Street Drugs Down And Dirty


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  • From the movie “Leon, The Professional” (international version, or “the professional” US version) Great movie about a hit-man who takes in an orphaned girl This is Jon Reno and a very young Natalie Portman in the photo, she is about 12, she later is the princess in the new star wars movies…(episodes 1-3)
  • It is a Multi-National culture, and is seen in multi-national cities (Seattle, New York, D.C., Miami, Frankfort (Ger.) etc). It has spread to some degree to every City in the US.
  • May have multiple Rooms, each with a Theme (“Jungle-Rave”) Usually has Multiple Water Venders ($$$) May or may not be BYOB Any where from 100 to 10,000 (“massives”) Some larger events hire an Private EMS agency to stand by, sometimes to limit police involvement. More respectable areas may even have a area for triage. All scenes are a potential volatile environment
  • Example: Boise High School drug free party
  • Soft fuzzy clothing or other interesting textured fabrics add to sensation & are popular. Special clothing & hats are sold with hidden compartments to hide their drugs at school & parties. In the hat below, it is behind the emblem; it is sealed with Velcro under the hat band.
  • The GHB Card, AKA “the Card”: about $9.00 USD DrinkSafe Date Rape Test Pack (10 cards/20 tests) about 9 dollars USD Each pack consists of 10 cards, each containing 2 test areas, that incorporate patented DrinkSafe technology that reacts with a visible color change if a test area come in contact with a drink spiked with major date rape drugs like GHB and Ketamine. DrinkSafe Date Rape Coaster 0.75 cents USD each
  • The Harm Reduction Coalition is a non profit organization committed to reducing drug-related harm to individuals and communities. It's activities include advocacy, the Harm Reduction Training Institute, community organizing efforts, conferences (including our 4th national conference, December 1-4 2002 in Seattle), a newsletter and the creation of educational materials for drug users. H.E.A.R. (Hearing Education and Awareness for Rockers) is a non-profit organization dedicated to raising awareness of the real dangers of repeated exposure to excessive noise levels which can lead to permanent, and sometimes debilitating, hearing loss and tinnitus. : links to harm reduction organizations in Europe http:// RaveSafe South Africa RaveSafe! A Harm Reduction Group Located in Edmonton, Canada! Drug
  • Great research site!!!!
  • The following is from the website: What is DanceSafe? DanceSafe is a nonprofit, harm reduction organization promoting health and safety within the rave and nightclub community. We currently have local chapters in twenty-six cities throughout the US and Canada. By the middle of next year we expect to have at least a dozen more. Our local chapters consist of young people from within the dance culture itself who have a sincere interest in bettering their communities and educating themselves and their peers. We train our volunteers to be health educators and drug abuse prevention counselors within their own communities, utilizing the principles and methods of harm reduction and popular education. Our volunteers staff harm reduction booths at raves, nightclubs and other dance events where they provide information on drugs, safer sex, and other health and safety issues concerning the electronic dance community (like driving home safely and protecting one's hearing). We also provide adulterant screening or pill testing services for ecstasy users. Pill testing is an important harm reduction service that saves lives and reduces medical emergencies by helping ecstasy users avoid fake and adulterated tablets that often contain substances far more dangerous than real ecstasy. ( note: this is not to say ex is not dangerous, but PMA, PCP, etc are far more dangerous, as well as certain cutting agents, the question is does the primative form of drug testing done at the raves help? I believe the detailed test they do and post on the web site do help, but the ones at the dances are questionable) Our information and services are directed primarily towards non-addicted, recreational drug users. Non-addicted drug users are an under-served population within the harm reduction movement, despite the fact that they comprise the vast majority of drug users in our society. While many organizations exist that provide services to drug-dependent individuals, few groups address the needs of the majority of non-addicted, recreational users. We hope to fill this gap. When needed, we will always refer people to appropriate treatment programs
  • GHB in pure form is clear & thicker than water; it bubbles when shaken. But it can be dyed any color, watered down & not all of its “analog” cousins bubble. It may also be seen in powder, capsule or a “putty” form.
  • Severe Dehydration and Hyperthermia: from hyperdynmamic drug use (MDMA, METH, PMA), low availability of H2O Poly-Pharm involvement: (intentional and accidental) Date Rape: Multiple Patients (approach with a plan): drug use, violance, heat Volatile Crowds
  • A ” trip sitter” or “sitter” is basically designated sober person, or more sober person, who is supposed to keep the person calm, and out of trouble while they are tripping A trend is developing within night clubs that are intended to keep their customers safer. While this is controversial since it seems to smack of endorsement of drug abuse, the reality is that we're seeing night club owners and dance event organizers taking steps such as: The prevention of overcrowding. This is obviously of crucial importance in the control of the temperature but also the humidity of the night club or dance. The availability of drinking water or chilled soft drinks --particularly sports drinks which contain sodium. Air conditioning and ventilation to control temperature rises in the night clubs and prevent overheating. Provision of "chill out" areas where people can sit and cool down in a quieter and cooler environment. DJs giving dancers a rest periodically, by placing breaks in the music or by slowing the tempo down intermittently. The provision of first aid or paramedics, particularly at large or remote events. A controversial issue in New York City (April 2001) came to light when it was discovered that many clubs hired private ambulances for their clubs to treat customers and protect their confidentiality. This practice is under review since the big problem is that the 911 system is bypassed and Police are never notified of the overdoses and are essentially prevented from investigating illegal practices.
  • Heroin - First synthesized from morphine (derived from the poppy plant) in 1874, was not extensively used in medicine until the beginning of this century. Commercial production of the new pain remedy was first started in 1898. While it received widespread acceptance from the medical profession, physicians remained unaware of its potential for addiction for years. It’s abuse was a major cause of the Harrison Narcotic Act of 1914.  One survey in 1999 saw 2% of HS students had used heroin, most (1.1%) under the age of 16. Use is mainly growing in the 30-40 age group (those w/ teenagers) There is some indication that heroin use is slowly increasing to levels seen in the 60’s and 70’s Source: SAMHSA, Office of Applied Studies, National Household Survey on Drug Abuse, 1994-1998. In the sixteenth century, Philippus von Hohenheim, better known as Paracelsus, invented laudanum by extracting opium into brandy. The alkaloids found in opium are significantly more soluble in alcohol than in water, so this new alcohol opium drink, essentially a tincture of morphine, easily drinkable and highly potent, became very popular. By the nineteenth century, vials of laudanum and raw opium were freely available at any English pharmacy or grocery store. Progress continued in 1805 when morphine was first isolated from opium by the German pharmacist Wilhelm Sertürner. He called it morphium, after Morpheus, the Greek god of dreams. Morphine proved far more useful than opium for the medical field, as opium taken orally has unpleasant gastric side-effects. With the invention of the hypodermic syringe later in the century, pure morphine could be injected without these unpleasant side-effects. In Europe and America, morphine injection became very popular with high society and middle-class professionals. At the time, people believed that injecting morphine wasn’t addictive, and was a safe substitute for opium addiction, which when discontinued caused malaise, flu-like symptoms, and depression. Completely synthetic morphine analogues include classes of drugs called the diphenylpropylamines (e.g. methadone), the 4-phenylpiperidines (e.g. meperidine), the morphinans (e.g. levorphanol) and 6,7-benzomorphans (e.g. metazocine). All contain a piperidine ring or part of its ring structure.
  • Enormous Increase Information from DAWN Network
  • China White : Pure heroin is a white powder with a bitter taste. Most illicit heroin is a powder form which may vary in color from white to dark brown because of impurities left from the manufacturing process or the presence of additives. Pure heroin is rarely sold on the street.. This heroin may be smoked. “ black tar," has also become increasingly available in the western United States. The color and consistency of black tar heroin results from the crude processing methods used to illicitly manufacture the substance in Mexico. Black tar heroin may be sticky, like roofing tar or hard like coal, and its color may vary from dark brown to black. It is often sold on the street in its tar-like state at purities ranging from twenty to eighty percent. This heroin is most frequently dissolved, diluted and injected.  Red Rum Heroin - is a highly potent form of heroin that was recently responsible for the overdose death of a rock musician in New York. Red Rum and other brands like it, including Fire Express, Green Honey, and Laundromat, are much more potent than brands of heroin a decade ago. They are designed to deliver a strong high by snorting or smoking instead of injecting. According to New York City police, a sample of the Red Rum heroin tested at a purity level between 60 and 70 percent. Red Rum's origins are believed to be South American. Speed Ball : Heroin mixed with cocaine Homicide, Buick, super Buick, twilight sleep: Mixed with scopolamine. Scopolamine, which causes amnesia, was introduced in 1902 and used up until the 1960s. Injected with morphine, this analgesic-amnesic technique known as "Twilight Sleep" provided painless birth. However, "Twilight Sleep" had its downside. Not only did it completely remove the mother from the birth experience, a growing concern in the 1950s, but it also caused neonatal depression.
  • Clockwise: Black tar heroin, various types of heroin and balloons, pure heroin…china white, and someone shooting up. Notice the dark color of the junk in the syringe. The typical heroin user today consumes more heroin than a typical user did just a decade ago, which is not surprising given the higher purity currently available at the street level. Until recently, heroin in the United States almost exclusively was injected either intravenously, subcutaneously (skin-popping), or intramuscularly. Injection is the most practical and efficient way to administer low-purity heroin. The availability of higher purity heroin has meant that users now can snort or smoke the narcotic. Evidence suggests that heroin snorting is widespread or increasing in those areas of the country where high-purity heroin is available, generally in the northeastern United States. This method of administration may be more appealing to new users because it eliminates both the fear of acquiring syringe-borne diseases such as HIV/AIDS and hepatitis, and the historical stigma attached to intravenous heroin use.  Howard Lotsof, a renowned researcher into ibogaine treatment of heroin addiction, has estimated that a "low end analgesic dose of heroin would be about 1mg." Most users start with doses much higher than this. Insufflated doses of heroin probably start at between 5 and 20mg of pure heroin and intravenous doses probably start between 5 and 10 mg. As usage increases, however, the doses get much higher. Dr Lotsof wrote "In close to twenty years of research and involvement with the treatment of opioid dependence with ibogaine the highest dose I personally saw used of heroin in Europe was 2 grams [per day], that is 2,000 mgs." 2 grams per day, however, is extremely high, much higher than most heroin addicts achieve. Heroin is very expensive and this dosage level would be fatal in most people who had not worked up their dosages slowly. When the Swiss government began allowing maintanence of heroin users, they were able to collect reliable data about exactly how much heroin was being used. The Swiss found that users offered unlimited quantities would, on average, max out at between 300 and 500 mg. of diacetylmorphine per day. One author writes "I've known people prescribed a full gram per day, but they were quite unusual, and such habits on the street are impossible except for relatively high level dealers. Remember, I'm talking about pure pharmaceutical or number 4 if on the street. There are certainly cases of pain patients receiving larger equivalent dosages of opioids, but I've never heard of one of these beating a 1000/1 ratio." The Swiss data was published in 1999 Prescription of Narcotics for Heroin Addicts: Main Results of the Swiss National Cohort Study Page 20 states that the mean daily dose of heroin IV ( when used alone, without methadone on the side) was 491.7mg. Page 22 states "A stable dose was achieved after 6 months at most; beyond this point, almost no further increases in dose were required
  • A dirty hit can result in a fairly quick and intense reaction or might take days or weeks to produce an effect. Symptoms often include sweating, headache, fever, and trembling. While the effects of a dirty hit may pass by themselves,. Shooting: IV Injection Skin Pooping: SQ injection Muscle Pooping: IM Chasing the dragon: Smoking ( it's put on aluminum foil and heated from the bottom and allowed to run down the foil if possible while inhaling the smoke…) freebasing Dirty Hit: The result of a dirty process usually resulting in an abscess, cellulites, etc
  • Oxycontin has been responsible for a huge resurgence in opiate use back east. OxyContin is a high potency pain killer derived from opium. When used as prescribed it provides effective pain management for cancer patients and others suffering from chronic pain. When properly taken, an OxyContin tablet is time-released and provides the patient with up to 12 hours of pain relief. The danger arises when that time release mechanism is bypassed. Abusers will either chew or crush a tablet, so that it can be snorted or mixed with water and injected -- like heroin. This puts the drug into the system all at once and delivers an intense high, much like high-grade heroin. This is why OxyContin is sometimes referred to on the street as "poor man’s heroin" or "hillbilly heroin.” (not to mention is first surged in Kentucky) On the street, prices for the drug vary depending on geographic location. But generally, OxyContin sells between 50 cents and $1 per milligram. So a 40 milligram tablet which sells legitimately for $4 will bring 10 times that amount on the street. Many people became opiate addicted on oxycontin, then as it is becoming harder to get, have switched over to heroin. Oxycontin goes for about $10-20 each on street. Pharm companies are attempting to reduce the abuse of Oxycontin secondary to bad press. A new formulation would make it "a lot more difficult to get a high" from OxyContin, said Robin Hogen, executive director of public affairs for Purdue Pharma of Norwalk, Connecticut.Hogen said the new drug would have to pass through clinical trials required by the Food and Drug Administration, which means it might be two to three years before it could be prescribed by doctors. Among the hurdles, Hogen said, are efficacy trials that would show how well the new formula handles pain relief.
  • Information Bulletin:Methadone Abuse Increasing Publication Date: September 2003 Document ID: 2003-L0424-004 Methadone, a Schedule II drug under the Controlled Substances Act, is a long-lasting synthetic opioid that, when used properly, reduces cravings for opiates--a leading cause in opiate abuse relapse. Methadone suppresses opiate cravings for 24 to 36 hours; thus, the drug can be administered once a day for the treatment of opiate addiction. Methadone also is prescribed as a narcotic analgesic to treat chronic pain. When abused, particularly in combination with other drugs, methadone causes effects in some users that are similar to those caused by the abuse of heroin and other opiates. Over time legitimate and illegitimate users may develop tolerance for and dependence on methadone. Methadone is available in several forms including tablets, dispersible tablets (dissolvable in water or juice), liquid, liquid concentrate, and an injectable solution. Only practitioners certified by the Substance Abuse and Mental Health Services Administration are permitted to prescribe and dispense methadone for treatment of opiate addiction. However, any physician may prescribe methadone as an analgesic for treatment of chronic pain. When prescribed as an analgesic, methadone may be dispensed by any licensed pharmacy. According to DAWN, the number of emergency department mentions for methadone increased overall from 3,832 in 1997 to 10,725 in 2001. Moreover, DAWN reports that 65 percent of methadone-related emergency department episodes also involved other drugs or alcohol in 2001. In that year alcohol was the substance most frequently used in combination with methadone, followed by cocaine and heroin. DAWN mortality data for 2001 show that in most methadone-related deaths the drug was used in combination with other substances; however, those substances were not identified. Nevertheless, the data show that methadone ranked among the top 10 drugs mentioned in drug-related deaths in 24 of 33 DAWN reporting cities including Baltimore, Chicago, Detroit, Newark, and Phoenix. The report further indicates that in 2001 fewer than half of decedents whose deaths were caused by methadone or in which methadone was a contributing factor had a documented prescription for the drug. Most of them had not been enrolled in a methadone maintenance program. In 2001 an analysis of 14 cases in which methadone was a cause of death or contributing factor statewide indicated that only three individuals had been receiving treatment from a methadone maintenance clinic.
  • I say a 17 year old GSW pt who had these odd rectangular patches of irritation all over his body. When I asked why, he told me they were from duragesic pathces . He buys them illicitly and uses them instead of IV opiods. A co-worker of mine encountered a pt who would draw/extract the Fentanyl from the patch for IV use - S. Cole 2003 I just had a report from East Idaho, on a pt who stole used duragesic from the garbage, duct taped 4-6 of these patches to her chest to feed her addicition.- S. Cole 3-2004 Comes in 25, 50, 75. 100 mcg /hour Active ingredient is fentanyl First synthesized in Belgium in the late 1950s, fentanyl, with an analgesic potency of about 80 times that of morphine, was introduced into medical practice in the 1960s as an intravenous anesthetic under the trade name of Sublimaze®. Thereafter; two other fentanyl analogues were introduced; alfentanil (Alfenta®), an ultra-short (5-10 minutes) acting analgesic, and sufentanil (Sufenta®), an exceptionally potent analgesic (5 to 10 times more potent than fentanyl) for use in heart surgery. Today, fentanyls are extensively used for anesthesia and analgesia. Duragesic®, for example, is a fentanyl transdermal patch used in chronic pain management, and Actiq® is a solid formulation of fentanyl citrate on a stick that dissolves slowly in the mouth for transmucosal absorption. Actiq® is intended for opiate-tolerant individuals and is effective in treating breakthrough pain in cancer patients. Carfentanil (Wildnil®) is an analogue of fentanyl with an analgesic potency 10,000 times that of morphine and is used in veterinary practice to immobilize certain large animals.
  • http:// "18 h after removal of transdermal fentanyl patch, approximately 10 mg of oxycodone q12h can be substituted for each 25 µg/h of transdermal fentanyl to start. Follow patient closely." A 25ug/h patch contains 2.5mg of fentanyl which if taken orally would provide about 600ug or 60mg of oxycodone. A 50ug/h patch contains 5mg of fentanyl which if taken orally would provide about 1,200ug or 120mg of oxycodone. A 75ug/h patch contains 7.5mg of fentanyl which if taken orally would provide about 1,800ug or 180mg of oxycodone. A 100ug/h patch contains 10mg of fentanyl which if taken orally would provide about 2,400ug or 240mg of oxycodone." NOTE: Fentanyl doesn’t provide oxycondone, this is equilivent Abuse of fentanyl pharmaceutical preparations initially appeared in mid 1970s. In the 1980s, a number of fentanyl analogs (referred to as "China White") were illicitly produced and sold as heroin on the illicit market. Several deaths resulted from these as addicts did not realize they were injecting fentanyls, but not heroin. Abuse of fentanyl products has increased in recent years. According to the Drug Abuse Warning Network (DAWN), fentanyl-related hospital emergency department mentions increased from 22 in 1995 to 1,506 mentions in 2002. There have been reports of deaths associated with abuse of fentanyl products. Illicit distribution: Fentanyl has been diverted by pharmacy theft, fraudulent prescriptions and illicit distribution by patients and registrants (physicians and pharmacists). Theft has also been identified at nursing homes and other long-term care facilities. Fentanyl oral transmucosal lozenges (Actiq®) are typically sold at $20-25 per unit or $450 per carton (contains 24 units) while transdermal patches (Duragesic®) are sold at prices ranging from $10 to $100 per patch depending upon the dose of the unit and geographical area. There is evidence of large illegal distribution rings selling fentanyl products along with other opioid pharmaceuticals. Fentanyl products have become one of the commonly diverted drugs in some selected areas of the country. According to the National Forensic Laboratory Information System (NFLIS), fentanyl drug cases expressed as percent of the total narcotic analgesic cases increased from 0.21% in 2001 to 0.31% in 2002 and 0.49% in 2003* (*based on data from the first half of 2003).
  • “ This is the key to the heroin high: Nothing matters, hot or cold, fun or boring, big or small. When one is high on smack, one looks at the outside world and has only one thought: Who gives a f*ck? You feel as if you've been wrapped in the most pleasing, warm, and comfortable blanket in the world. At high doses, you fall in and out of consciousness, and getting this 'nod' is what the veteran user prays for everytime he shoots up; to sleep the sleep of angels is the ultimate goal of the heroin addict.” ..from The bottom of a soda pop can is commonly used as a "spoon" to dissolve the heroin in because it is curved inward like a spoon. The bottom is torn off of a can as close to the bottom as possible. Polypharm OD may mask some s/s Oxycodone is a semi-synthetic opioid derived from the opium alkaloid thebaine. It is typically made into the salt form, oxycodone hydrochloride, a white, odorless crystalline powder that is highly soluble in water and slightly soluble in alcohol. It’s chemically known as 4, 5a-epoxy-14-hydroxy-3-methoxy-17– methylmorphinan-6-one hydrochloride. It has a high oral bioavailability relative to other opioids, between 60 and 87 percent, making it ideal for oral administration. Oral bioavailability is the percentage of active drug which reaches systemic circulation through oral administration relative to direct injection into the bloodstream. High oral bioavailability is desirable because it reduced the physical size of tablets, and gives the physician greater precision when titrating doses because of predictable pharmacokinetics. Oxycodone also has a high nasal bioavailability [5] , between 50 and 65 percent, which makes it a good candidate for a nasally administered formulation, but also for nasal abuse. It can also be given intramuscularly, intravenously, subcutaneously, and rectally.The serum half-life following oral administration (oxycontin) is 3.5 to 4 hours. Its effective duration of analgesic action is 3 to 4 hours. Subjective comments from users [9] [‘Oxy’ refers to OxyContin tablets whose active ingredient is oxycodone]: “ I’ve had some almost 99% pure Heroin and I have to say it’s definitely better than Oxy [10] , especially when considering the high price of Oxy.” “ Heroin has a very ‘narcotic’ feel to it, but oxy has a seriously ‘medical’ feel to it. It’s a very ‘clean’ high.” “ When you intravenously inject Oxy, the rush doesn’t last very long at all. The major part of it is over in about 20 minutes. Heroin lasts a lot longer.” “ Oxy is over quicker. Much cleaner [compared to heroin] though. Not as sleep and not so much of the itch. Oxy doesn’t make me as nauseated. Oxy makes everything beautiful.” “ All I can say is that I get a very giddy happy high from oxycodone while I get a knockout loaded feeling from heroin.” “ Morphine Sulfate is useless to me orally. It is extremely not well absorbed by this route. Morphine is not quickly absorbed even by injection compared to some others, and tends to cause more histemic and emetic reactions, not to mention more respiratory depression. It has a nice dreamlike quality though. Not at the top, but still very nice to have.” “ You get a lot more ‘nod [11] ’ with Heroin than with Oxy.” “ When you get that oxy buzz,” she says, “it’s a great feeling. You’re happy. Your body don’t hurt. Nothing can bring you down. It’s a high to where you don’t have to think about nothing. All your troubles go away. You just feel like everything is lifted off your shoulders.” [12]
  • BLOOD POISONING (Septicemia) Blood poisoning (septicemia) is a bacterial infection of the bloodstream that can be caused by injecting with contaminated water, re-using old cottons, or failing to clean the skin prior to injection. Early symptoms include chills, fever, and extreme fatigue. If you experience these symptoms, seek medical attention. Septicemia can be fatal! ENDOCARDITIS Endocarditis is an infection of the heart lining that is caused by bacteria, fungi, and other infection-causing microbes that enter the bloodstream during injection and build up around the valves of the heart, weakening them as well as other parts of the heart muscle. Endocarditis can eventually cause a heart murmur, as well as fever, chest pains, fainting spells, shortness of breath, and heart palpitations. It can be treated with antibiotics if detected early, but can be fatal if it goes untreated. TETANUS tetanus spores enter a wound and release tetanus bacteria, usually after a scab has already formed. The bacteria then enter the bloodstream and cause an infection, which is characterized by muscle spasms or rigidity, especially in the neck and jaw (tetanus is commonly called "lockjaw"). Tetanus is fatal if not treated. Tetanus spores live in the soil and on rust, which is why a tetanus shot is recommended if you step on an old nail or other rusty object. If your needle, syringe, or other injection equipment is contaminated with tetanus spores due to dirt or rust, you could infect yourself. Skin-poppers and muscle-poppers are particularly susceptible to tetanus infection and should always use new, sterile equipment. NECROTIZING FASCIITIS (Flesh-Eating Disease) Associated w/ black tar Necrotizing fasciitis is a bacterial infection commonly known as "flesh-eating disease" that enters the body through broken skin and then affects the surrounding tissue and nearby muscle. It can be transmitted by the exchange of blood during needle sharing, and has recently been traced to "black tar" heroin on the West Coast. Symptoms of necrotizing fasciitis include increasing redness and swelling and extreme pain at the wound or injection site accompanied by a fever. The flesh around the site of infection begins to decay and looks as if it had been "eaten" away. Since this infection is fatal, early treatment with antibiotics is crucial to survival, although even appropriate therapy does not prevent death in all cases. Wounds must be kept impeccably clean. WOUND BOTULISM Wound botulism is caused by a bacteria that produces a toxin on the skin where a puncture would is made and that eventually stops your breathing by paralyzing your muscles. Recent cases have been associated with the subcutaneous injection of "black tar" heroin on the West Coast. The source of the botulism could be the drug itself, a cut in the drug, dirty injection equipment, or contamination during the preparation process. Wound botulism can be prevented in the same ways as necrotizing fasciitis­by following excellent sterile technique when preparing and injecting your drugs. Symptoms of wound botulism include droopy eyelids, blurred or double vision, and a dry, sore throat which may progress into difficulty speaking and swallowing, a weakness of the neck, arms, and legs, and difficulty breathing.
  • medical detoxification is usually accomplished by giving decreasing doses of a long-acting opiate like methadone. After a few weeks of this, the patient is usually opiate-free without having suffered any appreciable physical discomfort. Since a percentage of the methadone marketed for medical use finds its way into the streets, many addicts also detox themselves this way without formal medical help Still others detox 'cold turkey'--without any pharmacological help at all. They simply tell their friends they have the flu, go to bed, and suffer in relative silence. A substantial portion of the physical symptoms of this stage seem to depend on the activity (previously suppressed) of a part of the brainstem called the locus coeruleus. The is believed responsible for the brain's fear-alarm system, and such hyperactivity would be consistent with the marked anxiety, hypertension, and agitation withdrawing addicts report.
  • MDMA (also commonly known as Ecstacy, X, E, XTC, Adam, etc.) is a semi-synthetic chemical compound. In its pure form, it is a white crystalline powder. It usually seen in capsule form, in pressed pills, or as loose powder. Average cost ranges from $10-$30 (U.S.) a dose. Common routes of administration are swallowing or snorting, although it can be smoked or injected as well. Currently, MDMA is on the U.S. Schedule I of controlled substances, and is illegal to manufacture, possess, or sell in the United States. Most other countries have similar laws. According to Nicholas Saunders (1993), "MDMA was patented as long ago as 1913 by the German company Merck. [...] The patent doesn't mention uses.“ empathogen-entactogen: Entactogenesis ("touching within") This is a generalized feeling that all is right and good with the world. People on MDMA often describe feeling "at peace" or experiencing a generalized "happy" feeling. Empathogenesis Empathogenesis is a feeling of emotional closeness to others (and to one's self) coupled with a breakdown of personal communication barriers. People on MDMA report feeling much more at ease talking to others and that any hangups that one may have with regard to "opening up" to others may be reduced or even eliminated. This effect is partially responsible for MDMA's being known as a "hug drug" - the increased emotional closeness makes personal contact quite rewarding. Many people use MDMA primarily for this effect, reporting that it makes potentially awkward or uncomfortable social situations (singles bars, dance clubs, etc.) much more easily dealt with. MDMA is primarily a seritonergic (5-HTergic) drug. Serotonin (5-hydroxytrytamine, 5-HT) is one of the major neurotransmitters in the brain, and is synthesized from tryptophan through the intermediate 5-hydroxytryptophan. It is synthesized in 5-HT neurons, and stored in synaptic vesicles. These vesicles release their 5-HT into the synaptic cleft in response to the firing of the 5-HT neurons. In the synaptic cleft the 5-HT neurotransmitter excerts its action on both pre- and post- synaptic receptor sites (sites on the 5-HT neuron itself, and on the neuron which it is communicating with.) 5-HT is then taken back into the 5-HT neuron via the synaptic membrane 5-HT transporter (aka "reuptake pump"), where it is again stored in the synaptic vesicles. 5-HT is metabolized primarily by monoamine oxidase (MAO) into 5-hydroxyindileacetic acid (5-HIAA). Serotonin is thought to be responsible for many psychological (and physiological) states including mood and sleep. It has been particularly associated with major depression and obsessive compulsive disorder, and drugs to treat these disorders tend to effect 5-HT (although things are not quite clear-cut). PMA, Para-methoxyamphetamine, was originally documented as a drug in the early 70’s. PMA has remained mostly unseen for almost 25 years. However as early as 1994, it has begun a deadly return in the illicit drug market. Although still relatively rare, PMA is considered one of the most dangerous hallucinogens. Sold as a beige, white, or pink powder, or in tablets, PMA is often misrepresented as MDMA, methylene-dioxy-methamphetamine. However, at doses considered “safe” for MDMA, PMA is highly toxic. The hallucinogenic effects of PMA are similar to LSD. Several deaths have been reported in connection to its use, mainly in Australia, New Zealand, and North America
  • As much PMA and Ecstasy are alike, a major difference (aside from toxicity) is onset of action. PMA takes about an hour to have a noticeable effect while MDMA takes about 10-20 minutes minutes. One possible reason that people overdose on PMA is because they think it's MDMA. After fifteen minutes with no results they take another "hit," thinking the first one was no good. In addition some people are believe they “know” their optimal Ecstasy dose, and apply this to what they think is MDMA, but is PMA instead. Still others mix their drugs. Substances like Cocaine and Methamphetamine may exacerbate the toxic effects of either PMA or MDMA. PMA is over 20 times as potent as MDMA as an inhibitor of 5-HT . (in rat studies) PMA, like MDMA, both inhibit uptake of 5ht and stimulates its release. Simply put PMA effects the same receptors in a similar fashion as MDMA. With PMA one should not thing about mild vs. severe toxicity. Think about how much time before the patient develops severe toxicity. Deaths have been seen with as few as 2-3 tablets of PMA.
  • Street doses of MDMA generally run from 50mg. to 150 mg. 100mg. or 1/10th of one gram is considered an average single dose. Monks have used lower doses (40-60 mg) to assist meditation, and therapists(especially in Israel for PTSD) have sometimes taken similarly low doses to become more in tune with clients. A benchmark standard dose is often considered to be 2 mg of MDMA per kilogram of body weight (though response to the drug is not strictly proportional to body weight). Users will take 1/3-1/2 the original dose to maintain at approx 1 ½ hours after ward. Initial effects include a brief "rush" of energy, usually described as mild but euphoric. After this rush, the high levels off to a plateau which lasts 2-3 hours and is followed by a gradual "coming down" sensation, culminating in a feeling of fatigue in about 4-6 hours
  • MDMA users may encounter problems similar to those experienced by amphetamine and cocaine users, including addiction MDMA use damages brain serotonin neurons. Serotonin is thought to play a role in regulating mood, memory, sleep, and appetite. Recent research indicates heavy MDMA use causes persistent memory problems in humans. Hyponatremia is defined as: a decrease in the plasma sodium concentration below 136 mEq/L caused by an excess of water relative to solute. Excessive perspiration, excessive urination and excessive thirst results in diluting sodium levels when the patient drinks too much water. If sodium is being lost, drinking plain water will not replace it. 'Isotonic' drinks, unlike pure water, will help replace some minerals like sodium and preserve the balance of fluids in circulation. Signs and symptoms of hyponatremia can be subtle and consist mainly of changes in mental status, including altered personality, lethargy, and confusion. When hyponatremia is accompanied by disturbances in total body sodium content, signs of volume depletion or overload are also present. As the plasma Na falls below 115 mEq/L, stupor, neuromuscular hyperexcitability, convulsions, prolonged coma, and death can result. Rarely, initial improvement in response to treatment may be followed by delayed neurologic symptoms culminating in coma, persistent vegetative state, or death. To treat this, infuse Normal Saline and titrate to support blood pressure and perfusion. In the Emergency Department hypertonic Saline can be administered. Low sodium levels cannot safely be corrected it the field.
  • MDMA-related fatalities at raves have been reported. The stimulant effects of the drug, which enable the user to dance for extended periods, combined with the hot, crowded conditions usually found at raves can lead to dehydration , hyperthermia , and heart or kidney failure . Overheating, causing life threatening malignant hyperthermia and severe dehydration with sodium loss is a major complication associated with MDMA and many other abused drugs. MDMA causes the body's thermostat to malfunction. Very high core body temperatures have been reported. The overheating effect of ecstasy is exacerbated by the following factors: MDMA users are thought to dance well beyond the point of which a "normal" person would tire and sit down. DJ's play seamless sequences of records which keep dancers active, and therefore producing more heat, over long periods of time. The club atmosphere is hot and humid. The evaporation of sweat is an essential body defence mechanism to prevent overheating. Hyperthermia leads rapidly to Disseminated Intravascular Coagulation (DIC) and the victim bleeds to death (in the most severe cases). First excessive clotting occurs that depletes the body's clotting factors. The blood coagulation process uses the blood's clotting factors such as platelets, fibrinogen and other substances faster than they can be replaced. This leads to an absolute depletion in the quantity of these elements and is called Disseminated Intravascular Coagulation, or DIC. The result of the depletion of clotting elements is that the disorder causes significant internal bleeding. Bruising occurs, hemorrhage from body orifices, IV sites, gums and internally occurs. With MDMA the onset of DIC can occur very quickly. Gather as much information as possible from the scene. Frequently the patient is not in a position to admit to taking drugs due to loss of consciousness and the best source of information are friends. These friends are not likely to be as forthcoming as they might otherwise be if they fear the response of the accident and emergency staff. Confidentiality and an open and non judgmental attitude is not only the basis of an ethical approach to MDMA related problems, it is of vital clinical importance. The friends are your best source of information if the casualty is unconscious. They must feel confident in you. They must feel safe with you. The EMS provider must create a relationship of trust.
  • The first step in treating an MDMA overdose is to secure your personal safety and the patient's safety. MDMA may cause agitation and violent behavior. Obtain assistance from Police as needed. A rapid tranquilization procedure can be used if your local protocols allow. If the patient is otherwise agitated and unmanageable you may administer IV/IM benzodiazepine agent like diazepam or lorazepam, or a sedative-hypnotic agent like Droperidol. Be careful when using physical restraint to prevent positional asphyxia. Gather as much information as possible from the scene. Frequently the patient is not in a position to admit to taking drugs due to loss of consciousness and the best source of information are friends. These friends are not likely to be as forthcoming as they might otherwise be if they fear the response of the accident and emergency staff. Confidentiality and an open and non judgmental attitude is not only the basis of an ethical approach to MDMA related problems, it is of vital clinical importance. The friends are your best source of information if the pt is unconscious. They must feel confident in you. They must feel safe with you. The EMS provider must create a relationship of trust. Some users of MDMA experience a dramatic worsening of mood as the peak effects wear off, often called the "crash". This is often the result of coming down from a wonderful experience, not wanting the feelings to go away, and being sad, scared, or annoyed afterwards. Crashes do not happen after every experience and some users never experience them. One of the primary problems associated with crashing is that some users find themselves redosing in order to stave it off.
  • Hangover and the Week After Many users report feeling extremely drained the day after MDMA use. This 'day after' effect means for many MDMA users that they need to plan 2 days for the experience: one for the peak experience and one recovery day, with very little planned. Many users also experience some level of post-MDMA depression, often starting on the second day after the experience and lasting for up to 5 days. A small percentage of users report depressive symptoms for weeks afterwards. Alternately, some users report feeling better than normal for a week or so after taking MDMA. The negative after-effects of taking MDMA appear to be worse with higher frequencies of use, higher dosages, and perhaps total lifetime usage. Long-term users often describe increasingly uncomfortable and prolonged "burn-out" periods, sometimes lasting two or more days Sore throats, flu like s/s, and other symptom are reported, its MOA is poorly understood MDMA exerts amphetamine-like effects which include dilated pupils, dry mouth and throat, tension in the lower jaw, grinding of the teeth, and overall stimulation. These side effects are dose dependent and will vary depending on the health of the individual user
  • Long Term effects More prolonged “burn out” or “crash periods” up to a week later Depression for weeks (in small %) Renal failure Hangover and the Week After Many users report feeling extremely drained the day after MDMA use. This 'day after' effect means for many MDMA users that they need to plan 2 days for the experience: one for the peak experience and one recovery day, with very little planned. Many users also experience some level of post-MDMA depression, often starting on the second day after the experience and lasting for up to 5 days. A small percentage of users report depressive symptoms for weeks afterwards. Alternately, some users report feeling better than normal for a week or so after taking MDMA. The negative after-effects of taking MDMA appear to be worse with higher frequencies of use, higher dosages, and perhaps total lifetime usage. Long-term users often describe increasingly uncomfortable and prolonged "burn-out" periods, sometimes lasting two or more days Sore throats, flu like s/s, and other symptom are reported, its MOA is poorly understood MDMA exerts amphetamine-like effects which include dilated pupils, dry mouth and throat, tension in the lower jaw, grinding of the teeth, and overall stimulation. These side effects are dose dependent and will vary depending on the health of the individual user
  • antitussive analog of morphine Several years ago, JW Olney discovered that dizocilpine (MK-801), a chemical being tested to prevent brain damage from strokes, actually caused damage to specific areas of the brain in rats. Since this time, numerous other drugs in the same class (the dissociatives) have been tested, and they all share this problem. As some of you might know, I have spent a great deal of time trying to make sure that the Internet community, and the larger world, has detailed information about this complex, difficult-to-use, and often dangerous class of drugs.
  • Plataeus" 1. Mild but insignificant buzz, difficulty concentrating approx. <200mg 2. Drunk feeling, slight "not quite there" sensation, mild stoned sensation approx <400mg 3. Robot-like walking, very dialated pupils, usually clearly intoxicated (although they may not think it is apparent), confusion (moderate), euphoria (moderate), forgetfulness (moderate), closed eye hallucenations-- usually volentarily able to control them. approx <600 mg 4. This is a very strong dosage. Walking maybe near impossible, discordination is severe, hallucenations occur (almost certianly), pupil dilation, dissociation (aka on another planet), etc... approx 600-1500mg+ Since you're medics, I jump to (in my opinion) the most obvious signs of intoxication. 1. The "Robo-Walk" as it is called. Very distinctive, robotic like walking. (lifting knees higher than necessary). I know of no other drug that does this than possibly other dissociatives. 2. Dialated pupils (any significant quantity of DXM will cause this) 3. Mumbling words in a distinctive fashion. It's hard to describe. Very little lip movement. At this point there is usually moderate to severe confusion (where am I? who? wha?). 3. Fever, Sweating, Fast/Fluttery Heartbeat, The "Robo-Itch" (rash, very itchy) Music and/or dark rooms are "trippy as hell" on the third and fourth plataeus, and can induce confusion, euphoria, and especially hallucenations. Lighting is very importiant. Light rooms are comparable to alcohol intoxication, even on the upper 3rd plataeu. Dark rooms will cause hallucenations (visual-- not auditory). From most of the stories that I've read, overdoses and trips to the hospital usually occur for two reasons... 1. Getting caught by another person while messed up 2. Mixing multiple drugs together (such as "Tripple C" Cordicin Cough and Cold)-- which is especially dangerous 3. Severe DXM overdose (in excess of 1000mg). For this reason, you will likely get 4th plataeu cases in the hospital which can be very serious. Initally the third plataeu is generally respected as safe (as far as hard drugs go)-- but after developing a tolerance, they may overdose. Many people use 1g a day, two or three times a week without ever landing a trip in the hospital. Brain damage is almost certianly a side-effect in long-term extreme cases like this-- many people report having the "DXM hangover" (a weakened state of DXM intoxication) for weeks after ceasing use. This appears to be a mild form of HPPD ("flashbacks"), and in most cases will go away on it's own. Some users, however, have reported perminant brain damage (disconnected and isolated feeling similar to the first plataeu-- after 2g+ trips) lasting for years. This drug is most definately addictive. In my opinion, fear of death and ignorance of DXM as a dissociative have kept it in check until now. DXM is far more potent than marijuanna (if you can call weed a hallucenogen), and on par with (some say exceeding) the effects [and far exceeding the physical dangers] of LSD or ketamine. Since the rise of the internet (pharmacudical grade DXM powder), and OTC 15mg pills of pure DXM now available in many drug stores, DXM overdose will almost definately become an increasing concern. The foul tasting cough syrup used to keep DXM use in check (nausea would cause a major hinderance), is no longer effective since alternatives are available. P.S. For some reason DXM tolerance seems to remain long after ceasing use, which may contribute to overdosing. This drug needs to be taken more seriously. At the very least, put mild laxatives in the pure DXM pills (as they do in Japan). Anyone taking a normal dosage (15 mg) would not be affected by the laxatives, or at the very least outlaw the sale of pure DXM powder which is so frequently the cause of accidental DXM overdoses.
  • Additionally, prolonged use of DXM can and has led to psychosis similar to PCP-induced psychosis. Individual differences in NMDA receptors may be at work here, but you're still potentially at risk. Effects at low dosage can be similar to alcohol producing carefree clumsiness with a touch of psychedelic and speedy effect. Intense and rhythmic music induces a state of euphoria and dancing becomes fun. On a higher dose imagination can become vividly experienced (not always pleasant), feelings of dissociation from the body can occur and on very high doses profound alterations in consciousness. Doses greater than 1000 mg are generally regarded as foolhardy 1st plateau (1.5-2.5 mg/kg): 2nd plateau (2.5-7.5 mg/kg): 3rd plateau (7.5-15 mg/kg): 4th plateau (15mg/kg-): 5th plateau (usually reported above 30 mg/kg): Overdose
  • Warn anybody who may be abusing Coricidin HBP Cough & Cold pills (a/k/a "Triple C", and other names) as a source of DXM (dextromethorphan). Coricidin is NOT a safe source of DXM for tripping. In addition to the 30 mg of dextromethorphan contained in Coricidin HBP Cough & Cold per pill, they also contain 4 mg of chlorpheniramine maleate. This is an anticholinergic drug, a class of drug which in general is very dangerous to take in large doses with dextromethorphan. Worse yet, chlorpheniramine maleate is also metabolized by the same liver enzyme (known as CYP-2D6) as is DXM. The competition for this limited enzyme by the two drugs makes taking them together, in large doses, a dangerous combination. Coricidin appears to be orders of magnitude more dangerous as a source of DXM than OTC medicines that contain only dextromethorphan, such as Robitussin Maximum Strength cough syrup, or Dexalone, which is a gelcap containing only DXM sold in the US; regrettably nowhere as easy to find as Coricidin. A. Signs and symptoms · Dry mouth · Hyperpyrexia · Dry, flushed skin · Tachycardia · Blurred vision · Urinary retention, Constipation · Delirium   B. Physostigmine challenge when anticholinergic toxicity is suspected: · Have atropine 0.4mg at bedside (antidote) · Push physostigmine 1mg IV over 2-3min. · Monitor vitals, EKG (for bradycardia)
  • Anticholinergic deliriants (atropine, scopolamine, and anti-nausea drugs) may increase damage to the hippocampus Major tranquilizers (antipsychotics like haldol and thorizine) may specifically increase damage to certain areas Sometimes dextromethorphan hydrobromide can cause an unwanted side-effect of itching. This does not happen all the time, but usually happens in 1st and 2nd plateau doses. This is similar to an opiate itch, and is mostly due to a histamine reaction and possibly a skin irritation from bromide. This can be prevented by taking a normal dose of benadryl about 45 mintues prior to dosing. Also this usually does not happen with another form of DXM called Dextromethorphan Citrate, which is the output of Agent Lemon . If you do get this, scratching wont help, sometimes a cold shower can help, because heat is usually associated with the irritation.
  • Mental health referral is a necessary step for all DXM overdoses for both substance abuse screening and education as well as for neuropsychological evaluation for long-term side effects (Olney's Lesions)
  • LD50: 2,000 mg/kg (male rats), 1,650 mg/kg (female rats) Obviously this doesn’t directly correspond to humans HO-(CH2)3-COOH This is GHB. For the sodium salt replace the right most H with a Na. Pretty simple huh? The precursor to sodium oxybate is called butyrolactone or gamma-hydroxybutyric acid lactone. It is fairly readily available (at least where Alice comes from) and not overly expensive. I would estimate US$20 for 100ml. It is supposedly an excellent electrolyte for batteries and capacitors and is used as an intermediate for numerous compounds. See Merk Ed. 11,1596 for more information. From GHB or gamma-hydroxybutyrate is usually prepared in a form called sodium oxybate which is just the sodium salt of GHB hence its alternative name sodium gamma-hydroxybutyrate. Just to make things more complicated CAS refers to this salt as butanoic acid, 4-hydroxy, monosodium salt. In the earlier abstracts butyric replaces butanoic. GHB is listed in Merk Ed. 11,8603 under Sodium Oxybate. Production of GHB consists simply of mixing "lactone" (short for gamma butyrlactone) and lye (sodium hydroxide) in the proper amounts. The only equipment necessary for doing this in grey and black market production are: a scale which can measure grams accurately (or premeasured chemicals such as what comes with a GHB kit, though kits are much less available now that GHB has been scheduled in the U.S.), a container for the reaction, pH papers, and some human-safe acid such as vinegar or lemon juice, and someblue food coloring. The chemicals are mixed according to simple ratios which are available on the internet. The biggest dangers of black market GHB is that the originating chemicals are often not human-consumption grade and may contain impurities or contaminants. In practice, however, high grade lactone and sodium hydroxide have been easily accessible from online and local chemical suppliers. Neither lactone nor lye are currently controlled anywhere in the US to my knowledge (Jan '99). There are many chemical suppliers on the net and otherwise who sell these very common chemicals.
  • Very easy to make, no cooking is required. Since no longer commercially available, its potency in variable.GBL, GBH, BD & One 4 B are just a few analogs The sodium salt of gamma-hydroxybutyric acid is known as sodium oxybate and has a number of other chemical names. Gamma-butyrolactone (GBL) is an industrial solvent which can be purchased from chemical distributors and is used in the clandestine manufacture of GHB. GHB is produced in clandestine laboratories using a relatively simple synthesis. GHB, itself, is a solid substance but is generally dissolved in a clear liquid. Confiscated samples have been found in "spring water" bottles or disguised as mouth-wash. GHB is abused to produce euphoric and hallucinogenic states, and for its alleged role as a growth hormone releasing agent to stimulate muscles. GHB can produce drowsiness, dizziness, nausea, visual disturbances, unconsciousness, seizures, severe respiratory depression and coma. Overdose usually requires emergency medical treatment. Illicit Uses GHB induces a sense of euphoria and intoxication. It is sometimes mixed with alcohol to intensify its effects resulting in respiratory depression and coma. The typical dose is 1 - 5 grams of powder (depending on the purity of the compound this can be 1-2 teaspoons mixed in a beverage). GHB has been sold already mixed in liquid and dispensed by the water-bottle cap to the user. The saturation and concentrations of these "home-brews" have varied so that the user is not usually aware of the actual dose they are drinking. The onset of effects occurs within 15-30 minutes, and lasts 3-6 hours.   User Population GHB is popular with high school and college students. GHB is found at "rave parties" and upscale "smart-drink" nightclubs. Body-builders also abuse GHB for its purported anabolic effects. GHB has been used to assist in the commission of sexual assaults. DEA has documented 15 sexual assault cases involving 30 victims under the influence of GHB. Urinalyses were conducted on samples submitted from victims of alleged sexual assault; of the 711 drug-positive urines 48 tested positive for GHB.   Illicit Distribution At bars or "rave" parties GHB is sold for $10 per capful or "swig". The most typical route of administration is oral consumption. Major source to the street is through clandestine synthesis. The product has been disguised by adding food coloring, flavorings, and/or storing it in bottles. GBL, the solvent precursor for GHB, is also being abused due to its rapid conversion to GHB soon after ingestion. GBL is more biologically available than GHB. In January 1999 the FDA issued a request for a voluntary recall of all GBL-containing products sold in health food stores and warned the public of its abuse potential and danger to the public health. 1,4-butanediol (One 4 B), a chemical related to both GHB and GBL has also been declared a Class I Health Hazard. In 1999 the FDA issued another warning on 1,4 butanediol, GHB, and GBL stating that these pose a significant health hazard. To date, FDA investigators have investigated 124 cases involving large scale inter-state manufacture and distribution of GHB. Law enforcement agencies have encountered GHB on 850 occasions, including 150 clandestine laboratories, and 500 seized and analyzed laboratory exhibits.  Control Status The "Hillary Farias and Samantha Reid Date-Rape Prohibition Act of 1999" (Public Law 106-172) was signed on February 18, 2000. On that date, GBL became a List I chemical, subject to the criminal, civil and administrative sanctions of the Controlled Substances Act. On March 13, 2000, GHB was made a Schedule I controlled substance (65 FR 13235-13238).At the recommendation of the W.H.O., the Commission on Narcotic Drugs on 20 March 2001 added GHB in Schedule IV of the 1971 Convention of Psychotropic Substances. *(including federal, state and local cases of possession, trafficking, clandestine manufacturing, forensic analyses) sucol-B, an alternative name for 1,4-butanediol GBL: gamma-butyrolactone, furonone di-hydro dihydrofuranone Metabolizes to GHB. BD: 1,4-butanediol, tetramethylene glycol, sucol-B, butylene glycol Precursors for GBL , which then become GHB. GHV: gamma-hydroxyvalerate, Valeric Acic, methyl-GHB* Is its own separate metabolite, however clinically is almost exactly like GHB GVL: gamma-valerolactone, 4-pentanolide, Precursor to GHV
  • GHB or gamma-hydroxybutyrate is usually prepared in a form called sodium oxybate which is just the sodium salt of GHB hence its alternative name sodium gamma-hydroxybutyrate. Just to make things more complicated CAS refers to this salt as butanoic acid, 4-hydroxy, monosodium salt. In the earlier abstracts butyric replaces butanoic. GHB is listed in Merk Ed. 11,8603 under Sodium Oxybate.
  • GHB is usually abused either for its intoxicating, sedative, and euphoriant properties. GHB's intoxicating and depressant effects on the CNS begin 10 to 20 minutes after the drug is taken orally. The effects typically last up to 4-6 hours, depending on the dosage. At lower doses, GHB can relieve anxiety and produce relaxation; however, as the dose increases, the sedative effects may result in sleep and eventual coma or death. The line between achieving euphoric effects and toxicity resulting in life threatening side effects is very narrow. GHB is often used with alcohol potentate its effects and increasing the likelihood of side effects and toxicity. Dose Effect 10 mg/kg Amnesia, hypotonia 20 mg/kg Drowsiness, somnolence, dizziness, euphoria 50 mg/kg Vomiting, bradycardia, Cheyne-Stokes respirations, seizures, coma and death.
  • Add from High Times
  • GHB is usually abused either for its intoxicating, sedative, and euphoriant properties. GHB's intoxicating and depressant effects on the CNS begin 10 to 20 minutes after the drug is taken orally. The effects typically last up to 4-6 hours, depending on the dosage. At lower doses, GHB can relieve anxiety and produce relaxation; however, as the dose increases, the sedative effects may result in sleep and eventual coma or death. The line between achieving euphoric effects and toxicity resulting in life threatening side effects is very narrow. GHB is often used with alcohol potentate its effects and increasing the likelihood of side effects and toxicity. Dose Effect 10 mg/kg Amnesia, hypotonia 20 mg/kg Drowsiness, somnolence, dizziness, euphoria 50 mg/kg Vomiting, bradycardia, Cheyne-Stokes respirations, seizures, coma and death.
  • GHB in pure form is clear & thicker than water; it bubbles when shaken. But it can be dyed any color, watered down & not all of its “analog” cousins bubble. It may also be seen in powder, capsule or a “putty” form.
  • Sweet or cinnamon flavored liquors like Goldschlager, Jagermeister, drinks such as Long Island Ice Tea, Hot Damn & other shots, fruity drinks, odd concoctions, all designed to hide the typically salty taste of GHB.
  • THEN THE NIGHT COMES words and music by: Billy Idol/Mark Younger-Smith, 1993 …. “Then the night comes She's gonna be free Yeah, then the night comes I'm gonna be me Then the night comes Baby make me If the devil comes He's gonna tangle with me I take some GHB I feel love, joy And wonderful ringing music Now, I just got to be me We're here now, embrace this madness We're here now, for sorcery We're here now, there is no sadness So take this town and bring it down When the night comes…” People Weekly, Nov 15, 1993 He had an overdose of GHB in LA either in 1993 or 94, depending on source, mixed with cocaine per 1 report
  • Actor Nick Nolte faces a six month prison spell if he fails to control his drug taking. The movie star was handed a three-year probation sentence in a Malibu, California, courthouse yesterday morning after pleading no contest to charges of driving under the influence of a controlled substance. He was arrested on September 11 after police spotted him driving recklessly. He later tested positive for an illegal club drug Ghb. Nolte's probation period will include drug counseling and testing. He was praised for his own self-imposed stint in rehabilitation, which the actor is still continuing.
  • Coma and seizures can occur following abuse of GHB and, when combined with methamphetamine, Alcohol, or MDMA there appears to be an increased risk of seizure. Combining use with other drugs such as alcohol can result in nausea and respiratory depression . ALCOHOL IS THE MOST COMMON DRUG CO CONSUMED IN GHB RELATED DEATHS GHB may also produce withdrawal effects, including insomnia, anxiety, tremors, and sweating. Because of concern about Rohypnol, GHB, and other similarly abused sedative-hypnotics, Congress passed the "Drug-Induced Rape Prevention and Punishment Act of 1996" in October 1996. This legislation increased Federal penalties for use of any controlled substance to aid in sexual assault. GHB is cleared from the body relatively quickly, so it is sometimes difficult to detect in emergency rooms and other treatment facilities. In fact, only about 2-5% of GHB is excreted renally. In those cases where it has been renally excreted, GHB can be found in urine samples that test specifically for the substance within 4-7 hours after ingestion. GHB is not part of routine urine toxicological testing.
  • There were some homicide cases linked to GHB, it is believed that the subject used GHB in a date rape type of scenario, and when the victim did not respond quickly enough, that more GHB was added to her drink, becoming toxic.
  • Dose Effect 10 mg/kg Amnesia, hypotonia 20 mg/kg Drowsiness, somnolence, dizziness, euphoria 50 mg/kg Vomiting, bradycardia, Cheyne-Stokes respirations, seizures, coma and death. Use with alcohol and stimulants (Meth, MDMA) are known to potentiate its effects. Seizures, Sudden onset of coma: Most often the cause of EMS notification
  • It is worth noting that alcohol severely exacerbates GHB’s effects. GHB analog Butanediol and Ethanol are metabolized through the same pathways, making concombant use of ETOH very dangerous.
  • As with other CNS depressants the emergency management is geared towards supporting a patient airway, supporting ventilation, oxygenation and adequate perfusion. There are no specific antidotes or completely safe reversal agents that can be administered. Although Physostigmine, a cholinergic drug, has been shown to reverse sedation, it is widely believed that the risks of bradycardia, seizures, AV block, cholinergic crisis, or asystole outweigh the potential benefits of reversal. Provide a patent airway. Suction sections as needed. Anticipate vomiting. Consider and assess for associated trauma or sexual assault that may have occurred. Position the patient for airway protection and to optimize perfusion. Oxygenate and ventilate if hypoventilation occurs. Reassess often for changes. Assess for concomitant problems such as hypoglycemia, opiate overdose, alcohol ingestion, other drugs. Monitor the cardiac rhythm. Bradycardia accompanies approximately 36% of ingestions. If bradycardia is present Atropine may be administered to hemodynamically unstable patients. Documented cardiac rhythms include first-degree heart block, atrial fibrillation, right-bundle branch block, and ventricular ectopy. Hypotension accompanies about 10% of GHB ingestions. This usually is associated with co-ingestion of GHB and alcohol or another drug and usually is mild. If hypotension is not resolved readily by stimulation or atropine administration, another ingestion or co-ingestion must be considered. When co-ingestion of another substance is suspected gastric decontamination by lavage with Activated charcoal with sorbitol is indicated. because GHB is rapidly absorbed from the GI system, lavage with an isolated GHB ingestion is probably not useful. Keep the patient warm. Mild hypothermia has been reported in about 70% of cases.
  • A recent study noted that two thirds of patients present with a GCS of less than 9, and a full third present with a GCS of 3. According to physician reports one peculiar characteristic of GHB toxicity is that patients often demonstrate extreme combativeness and agitation despite such profound CNS and respiratory depression. Several physicians have been surprised when the individual suddenly awakens during an intubation attempt. The coma usually lasts from 3 to 6 hours and spontaneously resolves. Those patients intubated for respiratory depression typically have a longer time to recovery, but extubation within 8-10 hours is common; extubation in the ED has been described. The resolution is characteristically rapid and usually accompanied by seizure-like movements, myoclonic jerks and agitation. (Cameron,, 2001)
  • Drug Slang Terms (NB: many of these refer to the carrier, ie, "Blotter" or "Sugar Cubes". Often the local names will refer to patterns printed on the blotter, eg, "Blue unicorn".): Acid, 'Cid, Sid, 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, Hits, Paper acid, Sacrament, Sandoz, Sugar, Sugar lumps, Sunshine, Tabs, Ticket, Twenty-five, Wedding bells, Windowpane, etc.
  • In spite of the impressive degree of prior problems noted in many of these patients, there are occasional reports of severe and prolonged reactions occuring in basically well adjusted individuals. In the same vein, there are many instance of faily poorly adapted individuals who suffer _no_ ill effects from repeated psychedelic drug use. In fact, it has been hypothesized that some schizophrenics do not suffer adverse reactions because of their familiarity with such acute altered states. Another possibility is that there individuals may be "protected" by possible "down- regulation" of the receptors for LSD, bu the (over-)production of some endogenous compound. _Individual_ prediction of adverse reactions, therefore, is quite difficult... Hensala et al. compared LSD-using and non-LSD-using psychiatric inpatients. They found that this group of patients was generally of a younger age and contained more characteristically disordered individuals than the non- LSD-using group. Patients with specific diagnoses with or without LSD histories were not compared. Based on their observations, they concluded that LSD was basically just another drug of abuse in a population of frequently hospitalized individuals in the San Francisco area, and that it was unlikely that psychedelic use could be deemed etiological in the development of their psychiatric disorders
  • The effect sets in after 30 to 90 minutes and gen- erally lasts 5 to 12 hours. However, intermittent distur- bances of affect may occasionally persist for several days. 1973: "Of 189 samples of LSD quantitatively analyzed, the average dose was 67.25ug LSD. Useful dose is 50-200 mcg, with “Transcending doses as high as 500 mcg
  • LSD acts to preferentially inhibit serotonergic cell firing and seems to spare postsynaptic serotnergic receptors. This preference is shared by other simillar hallucinogens but in a limited fashion. Nonhallucinogenic analogs of LSD show no preference. These results suggest that there are two different steric conformation of serotonergic receptors, one of which has higher affinity for LSD than the other. In general, 5-ht is an inhibitory transmitter; thus, when its activity is decreased, the next neuron in the chain is freed from inhibition and becomes more active. blocks 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 "classical" psychedelic drugs such as LSD, psilocybin and mescaline.
  • Since serotnergic systems appear to be intimately involved int eh control of sensation, sleep, attention, and mood, it may be possible to explain the actions of LSD and other hallucinogens by their disinhibition of these critical systems. There is also evidence for interaction with dopaminergic systems. These include an oxytocic action and constriction of the blood vessels of isolated vascular beds. In intact animals LSD causes a fall in blood pressure, but its adrenergic blocking potency is low. LSD causes mydriasis in man and other species. It also causes hyperglycaemia and mydriasis, has a hyperthermic action and causes piloerection. These effects are sympathetic in nature and are abolished by ganglion blocking or adrenergic blocking agents. Parasympathetic effects include salivation, lachyrmation, vomiting, hypotension, and brachycardia. Low doses stimulate respiration but larger doses depress it. (NB: mydriasis = pupillary dilation) The "speedy" quality of unadulterated LSD is due to the pharmacological actions of LSD itself, and not necessarily due to decomposition or impurities. LSD typically causes early adrenergic effects such as sweating, nervousness, jaw grinding and insomnia which are easily confused with the side effects of amphetamine. Actually, I think the fact that PharmChem analyzed something on the order of 2,000 LSD samples between 1972 and 1979 and never found one with strychnine in it would be better. I'm going over all their data with a toothpick and I'll get back to you on exactly what I find. It looks like the percent of LSD with strychnine in it is, however, at least under .05%. More a little later. The reported LD50 values for LSD are 46, 16.5, 0.3 mg/kg I.V. for mice, rats, and rabbits, respectively. Again, it's hard to accurately translate these numbers to oral values. Note that an average human dose is 0.001 mg/kg, ie, 1 microgram/kg, ie, 1 part per billion by weight.
  • Insomnia occurs frequently after the trip. A mild, over-the-counter sleeping aid can help, and these antihistamines do not produce adverse interactions. Also, some people like to consume a small amount of alcoholic beverage to "smooth the jitteries". The usual precautions about sleeping aids if alcohol has been consumed apply of course.
  • ADDICTION POTENTIAL: Zero physical addiction potential. Not something that makes you want to do it again immediately. Essentially zero psychological addiction potential. Rarely people use it to escape in a negative way or as part of "polydrug abuse" behavior or pattern of behavior. Usually in this case other drugs are causing more harm, and the fundamental problem is a personal difficulty; the escapism/distraction is a symptom. The mental effects of Delysid can be rapidly reversed by the i.m. administration of 50 mg. chlorpromazine. Literature available on request. SANDOZ LTD., BASLE, SWITZERLAND 9792*-Z1540 e.-sp./d.-fr. Printed in Switzerland. ..... ~From: An Introduction to Pharmacology 3rd edition, JJ Lewis, 1964 (p 385) Peripheral Actions
  • MDMA and other abused drugs can have serious consequences that are often unpredictable. EMS providers need to understand the unique problems associated with MDMA, realize the likelihood of a multiple drug and alcohol ingestion and be prepared for any of the medical complications that can occur. The drugs continue to gain popularity and the data indicate this is not a passing trend.
  • Lorna Spinks before taking Ecstasy One friend told the inquest how he saw Miss Spinks shortly before she was taken to hospital. "I saw Lorna coming towards me. She came and gave me a big hug. "Her skin was so hot all over. Her words were not coming out correctly. They were backwards or gibberish. "She was losing her sense of balance. I physically had to hold her to take her to the toilet." The friend said shortly afterwards security staff had called an ambulance and he saw Miss Spinks being taken away. Lorna was squirming so violently they had to strap her down. "She was also foaming at the mouth." Recording a verdict of death by misadventure, coroner David Morris said young people should be aware of the dangers when taking ecstasy because of its unpredictability. Miss Spinks died in hospital after spending 36 hours on a life support machine. Her parents, Alan and Elizabeth Spinks, released a picture of their daughter's body pictured shortly after she died.
  • MAY, 2001 The parents of a teenager, who died after taking Ecstasy, have released a picture of their daughter's body as a warning to other users. Lorna Spinks, who was studying sociology at Anglia Polytechnic University, Cambridge, was pictured at Addenbrooke's Hospital in Cambridge shortly after she died as a result of taking the drug. Police said she had taken two lime-coloured pills marked with a euro symbol before visiting The Junction nightclub in Cambridge. Miss Spinks' parents, Alan and Elizabeth, have been praised by the father of Leah Betts, who also died after taking Ecstasy Miss Spinks' parents were at her bedside when their daughter died. Her mother, who described her daughter as a "golden girl", said: "To see a child like Lorna, who was so, so pretty and when she was dying she looked like a monster who had been run over by a truck. "All her organs had been affected. She had been bleeding from everywhere. She couldn't do anything on her own and eventually her heart gave out." Paul Betts, whose daughter Leah died in 1995 after taking Ecstasy at her 18th birthday party at her home in Latchingdon, Essex, said the couple should be applauded for "sticking their heads above the parapet". Mr Betts, 55, a former policeman, agreed for a picture of his daughter to be released to the media while she was alive, but unconscious. "I've never regretted my decision about the photograph of Leah. If it saved one life it was worth it," he said. "I applaud Lorna's parents for their courage and for sticking their heads above the parapet. It must have been incredibly hard. But it may save a life. "I would encourage the media to use the picture. It will remind people of the damage drugs can do and bring home the reality of the situation." Cambridgeshire Police said Miss Spinks' parents had wanted their daughter to be photographed while she was in a coma but the student had died before the picture could be arranged. "They wanted the photograph to be taken in the hope that it would serve as a warning and after discussions we agreed to that," said the spokeswoman. "We hope that it will portray the full horror of what drugs can do - although we expect to be criticised because many people will not doubt feel it is in bad taste."
  • Since middle school, Shanna West had tried just about everything: She drank beer and smoked marijuana, she popped pills and snorted cocaine. Shortly before she turned 21, friends introduced her to a new high: GHB. It was cheap, easy to get and it calmed her racing mind. It had one other thing going for it -- the cops couldn't tell she was on it. The drug got her into trouble when she drove because, just like that, she would fall unconscious. She once passed out driving the Crosstown Expressway; her Chevy Cavalier bounced twice off the guardrail and barrelled 30 feet the wrong direction down the highway. The police drawing of her accident looked like a big curlicue. But the cop didn't smell alcohol and didn't know to test for GHB. He concluded that West lost control for "unknown reasons," ticketed her for careless driving and sent her on her way. Two weeks later, it happened again. She passed out at a red light on Dale Mabry Highway. When an officer opened her car door, she didn't even budge. But when paramedics arrived, it was like somebody snapped his fingers: She leaped from her seat and started talking . She blew a 0.00 on a Breathalyzer test and could have gotten away with it again , but this time she told the officers she had been drinking from the bottle on her front seat. It had GHB in it. Charged with driving under the influence, she bonded out of jail a few minutes before sunrise, her driver's license in good standing. At her boyfriend's place late that afternoon, West dropped two shots of GHB into a bottle of Arizona Iced Tea, downed it and slid back behind the wheel. She headed north on U.S. 41 into Pasco County. She had been out of jail less than 12 hours. As day wore toward dusk, West drove U.S. 41 toward her friend's house in Land O'Lakes, where she had grown up and attended school. She stopped at a convenience store and tore out of the parking lot minutes later, wheels screeching, headed north. In the front seat she carried the Arizona Iced Tea bottle with its extra ingredient. She started to fall in and out of consciousness at State Road 54 and U.S. 41; she remembers little of the next 8 miles. "I was swerving all around the road, but I didn't have control enough to pull over," she recalled later. What West has trouble remembering, Ron Nichols of Spring Hill cannot forget. "She passed me on the right side, over in the grass," Nichols said. "I was blinking my lights, honking my horn, just trying to get her attention. I've never seen anyone drive like that in my life. It looked like she had a death wish." In a Chevy Corsica heading in the other direction, Maria Florez and her two daughters were going to a School Board meeting in Land O'Lakes, where 14-year-old Virginia was to receive a college scholarship. In the front seat was 54-year-old Barbara Mercer, who had grown close to the family helping Habitat for Humanity build them a house in Dade City. Florez saw West's headlights up ahead weaving across the two-lane highway. Florez tried to swerve out of the way, but it was too late. West crossed the center line a final time. Barbara Mercer was dead.
  • Samantha left for the movies on Jan. 16, 1999, with two of her girlfriends and two male friends from high school. GHB and/or GBL was slipped into her Mountain Dew soft drink that night. Samantha was taken to the hospital with no vital signs and died after 18 hours on life support. The boys from high school are now serving 5 1/2 to 15 years in prison for the manslaughter death of Samantha...
  • Street Drugs Down And Dirty

    2. 2. Revision Info <ul><li>Revised 06-13-05 </li></ul><ul><li>For more information, contact </li></ul><ul><ul><li>Steve Cole </li></ul></ul><ul><ul><li>[email_address] </li></ul></ul>
    3. 3. Where our motto is :
    4. 4. Why am I talking to you today?
    5. 5. OBJECTIVES <ul><li>Quick intoduction to the drug culture </li></ul><ul><li>Quick review of the following drugs: </li></ul><ul><ul><li>Heroin and Oxycontin </li></ul></ul><ul><ul><li>MDMA and PMA </li></ul></ul><ul><ul><li>DXM </li></ul></ul><ul><ul><li>GHB </li></ul></ul>
    6. 6. The Rave…
    7. 7. The Rave Culture <ul><li>Generally speaking, “Rave” applies not just to the parties but to an entire subculture </li></ul><ul><li>Not just “Night time” Parties at clubs </li></ul><ul><li>Can extend into multi-day events (Burning Man) </li></ul><ul><li>Hallmarked by techno/new age music and Psychedelic visual displays. </li></ul>
    8. 8. Anatomy of a Rave
    9. 9. Anatomy of a RAVE <ul><li>Day or Night </li></ul><ul><li>Tend to be “Sponsored” (A.K.A. “Promoters”), limits liability on both sides </li></ul><ul><li>Sometimes marketed as “Drug Free Teen Dance Parties” </li></ul><ul><li>If not at a formal club, they tend to be located in remote locations to limit outside interference. </li></ul><ul><li>Often will have a DJ instead of a band. Some DJ’s are celebrities, called the “A-List”, traveling a “Circuit ” ($1000-5000/hr) </li></ul>
    10. 10. Anatomy of a Rave <ul><li>Remember, the overall event doesn't have to be a rave to have a strong Raver presence….. </li></ul>
    12. 12. Anatomy of a Rave- Clues <ul><li>Light Sticks </li></ul><ul><li>Water/Gatorade Bottles for sale </li></ul><ul><li>H2O shut off in bathroom </li></ul><ul><li>Crash Rooms/Candles/Etc. </li></ul><ul><li>Have Dance Breaks/cool down periods </li></ul><ul><li>In Idaho we are mainly seeing these in remote locations. </li></ul>
    13. 13. Lights are Captivating <ul><li>Three or more work on one X user’s eyes, up close & personal. Some lights are very bright. </li></ul><ul><li>It’s called “Eye Candy” </li></ul>
    14. 14. More “Eye Candy” <ul><li>Glow sticks of all sizes </li></ul><ul><li>Special mouthguards </li></ul><ul><ul><li>Protect from swallowing mini glow sticks </li></ul></ul><ul><ul><li>Also less visible than the pacifiers </li></ul></ul>
    15. 15. Why Face Masks & Vicks? <ul><li>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. </li></ul><ul><li>Remember, many report things like “being burned by a cigarette feels good.” It’s all about sensation </li></ul>
    16. 16. It’s About Sensation <ul><li>Many carry personal vibrators. Notice the “x” & “e” & butterfly beads. Butterfly is a common emblem for Ecstasy. </li></ul><ul><li>Every touch feels good. </li></ul><ul><li>They may rub each other with things like Tiger Balm or with hair brushes or gloves with the “gripper dots” to intensify touch. </li></ul>Vibration of the music through the balloon feels good too.
    17. 17. Drug Paraphernalia <ul><li>MDMA causes “bruxism”—teeth grinding & involuntary jaw locking; damages teeth. </li></ul><ul><li>Pacifiers, lollipops, mouthguards & other things to suck help reduce this. </li></ul><ul><li>Hidden compartments </li></ul>
    18. 18. GHB Test KITS False Security
    19. 19. Harm Reduction <ul><li>Web sites </li></ul><ul><ul><li> </li></ul></ul><ul><ul><li> </li></ul></ul>
    20. 20. WWW.EROWID.ORG
    21. 21. <ul><li> </li></ul><ul><li>Non Profit </li></ul><ul><li>Drug testing kits </li></ul><ul><li>Drug warnings </li></ul><ul><li>Drug testing and postings </li></ul><ul><li>HARM REDUCTION </li></ul>
    22. 22. What To Expect
    23. 23. Anatomy of a Rave-Common Medical concerns <ul><li>Severe Dehydration and Hyperthermia </li></ul><ul><li>Poly-Pharm involvement </li></ul><ul><li>Date Rape </li></ul><ul><li>Multiple Patients (approach with a plan) </li></ul><ul><li>Volatile Crowds </li></ul>
    24. 24. Interacting with Ravers <ul><li>Remember there is a cultural distrust </li></ul><ul><li>Don’t be afraid to ask for interpretation of slang </li></ul><ul><li>Generally not overtly violent singularly, but beware of crowds </li></ul><ul><li>Our attitude and interaction may have a positive or negative impact on the crowd. </li></ul><ul><li>Check for a “Trip Sitter” </li></ul>
    25. 25. Safety <ul><li>Hazards: Uncontrolled Scenes </li></ul><ul><ul><li>Patients </li></ul></ul><ul><ul><li>Environment </li></ul></ul><ul><ul><li>Bystanders </li></ul></ul><ul><ul><li>Weapons </li></ul></ul><ul><ul><li>CLAN LABS </li></ul></ul><ul><li>Tactics learned from law enforcement community </li></ul><ul><ul><li>Staging </li></ul></ul><ul><ul><li>Isolation and Control </li></ul></ul><ul><ul><li>Scoop and swoop </li></ul></ul><ul><ul><li>Travel in Packs </li></ul></ul>
    26. 26. SAFETY for the PT. <ul><li>Pt safety poses an extreme challenge for EMS </li></ul><ul><ul><li>Drug Interactions </li></ul></ul><ul><ul><li>Rapid Changes </li></ul></ul><ul><ul><li>Restraint </li></ul></ul>
    27. 27. The Drugs
    28. 28. Heroin and Oxycontin
    29. 29. Opiate Abuse
    30. 30. Coming to a Home near you!
    31. 31. Heroin <ul><li>Black Tar </li></ul><ul><li>China White </li></ul><ul><li>Speed Ball </li></ul><ul><li>Homicide, Buick, super Buick, twilight sleep </li></ul>
    32. 33. Methods of use: <ul><li>Shooting: </li></ul><ul><li>Skin Popping: </li></ul><ul><li>Muscle Popping: </li></ul><ul><li>Chasing the dragon: Smoking </li></ul><ul><li>Freebasing </li></ul><ul><li>Dirty Hit: </li></ul>
    33. 34. Oxycontin / MS Contin <ul><li>Time released capsules, some may have more than 100 mg </li></ul><ul><li>Often crushed and snorted, eliminating the “time release” </li></ul><ul><li>May be crushed, diluted, and injected like traditional heroin </li></ul><ul><li>Becoming much more common </li></ul>
    34. 35. Methadone <ul><li>Reportedly Harder to “kick” than Heroin </li></ul><ul><li>Like other prescription opiates, WIDELY Available </li></ul><ul><li>One study showed of 18 methadone related deaths: </li></ul><ul><ul><li>Less than ½ were prescribed methadone </li></ul></ul><ul><ul><li>Only three were prescribed methadone through a methadone tx program </li></ul></ul>
    35. 36. Duragesic <ul><li>Fentanyl Citrate </li></ul><ul><li>Transdermal Absorbtion </li></ul><ul><li>Used in chronic pain patients </li></ul><ul><li>100 times the potency of morphine </li></ul><ul><li>Fastest growing method of opiate abuse </li></ul><ul><li>Commonly Used for chronic pain </li></ul><ul><li>Synthetic opioid </li></ul><ul><li>Easily Acquired </li></ul><ul><li>Easily abused </li></ul>
    36. 37. Duragesic- methods of abuse <ul><li>Almost 70 fold increase in use from 1995-2002 (DAWN) </li></ul><ul><li>Rate of use is increasing. </li></ul><ul><li>Street price between $10-100/PATCH </li></ul><ul><li>Methods of abuse </li></ul><ul><ul><li>Topical </li></ul></ul><ul><ul><li>Injected </li></ul></ul><ul><ul><li>Chewed </li></ul></ul><ul><li>Oral Conversion </li></ul><ul><ul><li>Up to 50% may be lost in conversion, so it is often frozen first. </li></ul></ul><ul><ul><li>Preservatives may cause liver problems </li></ul></ul><ul><ul><li>25 ug/hr = 2.5 mg avail </li></ul></ul><ul><ul><li>50 ug/hr = 5 mg avail </li></ul></ul><ul><ul><li>75 ug/hr = 7.5 mg avail </li></ul></ul><ul><ul><li>100 ug/hr = 10 mg avail </li></ul></ul>
    37. 38. S/S OF AN OPIATE OVERDOSE <ul><li>Pin Point Pupils </li></ul><ul><li>Hypotension </li></ul><ul><li>N/V </li></ul><ul><li>Respiratory/CNS depression </li></ul><ul><li>Aspiration and Hypoxia </li></ul><ul><li>Hallucinations </li></ul><ul><li>Other s/s? Think poly-pharm involvement </li></ul><ul><li>Dirty Needles (“Diabetics”) </li></ul><ul><li>Cotton balls, Cig Filters </li></ul><ul><li>Spoons w/ residue or similar improvised device </li></ul>
    38. 39. BASIC TREATMENT <ul><li>Ventilation/stimulation first </li></ul><ul><li>Slow admin of Narcan, just enough to make them breath </li></ul><ul><ul><li>Narcan 0.4 mg-2 mg traditional, may need higher doses </li></ul></ul><ul><li>High doses may be needed if drug is synthetic </li></ul><ul><li>Watch for re-sedation due to Narcan’s short duration (about 20-30 minutes) </li></ul>
    39. 40. Long Term problems <ul><li>HIV, HEP-A/B/C, </li></ul><ul><li>BLOOD POISONING (Septicemia) “Cotton Fever” </li></ul><ul><li>ENDOCARDITIS </li></ul><ul><li>TETANUS </li></ul><ul><li>NECROTIZING FASCIITIS (Flesh-Eating Disease) Associated w/ black tar </li></ul><ul><li>WOUND BOTULISM </li></ul><ul><li>TRACKING AND BRUISING </li></ul><ul><li>CONSTIPATION, BOWEL OBSTRUCTION </li></ul>
    40. 41. Some weird things that have been done with a Heroin OD by Junkies <ul><li>Injected someone with salt water or Milk This is an old junky myth sometimes still used. </li></ul><ul><li>Injected someone who overdosed on heroin with cocaine or speed, or vice versa . Another old myth. </li></ul><ul><li>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) </li></ul><ul><li>Put ice on their genitals (down their pants) . </li></ul><ul><li>Placed in a cold shower </li></ul>
    41. 42. Dependence, Detox, and Withdrawal <ul><li>medical detoxification is usually accomplished by giving decreasing doses of a long-acting opiate like methadone. </li></ul><ul><li>While not truly physically addictive, Heroin withdrawal is clearly extremely uncomfortable and painful. </li></ul><ul><li>The previously suppressed Locus Coeruleus is believed responsible for most of the clinical problems: anxiety, HTN, agitation </li></ul>
    42. 43. MDMA and PMA
    43. 44. Introduction <ul><li>methylenedioxy-n- methylamphetamine (MDMA) </li></ul><ul><ul><li>MDMA is *chemically* an amphetamine, but psychologically its what's known as an empathogen-entactogen </li></ul></ul><ul><ul><li>Shares similarities to both mescaline (a hallucinogen) and amphetamines </li></ul></ul><ul><li>Para-methoxyamphetamine, ( PMA) , 4-METHOXYAMPHETAMINE </li></ul><ul><ul><li>Chemically similar to MDMA, first created almost 25 years ago </li></ul></ul><ul><ul><li>Since its cheaper to make, and uses non controlled substances, PMA is often misrepresented as MDMA. </li></ul></ul><ul><ul><li>At doses considered “safe” for MDMA, PMA is highly toxic. </li></ul></ul>
    44. 45. PMA <ul><li>Use is identical to MDMA, PMA is more toxic than MDMA </li></ul><ul><li>It often appears identical to MDMA, sometimes simply thicker. </li></ul><ul><li>Its onset of action is longer (almost 60 minutes) compared to MDMA at 15-30 minutes </li></ul><ul><li>Users will re-dose thinking its MDMA and push them selves into the toxic range </li></ul><ul><li>Some people think they know their MDMA dose and apply this to PMA, thus going toxic </li></ul><ul><li>Substances like Cocaine and Methamphetamine may exacerbate the toxic effects of either PMA or MDMA </li></ul>
    45. 46. PMA and MDMA <ul><li>Taken in tabs although inhalation and injection have been infrequently reported. </li></ul><ul><li>Effects generally appear within 15-30 minutes (MDMA) or almost 60 minutes (PMA). </li></ul><ul><li>The usual dose ranges from 100 to 150 mg. Toxicity may be seen at doses as little as 175 mg </li></ul>
    46. 47. MDMA/PMA how It Looks <ul><li>Powder </li></ul><ul><li>Pressed pills </li></ul><ul><li>Capsules (may not be full) </li></ul><ul><li>Wide range of logos </li></ul><ul><li>Wide variety of colors & shapes </li></ul><ul><li>Nicknames reflect logos & colors </li></ul><ul><li>Designed to look “innocent” & thus “harmless.” </li></ul>“ Euros”
    47. 48. MDMA/PMA Packaging <ul><li>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. </li></ul>
    48. 49. MDMA /PMA Toxicity Mild s/s <ul><li>Jaw clenching (Lower Jaw)/teeth grinding, and scratching (think Tweekers) </li></ul><ul><li>Nystagmus, Dilated Pupils </li></ul><ul><li>Tremors </li></ul><ul><li>Tachycardia, increased B/P </li></ul><ul><li>Sensation of chills (secondary to elevated temp) </li></ul><ul><li>Auditory Hallucinations (non specific)/sensitivity </li></ul><ul><li>Orthostatic s/s, syncope secondary to dehydration </li></ul>
    49. 50. MDMA/PMA Toxicity Major S/S <ul><li>Severe Dehydration with Hyponatremia </li></ul><ul><li>Malignant Hyperthermia (Think Heat Stroke, but worse) </li></ul><ul><li>Disseminated Intravascular Coagulation (DIC) (may have rapid onset) </li></ul><ul><li>Decreased LOC/Coma </li></ul><ul><li>Stroke S/S, Seizures </li></ul><ul><li>Severe Tachycardia, HTN, CHF </li></ul><ul><li>Kidney Failure </li></ul>
    50. 51. MDMA/PMA Basic Tx <ul><li>Calm low stimulus environment </li></ul><ul><li>VOMIT (standard ALS) </li></ul><ul><li>Fluid Resuscitation as needed for hypotension, dehydration, and/or orthostatic s/s </li></ul><ul><li>Active cooling if indicated </li></ul><ul><li>Core Temp if unresponsive </li></ul>
    51. 52. Long Term effects <ul><li>More prolonged “burn out” or “crash periods” up to a week later </li></ul><ul><li>Dental Damage </li></ul><ul><li>Depression for weeks </li></ul><ul><li>Renal failure </li></ul>
    52. 53. MDMA Focused Tx <ul><li>Benzodiazepines </li></ul><ul><ul><li>Ativan 0.5-2 mg </li></ul></ul><ul><ul><li>Valium 2.5-10 mg </li></ul></ul><ul><li>beta blockers have fallen out of favor (like Brevibloc), Consider an adrenergic blocker w/ alpha blocker properties as well. </li></ul>
    53. 54. Take Home Information <ul><li>Core Temp if unresponsive </li></ul><ul><li>Fluid Resuscitation </li></ul><ul><li>Sedation PRN </li></ul><ul><li>Watch for DIC, SZ </li></ul><ul><li>P.U.H.A. IF GROSSLY SYMPTOMATIC. </li></ul>
    54. 55. DXM- Introduction <ul><li>Yes, its in cough syrup OR COUGH TABS (CORICIDIN)”TRIPPLE C” </li></ul><ul><li>Dextromethorphan acts as a cough suppressant via its agonist (activating) activity at mu-opioid receptors. </li></ul><ul><li>In Canada: Contac CoughCaps (30 mg DXM) </li></ul><ul><li>Related in effects to Ketamine and PCP </li></ul>
    55. 56. DXM <ul><li>Yes, its in cough syrup OR cough tabs (CORICIDIN)”TRIPPLE C” </li></ul><ul><li>Dextromethorphan acts as a cough suppressant via its agonist (activating) activity at mu-opioid receptors. </li></ul><ul><li>In Canada: Contac CoughCaps (30 mg DXM) </li></ul><ul><li>Related in effects to Ketamine and PCP </li></ul>
    56. 57. DXM- How is it used? <ul><li>“ Robo-ing” (Old Term from early 90’s) </li></ul><ul><li>DXM is available over-the-counter in tablet form in several countries as a cough med. Robitussin Maximum Strength Cough (not Robitussin DM) syrup </li></ul><ul><li>Users often refer to DXM in “plateaus ” </li></ul><ul><li>Dose of Robitussin Maximum Strength Cough syrup is two to five full &quot;shots&quot; using the shot glass that comes with the bottle. </li></ul>
    57. 58. DXM- Coricidin Toxicity <ul><li>Coricidin Cough and Cold Caps, 30 mg DXM and 4 mgs of Chlorphineramine maleate </li></ul><ul><li>Chlorphineramine maleate is an anti-cholinergic drug like scopolamine. </li></ul><ul><li>Non Specific reports of “Respiratory Failure” at high doses. </li></ul>
    58. 59. DXM- Coricidin Toxicity <ul><li>Robo-Walk </li></ul><ul><li>Robo-Itch </li></ul><ul><li>Robo-Talk </li></ul><ul><li>Psychosis </li></ul><ul><li>Dialated Pupils </li></ul>
    59. 60. DXM- Treatment <ul><li>VOMIT </li></ul><ul><li>Symptomatic TX. </li></ul><ul><li>Be alert for and (Cautiously) treat hypertension or hypotension, and rarely, cardiovascular problems </li></ul><ul><li>Restraints (?) </li></ul><ul><li>Avoid Chemical Restraint (Haldol, Droperidol),Benzo’s are preferred (Be prepared to manage the airway) </li></ul><ul><li>Benadryl may be given for Dystonic reactions, and for s/s of histamine release. </li></ul>
    60. 61. DXM- What does this mean to me? <ul><li>Be Careful, take the same precautions you would with a PCP patient. </li></ul><ul><li>ALS eval is a must ( HTN, Hyperthermia, Respiratory Depression, and self harm) </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
    61. 62. BREAK?
    62. 63. GHB
    63. 64. GHB Analogs- Introduction <ul><li>Gamma-hydroxybutyrate (GHB) may be made in homes by using recipes with common ingredients. </li></ul><ul><li>&quot;Liquid Ecstasy,&quot; &quot;Georgia Home Boy,&quot; &quot;Grievous Bodily Harm, </li></ul><ul><li>“ Liquid ecstasy,&quot; do not confuse w/ MDMA </li></ul><ul><li>GBL, GBH, One 4 B </li></ul>
    64. 65. Recognizing GHB <ul><li>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) </li></ul>
    65. 66. So Many Names…. <ul><li>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. </li></ul><ul><li>There are more than 80 known names for GHB and its equally deadly analogs. </li></ul>
    66. 67. GHB analogs – How are they used? <ul><li>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 </li></ul><ul><li>It is often carried in an eye dropper, or in water/Gatorade bottles and passed around. </li></ul><ul><li>Typically measured out in capfuls. </li></ul><ul><li>Occasionally blue food coloring is used to identify it at some raves. </li></ul><ul><li>It is occasionally used as a body building aid </li></ul>
    67. 68. Other GHB Products
    68. 70. Efforts to Avoid Detection <ul><li>GHB & its analogs are NOT protected by the Dietary Supplement & Heath Education Act of 1994. </li></ul><ul><li>Unapproved for human use. </li></ul><ul><li>“ Misbranded” drugs. </li></ul><ul><li>May be listed as “weight belt cleaner” or other solvent use or plant growth formula—trying to avoid detection </li></ul>
    69. 71. Efforts to Avoid Detection <ul><li>Acetone free Nail Polish </li></ul>
    70. 73. GHB- No longer Just for Rapists <ul><li>Recreational Use </li></ul><ul><li>Muscle Gain </li></ul><ul><li>Those under mandatory drug testing </li></ul><ul><li>Elderly </li></ul>
    71. 74. What To Expect
    72. 75. Typical Drinks To Hide GHB Any Substance can be used to hide a GHB Analog!
    73. 76. Typical GHB Containers <ul><li>Typical bottles for hiding GHB-- film canisters, hair spray, liquid candy bottles, food coloring, breathe mint containers (may be liquid LSD or G), vanilla bottles, Gatorade, pump hand lotion bottles. </li></ul>
    74. 77. Recognizing Containers <ul><li>ANY container that will hold a liquid. </li></ul>GHB addicts have hidden it in engine compartments, attics, etc .
    75. 78. Billy Idol: Famous GHB’er Billy almost died in 1993 from (then legal) GHB in front of a L.A. Night club
    76. 79. Nick Nolte
    77. 80. GHB analogs - What does it do <ul><li>At lower doses, GHB has sedative effects, but, as the dose increases, GHB effects may result in sleep ,eventual coma, respiratory arrest, or death. </li></ul><ul><li>It is these effects that make it both a prime drug at Raves, and for Date Rape </li></ul>
    78. 81. GHB analogs toxicity- mild <ul><li>Lethargy, easily aroused with repeated stimulation </li></ul><ul><li>Drowsiness, somnolence, dizziness, euphoria </li></ul><ul><li>Confusion (dazed and confused) </li></ul><ul><li>Amnesia, Susceptible to suggestion </li></ul>
    79. 82. GHB analogs Toxicity- Severe <ul><li>66% with GCS <9, ½ of these may have GCS at 3! </li></ul><ul><li>Frequent Vomiting, </li></ul><ul><li>Bradycardia, </li></ul><ul><li>Respiratory depression or arrest </li></ul><ul><li>Seizures </li></ul><ul><li>Sudden onset of coma . Patients often demonstrate extreme SUDDEN combativeness and agitation despite such profound CNS and respiratory depression </li></ul><ul><li>Death (usually secondary to respiratory failure or aspiration) </li></ul>
    81. 84. GHB analogs-Treatment <ul><li>Primary Supportive </li></ul><ul><li>Beware of positional Asphyxia, but soft restraints are a good idea </li></ul><ul><li>Due to the risk of sudden airway failure, aspiration, and respiratory collapse, these patients need aggressive airway monitoring by ALS providers </li></ul>
    82. 85. GHB analogs-Treatment <ul><li>Protect your self </li></ul><ul><li>VOMIT </li></ul><ul><li>Be cautious using respiratory depressants </li></ul><ul><li>Making the decision to tube/not tube is tough, these patients do frequently vomit. </li></ul><ul><li>ETT placement is uncommon, but post ETT sedation/paralysis and restraint should be mandatory in the field </li></ul>
    83. 86. Difficulty in Prosecution <ul><li>Sort Duration </li></ul><ul><li>Amnesia clouds recall </li></ul><ul><li>Often pro-sexual appearing behavior </li></ul><ul><li>Lack of : </li></ul><ul><ul><li>Credible witness </li></ul></ul><ul><ul><li>Evidence </li></ul></ul>
    84. 87. GHB analogs- What does this mean to me? <ul><li>GHB analogs are unpredictable in clinical course, other than duration. </li></ul><ul><li>GHB analogs cause a rapid change in mental and respiratory status that makes it difficult to plan treatment and care </li></ul><ul><li>GHB’s presentation often mimics ETOH abuse and is often co-imbibed. </li></ul>
    85. 88. “ For about a week I couldn't 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, )
    86. 89. Background
    87. 90. Background <ul><li>Discovered by Dr. Albert Hofmann in 1938 </li></ul><ul><li>Extensive study, use, and abuse by the government in the late 40’s. 50’s, and 60’s. (OSS/CIA, US Navy) </li></ul><ul><li>Some documented cases of CIA Operatives taking it to “Immunize” them selves to its effects in the 60’s. </li></ul><ul><li>Now that’s job satisfaction! </li></ul>
    88. 91. Slang <ul><li>Many names refer to the carrier or “brand”(image printed on blotter) </li></ul><ul><li>Blotter, Sugar, Sugar Cube, “cid, Acid </li></ul><ul><li>Bart Simpsons, Barrels, Tabs, Blotter, Heavenly blue, &quot;L&quot;, 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. </li></ul>
    89. 92. Slang <ul><li>Hit- Dose </li></ul><ul><li>Body Kinks- Unexpected physical side effects I.e. nausea, jitters, etc </li></ul><ul><li>Bad trip- A person on LSD who becomes depressed, agitated, or confused may experience these feelings in an overwhelming manner that grows on itself. </li></ul><ul><li>LSD psychosis: The effects of LSD exacerbate pre-existing psychological problems for several days. </li></ul>
    90. 93. Methods <ul><li>Usually taken Sublingually or orally on paper (“Blotter”) </li></ul><ul><li>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. </li></ul><ul><li>Usual dose is 50-200 mcg, with “Transcending doses” as high as 500 mcg </li></ul>
    91. 94. How does it work? <ul><li>Similar to other drugs that give hallucinations: </li></ul><ul><li>It affects the re-uptake of 5-HT similarly to SSRI (serotonin specific reuptake inhibiting) anti-depressants such as fluoxetine (Prozac), sertraline, and paroxetine </li></ul><ul><li>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 </li></ul>
    92. 95. S/S OF AN OVERDOSE <ul><li>Dilated Pupils </li></ul><ul><li>Vivid Auditory, tactile, and visual perception </li></ul><ul><li>Nausea </li></ul><ul><li>Mild drops in B/P </li></ul><ul><li>Hyperglycemia </li></ul><ul><li>Piloerection (Goosebumps) </li></ul><ul><li>Mild Hyperthermia </li></ul><ul><li>Bradycardia </li></ul><ul><li>May exacerbate pre-existing behavioral tendencies </li></ul><ul><li>Mild stimulatory effects </li></ul>
    93. 96. After trip effects <ul><li>Insomnia (common) </li></ul><ul><li>“ Jitters” </li></ul><ul><li>Flashbacks (inconstantly proven and disproven in literature) </li></ul>
    94. 97. BASIC TREATMENT <ul><li>Supportive </li></ul><ul><li>Protect the patient </li></ul><ul><li>Calm low key, low light, environment </li></ul><ul><li>Calm low key, low light environment </li></ul><ul><li>Calm low key, low light environment </li></ul><ul><li>Calm low key, low light environment </li></ul><ul><li>Oh yes… </li></ul><ul><li>Calm low key, low light environment </li></ul>
    95. 98. FOCUSED TREATMENT <ul><li>Benzo’s for severe agitation (rare) </li></ul>
    96. 99. Dependence, Detox, and withdrawal <ul><li>No documented physical or psychological dependence </li></ul><ul><li>A rapid tolerance is built up (about 3-5 days) that just as rapidly disappears </li></ul>
    97. 100. Take Home Information <ul><li>Facilitate a low key trip, and all is well </li></ul><ul><li>The patients respond to your actions as much as we respond to them </li></ul><ul><li>Very little clinical problems from drug, just actions resulting from altered behavior </li></ul>
    98. 101. Summary <ul><li>The scariest things about these drugs are the uncertainties involved in poly-pharm overdoses, unknown ingredients, etc… </li></ul><ul><li>Careful case by case assessment and treatment is more important than a cook-book approach. </li></ul><ul><li>Knowing the onsets, durations, and warning signs is as essential as knowing the actual effects of a drug. </li></ul>
    99. 102. Anything I missed?
    100. 103. These Drugs in in Boise?
    101. 104. Seattle Wa., July 2002 Caffeine (83.3%) MDA (16.7%)
    102. 105. Houston, TX July, 2002 Caffeine (9.1%)MDA (90.9%)
    103. 106. Kuna Idaho, April 2002 MDA (100 %)
    104. 107. Lewiston Idaho, May 2002 MDMA (75.0%) Ephedrine/Pseudoephedrine (25.0%)
    105. 108. Summary <ul><li>“ ..Due to the poly-pharmacy drugs that are being sold to ravers, all of these patients deserve ALS evaluation…” </li></ul><ul><li>Knowing your onsets and durations will help you a lot . </li></ul>
    106. 109. Don’t let this pt….
    107. 110. … turn out like this:
    108. 111. And don’t miss this!
    109. 112. QUESTIONS???
    110. 113. Supplemental information follows:
    111. 114. Samantha Reid, Age 15 GHB induced death at a party The 4 guys who gave the GHB to her are serving 5 ½ -15 years in prison No alcohol was involved
    112. 115. Melanie Sidone, 15 at the time, was in a coma for 17 hours
    113. 116. Erick Limmer, 26, Owned the apartment that the GHB overdose took place in. CONVICTED!
    114. 117. Daniel Brayman, a senior, was one of two boys who picked up the freshman girls took them to the Party … CONVICTED!
    115. 118. Nicholas Holtschlag, 18, allegedly handed drinks that were poisoned with GHB to Melanie Sindone and Samantha Reid. CONVICTED!
    116. 119. Joshua Cole deliberately slipped the GHB into the girls non alcoholic drinks. CONVICTED!