Drugs of Abuse

What drugs are popular?
Drugs of Abuse
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Street names
Medical literature
Poison Center
Other sources eg www.erowid.org
George M Bosse, MD
U of Louisville - Emergency Medicine
KY Regional Poison Center
What’s Important?
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Antidote or specific therapy
Admission for agents that cause delayed
deterioration
H
Heat
Rhabdomyolyis
Psychosis
Is it something else?
Antidotes / Specific Therapy
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Coma secondary to which of the
following must be corrected rapidly?
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A. diazepam overdose
B. thiamine deficiency
C. heroin overdose
D. insulin overdose
Not many antidotes
Acetaminophen is a common component of
drugs of abuse and has an effective antidote
H
Hemodialysis
di l i
Other
Answers
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B. thiamine deficiency
D. insulin overdose
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Observation Duration
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Most, but not all, cases of drug overdose and
drug abuse will declare themselves within a 4 to
6 hour period of observation
Certain “toxic
toxic timebombs”
timebombs can ca
cause
se delayed
onset of clinical manifestations
Most, but not all, cases of toxic timebomb
exposure require admission
Toxic Timebombs – Drugs of Abuse
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Generation of Heat
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Wildly agitated
Persistent seizure activity
Is it Psychosis?
Sustained release products
Drug packets (usually either heroin or cocaine)
Acetaminophen
Mushrooms
Other
Rhabdomyolysis
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Wildly agitated
Persistent seizure activity
Is it Something Else?
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Recognition of the Drug Abuser
Synthetic / Designer Drugs
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Definition
Legal loopholes
Chemical types
Historical aspects
Cocaine
Sources of cocaine
Cocaine Pharmacology
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Half-life approximately one hour
HalfSodium channel blocker
Indirect acting sympathomimetic and inhibitor
off rere-uptake
k off certain
i neurotransmitters
i
3
Cocaine - Routes of exposure
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Nasal insufflation
Intravenous
Smoking (free(free-base, crack)
Body stuffing/packing
Cocaine -clinical effects
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Cocaine - clinical effects
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Cardiac (ischemia, infarction, dysrhythmias,
cardiomyopathy)
Aortic dissection
Pulmonary
P l
Rhabdomyolysis
Cocaine toxicity - treatment
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Case
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A 16 year old female is brought to the ER by
friends. They could not awaken her after a long
weekend of partying. Drugs of abuse included
ethanol and cocaine
cocaine.
Vasculitis/vasospasm
Hyperthermia
Hypertension
Tachycardia
Neurologic (seizures, hemorrhage, strokestroke-like
syndromes)
Rapid cooling
Benzodiazepines
Avoid beta
beta--blockers
Nitroprusside,, alphaNitroprusside
alpha-blocker, or nicardipine for
hypertension
Sodium bicarbonate for widewide-complex
dysrhythmias
Physical Exam
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Thin female unresponsive to painful stimuli
T - 98.9 F
R - 16
P - 108
BP - 115/70
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Management
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Ancillary tests?
Other therapies?
Labs
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Diagnostic Studies
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CT without contrast - normal
LP opening pressure - 150 mm
LP - 1 WBC, 3 RBC, glcglc-70, proteinprotein-38, GS
GS-NOS
Cocaine Coma
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Cocaine Residual Effects
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WBC - 12.1
Hgb - 12.5
Comp chem nl
Tox - cocaine positive
AKA “washed out syndrome”
History of binge for several days
Diagnosis of exclusion
Supportive care
Improvement after 66-12 hours
12--36 hours for normalization
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Amphetamines
Fatigue
Depression
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Phenylethylamine
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Terminology
Structure
Other hallucinogens/psychoactives
Designer Amphetamines
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Mescaline
MDMA (Ecstasy, Adam)
MDEA (Eve)
DOM (STP - serenity, tranquility, peace)
MDA (Love drug)
Methcathinone (Cat, Jeff)
Methamphetamine?
Methamphetamine
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Major problem
Methamphetamine Synthesis
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Easy for amateur chemists
Methamphetamine Synthesis
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Illicit synthesis often involves hazardous
chemicals or processes
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Potential Ingredients
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Anhydrous ammonia
Ephedrine / pseudoephedrine
Lithium
Red phosphorus
Iodine
Lead acetate
HCL
Amphetamines - routes of
exposure
Amphetamine Pharmacology
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Sympathomimetic effects
Stimulate release of neurotransmitter from
presynaptic terminal
Bl k d off reBlockade
re-uptake
k off neurotransmitters
i
Weak monomono-amine oxidase inhibition
Lipophilic
Half -life 8 to 30 hours
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Clinical Manifestations
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Can look like cocaine (but less likely to cause
seizures, dysrhythmias, and myocardial ischemia)
Oral
Intravenous
Smoking (“ice”)
Adverse Effects
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Tachycardia
Tremor
Tight jaw muscles, bruxism
Sweating
Headache
Nausea
Hypertension
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Adverse Effects
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Tachycardia
Dysrhythmias
Hypertension
Hyperthermia
Seizures
DIC
Rhabdomyolysis
Adverse Effects
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Residual Effects
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Fatigue
Depression
Hyponatremia – SIADH
“True” psychosis is possible
Treatment
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Principles similar to treatment of cocaine
toxicity
Decon all meth lab fire / explosion victims?
Airport Problem
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EMS is called to New York’s JFK airport
They encounter a lethargic 18 y/o male with cns
depression, a respiratory rate of 6/minute, and a
p lse oximetry reading of 84%
pulse
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Most appropriate management?
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A. Naloxone / respiratory support
B. Surgery to remove packets
C. Activated charcoal / whole bowel irrigation
D. Flumazenil
Answers
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A. Naloxone / respiratory support
C. Activated charcoal / whole bowel irrigation
Opioids
Opioid sources
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Poppy (morphine, codeine)
Semi--synthetic (heroin, oxycodone)
Semi
Synthetic (methadone)
Opioid terminology
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Opioids - “correct” term
Opiates - only those derived from the poppy
Narcotics - sleep inducing agents
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Opioids - routes of exposure
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Intravenous
Oral
Body packers/stuffers
Opioids - pharmacology
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Confusing array of opioid receptors
Opioids - clinical effects
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Respiratory depression
CNS depression
Non--cardiogenic pulmonary edema
Non
Miosis (not always – meperidine, propoxyphene,
pentazocine)
Any hypoxic brain insult may cause mydriasis
Opioids - clinical effects
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Seizures (meperidine, propoxyphene, tramadol)
Dysrhythymias (propoxyphene)
Rigidity (fentanyl)
Gastrointestinal
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Opioid toxicity - treatment
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Supportive
Naloxone (Do you really want to use it?)
Naloxone - low dose/high dose
Heroin
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Two Concerns
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Opioid of abuse has longer duration of action
than naloxone
Delayed pulmonary edema
My Recommendation
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Meperidine Analogs
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San Jose, CA 1982
MPPP
MPTP
Substantia nigra / dopamine depletion
How long do you watch a heroin overdose
patient that responds to naloxone following an
initial presentation of significant CNS and
respiratory depression
4 hours
Fentanyl Derivatives
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Orange County, CA - 1979
Tango and Cash - New York - 1991
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Fentanyl Derivatives
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Alpha-methyl fentanyl
Alpha3-methyl fentanyl
Other Street Names
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China White
Persian White
“Synthetic Heroin”
Mexican Brown
Clinical Presentation
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Potency
Death with needle in arm
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Bath Salts
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Synthetic cathinones
Phenylalkylamine derivatives
Like other opioids
Tox screens (routine tox analysis often negative)
Treatment
Cathinone
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Naturally occurring
Leaves of Catha Edulis
plant
Chewing
C
ew g leaves
eaves popu
popular
a
in certain Middle Eastern
countries
Amphetamine like
effects
Bupropion is a cathinone
derivative
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Other Cathinones
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Mephedrone
MDPV
Methedrone
Popular Use
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Patterns of Use
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Nasal insufflation
Ingestion
Adverse Effects
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Adverse Effects
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Chest Pain
Abdominal Pain
Dyspnea
Rhabdomyolysis
Hyperthermia
“Legal high”
“Bath salts”
“Plant food”
“Not for human consumption”
Cardiac, psychiatric, neurologic – “stimulant”
Agitation particularly common
Seizures
Tachycardia
Hypertension
Hyponatremia
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Similar to amphetamines?
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Treatment
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Supportive-similar strategy to cocaine,
Supportiveamphetamines
Cooling
S d i
Sedation
Synthetic Cannabinoids
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Synthetic Cannabinoids
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Herbal marijuana alternatives
Spice
K2
Zen
Marketed as incense and potpourri
Labelled as “not for human consumption”
Method of Use
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Adverse Effects
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“Stimulant – like”
Why do these not behave like marijuana?
Cannabinoid receptor agonists
Lack of structural similarity with delta
delta--9-THC
Typically smoked
Can be dissolved in a solvent, applied to plant
material, then smoked
Adverse Effects
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Altered mentation
Tachycardia
Hypertension
Seizures
Acute renal injury
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Unusual Adverse Effects
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CNS depression?
Bradycardia??
Bradycardia
Hypotension?
Eastern KY and western WV?
Treatment
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Supportive
Sedation
Cooling
Future Research
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What about a cannabinoid antagonist as a weight
loss agent?
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