STREETDRUGS :DOWN ANDDIRTY           BROUGHT TO YOU BY YOUR           FAVORITE DRUG FIENDS!
Revision Info• Revised 06-13-05• For more information, contact  – Steve Cole  – colemedic@hotmail.com
Where our motto is :
OBJECTIVES• Quick intoduction to the drug culture• Quick review of the following drugs:  – Heroin and Oxycontin  – MDMA an...
The Rave…
• Generally speaking,  “Rave” applies not just    The Rave Culture  to the parties but to an  entire subculture• Not just ...
Anatomy of a Rave
Anatomy of a RAVE           • Day or Night           • Tend to be “Sponsored” (A.K.A.             “Promoters”), limits lia...
Anatomy of a Rave• Remember,  the overall  event doesnt  have to be a  rave to have a  strong Raver  presence…..
A RAVE CAN BE ANYWHERE
Anatomy of a Rave- Clues•   Light Sticks•   Water/Gatorade Bottles for sale•   H2O shut off in bathroom•   Crash Rooms/Can...
Lights are   Captivating• Three or more work on one  X user’s eyes, up close &  personal. Some lights are  very bright.• I...
More “Eye Candy”• Glow sticks of all sizes• Special mouthguards   – Protect from swallowing     mini glow sticks   – Also ...
Why Face Masks & Vicks?      • The sensation of breathing        is intensified by the        menthol (eucalyptus) in     ...
It’s About Sensation                                 • Many carry personal                                   vibrators. No...
Drug Paraphernalia• MDMA causes “bruxism”—teeth  grinding & involuntary jaw  locking; damages teeth.• Pacifiers, lollipops...
GHB Test KITS      False Security
Harm Reduction• Web sites  – www.dancesafe.org  – www.erowid.org
WWW.EROWID.ORG
•   www.dancesafe.org•   Non Profit•   Drug testing kits•   Drug warnings•   Drug testing and postings•   HARM REDUCTION
What To Expect
Anatomy of a Rave-Common Medicalconcerns                 • Severe Dehydration                   and Hyperthermia          ...
Interacting with Ravers• Remember there is a  cultural distrust• Don’t be afraid to ask  for interpretation of  slang• Gen...
Safety• Hazards: Uncontrolled  Scenes   –   Patients   –   Environment   –   Bystanders   –   Weapons   –   CLAN LABS• Tac...
SAFETY for the PT.• Pt safety poses  an extreme  challenge for  EMS  – Drug    Interactions  – Rapid Changes  – Restraint
The Drugs
Heroin and Oxycontin
Opiate Abuse
Heroin•   Black Tar•   China White•   Speed Ball•   Homicide, Buick,    super Buick, twilight    sleep
Methods of use:• Shooting:• Skin Popping:• Muscle Popping:• Chasing the dragon:  Smoking• Freebasing• Dirty Hit:
Oxycontin / MS Contin• Time released capsules, some may have more than  100 mg• Often crushed and snorted, eliminating the...
Methadone            • Reportedly Harder to              “kick” than Heroin            • Like other prescription          ...
Duragesic            •   Fentanyl Citrate            •   Transdermal Absorbtion            •   Used in chronic pain patien...
Duragesic- methods of abuse•   Almost 70 fold increase in use from 1995-2002 (DAWN)•   Rate of use is increasing.•   Stree...
S/S OF AN OPIATE OVERDOSE• Pin Point Pupils         • Dirty Needles• Hypotension                (“Diabetics”)• N/V        ...
BASIC TREATMENT• Ventilation/stimulation first• Slow admin of Narcan, just enough to make them  breath   – Narcan 0.4 mg-2...
Long Term problems• HIV, HEP-A/B/C,• BLOOD POISONING (Septicemia) “Cotton  Fever”• ENDOCARDITIS• TETANUS• NECROTIZING FASC...
Some weird things that have been done with aHeroin OD by Junkies• Injected someone with salt water or Milk This  is an old...
Dependence, Detox, and Withdrawal• medical detoxification is usually accomplished  by giving decreasing doses of a long-ac...
MDMA and PMA
Introduction• methylenedioxy-n-  methylamphetamine (MDMA)  – MDMA is *chemically* an amphetamine, but    psychologically i...
PMA• Use is identical to MDMA, PMA is more toxic than  MDMA• It often appears identical to MDMA, sometimes  simply thicker...
PMA and MDMA• Taken in tabs although inhalation and  injection have been infrequently reported.• Effects generally appear ...
MDMA/PMA how It Looks•   Powder•   Pressed pills                “Euros”•   Capsules (may not be full)•   Wide range of log...
MDMA/PMA Packaging• Because of their small size, MDMA pills may  be easily hidden. They may simply be mixed  in with other...
MDMA /PMA ToxicityMild s/s• Jaw clenching (Lower Jaw)/teeth grinding,  and scratching (think Tweekers)• Nystagmus, Dilated...
MDMA/PMA ToxicityMajor S/S• Severe Dehydration with Hyponatremia• Malignant Hyperthermia (Think Heat Stroke,  but worse)• ...
MDMA/PMA Basic Tx• Calm low stimulus environment• VOMIT (standard ALS)• Fluid Resuscitation as needed for  hypotension, de...
Long Term effects• More prolonged  “burn out” or “crash  periods” up to a  week later• Dental Damage• Depression for  week...
MDMA Focused Tx• Benzodiazepines  – Ativan 0.5-2 mg  – Valium 2.5-10 mg• beta blockers have fallen out of favor (like  Bre...
Take Home Information•   Core Temp if unresponsive•   Fluid Resuscitation•   Sedation PRN•   Watch for DIC, SZ•   P.U.H.A....
DXM- Introduction• Yes, its in cough syrup OR COUGH  TABS (CORICIDIN)”TRIPPLE C”• Dextromethorphan acts as a cough  suppre...
DXM• Yes, its in cough syrup OR cough tabs  (CORICIDIN)”TRIPPLE C”• Dextromethorphan acts as a cough suppressant via  its ...
DXM- How is it used?                  • “Robo-ing” (Old Term from                    early 90’s)                  • DXM is...
DXM- Coricidin Toxicity• Coricidin Cough and  Cold Caps, 30 mg DXM  and 4 mgs of  Chlorphineramine  maleate• Chlorphineram...
DXM- Coricidin Toxicity•   Robo-Walk•   Robo-Itch•   Robo-Talk•   Psychosis•   Dialated Pupils
DXM- Treatment• VOMIT• Symptomatic TX.• Be alert for and (Cautiously) treat hypertension or  hypotension, and rarely, card...
DXM- What does this mean to me?• Be Careful, take the same precautions you would  with a PCP patient.• ALS eval is a must ...
BREAK?
GHB
GHB Analogs- Introduction• Gamma-  hydroxybutyrate (GHB)  may be made in homes  by using recipes with  common ingredients....
Recognizing GHBAKA: GHB, G, Jib, Scoop,  Liquid E, Liquid X, Woman’s  Viagra, Grievous Bodily  Harm, Easy Lay, Gamma 10,  ...
So Many Names….• Tranquili G, Midnight Blue, Verve, Rejoov,  Somax, SomatoPro, Flower Power, Puritech,  Alcover, G-riffick...
GHB analogs –How are they used?• GHB can be produced in clear liquid, or a  white powder, tablet, and capsule forms, and  ...
Other GHB Products
Efforts to Avoid Detection• GHB & its analogs are  NOT protected by the  Dietary Supplement &  Heath Education Act of  199...
Efforts to Avoid Detection• Acetone free Nail Polish
GHB- No longer Just for Rapists• Recreational Use• Muscle Gain• Those under  mandatory drug  testing• Elderly
What To Expect
Typical Drinks To Hide GHBAny Substance can be used to     hide a GHB Analog!
Typical GHB ContainersTypical bottles for hiding GHB--  film canisters, hair spray, liquid  candy bottles, food coloring, ...
Recognizing Containers ANY container  that will hold a  liquid.  GHB addicts have hidden it in  engine compartments, attic...
Billy Idol: Famous GHB’er                    Billy almost died in 1993                    from (then legal) GHB in        ...
Nick Nolte
GHB analogs - What does it do• At lower doses, GHB has sedative  effects, but, as the dose increases, GHB  effects may res...
GHB analogs toxicity- mild• Lethargy, easily aroused with repeated  stimulation• Drowsiness, somnolence, dizziness,  eupho...
GHB analogs Toxicity- Severe• 66% with GCS <9, ½ of these may have GCS  at 3!• Frequent Vomiting,• Bradycardia,• Respirato...
GHB• ALCOHOL IS THE  MOST COMMON  DRUG CO  CONSUMED IN  GHB RELATED  DEATHS
GHB analogs-Treatment• Primary Supportive• Beware of positional Asphyxia, but soft  restraints are a good idea• Due to the...
GHB analogs-Treatment• Protect your self• VOMIT• Be cautious using respiratory depressants• Making the decision to tube/no...
Difficulty in Prosecution• Sort Duration• Amnesia clouds  recall• Often pro-sexual  appearing behavior• Lack of :  – Credi...
GHB analogs- What does this meanto me?• GHB analogs are unpredictable in  clinical course, other than duration.• GHB analo...
“For about a week I couldnt walk through the lobby of A-entry at the dorm without getting   really scared, because of the ...
Background
Background• Discovered by Dr. Albert Hofmann in 1938• Extensive study, use, and abuse by the  government in the late 40’s....
Slang• Many names refer to the carrier or  “brand”(image printed on blotter)• Blotter, Sugar, Sugar Cube, “cid, Acid• Bart...
Slang• Hit- Dose• Body Kinks- Unexpected physical side effects  I.e. nausea, jitters, etc• Bad trip- A person on LSD who b...
Methods• Usually taken Sublingually or orally on paper  (“Blotter”)• The solution may also be injected s.c. or i.v.  (RARE...
How does it work?• Similar to other drugs that give hallucinations:• It affects the re-uptake of 5-HT similarly to SSRI  (...
S/S OF AN OVERDOSE• Dilated Pupils• Vivid Auditory, tactile, and  visual perception• Nausea• Mild drops in B/P• Hyperglyce...
After trip effects                     • Insomnia (common)                     • “Jitters”                     • Flashback...
BASIC TREATMENT•   Supportive•   Protect the patient•   Calm low key, low light,   environment•   Calm low key, low light ...
FOCUSED TREATMENT• Benzo’s for severe agitation (rare)
Dependence, Detox, and withdrawal• No documented  physical or  psychological  dependence• A rapid tolerance is  built up (...
Take Home Information• Facilitate a low key trip, and all is well• The patients respond to your actions as  much as we res...
Summary• The scariest things about these drugs are the  uncertainties involved in poly-pharm  overdoses, unknown ingredien...
Anything   Imissed?
These Drugs in in Boise?
Seattle Wa., July 2002Caffeine (83.3%) MDA (16.7%)
Houston, TX July, 2002Caffeine (9.1%)MDA (90.9%)
Kuna Idaho, April 2002MDA (100 %)
Lewiston Idaho, May 2002MDMA (75.0%) Ephedrine/Pseudoephedrine (25.0%)
Summary• “..Due to the poly-pharmacy drugs that  are being sold to ravers, all of these  patients deserve ALS evaluation…”...
Don’t let this pt….
…turn out like this:
And don’t miss this!
QUESTIONS???
Supplemental information follows:
Samantha Reid, Age 15GHB induced death at a party                                   No alcohol was involvedThe 4 guys who ...
Melanie Sidone, 15 at the time, was in acoma for 17 hours
Erick Limmer, 26, Owned the apartment thatthe GHB overdose took place in. CONVICTED!
Daniel Brayman, a senior, was one of two boyswho picked up the freshman girls took them tothe Party…CONVICTED!
Nicholas Holtschlag, 18, allegedly handed drinksthat were poisoned with GHB to Melanie Sindoneand Samantha Reid.CONVICTED!
Joshua Cole deliberately slipped the GHB into the girlsnon alcoholic drinks.CONVICTED!
Street drugs-down-and-dirty-1210047566000870-9
Street drugs-down-and-dirty-1210047566000870-9
Street drugs-down-and-dirty-1210047566000870-9
Street drugs-down-and-dirty-1210047566000870-9
Street drugs-down-and-dirty-1210047566000870-9
Upcoming SlideShare
Loading in …5
×

Street drugs-down-and-dirty-1210047566000870-9

3,945 views

Published on

Published in: Education, Health & Medicine
  • Be the first to comment

Street drugs-down-and-dirty-1210047566000870-9

  1. 1. STREETDRUGS :DOWN ANDDIRTY BROUGHT TO YOU BY YOUR FAVORITE DRUG FIENDS!
  2. 2. Revision Info• Revised 06-13-05• For more information, contact – Steve Cole – colemedic@hotmail.com
  3. 3. Where our motto is :
  4. 4. OBJECTIVES• Quick intoduction to the drug culture• Quick review of the following drugs: – Heroin and Oxycontin – MDMA and PMA – DXM – GHB
  5. 5. The Rave…
  6. 6. • Generally speaking, “Rave” applies not just The Rave Culture to the parties but to an entire subculture• Not just “Night time” Parties at clubs• Can extend into multi- day events (Burning Man)• Hallmarked by techno/new age music and Psychedelic visual displays.
  7. 7. Anatomy of a Rave
  8. 8. Anatomy of a RAVE • Day or Night • Tend to be “Sponsored” (A.K.A. “Promoters”), limits liability on both sides • Sometimes marketed as “Drug Free Teen Dance Parties” • If not at a formal club, they tend to be located in remote locations to limit outside interference. • Often will have a DJ instead of a band. Some DJ’s are celebrities, called the “A-List”, traveling a “Circuit” ($1000-5000/hr)
  9. 9. Anatomy of a Rave• Remember, the overall event doesnt have to be a rave to have a strong Raver presence…..
  10. 10. A RAVE CAN BE ANYWHERE
  11. 11. Anatomy of a Rave- Clues• Light Sticks• Water/Gatorade Bottles for sale• H2O shut off in bathroom• Crash Rooms/Candles/Etc.• Have Dance Breaks/cool down periods• In Idaho we are mainly seeing these in remote locations.
  12. 12. Lights are Captivating• Three or more work on one X user’s eyes, up close & personal. Some lights are very bright.• It’s called “Eye Candy”
  13. 13. More “Eye Candy”• Glow sticks of all sizes• Special mouthguards – Protect from swallowing mini glow sticks – Also less visible than the pacifiers
  14. 14. Why Face Masks & Vicks? • The sensation of breathing is intensified by the menthol (eucalyptus) in vapor rub products. This will be slathered on their upper lips or in face masks. Or inhalers will be used. • Remember, many report things like “being burned by a cigarette feels good.” It’s all about sensation
  15. 15. It’s About Sensation • Many carry personal vibrators. Notice the “x” & “e” & butterfly beads. Butterfly is a common emblem for Ecstasy.Vibration of the music through • Every touch feels good.the balloon feels good too. • They may rub each other with things like Tiger Balm or with hair brushes or gloves with the “gripper dots” to intensify touch.
  16. 16. Drug Paraphernalia• MDMA causes “bruxism”—teeth grinding & involuntary jaw locking; damages teeth.• Pacifiers, lollipops, mouthguards & other things to suck help reduce this.• Hidden compartments
  17. 17. GHB Test KITS False Security
  18. 18. Harm Reduction• Web sites – www.dancesafe.org – www.erowid.org
  19. 19. WWW.EROWID.ORG
  20. 20. • www.dancesafe.org• Non Profit• Drug testing kits• Drug warnings• Drug testing and postings• HARM REDUCTION
  21. 21. What To Expect
  22. 22. Anatomy of a Rave-Common Medicalconcerns • Severe Dehydration and Hyperthermia • Poly-Pharm involvement • Date Rape • Multiple Patients (approach with a plan) • Volatile Crowds
  23. 23. Interacting with Ravers• Remember there is a cultural distrust• Don’t be afraid to ask for interpretation of slang• Generally not overtly violent singularly, but beware of crowds• Our attitude and interaction may have a positive or negative impact on the crowd.• Check for a “Trip Sitter”
  24. 24. Safety• Hazards: Uncontrolled Scenes – Patients – Environment – Bystanders – Weapons – CLAN LABS• Tactics learned from law enforcement community – Staging – Isolation and Control – Scoop and swoop – Travel in Packs
  25. 25. SAFETY for the PT.• Pt safety poses an extreme challenge for EMS – Drug Interactions – Rapid Changes – Restraint
  26. 26. The Drugs
  27. 27. Heroin and Oxycontin
  28. 28. Opiate Abuse
  29. 29. Heroin• Black Tar• China White• Speed Ball• Homicide, Buick, super Buick, twilight sleep
  30. 30. Methods of use:• Shooting:• Skin Popping:• Muscle Popping:• Chasing the dragon: Smoking• Freebasing• Dirty Hit:
  31. 31. Oxycontin / MS Contin• Time released capsules, some may have more than 100 mg• Often crushed and snorted, eliminating the “time release”• May be crushed, diluted, and injected like traditional heroin• Becoming much more common
  32. 32. Methadone • Reportedly Harder to “kick” than Heroin • Like other prescription opiates, WIDELY Available • One study showed of 18 methadone related deaths: – Less than ½ were prescribed methadone – Only three were prescribed methadone through a methadone tx program
  33. 33. Duragesic • Fentanyl Citrate • Transdermal Absorbtion • Used in chronic pain patients • 100 times the potency of morphine • Fastest growing method of opiate abuse • Commonly Used for chronic pain • Synthetic opioid • Easily Acquired • Easily abused
  34. 34. Duragesic- methods of abuse• Almost 70 fold increase in use from 1995-2002 (DAWN)• Rate of use is increasing.• Street price between $10-100/PATCH• Methods of abuse – Topical – Injected – Chewed• Oral Conversion – Up to 50% may be lost in conversion, so it is often frozen first. – Preservatives may cause liver problems – 25 ug/hr = 2.5 mg avail – 50 ug/hr = 5 mg avail – 75 ug/hr = 7.5 mg avail – 100 ug/hr = 10 mg avail
  35. 35. S/S OF AN OPIATE OVERDOSE• Pin Point Pupils • Dirty Needles• Hypotension (“Diabetics”)• N/V • Cotton balls, Cig• Respiratory/CNS Filters depression • Spoons w/ residue or• Aspiration and Hypoxia similar improvised• Hallucinations device• Other s/s? Think poly- pharm involvement
  36. 36. BASIC TREATMENT• Ventilation/stimulation first• Slow admin of Narcan, just enough to make them breath – Narcan 0.4 mg-2 mg traditional, may need higher doses• High doses may be needed if drug is synthetic• Watch for re-sedation due to Narcan’s short duration (about 20-30 minutes)
  37. 37. Long Term problems• HIV, HEP-A/B/C,• BLOOD POISONING (Septicemia) “Cotton Fever”• ENDOCARDITIS• TETANUS• NECROTIZING FASCIITIS (Flesh-Eating Disease) Associated w/ black tar• WOUND BOTULISM• TRACKING AND BRUISING• CONSTIPATION, BOWEL OBSTRUCTION
  38. 38. Some weird things that have been done with aHeroin OD by Junkies• Injected someone with salt water or Milk This is an old junky myth sometimes still used.• Injected someone who overdosed on heroin with cocaine or speed, or vice versa. Another old myth.• Narcan Used PTA of EMS- Narcan is becoming more and more common among junkies for “emergencies” (some trials are being done in Seattle and Europe)• Put ice on their genitals (down their pants) .• Placed in a cold shower
  39. 39. Dependence, Detox, and Withdrawal• medical detoxification is usually accomplished by giving decreasing doses of a long-acting opiate like methadone.• While not truly physically addictive, Heroin withdrawal is clearly extremely uncomfortable and painful.• The previously suppressed Locus Coeruleus is believed responsible for most of the clinical problems: anxiety, HTN, agitation
  40. 40. MDMA and PMA
  41. 41. Introduction• methylenedioxy-n- methylamphetamine (MDMA) – MDMA is *chemically* an amphetamine, but psychologically its whats known as an empathogen-entactogen – Shares similarities to both mescaline (a hallucinogen) and amphetamines• Para-methoxyamphetamine, ( PMA) , 4- METHOXYAMPHETAMINE – Chemically similar to MDMA, first created almost 25 years ago – Since its cheaper to make, and uses non controlled substances, PMA is often misrepresented as MDMA. – At doses considered “safe” for MDMA, PMA is highly toxic.
  42. 42. PMA• Use is identical to MDMA, PMA is more toxic than MDMA• It often appears identical to MDMA, sometimes simply thicker.• Its onset of action is longer (almost 60 minutes) compared to MDMA at 15-30 minutes• Users will re-dose thinking its MDMA and push them selves into the toxic range• Some people think they know their MDMA dose and apply this to PMA, thus going toxic• Substances like Cocaine and Methamphetamine may exacerbate the toxic effects of either PMA or MDMA
  43. 43. PMA and MDMA• Taken in tabs although inhalation and injection have been infrequently reported.• Effects generally appear within 15-30 minutes (MDMA) or almost 60 minutes (PMA).• The usual dose ranges from 100 to 150 mg. Toxicity may be seen at doses as little as 175 mg
  44. 44. MDMA/PMA how It Looks• Powder• Pressed pills “Euros”• Capsules (may not be full)• Wide range of logos• Wide variety of colors & shapes• Nicknames reflect logos & colors• Designed to look “innocent” & thus “harmless.”
  45. 45. MDMA/PMA Packaging• Because of their small size, MDMA pills may be easily hidden. They may simply be mixed in with other candies, such as Skittles, M&Ms, etc. Pez containers are common too.
  46. 46. MDMA /PMA ToxicityMild s/s• Jaw clenching (Lower Jaw)/teeth grinding, and scratching (think Tweekers)• Nystagmus, Dilated Pupils• Tremors• Tachycardia, increased B/P• Sensation of chills (secondary to elevated temp)• Auditory Hallucinations (non specific)/sensitivity• Orthostatic s/s, syncope secondary to dehydration
  47. 47. MDMA/PMA ToxicityMajor S/S• Severe Dehydration with Hyponatremia• Malignant Hyperthermia (Think Heat Stroke, but worse)• Disseminated Intravascular Coagulation (DIC) (may have rapid onset)• Decreased LOC/Coma• Stroke S/S, Seizures• Severe Tachycardia, HTN, CHF• Kidney Failure
  48. 48. MDMA/PMA Basic Tx• Calm low stimulus environment• VOMIT (standard ALS)• Fluid Resuscitation as needed for hypotension, dehydration, and/or orthostatic s/s• Active cooling if indicated• Core Temp if unresponsive
  49. 49. Long Term effects• More prolonged “burn out” or “crash periods” up to a week later• Dental Damage• Depression for weeks• Renal failure
  50. 50. MDMA Focused Tx• Benzodiazepines – Ativan 0.5-2 mg – Valium 2.5-10 mg• beta blockers have fallen out of favor (like Brevibloc), Consider an adrenergic blocker w/ alpha blocker properties as well.
  51. 51. Take Home Information• Core Temp if unresponsive• Fluid Resuscitation• Sedation PRN• Watch for DIC, SZ• P.U.H.A. IF GROSSLY SYMPTOMATIC.
  52. 52. DXM- Introduction• Yes, its in cough syrup OR COUGH TABS (CORICIDIN)”TRIPPLE C”• Dextromethorphan acts as a cough suppressant via its agonist (activating) activity at mu-opioid receptors.• In Canada: Contac CoughCaps (30 mg DXM)• Related in effects to Ketamine and PCP
  53. 53. DXM• Yes, its in cough syrup OR cough tabs (CORICIDIN)”TRIPPLE C”• Dextromethorphan acts as a cough suppressant via its agonist (activating) activity at mu-opioid receptors.• In Canada: Contac CoughCaps (30 mg DXM)• Related in effects to Ketamine and PCP
  54. 54. DXM- How is it used? • “Robo-ing” (Old Term from early 90’s) • DXM is available over-the- counter in tablet form in several countries as a cough med. Robitussin Maximum Strength Cough (not Robitussin DM) syrup • Users often refer to DXM in “plateaus” • Dose of Robitussin Maximum Strength Cough syrup is two to five full "shots" using the shot glass that comes with the bottle.
  55. 55. DXM- Coricidin Toxicity• Coricidin Cough and Cold Caps, 30 mg DXM and 4 mgs of Chlorphineramine maleate• Chlorphineramine maleate is an anti- cholinergic drug like scopolamine.• Non Specific reports of “Respiratory Failure” at high doses.
  56. 56. DXM- Coricidin Toxicity• Robo-Walk• Robo-Itch• Robo-Talk• Psychosis• Dialated Pupils
  57. 57. DXM- Treatment• VOMIT• Symptomatic TX.• Be alert for and (Cautiously) treat hypertension or hypotension, and rarely, cardiovascular problems• Restraints (?)• Avoid Chemical Restraint (Haldol, Droperidol),Benzo’s are preferred (Be prepared to manage the airway)• Benadryl may be given for Dystonic reactions, and for s/s of histamine release.
  58. 58. DXM- What does this mean to me?• Be Careful, take the same precautions you would with a PCP patient.• ALS eval is a must ( HTN, Hyperthermia, Respiratory Depression, and self harm)• DXM differs from other drugs. Its presentation of s/s extend well beyond simple CNS depression and hallucinations but into basic cognitive functions as well.• Understanding that DXM effects last well beyond the 4 hours of intoxication , and that side effects may include “Psychotic Breaks” will help determine deposition of patients.
  59. 59. BREAK?
  60. 60. GHB
  61. 61. GHB Analogs- Introduction• Gamma- hydroxybutyrate (GHB) may be made in homes by using recipes with common ingredients.• "Liquid Ecstasy," "Georgia Home Boy," "Grievous Bodily Harm,• “Liquid ecstasy," do not confuse w/ MDMA• GBL, GBH, One 4 B
  62. 62. Recognizing GHBAKA: 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)
  63. 63. So Many Names….• Tranquili G, Midnight Blue, Verve, Rejoov, Somax, SomatoPro, Flower Power, Puritech, Alcover, G-riffick, Eclipse, GHGold, Soap, Vita G, Dormir, Enliven, FX, Serenity, Inner G, Zen, White Magic Cleaner, Weight Belt Cleaner, Ink Jet Cartridge Cleaner, Plant Food, Fingernail Polish Remover, Paint Stripper.There are more than 80 known names for GHB and its equally deadly analogs.
  64. 64. GHB analogs –How are they used?• GHB can be produced in clear liquid, or a white powder, tablet, and capsule forms, and it is often used in combination with alcohol, making it even more dangerous• It is often carried in an eye dropper, or in water/Gatorade bottles and passed around.• Typically measured out in capfuls.• Occasionally blue food coloring is used to identify it at some raves.• It is occasionally used as a body building aid
  65. 65. Other GHB Products
  66. 66. Efforts to Avoid Detection• GHB & its analogs are NOT protected by the Dietary Supplement & Heath Education Act of 1994.• Unapproved for human use.• “Misbranded” drugs.• May be listed as “weight belt cleaner” or other solvent use or plant growth formula—trying to avoid detection
  67. 67. Efforts to Avoid Detection• Acetone free Nail Polish
  68. 68. GHB- No longer Just for Rapists• Recreational Use• Muscle Gain• Those under mandatory drug testing• Elderly
  69. 69. What To Expect
  70. 70. Typical Drinks To Hide GHBAny Substance can be used to hide a GHB Analog!
  71. 71. Typical GHB ContainersTypical 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.
  72. 72. Recognizing Containers ANY container that will hold a liquid. GHB addicts have hidden it in engine compartments, attics, etc.
  73. 73. Billy Idol: Famous GHB’er Billy almost died in 1993 from (then legal) GHB in front of a L.A. Night club
  74. 74. Nick Nolte
  75. 75. GHB analogs - What does it do• At lower doses, GHB has sedative effects, but, as the dose increases, GHB effects may result in sleep ,eventual coma, respiratory arrest, or death.• It is these effects that make it both a prime drug at Raves, and for Date Rape
  76. 76. GHB analogs toxicity- mild• Lethargy, easily aroused with repeated stimulation• Drowsiness, somnolence, dizziness, euphoria• Confusion (dazed and confused)• Amnesia, Susceptible to suggestion
  77. 77. GHB analogs Toxicity- Severe• 66% with GCS <9, ½ of these may have GCS at 3!• Frequent Vomiting,• Bradycardia,• Respiratory depression or arrest• Seizures• Sudden onset of coma . Patients often demonstrate extreme SUDDEN combativeness and agitation despite such profound CNS and respiratory depression• Death (usually secondary to respiratory failure or aspiration)
  78. 78. GHB• ALCOHOL IS THE MOST COMMON DRUG CO CONSUMED IN GHB RELATED DEATHS
  79. 79. GHB analogs-Treatment• Primary Supportive• Beware of positional Asphyxia, but soft restraints are a good idea• Due to the risk of sudden airway failure, aspiration, and respiratory collapse, these patients need aggressive airway monitoring by ALS providers
  80. 80. GHB analogs-Treatment• Protect your self• VOMIT• Be cautious using respiratory depressants• Making the decision to tube/not tube is tough, these patients do frequently vomit.• ETT placement is uncommon, but post ETT sedation/paralysis and restraint should be mandatory in the field
  81. 81. Difficulty in Prosecution• Sort Duration• Amnesia clouds recall• Often pro-sexual appearing behavior• Lack of : – Credible witness – Evidence
  82. 82. GHB analogs- What does this meanto me?• GHB analogs are unpredictable in clinical course, other than duration.• GHB analogs cause a rapid change in mental and respiratory status that makes it difficult to plan treatment and care• GHB’s presentation often mimics ETOH abuse and is often co-imbibed.
  83. 83. “For about a week I couldnt walk through the lobby of A-entry at the dorm without getting really scared, because of the goblin I saw there when I was tripping….” ( …User, circa.1971, )
  84. 84. Background
  85. 85. Background• Discovered by Dr. Albert Hofmann in 1938• Extensive study, use, and abuse by the government in the late 40’s. 50’s, and 60’s. (OSS/CIA, US Navy)• Some documented cases of CIA Operatives taking it to “Immunize” them selves to its effects in the 60’s.• Now that’s job satisfaction!
  86. 86. Slang• Many names refer to the carrier or “brand”(image printed on blotter)• Blotter, Sugar, Sugar Cube, “cid, Acid• Bart Simpsons, Barrels, Tabs, Blotter, Heavenly blue, "L", Liquid, Liquid A, Lucy in the sky with diamonds, Microdots, Mind detergent, Orange cubes, Orange micro, Owsley, Paper acid, Sacrament, Sandoz, Sunshine, Tabs, Ticket, Twenty-five, Wedding bells, Windowpane, etc.
  87. 87. Slang• Hit- Dose• Body Kinks- Unexpected physical side effects I.e. nausea, jitters, etc• Bad trip- A person on LSD who becomes depressed, agitated, or confused may experience these feelings in an overwhelming manner that grows on itself.• LSD psychosis: The effects of LSD exacerbate pre-existing psychological problems for several days.
  88. 88. Methods• Usually taken Sublingually or orally on paper (“Blotter”)• The solution may also be injected s.c. or i.v. (RARE) The effect is identical with that of oral administration but sets in more rapidly.• Usual dose is 50-200 mcg, with “Transcending doses” as high as 500 mcg
  89. 89. How does it work?• Similar to other drugs that give hallucinations:• It affects the re-uptake of 5-HT similarly to SSRI (serotonin specific reuptake inhibiting) anti- depressants such as fluoxetine (Prozac), sertraline, and paroxetine• Agonist (stimulation rather than blocking) properties at the 5-HT2 receptor have been found to fairly universally be associated with other psychedelic drugs such as psilocybin and mescaline, and somewhat in MDMA
  90. 90. S/S OF AN OVERDOSE• Dilated Pupils• Vivid Auditory, tactile, and visual perception• Nausea• Mild drops in B/P• Hyperglycemia• Piloerection (Goosebumps)• Mild Hyperthermia• Bradycardia• May exacerbate pre-existing behavioral tendencies• Mild stimulatory effects
  91. 91. After trip effects • Insomnia (common) • “Jitters” • Flashbacks (inconstantly proven and disproven in literature)
  92. 92. BASIC TREATMENT• Supportive• Protect the patient• Calm low key, low light, environment• Calm low key, low light environment• Calm low key, low light environment• Calm low key, low light environment• Oh yes…• Calm low key, low light environment
  93. 93. FOCUSED TREATMENT• Benzo’s for severe agitation (rare)
  94. 94. Dependence, Detox, and withdrawal• No documented physical or psychological dependence• A rapid tolerance is built up (about 3-5 days) that just as rapidly disappears
  95. 95. Take Home Information• Facilitate a low key trip, and all is well• The patients respond to your actions as much as we respond to them• Very little clinical problems from drug, just actions resulting from altered behavior
  96. 96. Summary• The scariest things about these drugs are the uncertainties involved in poly-pharm overdoses, unknown ingredients, etc…• Careful case by case assessment and treatment is more important than a cook- book approach.• Knowing the onsets, durations, and warning signs is as essential as knowing the actual effects of a drug.
  97. 97. Anything Imissed?
  98. 98. These Drugs in in Boise?
  99. 99. Seattle Wa., July 2002Caffeine (83.3%) MDA (16.7%)
  100. 100. Houston, TX July, 2002Caffeine (9.1%)MDA (90.9%)
  101. 101. Kuna Idaho, April 2002MDA (100 %)
  102. 102. Lewiston Idaho, May 2002MDMA (75.0%) Ephedrine/Pseudoephedrine (25.0%)
  103. 103. Summary• “..Due to the poly-pharmacy drugs that are being sold to ravers, all of these patients deserve ALS evaluation…”• Knowing your onsets and durations will help you a lot .
  104. 104. Don’t let this pt….
  105. 105. …turn out like this:
  106. 106. And don’t miss this!
  107. 107. QUESTIONS???
  108. 108. Supplemental information follows:
  109. 109. Samantha Reid, Age 15GHB induced death at a party No alcohol was involvedThe 4 guys who gave the GHB toher are serving 5 ½ -15 years inprison
  110. 110. Melanie Sidone, 15 at the time, was in acoma for 17 hours
  111. 111. Erick Limmer, 26, Owned the apartment thatthe GHB overdose took place in. CONVICTED!
  112. 112. Daniel Brayman, a senior, was one of two boyswho picked up the freshman girls took them tothe Party…CONVICTED!
  113. 113. Nicholas Holtschlag, 18, allegedly handed drinksthat were poisoned with GHB to Melanie Sindoneand Samantha Reid.CONVICTED!
  114. 114. Joshua Cole deliberately slipped the GHB into the girlsnon alcoholic drinks.CONVICTED!

×