Title: Designer Drug Evolution: Managing Uncontrolled Patients On Controlled Substances Description: Emergency services are confronted by horrific events caused by a surge in the use of new types of designer drugs. In this program we'll use real world case studies to discuss the up-surge in mephedrone based drugs (“bath salts” and more), synthetic marijuana, salvia divinorum, datura weed, molly and more; what these drugs are, where they've come from, and what form they may take in the future. We'll also discuss what regulators and law enforcement are doing to stop them, and what field providers can do to manage the fallout from this new wave of designer drugs. Teaching Formats: -Lecture -Discussion -Case Studies -Question and Answer Learning Objectives: Students will be able to: - Identify, assess and manage designer drug abusers in acute crises and overdose situations. - Coordinate response and scene management across emergency services for designer drug emergencies. - Provide both basic and advanced emergency medical care for designer drug abuse and ex-cited delirium. - Understand past, present and future development of designer drugs presented through his-torical and contemporary case studies. As seen in Fire Engineering Magazine’s Fire/EMS Column Revised for 2024

3. V
8/21/2019
Johnson, E. (2019, July 11). Preliminary 2018 data shows decline in opioid deaths. Austin Daily Herald. https://www.austindailyherald.com/2019/07/preliminary-2018-data-shows-decline-in-opioid-deaths/

4. 9/21/2021
Center for Disease Control and Prevention. (2021). HAN Archive—00438 | Health Alert Network (HAN). Center for Disease Control and Prevention. https://emergency.cdc.gov/han/2020/han00438.asp

5. 3/6/2021
10/8/2021

6. Center for Disease Control and Prevention. (2023, August 8). Understanding the Opioid Overdose Epidemic | Opioids | CDC. https://www.cdc.gov/opioids/basics/epidemic.html

9. Bhullar, M. K., Gilson, T. P., & Singer, M. E. (Flannery, D. J. (n.d.). Cuyahoga County, Ohio, Heroin and Crime Initiative: Informing the Investigation and Prosecution of Heroin-Related Overdose: Final Research Overview Report.
2022). Trends in opioid overdose fatalities in Cuyahoga County, Ohio: Multi-drug mixtures, the African-American community and carfentanil. Drug and Alcohol Dependence Reports, 4, 100069.
Flannery, D. J. (n.d.). Cuyahoga County, Ohio, Heroin and Crime Initiative: Informing the Investigation and
Prosecution of Heroin-Related Overdose: Final Research Overview Report.

10. Bhullar, M. K., Gilson, T. P., & Singer, M. E. (2022). Trends in opioid overdose fatalities in Cuyahoga County, Ohio: Multi-drug mixtures, the African-American community and carfentanil. Drug and Alcohol Dependence Reports,
4, 100069. https://doi.org/10.1016/j.dadr.2022.100069

12. The
Problem
A critical threat to
Patient Families Community
EMS
• Physical
• Burnout
• Addiction
A continued overdose
epidemic born on the backs
of EMS

13. The Goal
Better understanding of designer/synthetic drugs
Improved short-term incident management strategies
Improved long-term care innovation

25. Novel
Psychoactive
Substances

26. Designer Drugs
Synthetic
Stimulants
Synthetic
Cannabinoids
Synthetic
Hallucinogens
Synthetic
Opioids

27. Designer Drugs
What are they?
What do they
look like and how
are they used?
How are they
dangerous?
What are the
signs and
symptoms?
How do I manage
an OD?

28. Intended Effects
Unintended Effects

34. Often sold in decorative foil packaging, glass vials, ziplock
baggies, droppers, and lip balm-like containers
• Bug repellent
• Potpourri
• Shoe deodorizer
• Jewelry cleaner
• Toilet cleaner
• Energy enhancer
• Bath salts
• Glass cleaner
• Fertilizer
• Plant food
• Decorative sand
• Herbal incense
Commonly sold in smoke shops, but may also be found in
liquor stores, gas stations, convenience stores, the internet

36. (The American College of Emergency Physicians’ Position Statement

37. (ACEP recognizes the existence of hyperactive delirium syndrome with
severe agitation, a potentially life-threatening clinical condition
characterized by a combination of vital sign abnormalities (e.g.,
elevated temp and blood pressure), pronounced agitation, altered
mental status, and metabolic derangements.
.

38. These patients are at high risk of direct physical trauma, not only
unintentional harm from trauma such as falls, but also the metabolic
stress that may result from physical restraint that may be required to
facilitate the safety of the patient, bystanders, and responding
professionals and ensure appropriate patient evaluation by EMS.

39. The goal when treating patients with signs of hyperactive delirium
syndrome is to focus on reducing stress, preventing physical harm, and
transporting them to an emergency department, where they can be
treated by an emergency physician.

40. 1) Coordinate
2) Rapport & de-escalate
3) Position & medicate*
4) Monitor & differentiate

42. Super Meth
2006: Ephedrine and pseudoephedrine moved
behind pharmacy counter
P2P methamphetamine: intense, long-lasting highs
Extreme aggression and paranoia

45. Overdoses associated with xylazine may be more difficult to
identify in clinical settings, as they often appear similar to opioid overdoses and may not be
included in routine drug screening tests. Xylazine has no approved antidote for human use, and
as xylazine is not an opioid, naloxone does not reverse its effects. death.
Overdoses associated with xylazine may be more difficult to identify in clinical
settings, as they often appear similar to opioid overdoses and may not be included
in routine drug screening tests.
Xylazine has no approved antidote for human use, and as xylazine is not an opioid,
naloxone does not reverse its effects. Consequently, the presence of xylazine may
render naloxone less effective; however, the administration of naloxone can still
address the effect of an opioid on breathing, which may be sufficient to prevent
death.

46. 1) Coordinate
2) Rapport & de-escalate
3) Position & medicate*
4) Monitor & differentiate

58. 1) Coordinate
2) Rapport & de-escalate
3) Position & medicate*
4) Monitor & differentiate

60. Cannabinoid Hyperemesis Syndrome
First described in 2004 in Adelaide Hills of Australia
Cyclic vomiting in the setting of chronic, high-dose cannabis
Frequently associated with compulsive hot baths/showers
Galli, J. A., Sawaya, R. A., & Friedenberg, F. K. (2011). Cannabinoid Hyperemesis Syndrome. Current Drug Abuse Reviews, 4(4), 241–249. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3576702/
Sorensen, C. J., DeSanto, K., Borgelt, L., Phillips, K. T., & Monte, A. A. (2017). Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology, and Treatment—a Systematic Review. Journal of Medical Toxicology, 13(1),
71–87. https://doi.org/10.1007/s13181-016-0595-z

61. Medical emergencies related to
marijuana use have increased with
legalization and greater availability
National Institute on Drug Abuse. (2020, June). What is the scope of marijuana use in the United States? National Institute on Drug Abuse. https://www.drugabuse.gov/publications/research-reports/marijuana/what-
scope-marijuana-use-in-united-states
It is unknown whether this increase is due to increased use,
increased potency of marijuana or other factors.
Mentions of marijuana in medical records do not necessarily indicate that
these emergencies were directly related to marijuana intoxication

62. Prodromal Phase
Mild discomfort and nausea upon waking.
Possible increased intake of cannabinoids
to treat persistent nausea.
Can last for months to years
Galli, J. A., Sawaya, R. A., & Friedenberg, F. K. (2011). Cannabinoid Hyperemesis Syndrome. Current Drug Abuse Reviews, 4(4), 241–249. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3576702/

63. Hyperemetic Phase
Nausea, vomiting, abdominal pain, and retching
Scromiting (screaming/vomiting)
Episode length varies significantly
Symptoms are cyclical and can recur in intervals of
weeks to months
Weight loss and dehydration due to decreased
intake and vomiting
Galli, J. A., Sawaya, R. A., & Friedenberg, F. K. (2011). Cannabinoid Hyperemesis Syndrome. Current Drug Abuse Reviews, 4(4), 241–249. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3576702/

64. Recovery Phase
Can last days to months
Weight gain, rehydration, sx relief
If patient consumes cannabis symptoms tend to
come back
Asymptomatic periods sometimes referred to as
the “Well Phase”
Galli, J. A., Sawaya, R. A., & Friedenberg, F. K. (2011). Cannabinoid Hyperemesis Syndrome. Current Drug Abuse Reviews, 4(4), 241–249. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3576702/

65. Assessment
History of present injury including
syndromic presentation
Past medical history including marijuana
use
A physical exam
Vital signs
Capillary blood glucose check
12 lead EKG

66. Assessment
Complications from chemotherapy
Bowel perforation / obstruction
Gastroparesis (stomach paralysis)
Cholangitis (Inflamed bile duct)
Cholecystitis (inflamed gall bladder /
stones)
Pancreatitis (enzymes digest the
pancreas)
Nephrolithiasis (kidney stone
formation)
Diverticulitis (infection / inflammation
of pouches in intestines)
Ectopic pregnancy
Pelvic inflammatory disease
Acute Coronary Syndrome (ACS)
Acute hepatitis
Adrenal insufficiency
Ruptured aortic aneurysm
Sorensen, C. J., DeSanto, K., Borgelt, L., Phillips, K. T., & Monte, A. A. (2017). Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology, and Treatment—a Systematic Review. Journal of Medical Toxicology, 13(1), 71–87. https://doi.org/10.1007/s13181-016-0595-z

67. Assessment
Most common complications
• Mild to moderate skin burns
• Electrolyte abnormalities (most commonly low
potassium)
• Dehydration or acute kidney injury
• Muscle cramping or spasms
Potential life threats
• Pneumomediastinum from a ruptured esophagus
• Electrolyte derangement causing seizures,
arrhythmias

68. Supportive
Treatment
Avoid narcotic pain medication
• Associated with bowel dysfunction
• Could theoretically worsen CHS symptoms
• Could potentially create opioid dependence
Sorensen, C. J., DeSanto, K., Borgelt, L., Phillips, K. T., & Monte, A. A. (2017). Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology, and Treatment—a Systematic Review. Journal of Medical Toxicology, 13(1),
71–87. https://doi.org/10.1007/s13181-016-0595-z

69. Supportive
Treatment
Patients with moderate to severe dehydration and/or acute renal
failure require aggressive fluid resuscitation
Sorensen, C. J., DeSanto, K., Borgelt, L., Phillips, K. T., & Monte, A. A. (2017). Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology, and Treatment—a Systematic Review. Journal of Medical Toxicology, 13(1),
71–87. https://doi.org/10.1007/s13181-016-0595-z

70. Supportive Treatment
• Chu, F., & Cascella, M. (2023). Cannabinoid Hyperemesis Syndrome. In
StatPearls. StatPearls Publishing.
http://www.ncbi.nlm.nih.gov/books/NBK549915/
• Senderovich, H., Patel, P., Jimenez Lopez, B., & Waicus, S. (2021). A
Systematic Review on Cannabis Hyperemesis Syndrome and Its Management
Options. Medical Principles and Practice, 31(1), 29–38.
https://doi.org/10.1159/000520417
• Sorensen, C. J., DeSanto, K., Borgelt, L., Phillips, K. T., & Monte, A. A.
(2017). Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology,
and Treatment—a Systematic Review. Journal of Medical Toxicology, 13(1),
71–87. https://doi.org/10.1007/s13181-016-0595-z

71. CHS: Take Home
Emergency departments have increases in cannabis related pathology
“Cyclical vomiting” has doubled in Colorado following marijuana legalization
Synthetic cannabinoid use is also on the rise and has been associated with CHS
CHS often remains undiagnosed
EMS is often the first medical provider to encounter the issue
CHS patients often receive expansive diagnostics, numerous pharmacological
interventions, and frequently require observation or hospitalization
EMS understanding, assessment, and communication can improve the process
Kim, H. S., Anderson, J. D., Saghafi, O., Heard, K. J., & Monte, A. A. (2015). Cyclic vomiting presentations following marijuana liberalization in Colorado. Academic Emergency Medicine: Official Journal of the Society for
Academic Emergency Medicine, 22(6), 694–699. https://doi.org/10.1111/acem.12655
Hopkins, C. Y., & Gilchrist, B. L. (2013). A case of cannabinoid hyperemesis syndrome caused by synthetic cannabinoids. The Journal of Emergency Medicine, 45(4), 544–546.
https://doi.org/10.1016/j.jemermed.2012.11.034

75. 1) Coordinate
2) Rapport & de-escalate
3) Position & medicate*
4) Monitor & differentiate

78. Isotonitazene
(ISO)
Nitazines in powder form can appear yellow, brown, or off-
white in color.
DEA regional forensic laboratories have seen this drug mixed
into heroin and/or fentanyl (and marketed as common street
drugs) with deadly consequences.
ISO has already been seen pressed into counterfeit pills and
falsely marketed as pharmaceutical medication (like Dilaudid
"M-8" tablets and oxycodone "M30" tablets).

80. 1) Coordinate
2) Rapport & de-escalate
3) Position & medicate*
4) Monitor & differentiate

82. Innovative EMS Strategies
ASTHO. (2021). Innovations in Overdose Response: Strategies Implemented by Emergency Medical Services Providers.

83. Among the 143 patients linked to peer recovery support specialist services, 87 (60.84%)
had accepted an NLB kit from EMS. The fully adjusted logistic regression model revealed
that those whose kit was left with a family member on the scene were 5.16 times more
likely to be connected to peer support specialists (OR = 5.16, CI= 2.35 - 11.29, p = 0.000)
while those whose kit was left with a friend or given directly to the patient were 3.69
times (OR = 3.69, CI= 1.13 - 12.06, p < 0.05) and 2.37 times (OR = 2.37, CI= 1.10 - 5.14, p
< 0.05) more likely, respectively, to be connected to follow up services as compared to
those who did not accept a kit, controlling for other variables in the model.
Scharf, B. M., Sabat, D. J., Brothers, J. M., Margolis, A. M., & Levy, M. J. (2021). Best Practices for a Novel EMS-Based Naloxone Leave behind Program. Prehospital Emergency Care, 25(3), 418–426. https://doi.org/10.1080/10903127.2020.1771490

84. Buprenorphine
Bridge Program
Buprenorphine or Suboxone® (a combination of
buprenorphine and naloxone) have been administered
successfully within structured opioid overdose bridge
programs. For patients who are not transported to a hospital,
these medications prevent the onset of opioid withdrawal
and can serve as a “bridge of survival” until the patient can be
linked to drug rehabilitation resources.
Hern, H. G., Lara, V., Goldstein, D., Kalmin, M., Kidane, S., Shoptaw, S., Tzvieli, O., & Herring, A. A. (2023). Prehospital Buprenorphine Treatment for Opioid Use Disorder by Paramedics: First Year Results of the EMS Buprenorphine Use Pilot.
Prehospital Emergency Care, 27(3), 334–342. https://doi.org/10.1080/10903127.2022.2061661

86. The
Problem
A critical threat to
Patient Families Community
EMS
• Physical
• Burnout
• Addiction
A continued overdose
epidemic born on the backs
of EMS

87. The Goal
Better understanding of designer/synthetic drugs
Improved short-term incident management strategies
Improved long-term care innovation

89. Thanks & Links!