This document discusses trends in drugs of abuse in Florida. It provides case studies and discusses the clinical effects and management of various substances including opioids, synthetic cannabinoids, fentanyl, marijuana, synthetic cathinones like flakka, MDMA, and excited delirium syndrome. Key points are the rise in heroin and fentanyl deaths, increasing potency of marijuana products, constant production of new synthetic drugs, and importance of controlling agitation in excited delirium cases.
1. Update on Drugs of Abuse
Trends in Florida
Melissa Parsons, MD
Department of Emergency Medicine
University of Florida College of Medicine-Jacksonville
2. Learning Objectives
1. Understand general trends for drugs of abuse
in Florida
2. Become familiar with toxidromes
3. Recognize excited delirium syndrome and
factors that increased morbidity/mortality
18. Fentanyl
• Synthetic opiate
– 100 times more powerful than
morphine
– 30-50 times more powerful
than heroin
• “Breaking Bad” “Blue Drop”
“Theraflu” “China White”
• Imported from Mexico and
China
31. Abuse of Synthetic Drugs an Epidemic
• 2012 Synthetic Drug Abuse Prevention Act
– Places 26 synthetic drugs including types of
cannabinoids and cathinones under Schedule 1
– Illegal drug makers have 100s more to take their place
– NO quality control (Russian Roulette)
– Often products labeled “not for human
consumption”
• Unknown chemicals
• Unknown potency
• Constantly changing
Russian Roulette
Mystery packages
32.
33. Drug makers constantly producing new synthetic
cannabinoids products to evade laws on older
compounds… impossible to keep up.
2015: >30
compounds
34. Synthetic Cannabinoids
• Synthetic chemicals sprayed onto dried plants
• They are 5-45 times more potent than THC
and more toxic to brain and the heart
Synthetic Marijuana is a misnomer
36. Synthetic Cannabinoid User
Man decapitated his wife, killed two dogs, cut off his left hand, and gouged his right eye out
Man kills two women using a knife and
tomahawk while trying to find the ‘portal to
hell” in their backyard shed
37. Synthetic Cannabinoids
Symptoms:
• Seizures
• Psychosis
– Patients without psych history
– Paranoia, agitation and anxiety
– Suicidal or homicidal ideation
• CV events
– Tachycardia and
tachydysrhythmias
– MI
– Stroke
• Respiratory failure
• Acute kidney injury
• Hyperthermia
• Hyperemesis
Management:
• Supportive care
• Sedation
– Benzodiazepines
– Ketamine
– Avoid antipsychotics
• IVFs for AKI or rhabdomyolysis
• Low stimulus environment
38. Risk Factors for increased mortality:
1. New Psychosis/ Excited delirium with use
• Trauma or injury
• Restraint procedures by law enforcement
• Chemically sedate… avoid restraints
2. Pre-existing cardiovascular conditions
3. Co-ingestions
43. • Can be difficult to
recognize and manage in
prehospital setting.
• May mimic other medical
conditions
• Attempt de-escalation
techniques
• Personal safety issue for
first responders
Excited Delirium Syndrome
44. • Management:
– Agitation: chemical and physical restraint
– Hyperthermia: Active and passive cooling
– Hypoxia: Airway support
– Acidosis: IVF, Bicarb if severe
– Rhabdo/Hyperkalemia: IVF, Calcium chloride,
Bicarb
Excited Delirium Syndrome
45. KETAMINE:
• 4-5 mg/kg IM or 2 mg/kg IV
• Rare side effects
• Increased oral secretions,
• Laryngospasm,
• Hypertension,
• Distress from emergence phenomena
BENZO’s:
• Effective.
• Potential for respiratory depression
ANTIPSYCHOTICS:
• Potential lethal side effects
• Increased QTc & risk for sudden
death
• Anticholinergic syndrome
Management of Excited
Delirium Syndrome
47. 3,4-methylenedioxymethamphetamine
(MDMA)
• Ecstasy
– Often adulterated with caffeine,
methamphetamine, and other harmful drugs
– Typically in tablet form
• Molly
– Slang for "molecular"
– Supposedly a “purer” form of MDMA sold as
powder or capsule
48. Synthetic Cathinones
• Synthetic chemicals
related to cathinone, an
amphetamine-like
stimulant found
naturally in the Khat
plant.
49. Synthetic Cathinones
• MDPV (Methylenedioxypyrovalerone)
– most common synthetic cathinone found in the
blood and urine of ED patients reportedly taking
"bath salts”
• Alpha-PVP
• Methylone
• Ethylone
• Butylone
• Many more
50. United Way of Broward County Commission on Substance Abuse Annual Drug Trends Report June 2015
51. United Way of Broward County Commission on Substance Abuse Annual Drug Trends Report June 2015
52. Alpha-PVP aka Flakka
Special considerations:
• Paranoia
• Pursued or chased
• Extreme hyperthermia (105-106)
• Excited Delirium Syndrome
53. 8 Duval
2 Clay
1 St Johns
1 Putnam
http://interactive.sun-sentinel.com/flakka-case/
Number of Flakka Cases in Florida 2015
54. http://interactive.sun-sentinel.com/flakka-case/
“In recent weeks in Florida, this new drug has led to a man trying to
break down the door to a police station, a man impaling himself while
trying to scale a fence, and an armed and naked man shouting about
hallucinations from a rooftop” – CBS
55. Synthetic Cathinones
Clinical effects
CNS:
Euphoria
Decreased need for food and sleep
Increase in alertness and awareness
Heightened sexual desire
Anxiety/agitation
Paranoia
Violent behavior
Hallucinations (auditory or tactile)
Suicidal thoughts
Excited Delirium Syndrome (ExDS)
57. Synthetic Cathinones
• Self-harm and bizarre/at risk behavior without
evidence of psychosis or depression is the
SECOND leading cause of death with use
58. Take Home Points
• Florida is seeing increased heroin/fentanyl use as opioid
prescription drugs become harder to acquire
– You may need larger doses of naloxone to reverse synthetic opioids
like fentanyl.
– Don’t give up if 0.4mg doesn’t work…
• Higher potency forms of marijuana and synthetic forms of
cannabinoids can lead to more severe clinical effects
– Synthetic cannabinoids do NOT equal marijuana
59. Take Home Points
• New synthetic drugs constantly being produced, which are
potentially more toxic and dangerous.
– It doesn’t matter what the compound is…treat them symptomatically
• Control of agitation/psychosis in Excited Delirium Syndrome is
high priority to reduce mortality.
– Use chemical sedation.
– Avoid restraints.
– Don’t forget to cool their hyperthermia.
– Get labs to check for end-organ dysfunction.
Name MP
Dept of EM
I’m not a pharmacologist or toxicologist but after enough night shifts on 8th street I’m qualified to give this talk
Discuss the street drug trends were seeing across the state since that impacts us clinically
Review the patient presentation as well as management and treatment options
Define excited delirium and be able to recognize factors that increase mortality
Case 1
Patient found down with laceration to scalp at home. 911 called by a friend. Unresponsive in the field.
On EMS arrival to scene, patient with a respiratory rate of 4. Active airway assistance started. Breath sounds clear bilaterally. Good peripheral pulses – radial and dorsalis pedis – noted bilaterally. Scalp hematoma without active bleeding noted. GCS 3.
EMS attempts to establish IV access and prepares for intubation.
Paramedic notices multiple track marks to both arms.
Pupils pinpoint bilaterally.
Great…yes this appears to be a trauma patient, but could this also be an opioid overdose with trauma secondary to use?
Obvious when you find the patient with an IV in the arm, but not always so obvious
Lets talk a little bit about the opioids
Most of us recognize pinpoint pupils as the tell tale sign of opioid use
They can also have BRADYCARDIA, HYPOTENSION, HYPOTHERMIA, SEIZURES and muscle rigidity
Propoxyphene is Darvon or Darvocet
Meperidine = Demerol
Narcan is indicated to reverse respiratory depression
DETAILS..
Fentanyl requires much higher doses b/c increased potency… naloxone has to replace 50% of receptors
Half life is an hour so patients can resedate…
Looking at recent trends in the state of Florida
Rise in Fentanyl, Heroin and Morphine…
Decrease in Methadone & Oxycodone
Rx opioids tougher to get ppl turn to heroin heroin seems to be much more potent (ppl requesting XXX)
Why are we seeing this surge in heroin deaths?
Prescription drug monitoring program in Florida “Eforsce database”
Crack down on “pill mills”
Chart shows a huge spike in heroin related deaths from 2013 to 2014
Spike continues into 2015
Jacksonville is in the orange… 17-24 cases per million population
May take additional narcan
Counties have also seen Carfentanil use – used to sedate elephants (100 times more potent than fentanyl)
lethal dose of heroin vs fentanyl
Counties have also seen Carfentanil use – used to sedate elephants (100 times more potent than fentanyl) and 10,000 times more potent than morphine.
Medical examiners have to carry narcan because if they even come into contact with carfentanil can experience overdose symptoms…
36 yo F requiring extrication from an MVC. She was the restrained driver that crashed into a telephone pole at approximately 55 mph. +airbag deployment. Significant front end damage. 25 minute extrication time. Only significant trauma is head lac.
During extrication, patient is argumentative, refusing transport. Appears paranoid.
As EMS transfers her to rescue, a packet labeled “Spice” falls out of her clothing. When asked about it, the patient sits up, climbs off the stretcher, and tries to abscond.
This case is not to bring up medico-legal issues of AMA. Just to make us all think about the use of these synthetic cannabinoids. They can make a patient unevaluable just like EtOH. Just because they may or may not be legal doesn’t mean they don’t alter the patient and the patient’s perception of pain etc. On this patient, you may not have enough information to decide whether or not the patient can leave AMA.
Marijuana typically causes SLOWING of symptoms – CNS depression, delayed psychomotor skills, slurred speech
Much higher concentration of THC than smoking.
Produced by soaking marijuana plant material in a solvent such as butane which extracts various cannabinoids of the plant. Then drying it out which leaves a sticky substance that can be placed on a traditional cig, e-cig, MJ joint
Hash - resin collected from the flowers of the cannabis plant
Different concentrations of THC between typical joint and wax
Wax proponents state you take in much less smoke/other chemicals by using wax to get the same effect…
Vaporizes the marijuana
Considered a less harmful method of ingestion, easy to use in public places
Now a note on the synthetic drugs – includes synthetic cathinones also
Graphs show the increased percentage of synthetic drugs of the total drugs seized in broward county from 2012-2015
Huge increase from 5% to 31 % in only 4 years… number continues to rise
2012 Obama administration passed the Synthetic drug abuse prevention act
List 26 specific compounds , however drug makers have 100s more to take their place
These drugs are not tested – there is no quality control, unknown potency so can be dangerous
- To get around these laws, tweaks to drug structure are performed and then drugs are packaged “not for human consumption”
These drugs were created as the federal ban was being passed and are not illegal…
THC is only a partial agonist at the cannabinoid receptors, these compounds are full agonists
More potent and efficacious at cannabinoid receptors
Have active metabolites
Often contain contaminants like synthetic cathinones, methylxanthines, clenbuterol
Increased risk of sudden death with hog-tied or taser use by law enforcement…
Patients are at high risk for trauma or other injuries.
How we restrain them can cause harm…
Study was done on people with excited delirium dying in police custody – showed that all (21) of them had restraint for violent behavior either in prone position or with pressure on the neck, so we should sedate these people in an expedited fashion and get them out of restraints that could exacerbate their condition and put them at risk for sudden death
Pollanen MS, Chiasson DA, Cairns JT, Young JG. Unexpected death related to restraint for excited delirium: a retrospective study of deaths in police custody and in the community. CMAJ: Canadian Medical Association Journal. 1998;158(12):1603-1607.
Labay LM et al. Synthetic cannabinoid drug use as a cause or contributory cause of death. Forensic Science International 2016(260):31–39
EMS is called for a 34 yo M in police custody with concerns for suicide attempt. Police found the patient in someone’s front yard, naked from the waist down and wrapped in a garden hose with lacerations to both wrists.
It is requiring multiple officers to restrain the patient, despite handcuffs and being hogtied.
There is pulsatile bleeding from one of the wrist lacerations.
You’re putting a bleeding tazmanian devil in the back of your rig… or in your trauma bay.
Where do you transport the patient?
Sedation?
Wound treatment?
ExDS is characterized by delirium, agitation, and hyperadrenergic autonomic dysfunction, typically in the setting of acute on chronic drug abuse or serious mental illness. These patients are reported to have superhuman strength and to be susceptible to further agitation by external stimulus
ExDS is characterized by delirium, agitation, and hyperadrenergic autonomic dysfunction, typically in the setting of acute on chronic drug abuse or serious mental illness. These patients are reported to have superhuman strength and to be susceptible to further agitation by external stimulus
Temperatures greater than 104
Tachycardia including HR in the 150’s-170s , HTN
ExDS has been linked to sudden death, often associated with prolonged ‘hog-tie’ or ‘hobble-position’ or electroshock weapons (i.e. Taser use) (D).
MIMIC OTHER THINGS_ THYROID STORM, NMS, SEROTONIN SYNDROME
Table shows symptoms associated with INCREASED MORTALITY
We already talked about synthetic cannabinoids causing ExDS, the synthetic cathinones can as well. Lets talk a little about MDMA and these other synthetics commonly referred to as “bath salts”
Only 13% of the Molly seized in New York from 2011-2015 actually contained any MDMA
Hundreds of Molly capsules tested in South Florida crime labs in 2012 contained methylone, a synthetic cathinone.