcan 0.4 mg-2 mg traditional, may need higher doses• High doses may be needed if drug is synthetic• Watch for re-sedation due to Narcan’s short duration (about 20-30 minutes)
Long Term problems• HIV, HEP-A/B/C,• BLOOD POISONING (Septicemia) “Cotton Fever”• ENDOCARDITIS• TETANUS• NECROTIZING FASCIITIS (Flesh-Eating Disease) Associated w/ black tar• WOUND BOTULISM• TRACKING AND BRUISING• CONSTIPATION, BOWEL OBSTRUCTION
Some weird things that have been done with aHeroin OD by Junkies• 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) .• Placed in a cold shower
Dependence, Detox, and Withdrawal• medical detoxification is usually accomplished by giving decreasing doses of a long-acting opiate like methadone.• While not truly physically addictive, Heroin withdrawal is clearly extremely uncomfortable and painful.• The previously suppressed Locus Coeruleus is believed responsible for most of the clinical problems: anxiety, HTN, agitation
Introduction• methylenedioxy-n- methylamphetamine (MDMA) – MDMA is *chemically* an amphetamine, but psychologically its whats 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.
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
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
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.”
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.
MDMA /PMA ToxicityMild s/s• 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)• Auditory Hallucinations (non specific)/sensitivity• Orthostatic s/s, syncope secondary to dehydration
MDMA/PMA ToxicityMajor S/S• Severe Dehydration with Hyponatremia• Malignant Hyperthermia (Think Heat Stroke, but worse)• Disseminated Intravascular Coagulation (DIC) (may have rapid onset)• Decreased LOC/Coma• Stroke S/S, Seizures• Severe Tachycardia, HTN, CHF• Kidney Failure
MDMA/PMA Basic Tx• Calm low stimulus environment• VOMIT (standard ALS)• Fluid Resuscitation as needed for hypotension, dehydration, and/or orthostatic s/s• Active cooling if indicated• Core Temp if unresponsive
Long Term effects• More prolonged “burn out” or “crash periods” up to a week later• Dental Damage• Depression for weeks• Renal failure
MDMA Focused Tx• Benzodiazepines – Ativan 0.5-2 mg – Valium 2.5-10 mg• beta blockers have fallen out of favor (like Brevibloc), Consider an adrenergic blocker w/ alpha blocker properties as well.
Take Home Information• Core Temp if unresponsive• Fluid Resuscitation• Sedation PRN• Watch for DIC, SZ• P.U.H.A. IF GROSSLY SYMPTOMATIC.
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
DXM• 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
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.
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.
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.
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.
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
So Many Names….• Tranquili G, Midnight Blue, Verve, Rejoov, Somax, SomatoPro, Flower Power, Puritech, Alcover, G-riffick, Eclipse, GHGold, Soap, Vita G, Dormir, Enliven, FX, Serenity, Inner G, Zen, White Magic Cleaner, Weight Belt Cleaner, Ink Jet Cartridge Cleaner, Plant Food, Fingernail Polish Remover, Paint Stripper.There are more than 80 known names for GHB and its equally deadly analogs.
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
Efforts to Avoid Detection• GHB & its analogs are NOT protected by the Dietary Supplement & Heath Education Act of 1994.• Unapproved for human use.• “Misbranded” drugs.• May be listed as “weight belt cleaner” or other solvent use or plant growth formula—trying to avoid detection
Efforts to Avoid Detection• Acetone free Nail Polish
GHB- No longer Just for Rapists• Recreational Use• Muscle Gain• Those under mandatory drug testing• Elderly
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
GHB analogs toxicity- mild• Lethargy, easily aroused with repeated stimulation• Drowsiness, somnolence, dizziness, euphoria• Confusion (dazed and confused)• Amnesia, Susceptible to suggestion
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)
GHB• ALCOHOL IS THE MOST COMMON DRUG CO CONSUMED IN GHB RELATED DEATHS
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
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
Difficulty in Prosecution• Sort Duration• Amnesia clouds recall• Often pro-sexual appearing behavior• Lack of : – Credible witness – Evidence
GHB analogs- What does this meanto 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.
“For about a week I couldnt walk through the lobby of A-entry at the dorm without getting really scared, because of the goblin I saw there when I was tripping….” ( …User, circa.1971, )
Background• Discovered by Dr. Albert Hofmann in 1938• Extensive study, use, and abuse by the government in the late 40’s. 50’s, and 60’s. (OSS/CIA, US Navy)• Some documented cases of CIA Operatives taking it to “Immunize” them selves to its effects in the 60’s.• Now that’s job satisfaction!
Slang• Many names refer to the carrier or “brand”(image printed on blotter)• Blotter, Sugar, Sugar Cube, “cid, Acid• Bart Simpsons, Barrels, Tabs, Blotter, Heavenly blue, "L", Liquid, Liquid A, Lucy in the sky with diamonds, Microdots, Mind detergent, Orange cubes, Orange micro, Owsley, Paper acid, Sacrament, Sandoz, Sunshine, Tabs, Ticket, Twenty-five, Wedding bells, Windowpane, etc.
Slang• Hit- Dose• Body Kinks- Unexpected physical side effects I.e. nausea, jitters, etc• Bad trip- A person on LSD who becomes depressed, agitated, or confused may experience these feelings in an overwhelming manner that grows on itself.• LSD psychosis: The effects of LSD exacerbate pre-existing psychological problems for several days.
Methods• Usually taken Sublingually or orally on paper (“Blotter”)• The solution may also be injected s.c. or i.v. (RARE) The effect is identical with that of oral administration but sets in more rapidly.• Usual dose is 50-200 mcg, with “Transcending doses” as high as 500 mcg
How does it work?• Similar to other drugs that give hallucinations:• It affects the re-uptake of 5-HT similarly to SSRI (serotonin specific reuptake inhibiting) anti- depressants such as fluoxetine (Prozac), sertraline, and paroxetine• Agonist (stimulation rather than blocking) properties at the 5-HT2 receptor have been found to fairly universally be associated with other psychedelic drugs such as psilocybin and mescaline, and somewhat in MDMA
S/S OF AN OVERDOSE• Dilated Pupils• Vivid Auditory, tactile, and visual perception• Nausea• Mild drops in B/P• Hyperglycemia• Piloerection (Goosebumps)• Mild Hyperthermia• Bradycardia• May exacerbate pre-existing behavioral tendencies• Mild stimulatory effects
After trip effects • Insomnia (common) • “Jitters” • Flashbacks (inconstantly proven and disproven in literature)
FOCUSED TREATMENT• Benzo’s for severe agitation (rare)
Dependence, Detox, and withdrawal• No documented physical or psychological dependence• A rapid tolerance is built up (about 3-5 days) that just as rapidly disappears
Take Home Information• Facilitate a low key trip, and all is well• The patients respond to your actions as much as we respond to them• Very little clinical problems from drug, just actions resulting from altered behavior
Summary• The scariest things about these drugs are the uncertainties involved in poly-pharm overdoses, unknown ingredients, etc…• Careful case by case assessment and treatment is more important than a cook- book approach.• Knowing the onsets, durations, and warning signs is as essential as knowing the actual effects of a drug.