Nithya SwamyNithya Swamy

Resident’s ConferenceResident’s Conference

October 7, 2008October 7, 2008

IntroductionIntroduction4.7% of the world’s population participate in

illicit drugsIn the US, of those 12 years or older

8-9% of individuals in the US abuse illicit drugs 46.1% have tried it in their lifetime

Drug use or drug withdrawal can be the cause of a presenting illness or it can mask an underlying illness

It is important to recognize the symptoms of drug intoxication and how to treat it

Goals of PresentationGoals of Presentation1. Drug Use Stats in the US2. How Drugs Work3. Cases/Common Recreational Drugs4. Street Lingo5. Drug Effects6. Management and Treatment

Drug Use in the USDrug Use in the US

• 22.5 million > 12y were classified with drug abuse or drug dependence. This includes tobacco, alcohol and illicit drugs.

• 26% American Indian or Alaska Native• 12.2% for mixed races• 11.1% Caucasian• 10.2% Hispanic• 9.3% African-American• 6.0% Asian

• Random Scary Fact: By eighth grade, 52 percent of teenagers have consumed alcohol, 41 percent have smoked cigarettes, and 20 percent have used marijuana.

Drug use at least once in the last 30 days among those 12 and older

Drug Use in the USDrug Use in the US25-40% of hospitalizations in the US involve

substance abuse10-16% of outpatients have substance use

problems16,000 deaths/year are due to illicit drug use

whether directly or indirectly (HIV/AIDS, hepatitis, tuberculosis, homicides, and other violent crimes and incidental injuries)

Cost: $531 billion dollars annually ($181 billion in illicit drugs, $168 billion for tobacco and $185 billion for alcohol)

527000 ER visits each year

Drug Use in the USDrug Use in the US6-7% of senior citizens admitted exhibit symptoms of

alcoholism. Prevalence of problem drinking in the nursing homes is high as 49%In this subpopulation, the majority are women.They are more prone to dependence on prescription

medications 2/2 overmedication by their own physicians Opiods for pain and sedative/hypnotics for anxiety or

insomnia

Random Scary Fact #2: Health care workers are at

increased risk of addiction due to high stress jobs and access to drugs. Anesthesiologists, surgeons, and emergency room

physicians are at highest risk for drug dependence.

How Drugs WorkHow Drugs WorkAcute Drug Use:

Release and Prolonged action of dopamine and serotonin within the reward circuit.

Reward Circuit (mesolimbic system) Addictive drugs lead to the release of dopamine. Dopamine binds to D1

receptor triggering a signaling cascade that leads to a pleasurable response.

There is also a 2nd cascade activated involving a cAMP dependent PK which activated a CREB tf which when activated inhibits dopamine release. In drug users this pathway is chronically active resulting in the need for

larger doses to achieve the same pleasurable response.

DSM IVDSM IVSUBSTANCE DEPENDENCIES303.90 Alcohol304.40 Amphetamines304.30 Cannabis304.20 Cocaine304.50 Hallucinogens304.60 Inhalants305.10 Nicotine304.00 Opiods304.70 PCP304.10 Sedative, Hypnotic or anxiolytic304.80 Polysubstance dependence304.90 Other (or unknown) substance

The DrugsThe Drugs

AlcoholAlcohol

Short Term EffectsShort Term Effects Euphoria: BAC = 0.03 to 0.12% Lethargy: BAC = 0.09 to 0.25% Confusion: BAC = 0.18 to 0.30%

Ataxia Stupor: BAC = 0.25 to 0.40%

Anterograde amnesia Coma: BAC = 0.35 to 0.50% Death: BAC more than 0.50%

Alcohol->Acetylaldehyde->Acetic Acid->fats, CO2, Water Death in the acute phase:

Alcohol poisoning and respiration depression, loss of gag reflex and asphyxiation

Wernicke encephalopathy: ataxia, ophthaloplegia, confusion and impairment of short-term memory. Lesions in the CNS & PNS. Heavy alcohol use interferes with thiamine breakdown. Tx: Thiamine IV/IM

Long Term EffectsLong Term Effects Brain

Impairs brain development and neurogenesis Myopathy in the proximal muscles: 50% Polyneuropathy Wernicke-Korsakoff:

Korsakoff’s psychosis: progression from Wernicke’s; anterograde and retrograde amnesia, anisocoria, confabulation, ataxia, tremors & lack of insight.

Long-term tx with thiamine but at this point, may never return to their baseline. Heart:

Dilated cardiomyopathy and CHF Tx: ACE I, BB, Diuretics, or heart transplant

GI: mucosal damage Inflammation of GI tract Impairs esophageal motility, esophagitis, Barrett’s, esophageal Ca, Mallory

Weiss Steatohepatitis Alcoholic hepatitis: Inflammatory response to fatty accumulation: jaundice,

ascites, AST>ALT, encephalopathy, increased PT Tx: cortiocosteroids, sometimes pentoxyfilline

Cirrhosis: fibrosis and altered architecture Portal HTN: gastric & esophageal varices Coagulopathy Ascites, encephalopathy and hepatorenal syndrome Tx: symptomatic: lactulose, vitamin K or FFP, nadalol

Alcohol WithdrawalAlcohol WithdrawalHigh mortality rate if not effectively treated. Alcohol’s primary effect is the stimulation of

GABA and promotes CNS depressionWhen abruptly stopped, the CNS undergoes

uncontrolled synapse firing. Leads to anxiety, shakiness, diaphoresis,

insomnia, tachycardia, tremor and in more severe cases seizures & delirium tremensDT: autonomic instability, hallucinations

Treatment: symptomatic and supportive: Benzodiazepines followed by taper, vitamin and

fluid replacement

CaseCaseA 35 year old male presents to the ER and is

hyperactive and tremulous. His girlfriend brought him in for AMS. He keeps saying he is “the authority of the human mind” and that because of that, people are trying to kill him. His girlfriend reports he has not slept much in days.

Physical Exam:H: 5’9; 95lb. T: 103.6, HR: 115, BP: 178/110, Pupils are equal but dilated, dry membranes with

very poor dentitionCV: Irregular rhythm and tachycardic

What drug has he been taking?

AmphetaminesAmphetamines

Common Amphetamines: (aka Pep Pills, Uppers, Rippers, Sparklers)

Amphetamine Sulphate: Speed, benzedrine, bennies, sulph, whiz, billy

Dextroamphetamine: Dexedrine, Dexy’s Midnight Runners, Dexies

Methamphetamine: Methedrine, Crank, Crystal Meth, Ice, Meth,

Redneck cocaine, Tina, Geek

Amphetamines are stimulants that increase levels of the neurotransmitters: norepinephrine, serotonin and dopamine.It stimulates NT release and at high doses inhibits NT

uptakeRoutes: smoking, injection, snorting and rectallyIntoxication:

Short term: mydriasis, hyperactivity, increased physical activity, decreased appetite, tachypnea, tachycardia, irregular heartbeat, hypertension & hyperthermia. symptomatic tx with benzos and antipsychotics

Long term: extreme weight loss, hypoglycemia, severe dental problems, anxiety, confusion, insomnia, intracerebral hemorrhage, mood disturbances, and violent behavior. Also, psychotic features, including paranoia, visual and auditory hallucinations, and delusions.

Overdose:Sympathetic overload: diaphoresis, tachycardia,

vasoconstriction, hypertension, hyperthermia Hyperthermia and vasoconstriction can lead to

rhabdomyolysis, renal failure, CV collapse & death.

Withdrawal: 7 -10 days

Hypersomnia Depression Hyperphagia

Treatment:No medications, primarily behavioral rehab

Chronic use: Noninvasive human brain imaging studies have shown alterations in the activity of the dopamine system that are associated with reduced motor performance and impaired verbal learning. Recent studies revealed severe structural and functional changes in areas of the brain associated with emotion and memory

CaseCaseA 37 yo female presents drowsy and disinhibited.

She keeps trying to get out of bed and when she does, she is staggering. She is difficult to understand as her speech is slurred and she is obviously confused. She becomes more somnolent and soon becomes difficult to arouse. He breathing decreases and she requires intubation. Her husband says “she takes some pills everyday. She has to take them because if she stops, she has a fit”

PE:T: 95, P: 85, R 18, BP: 76/50Eye: lateral nystagmus

What kind of drug is she on?

BarbituratesBarbiturates

COMMON BARBITURATES:Amobarbital:

Downers, blue heavens, blue velvet, blue devilsPentobarbital:

Nembies, yellow jackets, abbots, Mexican yellowsPhenobarbital:

Purple hearts, goof ballsSecobarbital:

Reds, red birds, red devils, lilly, F-40s, pinks, pink ladies, seggyTuinal:

Rainbows, reds and blues, double trouble, gorilla pills, F-66s

Barbiturates are CNS depressants: mild sedation and anesthesia.

Anxiolytics, hypnotics and anticonvulsantsPotentiates inhibitory GABA receptor and a

glutamate receptorUpregulates CYP 450 in the liver

Routes: Oral and IV/IMSx: Respiratory depression, hypotension.

Fatigue, hypothermia, irritability, dizziness, sedation, lateral & vertical nystagmus, confusion and ataxia.

Drug users often abuse barbiturates to counteract the symptoms of stimulants like cocaine or methCommonly abused barbiturates are short acting

Overdose can lead to respiratory failure and deathTx: symptomatic and charcoal

Withdrawal: 12-20h after the last dose. Symptoms include anxiety, irritability, elevated heart and respiration rate, muscle pain, nausea, tremors, nightmares, insomnia, vivid dreams, hallucinations, confusion, and seizuresTx: stabilization with an intermediate acting

barbiturate like pentobarbital. Newer techniques involve loading doses of phenobarbital titrated to the clinical or toxic effects. Eventually they require a gentle taper and rehab

CaseCaseA 45 year old physician presents complaining

of anxiety, palpitations and profuse sweating. He did not sleep the night before. He has his sunglasses on and he’s asking you to whisper b/c anything louder hurts his years

PE: He seems anxious and agitated.T:98.6, P: 110, R: 33 BP: 150/95What drug is he withdrawing from?

BenzodiazepinesBenzodiazepines

COMMON BENZODIAZEPINES:Alprazolam (Xanax)Lorazepam (Ativan)Clonazepam (Klonopin)Diazepam (Valium): Valley GirlTriazolam (Halcion)

Street Names: BZDs, Benzos, Downers, Goofballs, Heavenly Blues, Robital, Stupefy, Tranx

Psychoactive drugs with hypnotic, sedative, anxilytic, anticonvulsant, muscle relaxant and amnesic properties mediated by slowing of the CNS.

Tolerance develops quickly and higher doses are required to achieve the same effect. Often, by 4-6 months, benzos have little efficacy

Benzodiazepines can give rise to physiologic and psychologic dependence based on the drug's dosage, duration of therapy and potency.

Benzos are rarely the sole drug of abuse. An estimated 80 percent of benzodiazepine abuse is part of polydrug abuse, most commonly with opioids.

Overdose: respiratory depression, hallucinations, coma. Mortality rates are not as high as barbituratesTx: supportive; flumazenil is used only for severe cases,

as it can cause acute withdrawal and subsequent seizures.

Flumazenil should only be used if Benzodiazepines is the only drug of abuse.

Withdrawal: Anxiety, tachycardia, hypertension, diaphoresis, insomnia and sensory hypersensitivity.Tx: Taper with a longer acting benzo like

chlordiazepoxide

CaseCaseA 26 year old male presents to the ED complaining

of progressively worsening productive cough and shortness of breath for 3 days. He does have chest pain but attributes it to his persistent cough. His sputum is productive of white foamy sputum.

When you are assessing him, his breathing becomes more labored and eventually he has to be intubated. He progressively becomes hypotensive and requires pressors. An TTE is done at the bedside and reveals severe dilated cardiomyopathy with an EF of 15%.

What is the offending drug?

CocaineCocaine

Common Street Names:Blow, C, California Cornflakes, Nose candy, Coke,

Columbian foot soldiers, Flake., Lady C, snowball, tornado, wicky stick, Showbiz Sherbert, White Lady, Shnazzle

Routes: Freebase: smoking the base form of cocaine. Absorbed directly into

the bloodstream from the lungs. Rush is more intense than snorting.

Crack/Cocaine: smokable. Freebase form of cocaine that is made from a reaction between cocaine and sodium hydroxide.

Insufflation (snorting, sniffing, blowing) Oral: rubbed along gum line: "numbies", "gummers" or "cocoa

puffs"

Strong CNS Stimulant: increase levels of dopamine through the reward circuit

Acute: Moderate amounts: vasoconstriction, dilates pupils,

hyperthermia, tachycardia, hypertension, euphoria Large amounts: Intensify the user’s high, but may also lead

to bizarre, erratic, and violent behavior. Arrhythmias, tremors, vertigo, muscle twitches, paranoia, or with overdose, cardiac and respiratory arrest

Chronic: bronchospasm, pruritus, fever, diffuse alveolar infiltrates

without effusions, dilated cardiomyopathy, stroke, MI, degradation of septum nasi, shortness of breath, tooth decay, renal failure

Withdrawal Depressed mood, Fatigue, Generalized malaise, Vivid and

unpleasant dreams, Agitation and restless behavior, Slowing of activity and Increased appetite

Low to non-existent mortality; high risk of relapseTreatment:

Supportive, behavioral treatment and detox

Cocaine and ACSCocaine and ACS Risk of MI is increased 24-fold in the 1st hour after cocaine use. 6% of patients with cocaine-associated chest pain are having an

AMI. An additional 15% meet the criteria for ACS. Ischemia may be delayed for up to 24 hrs after use. Acute:

Vasoconstriction Immediate and delayed coronary vasoconstriction Vasoconstriction may be worsened if cocaine is used with tobacco Hypercoaguability Platelet activation & aggregation Increased oxygen consumption

Chronic: Early atherosclerosis and coronary ectasia Cardiomyopathy

EKG: may be normal, non-specific or show ST changes 56-84% of patients will have an abnormal EKG. Up to 43% meet EKG criteria for reperfusion therapy.

CaseCaseA 17 year old female presents to ED with

altered mental status. She has rapid speech and discussing her important role in the universe. She is trying to hug/kiss/grope your male resident.

PE: T: 105, P: 120 R: 25, BP: 140/90 Difficult to assess as she can’t stop moving, but

you do note she grinding her teeth.Her lab values are significant for a Na 115 and a

Cr 2.0

MDMAMDMA

Common street names:Ecstasy, Adam, Beans, Ex, hug drug, Jack and Jills, Mandy, Smartees, Sweets, Vitamin E

Routes: oral as capsule or tabletSemi-synthetic member of amphetamines

Sub-class of phenylethylaminesConsidered a stimulant, psychedelic,

empathogen (emotional lability)Affinity for SERTs (serotonin transporter)

MDMA inhibits the reuptake of serotonin and it reverses the action of the transporter so that it begins pumping serotonin into the synapse from inside the cell

Stimulates norepinephrine and dopamine release

Acute: Euphoria, decreased anxiety, intimacy, decreased appetite, urinary

retention, pupil dilation, increased energy, tachycardic, hypertensive, also, oral fixation such jaw clenching and teeth grinding.

Danger signs: Hyperthermia, Dehydration, Hyponatremia and Serotonin syndrome

Chronic: Serotonergic change

Overdose: Serious adverse events in MDMA users may be an interaction of the drug with a preexisting medical condition. Risk of adverse event after MDMA consumption is thought to be

increased by preexisting cardiovascular problems, such as cardiomyopathy, hypertension, viral myocarditis, and congenital cardiac conduction abnormalities

Neuro: subarachnoid hemorrhage, intracranial bleeding, cerebral infarction due to MDMA-induced increases in blood pressure may occur in people with preexisting congenital AVMs or cerebral angiomas.

Hyperpyrexia: resulting rhabdomyolysis and renal failure Hyponatremia: Convulsions

Tx: SSRIs prevent neurotoxicity. Symptomatic with benzos or dantrolene

CaseCaseA 42 year old cachectic male presents with a

RR of 4 and is unresponsive. His pupils were constricted but reactive. The paramedics gave him a medication in which he woke up and reported he took some “cheeba”. Later, he reported he was freezing and had rigors. He also had diffuse abdominal cramping, vomiting and persistent diarrhea.

Name that drug!

HeroinHeroin

Common Street Names:Black, Brown Sugar, Cheeba, Diesel, Hero,

Horse, Junk, Lady H, Poppy, Smack

Routes: IVInsufflationSmoking

Other: Speedball or snowballCocaine plus heroin leading to a more intense

rush than one alone

Synthetic opiod synthesized from morphineCrosses blood brain barrier, is converted to

morphine and binds opiod receptors Symptoms

Injection leads to rush of euphoria followed by dry mouth, periods of wakefulness and sleep, mental slowing. Other routes have the same symptoms without the intense rushRisks:

Infections, HIV, Hepatitis, collapsed veins, endocarditis, pericarditisrenal insufficiencychronic constipationpulmonary complications (pneumonia,

respiratory depression). Vascular and organ damage from toxic

contaminants in the heroin

Overdose: Respiratory depression, constricted pupils, hypotension, coma, delirium, muscle spasticity

Treatment: Naloxone or Naltrexone

WithdrawalOccurs 6-24h after last doseRebound hyperactivity of the sympathetic nervous

systemSweating, malaise, anxiety, depression, cramps,

excessive yawning or sneezing, insomnia, chills, rigors, vomiting, diarrhea, restless leg

Tx: longer-acting opiod such as methadone or

buprenorphine. Benzos can be used for symptomatic treatment of

anxiety, insomnia and muscle spasms. Loperamide is used for diarrhea and Clonidine for hypertension.

Prescription OpioidsPrescription OpioidsCommonly abused prescription opioids

OxyContinHydrocodoneMethadoneMorphineHydromorphoneFentanylBuprenorphine

Similar symptoms to heroin but lack heroin’s potency and therefore its severe intoxication and withdrawal.

CaseCaseA 35 year old male presents with a knife in his left

shoulder. He does not seem to be in pain, but is very agitated and has to be restrained. According to the police, he started a fight by attacking a large group of people. On admission, he continuously yells the aliens are going to abduct him and that they are talking to him through the TV.

PE: T: 98.6, P: 122, R: 28, BP: 185/115Diffusely erythematousSubconjunctival hemorrhage, Dilated pupils, non-

reactiveDry mucous membranesDoes not withdraw to pain

PCPPCP

Common Street Namesangel dust, illy, water, BrainTree, fry, dumb

dust, rocket fuel, cake, nature boy, love boat, elephant tranquilizer cornbread, Hairy Jerry, George Jefferson

Routes:Powder: insufflatedLiquid: dipped on cigarettes and marijuana and

smoked. IV/IM as well.

Dissociative drug causing hallucinogenic and neurotoxic effects.Blocks conscious mind from other parts of the brain.

Depersonalization, derealization and anesthesia. NMDA receptor antagonist similar to ketamine and

dextromethorphan.AnestheticAssociated with memory deficits, psychotomimetic effects

similar to psychosis. Confusion, difficulty concentrating, agitiation, nightmares, catatonia and ataxia

Effects:Acute: Diaphoresis, HTN, tachycardia. Also, numbness in

the extremities and intoxication, characterized by staggering, unsteady gait, slurred speech, bloodshot eyes, and loss of balance. More prone to physical injury as they can’t feel pain.

Psych: resembles schizophrenia: unpredictable and driven by their delusions. Auditory hallucinations

RED DANES: Rage, Erythema, Dilated pupils, Delusions, Amnesia, Nystagmus, Excitation, Skin Dry.

Rarely, cardiac failure can result.

CaseCaseA 68 year old female presents to the ED. She

reports seeing “beautiful colors swirling around” as well as being able to “smell the lovely music”. She otherwise will not answer any questions.

PE: T: 94.7, P 50, R 18 BP 120/80 Drooling, staring at something/nothing in the air. Pupils dilated but sluggishly reactiveNeuro: Reflexes are 4+ bilaterally

And the drug is……

LSDLSD

Common Street Names:Acid, Alice, California Sunshine, Trip, Timothy

Leary Ticket, Sugar cubers, Tabs

Route:Tabs, LSD blotter paper dissolved in

LSD/Water/Alcohol solutionIV/IM

Synthesized from lysergic acid derived from ergot, a grain fungus that grows on rye.

Unknown mechanism of action, but thought to bind dopamine and serotonin receptors promoting their release

Physical Sx: Hypothermia, fever, hyperglycemia, bradycardia, goose bumps,

perspiration, pupil dilation, saliva production, mucus production, sleeplessness, paresthesia, euphonia, hyperreflexia, tremors

Psychological Sx:

Varies person to person. Synesthesia radiant colors, objects and surfaces appearing to ripple or "breathe,"

colored patterns behind the eyes, a sense of time distorting, crawling geometric patterns, morphing objects

loss of a sense of identity, powerful, and sometimes brutal, psycho-physical reactions interpreted by some users as reliving their own birth.

Lasts 6-14h Withdrawal:

Minimal: Diarrhea, chills, tremors

Risks: Minimal as it is non-addictive. In patients who take Lithium, SSRIs or tricyclics with antidepressants, there is an increased risk of a dissociative fugue. They are unaware of their actions and can harm themselves.

The EndThe EndThis is your brain

after this presentation.

Any Questions ??????