Drug Crisis Response - Do It Now!

Box 27568 ■ Tempe, AZ 85285-7568 ■ 480.736.0599

DRUGRESPONSE

■ a do it now foundation publication by jim parker

how to help whennobody else can

CRISIS

Rights & Restrictions

Contents © 2002 by Do It Now Foundation. All rights reserved. Unauthorized use, reproduction and distribution, in both print and electronic forms, is prohibited. To obtain print copies of this publication or a license to unlock and print this electronic document, contact us at (480) 736-0599.

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1. KamikazesBody count ....................................................................... 5

2. Risk FactorsStatshots: Who needs help .................................................7

3. Focal PointsBasic skills: What works and why ..................................... 9

4. Judgment CallsInitial assessment: The ABC’s of response ....................... 13

5. Physical Intervention: Life-SupportRescue breathing, CPR, vomiting, recovery position,coma, convulsions, diabetic emergencies, shock ............ 19

6. Response Sets/Arousal & StuporCNS arousal & agitation, depressive stupor,Universal overdose response .......................................... 29

7. Between (& Outside) the Lines: Jumping TreesAnticholinergic drugs, aspirin & acetaminophen,inhalants, PCP & ketamine .............................................. 35

8. Emotional Rescue: Managing MeltdownsSet & setting, re-framing fear, alternative-focus,drug & non-drug emotional emergency responses .......... 43

9. Final Focus: Pay AttentionThe magic of attention .................................................... 49

; Appendix:Overdose Symptoms & Management ............................... 51

lcontents

Jim Parker earned his crisis-management stripes at Gemini House,an alternative street-drug program in Champaign-Urbana, Illinois,where he coordinated emergency services and supervised crisis train-ing from 1978 to 1980.

He is the author of numerous articles and publications on drugs,behavior and health, including Drugwise, Tranx, and Total Recovery.He also co-authored (with Erica Wittenberg) Drug-Proofing the Fam-ily: How to Raise “I’m Okay” Kids in a “No You’re Not” World.

He has served as Executive Director of the Do It Now Foundationsince 1981 and lives in Tempe, Arizona with his daughter, Sara.ab

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t here’s a silent drug war and it’s exploding all over America. It’s theworst kind of war in all kinds of ways: Mostly unheralded andunnoted, it’s also getting unbelievably deadly.

Even worse, it’s the kind of war where people volunteer to die—often alone and in the dark, like modern-day kamikazes.

But they don’t scream “Banzai” to dull their fright. As often as not,they don’t make a sound when they go.

Let’s consider the casualties for a moment.In figures released in 2002 for the year ending December 31, 2000,

emergency-room (ER) admissions for crystal meth and other forms of amphet-amine were up 51 percent in Los Angeles, 53 percent in Seattle, 76 percent inPhoenix.

It’s the same virtually across the board and across the country.Heroin mentions were up 31 percent in Buffalo, 35 percent in Boston, 50 per-

cent in New Orleans, 58 percent in Miami.Even prescription drugs are getting into the act: Vicodin, for example.Due to the pull of pop-culture (Eminem has rapped about it, pictured it on

CD covers, and even has a Vicodin pill tattooed on his shoulder; Courtney Loveand Matthew Perry only beat their addictions through stints in rehab), this pre-viously little-known prescription painkiller is going through the roof of the drug-crisis emergency-room admission list charts, jumping 108 percent nationallyfrom 1998 to 2000.

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l kamikazes bodycount

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There are bright spots amid the gloom, too, but on balance, the numbersreveal the most deadly-serious growth area in the entire American drug culture.

That’s why we’ve developed this booklet: Because a simple familiarity withcrisis assessment and intervention techniques can mean the difference betweenlife and death for untold numbers of people each year. For others, it can be thedifference between overcoming a moment of panic and coming apart at theseams. For still others, it can be the first step in a process that extends beyondan immediate crisis to real recovery.

It isn’t glamorous and it often isn’t easy. But in the lives of the people ittouches, it’s as important as the other, headline-grabbing, “official” war on drugs,the endless struggle to stop the flow of drugs at the border and on the street.

In the chapters that follow, we’ll do our best to make your introduction to drugcrisis management manageable. We’ll provide a general orientation to crisis-intervention strategies and an overview of specific techniques for helping peoplein emergencies. We’ll discuss how to assess a crisis and how to perform basiclife-support techniques.

We’ll also review drugs that figure into today’s drug scene and consider, inas neat and orderly and logical a fashion as possible, approaches to resolvingproblems that are usually anything but neat and orderly and logical.

Still, we want to emphasize that this information is intended to supplement,rather than to substitute for, actual hands-on training. Classroom training is in-dispensable for the necessary skill-building (particularly CPR and other life-sup-port techniques), which should form the core of any true introduction to drugcrisis management.

Building those skills and cultivating the sensitivity necessary to real effective-ness in a crisis—takes more time than the time it takes to read a booklet.

But it’s time well spent. Because even though we regard substance abuse asa social ill, the people who suffer because of abuse aren’t evil.

They’re our brothers and sisters—and they deserve the best, most careful carewe can give them.

The numbers reveal the most deadly-serious growth area inthe entire American drug culture.

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l riskfactors

s o who are the people in drug emergencies and how do we helpthem? Let’s consider who they are first. Because even though theycan be almost anyone, they tend not to be.

According to figures compiled by the Drug Abuse Warning Network(DAWN), a federally-funded information project that monitors hospitalemergency room admissions and drug-related deaths, drug victims arepredominantly male, non-white, and young.

Specifically, of the 601,776 emergencies tracked by the project intheir year-end 2000 report, more than 51.4 percent involved males, 48.6percent females.

Ethnically, the numbers show a disproportionate share of Blacks and Hispan-ics, with 22 percent and 11 percent of total admissions, respectively. Whites wereinvolved in 56 percent of the DAWN emergencies.

In terms of age, ER victims tend to be younger than drug fatalities.According to DAWN, 53.7 percent of all drug-related ER cases in 2000 involved

people under age 34, while 72 percent of the 11,651 drug fatalities tracked during1999 involved people 35 and over.

Why did they seek help—or have help sought for them?More than 43.9 percent were overdoses, while 15.4 percent were labeled “un-

expected reactions.” Chronic effects were cited in another 8.7 percent of admis-sions. The balance were in various stages of withdrawal or seeking detoxification,or were victims of accidents and injuries.

statshots

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Those are the demographics—pictures of people made of numbers. We’llconsider other numbers throughout this booklet to prepare you for what you’relikely to encounter in an emergency.

The numbers should help in providing a context for understanding emergen-cies—most-often-used drugs, lethality, duration of effect, etc.

But in a more fundamental way, numbers can never completely prepare youto help in a crisis.

That’s because statistics are built on averages, and people in crisis go to ex-tremes.

To discover the qualities you’ll need (or need to master) to respond effectively,you’ll need a little intuition and a lot of training.

You’ll also need to consider the interpersonal skills that are important in acrisis—and invaluable in a crisis helper.

Numbers will never completely prepare you to help in a crisis.That’s because statistics are built on averages, and people incrisis go to extremes.

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Los A

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Atlanta

Crystal Meth/Speed

Marijuana

Heroin

Cocaine

■ A Tale of 10 Cities

Drug data: Data from hospital E.R. admissions reflect national trends and variations in local patterns andproblems. This chart shows admission rates, per 100,000 population, for the top four street drugs for 2000.

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t here’s more than a little overlap and interaction between the twobasic categories of drug-related problems we’ll consider in thisbook, overdoses and psychological emergencies.

Still, to be effective as a crisis helper, it’s important to keep your rolein perspective as it applies to both types of crisis.

k In a psychological emergency: You’re there to create a safe en-vironment and provide emotional support until a person is ableto resume emotional control.k In an overdose: You’re there to help monitor vital signs andprovide needed life support until emergency medical support(EMS) arrives.

It’s as simple—and complex—as that. Still, in both contexts, the same per-sonal qualities are essential to effectiveness.

They probably include a lot of the same traits you’d bump into if you weresearching for words to describe a good therapist or qualities you’d look for in afriend.

■ Stay calm. There’s no special trick to remaining calm in a crisis. If youknow what you’re doing and you’re doing what you know, you shouldn’t haveproblems staying calm.

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Still, problems can come up when you stumble into areas in which you’re notfully comfortable. No matter how well prepared you are, there will likely alwaysbe situations you’re not fully knowledgeable about or comfortable in.

On top of that, we all have psychological “buttons” that get pushed in specificsituations or by particular people. Some can’t stand the sight of blood. Othersfreak out in stressful circumstances. Others handle stress well in a one-to-one en-counter, but are less effective when they’re called upon to deal with groups.

No matter what plugs you in or weirds you out, remain in emotional control.We’re not asking you to deny your feelings or “pretend” things are other than theway they are. We’re simply suggesting that you allow whatever feelings you haveto be on the inside, while on the outside you’re busy attending to what needs tobe done.

How do you best do that? Focus on the person you’re helping, not on your feel-ings. Respond to the circumstances that present themselves, and apply the prin-ciples we’ll present in this book.

And remember: Fear and uncertainty are contagious, but so is confidence andself-assurance.

■ Don’t impose your values. Maintain a non-judgmental attitude. Attitude isimportant, but opinions aren’t—at least not in the context of resolving a crisis.

Stay friendly, supportive, and non-threatening. Your attitude is of fundamen-tal importance because it creates a climate of acceptance in which to conduct theintervention. People are more likely to open up in an atmosphere of trust. Letthem.

■ Communicate. Acknowledge, reflect, reassure. Help the person workthrough any embarrassment or fear he or she might have. Remind the person thatothers have been through similar situations with similar feelings.

And when you communicate in a crisis, make the power of suggestion workfor and not against you.

Often, suggestibility runs wild in a drug emergency. Physical and psychologi-cal effects can snowball from apprehension and fear as much as from the drugitself.

No matter how well prepared you are, there will likely alwaysbe situations that you’re not fully knowledgeable about orcomfortable in.

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Reassure the person in a psychological emergency that their problem is a re-sult of drug use and will go away.

Still, don’t lie — or unnecessarily distort reality.If someone asks you a question and you’re not sure of the answer, tell them

so. Forget having to have all the answers. To be effective as a crisis helper, it’senough to ask the right questions.

■ Be sensitive to contextual cues. Learn to look above and below the sur-face of a crisis. Get to know the characteristics and flavor of different crisis situ-ations and respond accordingly.

Just as you refrain from imposing your values and judgments, you should alsoavoid forcing yourself too far into the foreground in certain situations—or toofar into the background, when the situation calls for you to assert a leadershiprole.

Simply put, the way you respond to a person who’s behaving dangerously onPCP may well be different than the way you’ll respond to someone who’s overdosedon heroin or barbiturates.

Similarly, be sensitive to the personalities present. If a parent is present witha child undergoing a bad LSD reaction, for example, you might choose to play asecondary role to the parent.

Then again, you might not, depending on how you evaluate his or her rapportand effectiveness.

Those are the main personal qualities you should bring to any crisis.

Critical Skills. The personal style of a helper can help resolve both overdoses and psychologi-cal emergencies. Key elements: Calm, honest communication, sensitivity to crisis cues, anda non-judgmental manner.

■ Setting the Stage

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They’re not the only important personality traits by any means, but they do pro-vide a basis for working effectively with others.

But beyond personal qualities, there is one other attribute you should focuson as we prepare to move into a discussion of specific intervention and life-sup-port techniques. It becomes increasingly important as the level of physical inter-vention increases in a crisis. It’s just this:

■ Know your limitations. Don’t try to provide treatment beyond the limits ofyour skills.

If you attempt a life-saving technique which you may be unqualified or unpre-pared to perform (CPR, for example, or moving a seriously-injured person), youcan cause more harm than good. Serious, even permanent, harm.

That’s why crisis workers—no less than medical doctors and other healthprofessionals—should always be guided by the ancient oath: “Primum nonnocere.”

Don’t speak Latin? Here it is, in English: “First, do no harm.”

Don’t provide treatment beyond the limits of your skills. Ifyou attempt a life-saving technique which you’re unqualifiedto perform, you can cause serious, even permanent, harm.

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l l l l l intialassessment

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i n discussing ways of sizing up and responding to drug emergen-cies, it’s hard to resist the temptation not to present things in asimplistic way—with neatly-drawn borders around clearly defined

problems, each inviting a can’t-miss response from a too-cool-to-foolcrisis worker.

But if things were that easy, we could just throw all the variables intoa laptop or handheld computer and let it sort things out.

[(Crisis A + Setting B) x Stressor C] divided by Strategy D = Outcome E.

The problem is that most drug emergencies aren’t so clear-cut.Things get even dicier when you’re presented with an unconscious

or hysterical victim.Then it can be tough to pin down precisely what a specific problem even is,

much less figure out how to proceed.The range of complicating variables in the drug world today is too vast to do

much more, in a booklet of this type, than present a basic guide for thinking onyour feet—and sorting things out quickly with your head and heart.

But learning to do that is possible—and necessary, if you ever plan to applythe information in this book.

In this chapter, we’ll create a basic context for all the specific interventionsand crisis-management methods that follow.

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We’ll begin with basic assessment techniques and move on to more advancedlife-support procedures that are essential to effective crisis aid.

The old saying that you can’t build on a shaky foundation was never more true:Because if you encounter someone in a crisis who needs life-support and youcan’t provide it, it doesn’t matter what else you may know.

Because no one’s going to be around to take advantage of it.

■ Making An AssessmentWhenever you encounter someone who is either unconscious or otherwise im-

paired, your initial inspection of the person and his/her condition assumes criticalimportance.

In such a situation, an assessment needs to be both fast and thorough. The onlyway to accomplish both is to be both systematic and prepared.

The American Red Cross calls the following “Emergency Action Principles.”You can call them whatever you like—as long as you can call them to mind whenyou need them.

1. Survey the scene.

2. Do a ‘primary survey’ of the victim.

3. Phone the emergency medical services (EMS) system for help.

4. Do a ‘secondary survey’ of the victim.

� Survey the scene. The first principle is as simple as it sounds. Quickly lookover the entire scene. Decide whether or not it’s physically safe for you to be there.Look for any cues that might give you an insight into the emergency—signs of aphysical struggle, suicide notes, pills or syringes, etc.

If the person is conscious or if others are present, take charge of the situa-tion. Identify yourself as someone with crisis training and ask specific questionsto determine the problem.

If others are present, decide whether they may be of value in the intervention.Ask if they know the victim or are aware of any medical problems. Ask if they canhelp, if help becomes necessary.

If the person is conscious, ask for his or her consent before you go any fur-ther. The Red Cross recommends simply saying, “Hi, my name is ______. I knowfirst aid and can help you until an ambulance arrives. Is that okay?”

If the person is unconscious, a minor, or emotionally upset, get per-mission from a parent or guardian, if one is present.If a legal guardian isn’t present or if the person is un-

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conscious or impaired and consent cannot be obtained, assume that consentwould be given, and proceed with the intervention.

� Do a primary survey of the victim. The “primary survey” is a fast check ofthe person’s basic life systems. It’s as simple to learn—and recall in an emer-gency—as ABC. And it’s as fundamental to everything else that follows.

With an unconscious or unmoving victim, check their degree of responsive-ness by gently tapping them on the shoulder and asking, “Are you OK?”

If there’s no response, repeat the process. If there’s still no response, call forhelp. Ask a partner or anyone else nearby to phone for help, while you continuethe primary survey.

If no one is available to make the call, continue the primary survey by checkingthe victim’s ABC’s: airway, breathing, and circulation.

■ Airway. If the person is lying on the ground, make sure the airway (the pas-sage from the nose and mouth to the lungs) is clear. If it isn’t or it’s obstructedin some way, use the head-tilt/chin-left method to re-establish a clear breathingpassage. (Figure 1, p. 16)

Place one hand on the victim’s forehead, and place your other hand under thevictim’s chin. Tilt the forehead back as you lift up on the jaw. Lifting the chinreduces the possibility of further injury, if the person has suffered a neck or backinjury.

■ Breathing. Check for breathing. Place your ear over the victim’s mouth andnose. (Figure 2) As you look for chest contractions, listen and feel for the move-ment of air through the nose and mouth. If the person is breathing, count thenumber of breaths for 30 seconds and multiply by two.

■ Circulation. Find out if the heart is beating by checking the carotid arteryat the left side of the neck for a pulse (Figure 3). Hold one hand on the person’sforehead, and slide your middle and index fingers into the groove alongside theAdam’s apple.

If you run into someone who needs life-support and you can’tprovide it, it doesn’t matter what else you may know. Becauseno one’s going to be around to take advantage of it.

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■ The ABC’s of Assessment

l Airway. If the victim isn’t breathingnormally, insure an adequate airway us-ing the head-tilt/chin-lift method (shown).Place one hand on the forehead, whilelifting the jaw with two fingers of the otherhand under the chin. Tilting the head andlifting the chin will open the airway, with-out risking injury to the neck.

l Circulation. Check to see if the victim’sheart is beating by checking the carotidpulse. While maintaining head-tilt posi-tion on the forehead with one hand, locatethe Adam's apple with the index and middlefinger of the other hand. Then slide fingersinto the groove on the side of the neckcloser to you. Check for 5-10 seconds.

l Breathing. Position your head over thevictim’s nose and mouth while watchingchest area for breathing contractions. Lis-ten and feel for the sound and movementof air.

Life-Support Basics. The primary survey focuses on the ABC’s of a victim’s life-supportsystems: airway, breathing, and circulation.

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� Phone emergency medical services (EMS) for help. Getting help isn’t alwaysas cut and dried in an emergency as it sounds. Essential information can be easilyomitted, addresses jumbled, ambulances dispatched to the wrong city.

That’s why it’s as important to be as prepared here as in any other area of crisisresponse.

For starters, be aware of who to call in your community for EMS back-up.If you’re unsure, call 911 or ‘O’ for operator assistance. Even better, have acrisis partner or bystander call for you, while you continue to monitor thevictim.

But if you do transfer responsibility for the call to someone else, make surethat person handles the call correctly.

Give as much information as possible to the EMS dispatcher. Include

k Exact location (include street, number, city, landmarks, etc.)k The phone number being usedk Description of personk Drug(s) involvedk Physical condition, including breaths per minute and pulse.

� Do a secondary survey of the victim. The purpose of the primary surveyis to identify and respond to any immediate life-threatening problems.

The purpose of the secondary survey is to gather additional information andrespond to other problems that may be present.

The focus shifts to four main areas at this stage of the intervention:

k Identify drug(s) involved.k Check for other danger signals and “red flags.”k Continue to monitor vital signs.k Provide emergency care and support.

Identify drug(s) involved. Question the person or others present. Be friendly,but firm.

Find out: How much of what when?If the person is unconscious or no one else knowledgeable (or communica-

tive) is present, look for evidence of use, such as prescription containers, sy-ringes, pipes, pills, or bottles.

Look in the medicine cabinet or the night table, if necessary. Evidence ofcombination drug use could be vitally important.

Check for other danger signals and “red flags.” Is the person diabetic? Hy-poglycemic? Hypertensive? Epileptic? Suicidal?

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All the above risk factors apply to drug emergencies, including the following:

l Unconsciousness. Person is completely unresponsive and can’t be rousedor drifts in and out of consciousness when awakened.l Respiratory problems. Unusually fast, slow, or irregular breathing. Lackof oxygen is indicated if person’s skin takes on a blue or purple coloration,particularly around the mouth and lips. In dark-skinned people, this con-dition (called cyanosis) is best seen in the discoloration of gums and nails.k Heartbeat irregularities. Rapid pulse (more than 120 beats per minute) orslow pulse (less than 60 beats/minute). Irregular or unsteady pulse is an-other danger signal.k Fever. Body temperature above 102° can mean trouble. Sweatiness or de-tectable warmth on the forehead is a signal of possible trouble.k Pupil size. Dilated pupils may mean shock or overdose on cocaine or am-phetamines. Constricted pupils may signal an overdose of heroin or anothernarcotic. Unequal size pupils may indicate head injuries or a stroke.k Vomiting. Can be particularly serious if the person is unconscious or semi-conscious.k Convulsions. May signal overdose or withdrawal.k Shock. Very fast or slow pulse rate; fast or slow breathing; cool, moist, andpale (even bluish) lips, skin, and nails.

Continue to monitor vital signs. Compare with earlier results. Things to lookfor: speeded up, slowed, or irregular pulse rate; breathing rate changes or prob-lems (wheezing or otherwise noisy breathing); skin tone or body temperaturechanges.

Repeat every five minutes—or more—until help arrives. If vital signs areextreme, write down measurements and reading times, if possible, or have some-one else write them down for you. General terms will do: “sweaty,” “cold andclammy,” “flushed,” etc. are fine.

Provide emergency care and support. In a drug crisis, any of the above “redflags” can signal serious problems. Still, the two most vital signs are B and C inthe ABC checklist.

Because when breathing and heartbeat are suppressed, oxygen flow to thebrain stops. And when the brain is cut off from a constant supply of oxygen, itstarts to die. Then so does the rest of the person.

In the next chapter, we’ll discuss life-support techniques aimed at preventingthat from happening.

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n o matter what other problems may arise in a drug-related emer-gency, heart and respiratory failure are two of the most obviousand certainly the two most immediately serious.

Biological thunder and lightning that strike suddenly and withoutwarning, heart attack and respiratory failure are the main causes ofdeath in drug crises.

Irregular heartbeat and heart failure can follow cocaine and amphet-amine use, as well as use of other drugs, including anti-depressants andinhalants (in a syndrome known as “sudden sniffing death”), whilerespiratory collapse is often linked to overdoses of narcotics, barbitu-rates, alcohol, and other depressants.

That’s why we stress the physical management techniques in this chapter somuch. They’re simply too indispensable to be taken for granted.

Still, we need to emphasize that the information in this section isn’t intendedto replace actual training and periodic refresher courses offered by the Red Crossor other groups. It’s meant for review purposes only.

CPR, in particular, can create life-threatening problems if performed incor-rectly or if attempted on someone who doesn’t need it.

So if you haven’t received hands-on training in CPR, artificial respiration, orother first-aid techniques, get it. Contact a local branch of the American RedCross.

They’ll tell you how to register for training in your area.

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■ Breathing EmergenciesThere are three basic ways in which breathing can stop in a drug emergency:

k via direct drug action on brain breathing centers (particularly in the caseof depressant overdoses), or indirectlyk by blocking the airway (especially through aspiration of vomitus), ork through the “behavioral toxicity” of risky or unsafe actions (e.g. swim-ming, and drowning, while high)

But no matter what causes breathing to stop, causing it to start again is alwaysthe first priority in a crisis. Permanent brain damage or death can result whenthe brain is deprived of oxygen for as little as 4-6 minutes.

Fortunately, artificial respiration (or rescue breathing, as it’s also known) isa skill that’s easily learned and always available. The procedures flow directlyfrom the ABC’s of the primary survey, discussed in the last chapter.

l Rescue Breathing

The basic premise of rescue breathing is simple enough.The air we breathe in is about 21 percent oxygen and the air we breathe out

is about 16 percent oxygen.That means there’s more than enough oxygen left over to keep someone else

alive in an emergency.Rescue breathing is the technique that gets it to them.If you discover in the primary survey that a person is not breathing and re-

quires life support, start by rolling the victim onto his/her back, if necessary.Make sure the airway is open and check for and remove any obvious obstruc-

tions in the mouth (gum, dentures, vomitus, or other fluids).Position your ear over the person’s nose and mouth, and check for breath-

ing for 3-5 seconds. If there’s no breath, pinch the nostrils shut.Then take a deep breath, open your mouth wide, and form a seal with your

lips around the person’s mouth.Exhale for 1-1.5 seconds, which should be enough to make the person’s chest

rise. Pause between rescue breaths to inhale.Then look, listen, and feel for chest movements or the sound of escaping air.If you don’t detect breathing, re-check the carotid pulse for 5-10 seconds.If the victim still isn’t breathing, but does have a pulse, resume rescue

breathing.If there is no pulse, begin CPR.

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■ Life Support/1: Rescue Breathing

4. Check for pulse. Slide fingers into grooveof neck alongside Adam’s apple. Check pulsefor 5-10 seconds.

Fundamental First Aid. Rescue breathing is a cornerstone of first aid and drugcrisis response. It builds on the basic steps of the primary survey.

2. Check for breathing. Position your earover nose and mouth of victim. Look, lis-ten, and feel for breathing sounds andmovement.

1. Open the airway. Place one hand on thevictim's forehead, the other beneath thechin. Lift chin with two fingers, while tilt-ing back forehead.

3. Give two full breaths. Pinch nose shut andform a seal around victim’s mouth withyour lips. Breathe for 1-1.5 seconds eachbreath. Pause for 5 seconds between breaths.

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■ Life Support/2: CPR

4. Square your shoulders over your handswith elbows locked and arms straight.

3. Place heel of hand used to find notchdirectly on top of heel of other hand. Keepfingers off victim’s chest.

1. Slide middle and index fingers of handnearer victim’s legs along rib cage to notchat lower end of breastbone. Place middlefinger in notch, with index finger alongsideat lower end of breastbone.

2. Place heel of hand nearer victim’s headnext to index finger above breastbone.

Advanced Assistance. CPR takes life-support a step further, adding external cardiacmassage to rescue breathing. Still, even miraculous tools can be dangerous ininexperienced hands. Incorrectly performed or unneeded CPR can be deadly.

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l Special ProblemsAlthough rescue breathing is a fairly simple technique, you need to be care-

ful not to force air into the person’s stomach.Air in the stomach can cause vomiting, which raises the risk of a different type

of potentially-lethal problem—aspiration of vomit fluids into the lungs.To avoid breathing air into the stomach, the Red Cross recommends the fol-

lowing safeguards:

k Make sure the person’s head is tilted all the way back.k Don’t force too much air into the victim’s lungs. Breathe in only enoughto make the chest rise.k Pause to let the victim’s lungs empty between breaths.

Another special problem that can arise during rescue breathing is vomiting.If this happens, quickly tilt the person’s head and body to the side. After-

wards, wipe away any vomited material, and resume rescue breathing, ifnecessary.

■ Cardio-Pulmonary ResuscitationCPR, or cardio-pulmonary resuscitation, is a life-support technique aimed at

re-establishing heart beat and respiration in a person whose heart and lung func-tions have stopped.

CPR builds on the basic processes of the primary survey and rescue breath-ing, and should be undertaken only if both breathing and pulse are absent, as de-termined in the primary survey.

To administer CPR, a rescuer kneels beside the victim, and performs asingle cycle (two full breaths and a check for carotid pulse) of rescue breath-ing. Then, if no pulse is present, he/she places the heel of one hand over thelower part of the victim’s sternum (or breastbone), 1-1.5 inches from its tip,puts the other hand over the first and positions the shoulders squarely overthe victim.

The rescuer then presses down forcefully and rhythmically onto the sternumfor a count of 15 compressions (at a rate of 80-90 compressions per minute),before going back to the rescue breathing cycle, and checking carotid pulse. Ifthe pulse returns, the rescuer continues to check for breathing.

If breathing resumes, he/she checks ABC’s. If neither pulse nor breathing resu-mes, the rescuer continues CPR.

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To reduce the risk of CPR-related problems, the Red Cross makes the follow-ing recommendations:

k Don’t perform CPR on a person who has a pulse, no matter how weak orslow. If a victim with a slight or irregular pulse is not breathing, performrescue breathing. If the person is breathing, continue to monitor ABC’s.k Don’t waste time removing clothing from a victim’s chest area unless theclothing prevents you from establishing the location for chest compressions.k Perform CPR only on a hard, flat surface. If the victim is in bed, move himor her to the floor, before beginning the procedure.

As we pointed out earlier, CPR should be performed only by persons trainedand certified by the American Red Cross. Because of its inherent dangers, itshould be considered a last-resort life-support technique.

For a review of specific CPR procedures, please refer to the accompanying textand illustrations on page 22.

■ Other Skills

l Inducing Vomiting

Although induced vomiting has long been a standard ER response to oral drugoverdose, the value of the practice is currently up in the air.

Why? For a couple of reasons.For one, syrup of ipecac (a substance often used to promote vomiting) doesn’t

seem to work that well at removing drugs from the stomach. For another, ipecac-induced vomiting and gastric lavage (stomach pumping) each can cause signifi-cant health problems of their own.

And for yet another other reason, often by the time ER’s (or crisis workers,for that matter) come into contact with OD victims, the drugs may have been intheir stomachs for hours.

Those are three reasons that activated charcoal is now being promoted as abetter alternative to ipecac in cases of overdose or drug poisoning.

According to recent studies, charcoal is better adapted at blocking drug ab-sorption than vomiting, so much so that some experts recommend that activatedcharcoal be “routinely administered” in all ER admissions involving possible drugoverdose.

Still, we think it’s good advice to induce vomiting if pills were recently taken(within the past hour or so).

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Best bet: If the victim is still fully conscious, get him or her to induce vomit-ing, either by tickling the back of the throat or by taking syrup of ipecac. Precautions:

k Never induce vomiting if person is semiconscious or comatose.k Don’t induce vomiting if drug(s) were smoked, injected, or inhaled.k If you use syrup of ipecac to induce vomiting, don’t administer charcoalbefore vomiting starts.

l Recovery Position

Another serious problem that arises in drug emergencies is the risk of vom-iting while unconscious or semi-conscious and choking on the aspirated vomitfluid.

Because of the danger this represents and the frequency with which it kills,it may become necessary to place a semi-conscious person into the so-called “re-covery position,” if the person begins to vomit or if, for any reason, it becomesimpossible for you to continuously monitor the airway.

An unconscious person should only be moved into the recovery position ifyou’re sure there’s no serious injury to the neck or spine.

To move someone into the recovery position, simply kneel at their side andturn the head to the side.

Gently lift up on the thigh and shoulder and carefully roll the victim onto theabdomen, with the face to one side.

Continue to maintain and monitor airway.

■ Life-Support, 3: Recovery Position

Airway Assurance. Vomiting while semi-conscious or unconscious can create serious risksthat are reduced by moving the person into the “recovery position.”

Kneel at side of victim.Turn head to one side,maintaining airway.Gently lift thigh andshoulder.

Carefully roll victim ontoabdomen, with face to oneside. Check and maintainairway.

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If the person’s body size makes movement difficult, try the following:

k Kneel at the person’s right. Turn the head to the right, maintaining airway.k Tuck the right arm under the right buttock, place left arm across chest.k Cross the left leg over the right leg.k Pull gently on the left thigh and shoulder until the person is lying facedown, with the head turned to one side.k Check ABC’s.

■ Other ProblemsA variety of other physical problems can also arise in a drug crisis that are no

less life-threatening than heart or respiratory problems.Most of these conditions involve the “red flag” symptoms we discussed in the

last chapter. The problems themselves—including shock, coma, and convul-sions—may involve physical responses to drug toxicity or may arise completelyapart from drug use, and can be mistaken for drug emergencies.

Still, no matter how they arise, each represents a potentially life-threateningemergency and should be regarded as such. Standard assessment and life-sup-port techniques apply regardless of the origin of the problem. And remember thatnot all symptoms listed may be present in any given situation.

l Coma

Definition. Abnormal stupor caused by injury or illness in which the personcannot be aroused by external stimuli.

Causes. More than half of all cases are caused by injury or impaired blood flowto the head and brain (e.g. hypertension, tumor, fever, infection, hemorrhage, drugs).

Types. Alcoholic, apoplectic (caused by stroke, results in paralysis to one sideof the body), diabetic (caused by lack of insulin and which may be confused withhypoglycemic coma), uremic (caused by impaired kidney function; results inbuild-up of toxic body waste products).

Management. Do not move patient; may exacerbate headinjury. Loosen collar. Apply cool compresses to forehead ifperson is feverish. Monitor ABC’s. Call EMS.

l Convulsions

Definition. Sudden, involuntary muscular spasms, often violent. Seizures ofteninvolve loss of consciousness.

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Causes. Seizures can occur as a result of drug withdrawal and poisoning.Other factors: epilepsy, diabetes (low blood sugar), high fever (especially in chil-dren), brain tumors, head injuries.

Drug factors. Amphetamines can cause convulsions. Seizures can occur dur-ing withdrawal from alcohol or other depressants, usually within a day or two ofthe time use was stopped.

Symptoms. The person may lie rigid for a few seconds before convulsing. Sei-zures usually last about a minute.

Management. Reduce stimuli, if possible. Lay the person down. Cradle his/herhead and neck, if possible, to prevent head injuries. Goal: Keep the person frombiting his/her tongue, suffocating, or causing self-injury. Move away furniture orother objects that could cause injury. Don’t attempt to stop convulsion by restrain-ing the person, which may cause injury.

After seizures: Check ABC’s; examine the person for injuries. If breathing hasstopped, check to see if the tongue is blocking the airway. If not, perform res-cue breathing.

l Diabetic Emergencies

Definition. Any major problem involving shock, unconsciousness, or comaarising from diabetes or related complications.

Types. Insulin reaction, diabetic coma.Causes. Too much insulin and too little blood sugar available to brain (insu-

lin reaction); insulin insufficiency (diabetic coma). Diabetic coma can be causedby eating too much sugar, stress, or infection. Insulin reaction can be caused byan insulin overdose or other factors.

Symptoms. Insulin reaction: Rapid, shallow breathing and pulse; dizziness;sweating; headache; numbness in extremities; unconsciousness.

Diabetic coma: Rapid, deep breathing; sleepiness; confusion; thirst; dehydration;fever; sweet-smelling breath.

Management. Give juice, candy, or sugar. This will help reverse an insulin re-action, but will not harm someone in a diabetic coma. If unconscious, check ABC’sand call EMS.

A variety of other physical problems can also arise in a drugcrisis that are every bit as life-threatening as heart or respi-ratory problems.

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■ ShockDefinition. Physical collapse caused by inadequate blood flow to body tissues.Types. Anaphylactic, hypoglycemic, insulin, traumatic, etc.Causes. Trauma, including heart attack, allergic reaction, burns, infection,

sudden blood loss, dehydration, drug reaction or poisoning.Symptoms. Pale skin, blue or gray discoloration, weak and rapid pulse, irregu-

lar (esp. fast and shallow or deep and uneven) breathing. If conscious, a personin shock may seem excited and disoriented, have glassy eyes, be oblivious to pain,and be extremely thirsty.

Management. Help the person lie down, with head lower than body. Elevatethe lower extremities by propping on pillows. Keep the person warm, but not hot.Reduce stimuli.

Treat any seriously injured person for shock to keep them from going intoshock. Even though he/she may complain of thirst, discourage excessive drink-ing to reduce the risk of unconscious vomiting. Emotional support and gentlehandling are also important.

Due to their similarity to drug emergencies, it’s not uncommon for any of theabove conditions to be confused with a drug overdose. That’s why we emphasizethe need for responding to what you see rather than what you might think.

Sometimes, there’s a world of difference between the two.

Treat any seriously injured person for shock to keep themfrom going into shock.

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O ne way of looking at drug emergencies is to focus on their dif-ferences. And to be sure, there are a lot of those. But looking atdifferences, it’s easy to be overwhelmed by details. Just trying to

sort out all the new names for drugs on the street—“ice” and “crack”or “squeeze” and “wack”—can turn into a full-time job.

And forget all the new prescription drugs that appear—the Prozacsand Xanaxes and Viagras, the ones that sweep into medical journal adsone year and into patients’ lives and emergency rooms the next.

Each one comes with a package insert that could choke a police dog,listing contraindications and adverse reactions and overdose treatmentsuggestions.

And if you think you have to know all of that and everything elsethere is to know about drugs to be useful in an emergency, there aren’tgoing to be enough crisis helpers to go around—not by a long shot.

That’s why we think it makes more sense, in discussing short-term crisis re-sponse, to focus on the similarities of drug crises.

Viewed from this perspective, it’s more important to reduce the number ofvariables than to split hairs trying to delineate differences between drugs and druggroups that produce generally similar sets of response.

Put in everyday terms, this means that it doesn’t matter all that much whetheran unconscious person is overdosed on Nembutal or alcohol or codeine—at leastnot from the viewpoint of making a fast assessment, getting EMS support, and per-

arousal&stupor

l responsesets

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forming needed short-term life support.By the time you get the person to a hospital emergency room, it’ll make all the

difference in the world. But at the crisis scene, the distinctions are less meaning-ful, since each of the above OD’s can be deadly and all can be managed in simi-lar ways.

Don’t think this means that the distinctions between different groups of drugsare irrelevant—far from it. A Valium or Xanax OD is almost always less lethal thana barbiturate OD. It simply means that our role in dealing with an unconsciousvictim is to respond to what we see and manage what’s there.

And we begin to do that best when we eliminate unnecessary distinctions andstreamline the response process.

In this chapter, we’re going to do just that, by reducing the entire spectrumof drug emergencies to two basic types: arousal-agitation and depressive stupor.

From there, we’re going to be looking for commonalties that apply to all drugemergencies of whatever type. Because the fact is that they’re the same in as manyways as they’re different.

■ CNS Arousal ContinuumViewed in this way, it’s possible to see psychoactive drug effects as points on

a continuum of consciousness, reflecting levels of central nervous system (CNS)arousal.

This is not meant to imply that psychoactive drugs only produce CNS arousalor depression—that’s plainly untrue. There are simply too many exceptions—hallucinogens, anti-depressants, inhalants, and others—for this model to applyto anything more general or specific than crisis response.

But it’s useful for our purposes, for the simple reason that drug crisis reac-tions conform more closely to a bipolar model than do individualized non-cri-sis drug reactions and because CNS activity—although not the only site of drugaction or the only important index of drug toxicity—covers most of the territorywe need to consider at this level of analysis.

So what, then, are the bipolar “caps” of our hypothetical two-crisis world?At one extreme is a state of CNS hyperarousal, or agitation. It ends in death,

usually from heart failure.At the other extreme is hypoarousal, or CNS depression and stupor. It often

terminates in death from respiratory collapse.All drugs push the user up or down, in one way or another, along this con-

tinuum. And the outer limits of the continuum always mean trouble, life-threat-ening trouble.

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■ General Response Groupsl Signs & SymptomsThe signs and symptoms of the two main drug crisis states are as different as

the drug groups and individual drugs within the groups that inspire them.Symptoms of arousal-agitation states are intensified, high-amplitude variations

on the basic CNS-stimulant drug theme.Prototype drugs for the class (and the crisis state) are amphetamines and

cocaine—including each drug’s smokable form, “glass” (or “ice”) and“crack”—which not uncoincidentally, are two of the main instigators of drugemergencies in the early 21st Century.

Symptoms and complications can range from the very mild to the very severe;problems can vary, on the emotional side, from ordinary nervousness to full-blown psychotic states. On the physical side, effects can swing from mildly el-evated heart beat to complete cardiovascular collapse.

States of Mind, States of Emergency. Progressive symptoms of the two basic psychoactive-drug overdose states viewed on a continuum of CNS arousal.

Symptoms of arousal-agitation states are intensified, high-amplitude variations on the basic CNS-stimulant drug theme.

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● Arousal/Agitation EmergencyEmotional component: Anxiety, panic, feelings of unreality.Physiological signs: Rapid breathing, breathlessness, rapidpulse, dilated pupils, excessive body heatBehavioral signs: Restlessness, apprehension, emotional upsetLife-threatening complications: Convulsions, stroke, heart attack

On the other side of the continuum, the depressive-stupor crisis state is trig-gered by drugs whose primary action is depression of the central nervous system:narcotics, sedative-hypnotics, tranquilizers, and alcohol.

● Depressive-Stupor CrisisEmotional component: Depression, lassitude, lethargyPhysiological signs: Reduced or irregular breathing, slowpulseBehavioral signs: Slurred speech, impaired motor control, slowed reflexesLife-threatening complications: Respiratory failure, heart attack

General Response Groups: Intervention Procedures

l Arousal/Agitation Response

If the person is conscious:

k Establish a relationship. Ask for permission to help.k Find out what drugs were taken and when.k Reduce stimuli as much as possible: Turn down music and bright lights;ask passersby or onlookers to leave; move the person to a quiet place.k Reassure the person that the effects he or she is experiencing are causedby a drug and that they will wear off.k Demonstrate by actions and attitude that you’re relaxed and in control.k Stay with the person until he/she regains control and drug effects have ended.

If the person is unconscious:

k Check ABC’s.k Call EMS.k Monitor vital signs.k Provide life-support or other emergency care.

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l Depressive-Stupor Response


k Establish a relationship. Ask for permission to help.k Find out what drugs were taken and when.k If the amount taken is significantly more than a prescribed dose oris enough to arouse your concern, keep the person awake and mov-ing and call EMS.k If the drugs were taken in the past hour, suggest that the person inducevomiting by sticking his or her finger down throat or by taking syrup ofipecac or activated charcoal, if available.


k Check ABC’s.k Call EMS.k If the person is vomiting, or you suspect he or she might, move him/herinto the recovery position.k Monitor vital signs.k Provide life-support or other emergency care.

The depressive-stupor crisis state is triggered by drugs whoseprimary action is depression of the central nervous system:narcotics, sedative-hypnotics, tranquilizers, and alcohol.

Symptom/Set Arousal-Agitation Crisis Depressive Stupor Crisis

Emotional Anxiety, panic, feelings of Depression, sluggishness,unreality of impending doom lethargy

Physical Rapid breathing & pulse, Slow or irregular breathing,dilated pupils, body heat slow pulse

Behavioral Restlessness, panic, frenzy, Slurred speech, slowed reflexes.seizures impaired motor control

Life-threatening Convulsions, stroke, cardiac Respiratory collapse, coma,complications arrhythmia, heart attack heart failure

Through a glass, darkly: Symptoms of the two main crisis states mirror each other, start to finish.

■ Symptom Sets: Upside, Downside

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■ Universal OD ResponseNow that we’ve set some general parameters for an arousal-depression,

crisis-continuum worldview, we’ll take things a step further, and propose a single,general set of principles that apply to every overdose emergency.

The guidelines are simple, but reasonably comprehensive.They touch on everything we’ve talked about thus far, and will even expand

to include specific recommendations that we’ll make in the chapters to follow.The recommendations below apply to all drug overdoses involving an uncon-

scious victim:

k Check ABC’s.k Move the person into the Recovery Position, if vomiting.k Call EMS if the victim displays any of the following:

k problems breathing (respirations below 8 or above 20 per minute);k is unconscious and cannot be roused;k vomiting while unconscious or semi-conscious;k pulse is above 120 or below 60 per minute;

k Provide life support or emergency care.

Common Ground. Despite the variety and complexity of drug emergencies, the same responseprinciples apply to all drug crises involving unconsciousness.

■ Overdose Aid: One Size Fits All

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l between&outsidethelines

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t he point we just made—that drug crises contain similar elementswhich can be assessed and managed in similar ways—is valid anduseful, as far as it goes. But it’s still only part of the picture, and only

a general way of approaching drug emergency response. From here onout, we’ll focus on specifics.

Because even though it may be helpful to see through the forest ofdetails that inevitably surrounds a discussion of drug effects and emer-gency procedures, it can be absolutely vital to see a tree when it jumpsright in front of you.

Among other “jumping trees” we’ll be discussing in this section aredrugs that hop over both classification lines and the response sets weproposed earlier. We will particularly emphasize life-threatening emer-gencies, such as aspirin and acetaminophen overdose and anticholinergic drugsyndrome, which don’t fit well into the CNS crisis model we proposed earlier.

That isn’t meant to contradict what we’ve said thus far about the value of theCNS crisis continuum or the universal crisis response. Both are important toolsfor viewing the context and structure of crisis response.

If the earlier sections constituted the bare bones of drug crisis response, thischapter represents the skin and teeth and bones and hair.

jumpingtrees

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■ Anticholinergic Drug Overdose Syndrome

Of all the exceptions to the CNS-arousal crisis model, perhaps themost distinctive is the toxic reaction produced by anticholinergicdrugs.

These drugs, which include a variety of prescription and non-prescription medications based on the plant belladonna and its de-rivatives, are used to treat problems as diverse (and far-flung) assinus congestion and irritable bowel syndrome. Other drugs havingsignificant anticholinergic properties are the antidepressants.

The term anticholinergic itself refers to inhibition of the neu-rotransmitter acetylcholine, which is involved in the regulation ofa number of body processes in the central and parasympatheticnervous system.

Why do anticholinergics figure so highly into drug emergencies? Onereason is the sheer volume and variety of drugs with anticholinergicproperties.

It’s possible, for example, for a person taking one product forsniffles, say, and another for diarrhea and yet another for depres-sion to be completely unaware of the risk of drug synergism.

Another reason is that antidepressants are prescribed to depressedpeople and depressed people sometimes try to kill themselves.

Any overdose involving drugs with anticholinergic properties shouldbe regarded as a serious medical emergency. Symptoms can be tricky.

Doing What Needs To Be Done. Priorities in specific drug crises include providing relief forpotentially dangerous complications (fever, overstimulation, etc.).

■ Priority Pyramid

■ Ex

trem

e Dr

ug R

eact

ions

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Both physiological and psychological effects can be determined by a numberof factors, including drug type and dosage, interactions with other medica-tions, route of administration, even user age and personality.

Similarly, symptoms can run the gamut, incorporating features that canbe mistaken for both arousal-agitation and depressive-stupor emergencies.

In addition, a severe psychological syndrome can develop, particularly whenthe drugs are used with phenothiazine tranquilizers. Symptoms include auditoryand visual hallucinations and toxic delirium.

When responding to anticholinergic drug emergencies, it’s important to re-member that a specific antidote, physostigmine, does exist for the syndrome.That’s only one more reason EMS back-up is essential in resolving anticholiner-gic emergencies.

● Anticholinergic Drug Crisis

Emotional component: Agitation, anxiety, confusion, delusionsPhysiological signs: Dilated pupils, rapid or irregular heart beat, dry skin and

mouth, flushed face, fever, abdominal pain, urinary retention, ringing in the ears,muscle spasms, coma

Behavioral signs: Disorientation, incoordination, impaired concentration,hallucinations.

Life-threatening complications: Convulsions, stroke, heart attack

l Anticholinergic Drug OD Response


l Find out what drugs were taken and when.l Monitor vital signs.l Reduce stimuli.l Induce vomiting, if drugs were taken in past hour.l Call EMS, if necessary.


l Check ABC’s.l Call EMS.l If the victim is vomiting, place in recovery position.l Provide life-support and other emergency care.

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■ Aspirin/Acetaminophen EmergenciesAspirin and acetaminophen are main players in the drug crisis world, for rea-

sons that might surprise you.Acetaminophen (which is sold generically and under the brand names Tyle-

nol™ and Datril™) was the fourth-most common drug mentioned in U.S. emer-gency room admissions during 2000 (figuring into 33,613 emergencies), whilegood old-fashioned aspirin was right behind, in the fifth spot, helping to land15,657 folks in the hospital.

Why?A main reason is that both drugs are often combined with other more-potent

analgesic and psychoactive drugs, like codeine (in Empirin™ or Tylenol™ #1,2, 3, and 4), oxycodone (Percodan™, Percocet™), and even barbiturates(Fiorinal™).

One result for users can be dependence on the psychoactive component andoverdose on the acetaminophen or aspirin.

And that can be a real problem, particularly since each of the non-prescrip-tion painkillers can trigger a life-threatening overdose syndrome.

A special danger of acetaminophen involves the mildness of symptoms afteran overdose.

Symptoms may go unnoticed for up to two days after an overdose, before se-rious problems emerge due to cumulative toxic effects on the liver.

At high risk for both types of overdose are older people, who can come to relyon either or both of the drugs for pain management.

Overdose can occur with as little as one or two tablets above an ordinary tol-erated dose, when a regular user crosses his or her “metabolic threshold.”

A specific antidote, N-acetylcysteine, exists for acetaminophen OD whenadministered in the first 10 hours of overdose, making quick assessment andresponse—and quick action (and movement in the direction of a hospitalemergency room)—vital.

● Aspirin Overdose

Emotional component: Confusion, fatigue, anxietyPhysiological signs: Headache, ringing in the ears, dim vi-

sion, sweating, thirst, rapid breathing, nausea, vomiting, ab-dominal pain, skin eruptions, convulsions, coma

Behavioral signs: Incoherent speech, delirium, hallucinationsLife-threatening complications: High body temperature, dehydration, res-

piratory failure, heart attack

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l Aspirin OD ResponseIf the person is conscious:

l Find out what drugs were taken and when.l Induce vomiting, if drugs were taken in past hour.l Monitor vital signs.l Reduce body heat, if excessive, by applying wet towels, etc.l Call EMS, if necessary. Crisis symptoms can develop quickly.


l Check ABC’s.l Call EMS.l If the victim is vomiting, place in recovery position.l Reduce body heat, if excessive, by applying wet towels, etc.l Provide life-support and other emergency care.

● Acetaminophen Overdose

Emotional component: Unease, anxiety, emotional distressPhysiological signs: Nausea, vomiting, pallor, profuse sweating, skin rash, feverBehavioral signs: Delirium, unconsciousnessLife-threatening complications: Liver and kidney damage, hypoglycemic coma

l Acetaminophen OD Response


l Find out what drugs were taken and when.l Monitor vital signs.l Induce vomiting, if drugs were taken in past hour.l Call EMS, if needed.


l Check ABC’s.l Call EMS.l If the victim is vomiting, place in recovery position.l Monitor vital signs.l Provide life-support and other emergency care

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■ Inhalant Overdose & ‘Sudden Sniffing Death’

Of all the drugs that strain the CNS-arousal emergency model, perhaps thegroup that’s most immediately lethal is the inhalants, particularly volatile solvents(“volatile” means they change from liquid to gas when exposed to air) and aero-sols.

Inhalants can get you in a couple of ways.Probably the best-known way is the syndrome known as “sudden sniffing

death,” or SSD.SSD typically follows a consistent pattern: After sniffing to the point of intoxi-

cation, a user is suddenly surprised or abruptly begins a strenuous activity—running at top speed, for example, or lifting a heavy object.

Physical collapse and death frequently follow, usually due to severe cardiacarrhythmia.

Besides SSD, inhalants can also cause a variety of other serious problems:

■ Freon can cause suffocation in the form of “airway freezing,” as the re-frigerant vaporizes in the throat.■ Industrial solvents can cause a number of problems related to their tox-icity, including irreversible organ damage.■ Deaths can also result from the inhalation of various solvents (includ-ing naptha, benzene, acetones, and others) or when users pass out withsolvent-soaked plastic bags still covering their nose and mouth.

Psychological effects of inhalants can also be perplexing, with excited, agitatedbehavior sometimes giving way rapidly to profound CNS depression.

Still, from a crisis perspective, the most distinctive element of an inhalant OD

is its speed of onset.Rapid response is the only way to even the odds.

● Inhalant Overdose

Emotional component: Excitement, euphoria, disorientation, depressionPhysiological signs: Headache, ringing in the ears, double vision, dilated pu-

pils, increased heart rate, irregular heartbeatBehavioral signs: Slurred speech, incoordination, increased activity, slowed

reflexes, unconsciousness, delusions, hallucinationsLife-threatening complications: Sudden sniffing death, behavioral toxicity

(sometimes brought on by impulsive, hazardous actions)

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l Inhalant Overdose Response


l Find out what chemicals were inhaled and when.l Monitor vital signs.l Call EMS, if needed.


l Check ABC’s.l Call EMS.l Remove rags, bags, or other sources of toxic fumes.l Monitor vital signs.l Provide life-support and other emergency care.

■ PCP/Ketamine Emergencies

The last drug group that we’ll focus on that significantly deviates from our agi-tation-stupor continuum is phencyclidine, or PCP, and its chemical cousin,ketamine (commonly known as “K” or “Special K”).

Developed and used medically as animal tranquilizers and surgical anesthet-ics, they deserve special consideration because each combines wildly varying,even contradictory, effects in a single pharmacological package.

Depending on dosage and personality characteristics of the user, both PCP andketamine can produce effects that mix—in the same episode—stimulant, anes-thetic, hallucinogenic, and depressant properties. In addition, both drugs cantrigger bizarre psychological effects, including depersonalization, delusions, andvisual and auditory hallucinations.

Effects are dose-related, meaning that higher doses cause more intense andmore dangerous physical and psychological effects. Still, since both drugs aredepressants, it’s important to bear in mind that both react synergistically with

The most distinctive element of an inhalant OD is the speedof its onset. Quick response is the only way to even the odds.

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other CNS depressants (including alcohol), which can lower overdose thresholdand raise overdose risk.

Effective crisis response must involve a careful reading of the user’s behavioraland emotional state and physiological symptoms.

Paranoia and delusional thinking can so distort personality as to pose a physi-cal risk to the crisis helper. For this reason, do not attempt to enter a user’spersonal space without being invited.

Stay calm and demonstrate relaxed self-control with a psychologically-dis-traught user, but call for EMS back-up if obviously psychotic ideation or danger-ous behavior persists.

● PCP/Ketamine Overdose/Agitation Response

Emotional component: Excitement, agitation, anxiety, disorganized thought,paranoia, terror

Physiological signs: Blank stare, flushing, vomiting, convulsions, increasedheart rate, rapid and shallow breathing, involuntary rapid eye movements

Behavioral signs: Incoherence or inability to speak, incoordination, fever,decreased reflexes and sensitivity to pain, hallucinations, delusions, hostile or vio-lent behavior

Life-threatening complications: Convulsions, stroke, respiratory failure, be-havioral toxicity

l PCP/Ketamine Crisis Response


l Establish a friendly relationship.l Ask for permission to help.l Reduce stimuli.l Reassure person that he/she is experiencing the effects of a drug thatwill wear off soon.l Call EMS, if needed.


l Check ABC’s.l Call EMS.l Monitor vital signs.l Provide life-support and other needed care.

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l emotionalrescue

n ow that we’ve covered the main bases of crisis response, we’regoing to focus on home plate: psychological management. Of-ten, it’s the busiest corner of the whole crisis ball park.

We say that for a couple of reasons.For one, psychological emergencies involving drugs—hallucino-

gens, stimulants, and marijuana, primarily, but any other drug (or evenno drug at all) will do in a pinch—probably account for more crisisproblems than physical overdoses and toxic reactions put together.

For another, although drug-induced psychological crises are rarelyfatal, they can be unpleasant—and result in toxic memories and fearsthat can last a lifetime.

They do, that is, unless an experienced person is around to helpsomeone on the business end of a drug freak-out or other personalcrisis to re-contextualize his or her fears and re-channel the experience.

How do you do that? There are a lot of ways. And in this section, we’llconsider some of the best.

■ Re-Framing FearAnxiety is the fuel that most simple drug emergencies run on. The range of

problems that are powered by panic can include everything from minor caffeinejitters to full-blown LSD freak-outs.

managingm

eltdowns

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Fortunately, there are a lot of things you can do from the outset to help peopleput themselves back in their own control and pull the plug on panic:

■ Begin by establishing a friendly personal relationship. Tell who you are, andexplain why you’re there. Ask for permission to stay and help.

■ Be real. Don’t try to come across as a mental health worker if you’re not,and don’t pretend to have been through similar experiences if you haven’t. Good,old, safe, everyday reality is the best treatment for panicky unreality. Be who youare.

■ Relax. Since most psychological emergencies are built around anxiety, turnyourself into a relaxation role model: Use body language. Stretch. Yawn. It reallyis contagious.

Relaxation is to panic what joy is to anger: You can’t have one with the other.So refuse to be awed by anxiety. Don’t ignore it or minimize it, certainly. But don’tunnecessarily reinforce it, either.

Just let the person know that anxious feelings are a common side effect ofover-amping the central nervous system, and let him or her know that the feel-ings will change.

Everything does.

■ Set & Setting

A key element in re-framing panic in a drug experience involves the notion of“set and setting.” To be effective, you’ll need to focus on both.

■ Set refers to the mind set a user brings to a drug experience. It includesexpectations, previous drug history, physical and psychological factors, and anyemotional baggage a person may have brought along on the trip. Any one of thesefactors can emerge as a major determinant of the quality of the experience.

■ Setting implies the external environment in which the experience takesplace. “Setting” variables can include physical factors, such as room temperatureor noise level, or interpretive elements— whether a place or companions seemcheerful or gloomy, safe or dangerous, “weird” or “cool.”

Pay special attention to setting in the initial assessment of apsychological crisis.

Variables here are often easier to alter than are elements ina user’s internal world, and sometimes merely changing the set-ting is enough to significantly alter the dynamics of the experience.

Optimizing setting variables can at least provide a stable context for helpingfurther. That’s important because most drug-induced psychological emergenciesdon’t disappear just because we turn down the stereo. Still, it is a start.

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Since most psychological emergencies are built around anxi-ety, turn yourself into a relaxation role model: Use body lan-guage. Stretch. Yawn. It really is contagious.

That’s when you have to dive down deep into a person’s “set” and hope youcome back up with a pearl. And the only way to do that is to be patient—and per-sistent.

Because the simple fact is that the emotional turbulence of a bad trip can seemoverwhelming to the person experiencing it. And it can be hard to tell, in somecases, if your communication is even getting across.

Because of the absence of objective standards to measure the crisis, it’s im-portant that you approach psychological emergencies consistently in terms ofboth the message you send and the support you give.

That’s why we’ve put together the following guidelines for helping. They’re ameans for reminding crisis victims that they don’t have to stay crisis victims.

■ Drug-Related Emotional Crisis Response

■ Define reality. Remind the person of his/her name and explain what’s goingon. Repeat the information, if necessary. Say, “Your name is _____________and I’m ________________. We’re sitting in your apartment (or wherever).You’ve taken a drug that’s affecting the way you think and feel, and I’m going tostay with you until you come down.” Or say something similar.

■ Reduce stimuli. Because sensory impressions can seem so vivid during a trip,users can saturate themselves with stimuli to the point that they OD on sounds,images, and other input.

Turn down or turn off unnecessary audio or video equipment, too-brightlights, etc. Similarly, make any adjustments in room temperature or ambiance thatyou think will make the person more comfortable.

■ Reassure. Emphasize that the effects the person is experiencing are by-prod-ucts of a drug that will wear off.

■ Use suggestibility. Make verbal suggestion carry some of the load in a cri-sis. If someone is experiencing panic, let them know that panic attacks usuallysubside within 60-90 minutes. Plant the seed for the end in the beginning ormiddle of a crisis.

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Similarly, if a person hasn’t eaten in a while, you might suggest drinking a glassof milk or juice to bring up blood-sugar levels, which will also tend to improvemood.*

■ Use “alternative-focus” activities. Sometimes adverse drug reactions derivefrom simply focusing attention on oneself too long. Help throw the switch onunhealthy self-consciousness by suggesting activities that create an external fo-cus or help bring about a more integrated sense of well-being. Possibilities:

l Taking a bath or shower. A bath has soothing mental associations for allof us. The sensory experience also helps re-establish the psychic connectionbetween body and mind.l Going for a walk. Simply moving can change the setting enough to enhancethe qualitative content of a trip. And a long walk may increase endorphin pro-duction to physically improve mood.l Eating. Food can re-balance blood-sugar equilibrium and speed upbiotransformation and excretion of drugs. Keep it simple, though: An orangeor an apple will do—and they can also enhance the esthetic component ofa trip.l Listening to music or watching a favorite TV show. This is the opposite ofreducing stimuli. If there are no stimuli, turn some on. There’s nothingwrong with a little “cocooning” under the circumstances.

The list of alternative-focus activities is limited only by imagination.Still, avoid activities that are dangerous or otherwise inappropriate. Even our

first suggestion—taking a bath—could be a problem for some people in somesituations.

Otherwise, do whatever works.

■ Non-Drug-Related Emotional Emergencies

Even if drugs don’t figure into an emotional crisis, the same basic rules ap-ply that pertain to re-framing fear. The only difference between a psychologicalemergency involving drugs and an emergency that doesn’t involve drugs is thesubjective distractions of the drugs themselves.

The feelings—the fear and sadness and anger and pain—are the same, andneed to be handled the same.

* You might even want to suggest cranberry juice, which is so acidic that it actually increases excretion of anumber of drugs, including cocaine, amphetamines, and some hallucinogens.

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Begin by applying the same helper’s skills that we discussed in Chapter 3. Staycalm. Don’t impose your values and point of view. Communicate honestly. Be sen-sitive to any behavioral or situational cues the person might present.

And remember: In dealing with people in psychological crisis, you’re dealingwith people with great vulnerability—and often, great motivation to change.

Don’t even try to “solve” their problems. Your role is to provide interpersonalspace in which to experience their feelings with someone else present and thepersonal perspective to create new possibilities for themselves.

Important skills in this process include:

■ Listening. Don’t say what you think so much as reflect what you hear. Ifthere’s pain or uncertainty in a communication, reflect and acknowledge it. Don’ttry to minimize it—or make it go away. Just get it out in the open.

■ Giving support. Don’t be drawn into the web of helplessness at the centerof the person’s problem. Reassure the person that they’re the source of their ex-perience and have the personal resources to turn it around.

■ Generating alternatives. Often emotional crises revolve around “stuck”problem-solving. If a personal problem is the basis of an emergency, suggestother ways to view or approach the problem. But don’t try to “fix” things or re-solve everything then and there. Simply point out alternative ways of thinking andacting.

■ Keeping it here and now. Try to keep things focused in the present as muchas possible. You’re not there to psychoanalyze. You’re there to assess and sup-port. Keep the focus on what a person can do now to re-contextualize his or hersituation or problem.

■ Other Emotions & Problems

Anxiety and panic aren’t the only emotions that come up in a crisis, but theyare common, and they can unleash other intense emotions.

The only difference between a psychological emer-gency involving drugs and one that doesn’t is thesubjective distractions of the drugs themselves.

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Anger, depression, even aggression and rage can ride in their wake, spillingout when normal behavioral controls are impaired.

Fall back on the same basic approach regardless of the emotion powering thecrisis. And remember that the same rules apply: You’re there to create a safe en-vironment and provide emotional support until the person is able to resume emo-tional control.

If there’s any doubt about whether the person will be able to resume emotionalcontrol, don’t hesitate to call EMS or other emergency services for back-up.People always resume emotional control—at least to some degree.

But sometimes, they need time and professional help to do it.

If there’s any doubt about whether the person will be able toresume emotional control, don’t hesitate to call EMS or otheremergency services for back-up.

■ Top 10 List: America’s Hit Squad

Hit Parade. Ten drug groups account for 78 percent of all drug-related emergency-roomadmissions, according to figures released by the Drug Abuse Warning Network in 2002.

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l finalfocus

n ow that we’re closing in on the end of the book, we might as welllet you in on a secret about drug crisis management. It’s this:There’s no “right” way to handle a drug emergency.

Depending on the people and drugs involved, and on the situationand circumstances, there are often all kinds of right ways to respond,depending on what you see and when you see it.

This is particularly true in the case of psychological emergencies.Response in physical OD’s is a little more tightly circumscribed,

which is why we emphasized physical skill learning and response hier-archies at the beginning of this book. Fumbling over details in a physi-cal crisis can cause delays that can be disastrous.

Still, even in physical crises there are often a range of options that presentthemselves and a variety of actions that an effective crisis helper can perform toproduce a desired outcome.

And getting to this point has really been the purpose of this entire book: Topoint out effective crisis management techniques and strategies so you can be freeto focus your attention on what works best with the person you’re working with.

Because attention is the ultimate medicine in an emergency—the attention yougive in noticing and responding to physical and psychological symptoms and situ-ational cues, and the attention you give to bringing yourself out of the shell of cir-cumstances and problems in your own life to give what you can to someone elsein theirs.

payattention

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So if you need a magic word or mantra to repeat in a crisis, try this one: At-tention.

Because creating the information base you need to free yours in an emergencyis what this entire book has been about.

Because it’s only when you know that you know what you need to know in acrisis that you can give all your attention to the person in front of you.

And in a crisis, they’re the only ones in the world that matter. ■

If you need a magic word or mantra to repeat in a crisis, trythis one: Attention.

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Name Examples Progressive symptoms Management

Acetaminophen Tylenol™ Nausea, vomiting, sweating, AcetaminophenDatril™ kidney failure, breathing OD response

difficulties, delirium, p. 39unconsciousness

Alcohol beer, wine, Mood swings, impaired motor Depressant ODliquor skills, slurred speech, rapid response

pulse, vomiting, coma, p. 33respiratory failure

Amphetamines Desoxyn™ Excitement, dilated pupils, Stimulant ODPreludin™ agitation, tremors, fever, response, p. 33methamphetamine rapid/irregular pulse, delirium, psychological“crystal,” “ice” hallucinations, convulsions, crisis response

coma p. 45

Antidepressants 1) tricyclics: 1) Dilated pupils, agitation, AnticholinergicElavil™ confusion, hypertension, OD responseTriavil™ hallucinations, convulsions, p. 37Sinequan™ unconsciousnessTofranil™2) MAO Inhibitors: 2) Headache, vomiting, rapid/ AnticholinergicParnate™ irregular pulse, agitation, seizures OD responseNardil™3) Others: 3) Nausea, vomiting AnticholinergicProzac™ agitation, seizures OD response

Antihistamines Atarax™ Anxiety or depression, DepressantBenadryl™ dilated pupils, irregular pulse, OD responsePBZ™ fever, delusions, convulsions, p. 33Vistaril™ coma

Aspirin Anacin™ Abdominal pain, vomiting, AspirinBufferin™ ringing in the ears, deep/rapid OD response

breathing, fever, sweating, p. 39delirium, convulsions, coma

Atropine Donnatal™ Blurred vision, dry mouth, Anticholinergicscopolamine vomiting, rapid pulse, headache, OD responsehyoscyamine hot/dry skin, difficulty swallowing, p. 37jimson weed excitement, confusion, delirium,

convulsions, unconsciousness

Barbiturates Butisol™ Slight pupil constriction (pupils DepressantMebaral™ may dilate in extreme OD), OD responseNembutal™ slurred speech, slowed reflexes, p. 33

respiratory depression, coma

l Overdose Symptoms & Management

■ Appendix

l Overdose Symptoms & ManagementName Examples Progressive symptoms Management

Benzodiazepines Ativan™ Drowsiness, confusion, DepressantLibrium™ slowed reflexes, impaired OD responseValium™ coordination, dizziness, p. 33Xanax™ coma

Caffeine No-Doz™ Nervousness, excitement, StimulantVivarin™ rapid pulse, nausea, vomiting, OD responseOTC stimulants fever, tremors, delirium, p. 33and diet aids convulsions, coma

Cocaine crack, rock, CNS arousal (followed by Stimulantfreebase depression in severe OD), OD response

confusion, nausea, vomiting, p. 33anxiety, hallucinations, rapid/irregular/shallow breathing,coma, cardiac arrest

Hallucinogens 1) Organic: 1 & 2) Psychological effects Psych. crisispsilocybin, peyote predominate; hallucinations, response, p. 452) Synthetic: LSD delusions, anxiety3) Amphetamine- 3) Same as 1 & 2 above with 3) Stimulant ODbased: MDA, MDMA amphetamine OD symptoms response, p. 33

Inhalants 1) Aerosols: Numbness, hallucinations, InhalantFreon™, delusions, rapid/irregular pulse, OD responseisobutane respiratory depression, p. 41

heart failure2) Solvents: Slurred speech, dilated pupils, Inhalantgasoline, hallucinations, delusions, OD responseplastic cement, rapid/irregular pulse, headache, p. 41industrial solvents vomiting, coma, heart failure

Marijuana marijuana Disorientation, rapid pulse, Psych. crisishashish panic response, p. 45

Narcotics codeine, heroin, Drowsiness, shallow breathing, Depressantmorphine, muscular flaccidity, pinpoint OD responseDemerol™ pupils, slow pulse, cold/clammy p. 33Dilaudid™ skin, unconsciousness,Percodan™ respiratory failure

Phenothiazines Compazine™ Drowsiness, dry mouth, fever, DepressantStelazine™ impaired motor skills, muscular OD responseThorazine™ rigidity, tremors, facial grimacing, p. 33

low temperature, irregular pulse

PCP angel dust, Blank stare, rapid pulse, PCP ODsherms vomiting, muscular rigidity, response

anesthesia, convulsions, p. 42stroke, respiratory failure

■ Appendix

D.I.N. 208

© 2003 Do It Now FoundationFirst Edition: June 1990

Revised Edition: September 2003

Published and Distributed byDo It Now Foundation

P. O. Box 27568Tempe, AZ 85285

ISBN 0-89230-234-8

Box 27568 ■ Tempe, AZ 85285-7568 ■ 480.736.0599

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Drug Crisis Response - Do It Now!