Drugs of AbuseDrugs of AbuseOtto F. Sabando DOOtto F. Sabando DOProgram DirectorProgram Director

Emergency Medicine ResidencyEmergency Medicine ResidencySt. Joseph’s Regional Medical CenterSt. Joseph’s Regional Medical Center

Paterson NJPaterson NJwww.emresidency.infowww.emresidency.info

Marijuana Marijuana (tetrahydrocannabinol(THC))(tetrahydrocannabinol(THC))

EpidemiologyEpidemiology– Most frequently utilized illegal substance Most frequently utilized illegal substance

in US (20 million Americans)in US (20 million Americans)– Adolescent use on the riseAdolescent use on the rise

HistoryHistory– Cultivated for thousands of years for Cultivated for thousands of years for

ritual, medicinal, fiberritual, medicinal, fiber

Pathophysiology and Pathophysiology and PharmacologyPharmacology

After smoking, effects to brain within After smoking, effects to brain within 15 seconds15 seconds

Specific cannaboid receptors?Specific cannaboid receptors?– Perception and cognitionPerception and cognition– Pain modulationPain modulation

Effects peak 10-30min and may last Effects peak 10-30min and may last 1-4hrs. THC is lipophylic and highly 1-4hrs. THC is lipophylic and highly protein boundprotein bound

Clinical EffectsClinical Effects

PsychologicPsychologic– Alterations in sensation, perception, Alterations in sensation, perception,

cognition and psychomotor functioncognition and psychomotor function

Danger with acute toxicityDanger with acute toxicity– Loss of motor skills and judgmentLoss of motor skills and judgment– Alcohol and marijuana use impair Alcohol and marijuana use impair

further the motor skills and judgmentfurther the motor skills and judgment

Clinical FindingsClinical Findings

On examOn exam– Tachycardia, psychotic, muscle tremors, Tachycardia, psychotic, muscle tremors,

weakness, and bronchodilitationweakness, and bronchodilitation– Urinary retention, decreased Urinary retention, decreased

testosterone, increased appetite, testosterone, increased appetite, conjunctival injectionconjunctival injection

– Dyspnea and chest painDyspnea and chest pain– Pneumothorax and pneumomediastinumPneumothorax and pneumomediastinum

TreatmentTreatment

No known cases of lethal marijuana No known cases of lethal marijuana intoxicationintoxication

Supportive careSupportive care Benzodiazepines for agitation due to Benzodiazepines for agitation due to

psychosispsychosis

WetWet

Marijuana dipped in FormaldehydeMarijuana dipped in Formaldehyde– Enhances the effects of marijuanaEnhances the effects of marijuana– Causes major psychotic reaction similar Causes major psychotic reaction similar

to PCPto PCP– Treatment is 4 point restraints with Treatment is 4 point restraints with

administration of benzodiazepinesadministration of benzodiazepines

Drugs of AbuseDrugs of Abuse

PCP and KetaminePCP and Ketamine

History and EpidemiologyHistory and Epidemiology PCP first discovered in 1926PCP first discovered in 1926 1950’s Parke Davis1950’s Parke Davis

– Serenyl use 1963Serenyl use 1963– Rapidly discontinuedRapidly discontinued

10%-30% incidence post-op psychosis and dysphoria10%-30% incidence post-op psychosis and dysphoria– 1967 Sernylan for veterinary use1967 Sernylan for veterinary use

1970’s recreational use seen1970’s recreational use seen– ““the PeaCe Pill”, angel dust, crystal joints (CJs)the PeaCe Pill”, angel dust, crystal joints (CJs)– 1977-78 epidemic proportions1977-78 epidemic proportions– Mid 1980’s the Controlled Substance Analogue Mid 1980’s the Controlled Substance Analogue

Enforcement Act 1986Enforcement Act 1986 Lead to a drop in useLead to a drop in use

History and EpidemiologyHistory and Epidemiology

Ketamine entered clinical practice in 1970Ketamine entered clinical practice in 1970– One tenth to one-twentieth the potency of PCP, One tenth to one-twentieth the potency of PCP,

shorter duration of action and less emergence shorter duration of action and less emergence reaction than PCPreaction than PCP

Ketamine abuse noted in 1971Ketamine abuse noted in 1971– 1980’s increase use amongst professional's1980’s increase use amongst professional's

Most abused drug by doctors and other health care Most abused drug by doctors and other health care workersworkers

– ““Date rape Drug”Date rape Drug”– Rave partiesRave parties

Pathophysiology and clinical Pathophysiology and clinical manifestationsmanifestations

Clinical ManifestationsClinical Manifestations

NeuroNeuro– Nystagmus (rotary, horizontal, vertical) Nystagmus (rotary, horizontal, vertical)

ataxia, altered gaitataxia, altered gait– Dystonic reactions: opisthotonos, Dystonic reactions: opisthotonos,

torticollis, tortipelvis, and risus torticollis, tortipelvis, and risus sardonicussardonicus

Cardiac:Cardiac:– Severe hypertension, Intracranial bleedSevere hypertension, Intracranial bleed– No prodysrhythmic effectsNo prodysrhythmic effects

Clinical ManifestationsClinical Manifestations

Lanrygospasm with ketamine useLanrygospasm with ketamine use– 0.017%0.017%

Cholinergic and anticholinergic Cholinergic and anticholinergic manifestationsmanifestations– Miosis, Mydriasis, blurred vision, profuse Miosis, Mydriasis, blurred vision, profuse

diaphoresis, hypersalivation, bronchospasm, diaphoresis, hypersalivation, bronchospasm, bronchorrhea, urinary retentionbronchorrhea, urinary retention

HyperthermiaHyperthermia– Encephalopathy, rhabdomyolysis, Encephalopathy, rhabdomyolysis,

myoglobinuria, liver function abnormalitiesmyoglobinuria, liver function abnormalities

ManagementManagement

Supportive careSupportive care Activated charcoal if orally ingestedActivated charcoal if orally ingested Quiet roomQuiet room

– Decrease sensory stimulationDecrease sensory stimulation 4 point restraints4 point restraints Sedation with midazolam is preferredSedation with midazolam is preferred

Drugs of abuseDrugs of abuse

Cocaine Cocaine

CaseCase

A 24 y.o. male runs into the ED A 24 y.o. male runs into the ED complaining of chest pain for the last complaining of chest pain for the last 30 minutes. The pain is substernal, 30 minutes. The pain is substernal, sharp and constant. The patient is sharp and constant. The patient is diaphoretic and short of breath. He diaphoretic and short of breath. He admits to binging cocaine over the admits to binging cocaine over the last two days. The route of cocaine last two days. The route of cocaine ingestion is intranasal.ingestion is intranasal.

CaseCase

PE: VS: T101.2 F oral, P:120, R: 22, BP PE: VS: T101.2 F oral, P:120, R: 22, BP 150/100, Pulse ox 100%150/100, Pulse ox 100%

Gen: Thin, anxious, and in moderate Gen: Thin, anxious, and in moderate distressdistress

Eyes: Pupils 6mm and reactiveEyes: Pupils 6mm and reactive CV: tachycardic no murmursCV: tachycardic no murmurs Lungs: BLCTALungs: BLCTA Neuro: GCS 15 Neuro: GCS 15 Skin: diaphoretic, flushed and warmSkin: diaphoretic, flushed and warm

CaseCase

MonitorMonitor OxygenOxygen S/L nitroS/L nitro ASAASA EKG Sinus tachycardiaEKG Sinus tachycardia PCXR – NegPCXR – Neg Labs: CBC, CMP, CPK, CE, Troponin, U/A, Labs: CBC, CMP, CPK, CE, Troponin, U/A,

Urine ToxUrine Tox Ativan 2 mgAtivan 2 mg

CocaineCocaine

HistoryHistory– Inca Empire 5000 yrs, a divine plantInca Empire 5000 yrs, a divine plant– 1859 recognized for anesthetic 1859 recognized for anesthetic

propertiesproperties– 1892 Coca Cola tonic for the tired 1892 Coca Cola tonic for the tired

elderlyelderly– 1906 U.S. controlled cocaine use1906 U.S. controlled cocaine use– 1980’s cocaine epidemic1980’s cocaine epidemic

CocaineCocaine

Clinical manifestationsClinical manifestations– HyperthermiaHyperthermia– Neurologic effectsNeurologic effects

StrokeStrokeSeizure (especially IV and crack cocaine)Seizure (especially IV and crack cocaine)Cocaine “wash out”Cocaine “wash out”

– Cardiac effects:Cardiac effects:MI risk increased 24-fold in the hour MI risk increased 24-fold in the hour

following cocaine usefollowing cocaine use

CocaineCocaine

– Chest pain atypical (hours to days)Chest pain atypical (hours to days)– Q wave and non Q wave infarctions can Q wave and non Q wave infarctions can

be seen equallybe seen equally– Dysrhythmias can be seen in high Dysrhythmias can be seen in high

dosages. Low dosages can cause dosages. Low dosages can cause bradycardia.bradycardia.

– Cardiomyopathy- chronic cocaine useCardiomyopathy- chronic cocaine use““stunned myocardium”stunned myocardium”

CocaineCocaine Endocarditis and DVT are associated with Endocarditis and DVT are associated with

IV use.IV use. Aortic dissectionAortic dissection Pulmonary and upper airway effectsPulmonary and upper airway effects

– Asthma exacerbations, PTX, Asthma exacerbations, PTX, pneumomediastinum, pulmonary edemapneumomediastinum, pulmonary edema

– Crack smokingCrack smoking Rhabdomyolysis lead to ARF, hypotension Rhabdomyolysis lead to ARF, hypotension

and hyperthermiaand hyperthermia ““Crack eye” : corneal abrasion, ulcerationsCrack eye” : corneal abrasion, ulcerations

– central retinal artery occlusion and bilateral central retinal artery occlusion and bilateral blindness from diffuse vasospasm.blindness from diffuse vasospasm.

CocaineCocaine

GastrointestinalGastrointestinal– Highly sensitive to catecholamineHighly sensitive to catecholamine– ““Body packers” vs. “body stuffers”Body packers” vs. “body stuffers”

Uterus:Uterus:– Placental abruption 2Placental abruption 2ndnd and 3 and 3rdrd trimester trimester– Intrauterine growth retardationIntrauterine growth retardation

Breast milkBreast milk– Cocaine can be passedCocaine can be passed

CocaineCocaine

ManagementManagement– Benzodiazepine (Ativan) and cooling measures Benzodiazepine (Ativan) and cooling measures

decreases mortalitydecreases mortality– Utox: cocaine last for three daysUtox: cocaine last for three days– CP ProtocolCP Protocol– Uncontrolled HTNUncontrolled HTN

Tx with calcium channel blocker or phentolamineTx with calcium channel blocker or phentolamine

– DysrhythmiasDysrhythmias Tx with calcium channel blocker, sodium bicarb, Tx with calcium channel blocker, sodium bicarb,

lidocaine, amioderone??lidocaine, amioderone??

CocaineCocaine

EM PearlEM Pearl– Never treat the patient with a beta-Never treat the patient with a beta-

blocker!!!blocker!!!

Unopposed alpha-adrenergic agonism leads Unopposed alpha-adrenergic agonism leads to worsening vasoconstrictionto worsening vasoconstriction

Drugs of abuseDrugs of abuse

OpiatesOpiates

Opioid’sOpioid’s

HistoryHistory– Used medicinally since 1500 BCUsed medicinally since 1500 BC– 1804 Morphine isolated from opium1804 Morphine isolated from opium– 1898 heroin synthesized and marketed 1898 heroin synthesized and marketed

by Bayer as antitussiveby Bayer as antitussive– 1999 208,000 Americans use heroin1999 208,000 Americans use heroin

OpioidsOpioids

CaseCase 54 y.o. female BIBA from the beach. The patient 54 y.o. female BIBA from the beach. The patient

is noted to be unconscious. EMS arrived and is noted to be unconscious. EMS arrived and intubated the patient. Accucheck was 176intubated the patient. Accucheck was 176

On arrival to the ED the patient is intubated and On arrival to the ED the patient is intubated and does not respond to painful stimuli. V.S. T:99R does not respond to painful stimuli. V.S. T:99R P:72, R:8,BP:140/80, Pulse ox: 100%.P:72, R:8,BP:140/80, Pulse ox: 100%.

PE: Eyes pupils are constricted.PE: Eyes pupils are constricted.– CV: normal, Resp: BLCTA, Neuro: GCS 3CV: normal, Resp: BLCTA, Neuro: GCS 3

Pt. was immediately given 0.2 mg of narcan IV Pt. was immediately given 0.2 mg of narcan IV and pulled her ET tube out. and pulled her ET tube out.

Patient admitted to taking 6 percocet pills this am Patient admitted to taking 6 percocet pills this am and robitussin for her migraine and robitussin for her migraine

Opiate ReceptorsOpiate Receptors

OpioidsOpioids

Clinical effectsClinical effects– CNS depression leading to hypotension, CNS depression leading to hypotension,

bradycardia and hypothermiabradycardia and hypothermia With MAOI’s and Meperidine (Libby Zion 1984), With MAOI’s and Meperidine (Libby Zion 1984),

tramadol and dextromethorphantramadol and dextromethorphan SeizuresSeizures

– Propoxyphene, Meperidine, or tramadolPropoxyphene, Meperidine, or tramadol

– EKG: QT prolongation with LAAM or high dose EKG: QT prolongation with LAAM or high dose methadone.methadone.

– Pulmonary: respiratory depressionPulmonary: respiratory depression Pulmonary edemaPulmonary edema

OpioidsOpioids

Clinical effectsClinical effects– GastrointestinalGastrointestinal

Increase smooth muscle tone and depress Increase smooth muscle tone and depress gut motility leading to constipation and gut motility leading to constipation and obstipationobstipation

OpioidsOpioids

Lab and bed side testingLab and bed side testing– Finger stickFinger stick– CXRCXR– Acetaminophen and pregnancy testingAcetaminophen and pregnancy testing– Urine drug screenUrine drug screen

OpiatesOpiates– Meperidine or methadone not detectedMeperidine or methadone not detected– False positive- fluoroquinolonesFalse positive- fluoroquinolones

Dextromethorphan, false positive PCPDextromethorphan, false positive PCP

OpioidsOpioids

TreatmentTreatment– Respiratory support is lifesaving and Respiratory support is lifesaving and

criticalcritical– Naloxone/NarcanNaloxone/Narcan

Start slow: 0.05 mg IVStart slow: 0.05 mg IVRedose as needed with observation for signs Redose as needed with observation for signs

of withdrawal (i.e. Diaphoresis, piloerection, of withdrawal (i.e. Diaphoresis, piloerection,

OpioidsOpioids

Special situationsSpecial situations– Oxycontin (oxycodone hydrochloride)Oxycontin (oxycodone hydrochloride)

Crushed for snorting or IV useCrushed for snorting or IV useMore drug than Percocet, up to 160 mg/pillMore drug than Percocet, up to 160 mg/pillEpidemic deaths (Maine, Kentucky, Virginia Epidemic deaths (Maine, Kentucky, Virginia

and Florida)and Florida)Treatment: requires high amount of narcan Treatment: requires high amount of narcan

OpioidsOpioids

Atypical opioid'sAtypical opioid's– DextromethorphanDextromethorphan

Movement disorders, hallucinations, serotonin Movement disorders, hallucinations, serotonin syndrome, sedationsyndrome, sedation

Opiod findings may or may not be presentOpiod findings may or may not be present

– Lomotil (diphenoxylate+atropine)Lomotil (diphenoxylate+atropine) Present with opiod or anticholinergic findingsPresent with opiod or anticholinergic findings Adult patients with OD or children with single tablet Adult patients with OD or children with single tablet

ingestion, monitor for 24hrsingestion, monitor for 24hrs Naloxone reverses only the opiod componentNaloxone reverses only the opiod component

OpioidsOpioids

Atypical opioid'sAtypical opioid's– Fentanyl and its analoguesFentanyl and its analogues

Short acting with potencies of up to 6000 Short acting with potencies of up to 6000 times that of morphinetimes that of morphine

Clonidine and other central alpha 2 Clonidine and other central alpha 2 agonistsagonists– Clinical syndromes indistinguishable Clinical syndromes indistinguishable

from opioid'sfrom opioid's– 50% of children with Clonidine toxicity 50% of children with Clonidine toxicity

respond to Naloxonerespond to Naloxone

OpioidsOpioids

Demerol (Meperidine)Demerol (Meperidine)– Normeperidine, toxic, renally eliminated Normeperidine, toxic, renally eliminated

hepatic metabolite.hepatic metabolite.– Increases noted with accumulated doses Increases noted with accumulated doses

and renal insufficiencyand renal insufficiencyDelirium, tremors and intractable seizuresDelirium, tremors and intractable seizures

– Acts on serotonin receptorActs on serotonin receptorBlockade of presynaptic reuptake may Blockade of presynaptic reuptake may

produce serotonin syndromeproduce serotonin syndrome– Muscle rigidity, hyperthermia, altered mental Muscle rigidity, hyperthermia, altered mental

statusstatus

Opioid'sOpioid's

MPTP (1-methyl-4-phenyl-1,2,3,6-MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine)tetrahydropyridine)– Introduced in 1982 Introduced in 1982 – Incorrect heating of synthetic mixture (MPPP) Incorrect heating of synthetic mixture (MPPP) – Selectively destroyed dopamine-containing Selectively destroyed dopamine-containing

cells of the substantia nigra by inhibiting cells of the substantia nigra by inhibiting mitochondrial oxidative phosphorylation mitochondrial oxidative phosphorylation

““frozen addicts”, acute severe parkinsonian frozen addicts”, acute severe parkinsonian symptoms symptoms

– Invaluable in experimental model for study of Invaluable in experimental model for study of Parkinson's diseaseParkinson's disease

Other factsOther facts Body packersBody packers

– Mules from other Mules from other countriescountries

– Rupture of packetsRupture of packets CocaineCocaine

– Ischemic bowel, Ischemic bowel, emergent surgeryemergent surgery

Opiates (i.e. heroin)Opiates (i.e. heroin)– Airway management Airway management

with Naloxonewith Naloxone

Body stufferBody stuffer– On the run criminals On the run criminals

ingesting the drug sale ingesting the drug sale of the dayof the day

– Usually benign course.Usually benign course.

Drugs of AbuseDrugs of Abuse

AmphetaminesAmphetamines

CaseCase

19 y.o. male is BIBA for severe 19 y.o. male is BIBA for severe agitation. The patient was reported agitation. The patient was reported to be using “X” at a dance club and to be using “X” at a dance club and became severely agitated.became severely agitated.

The patient continues to be agitated The patient continues to be agitated with the following vital signs: with the following vital signs: T:103.4 F oral, P:120, R:18, T:103.4 F oral, P:120, R:18, BP:170/100, Pulse ox 97% room air.BP:170/100, Pulse ox 97% room air.

CaseCase

Physical examPhysical exam– Gen: agitated and confusedGen: agitated and confused

Eyes: pupil: 6mm and reactive b/lEyes: pupil: 6mm and reactive b/lNeck: supple no massesNeck: supple no massesCV: tachycardicCV: tachycardicLungs: BLCTALungs: BLCTAExt: no cyanosis, clubbing, edemaExt: no cyanosis, clubbing, edemaNeuro: Confused, normal DTR’s, good Neuro: Confused, normal DTR’s, good

strength B/Lstrength B/LSkin: flushed and diaphoreticSkin: flushed and diaphoretic

AmphetamineAmphetamine

MethylyenedioxymethamphetamineMethylyenedioxymethamphetamine (MDMA) i.e. Ecstasy, X, E, XTC, (MDMA) i.e. Ecstasy, X, E, XTC,

Adam, M&MAdam, M&M– HistoryHistory

Synthesized in 1912, rediscovered 1965Synthesized in 1912, rediscovered 1965Most widely used amphetamine by college Most widely used amphetamine by college

studentsstudents1980’s used by psychiatrist’s to enhance 1980’s used by psychiatrist’s to enhance

psychotherapy now bannedpsychotherapy now bannedEpidemic in the Mid-WestEpidemic in the Mid-West

AmphetamineAmphetamine

Current use:Current use:– Dose range: 50-150 mg or 1-2 pills per Dose range: 50-150 mg or 1-2 pills per

party (content can vary from 0-200mg)party (content can vary from 0-200mg)– Many users are knowledgeable in Many users are knowledgeable in

pharmacology of drugpharmacology of drug– Common in “rave” party'sCommon in “rave” party's

AmphetamineAmphetamine

Clinical effectsClinical effects– Effects 15-60 minutes, last for 1-6 hrs. Effects Effects 15-60 minutes, last for 1-6 hrs. Effects

may be present for 40 hrs!may be present for 40 hrs!– Enhances pleasure, heightens sexuality, jaw Enhances pleasure, heightens sexuality, jaw

clenching (use of pacifiers), insomnia, loss of clenching (use of pacifiers), insomnia, loss of appetite, poor concentration, memory appetite, poor concentration, memory problems.problems.

– Acute large ingestions present with Acute large ingestions present with sympathetic effect (amphetamine) can cause sympathetic effect (amphetamine) can cause death (hyperthermia, Dysrhythmias, death (hyperthermia, Dysrhythmias, rhabdomyolysis) rhabdomyolysis)

AmphetamineAmphetamine

Chronic useChronic use– Irreversible deterioration of serotonergic Irreversible deterioration of serotonergic

neuronsneurons Complications of MDNAComplications of MDNA

– Hyponatremia- increase serotonin leads Hyponatremia- increase serotonin leads to vasopressin increase; large amounts to vasopressin increase; large amounts of free-water intake combined with of free-water intake combined with sodium loss from physical exertion sodium loss from physical exertion (dancing)(dancing)

– DehydrationDehydration

AmphetamineAmphetamine Complications of MDMAComplications of MDMA

– Hyperthermia: more frequent than other Hyperthermia: more frequent than other amphetaminesamphetamines

– Serotonin syndrome:Serotonin syndrome: MDMA combined with SSRI’sMDMA combined with SSRI’s

– MDMA increases release of stored serotonin and SSRI’s MDMA increases release of stored serotonin and SSRI’s prevents reuptake of serotoninprevents reuptake of serotonin

– Treatment:Treatment: Monitor, O2, EKG, Activated charcoal, labs, accucheckMonitor, O2, EKG, Activated charcoal, labs, accucheck

– Hyponatremia- fluid restrict if patient is clinically Hyponatremia- fluid restrict if patient is clinically euvolemiceuvolemic

Volume repletion with saline must be cautiousVolume repletion with saline must be cautious Hypertonic saline if symptomaticHypertonic saline if symptomatic

AmphetamineAmphetamine

TreatmentTreatment– Seizures/agitationSeizures/agitation

Benzodiazepines, HaldolBenzodiazepines, Haldol

– HyperthermiaHyperthermia Aggressive cooling measuresAggressive cooling measures

– Best is mist with fansBest is mist with fans– Ice water bathIce water bath

– Serotonin syndromeSerotonin syndrome Rapid cooling measures, large amounts of Rapid cooling measures, large amounts of

benzodiazepines, paralyticsbenzodiazepines, paralytics Cyproheptadine? 4mg p.o. Non-specific antagonist at Cyproheptadine? 4mg p.o. Non-specific antagonist at

5-HT 1A, and 5-HT 2 receptors. Antihistamine used in 5-HT 1A, and 5-HT 2 receptors. Antihistamine used in animal studies animal studies

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