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Recreational Drugs in ED Toxidromes and Toxidramas

Recreational Drugs in ED Toxidromes and Toxidramas. Angelina Pera ED Registrar. Objectives: Understand the basics. Classifying recreational drugs and their toxidromes Case scenarios of some common recreational drugs Discuss their effects and the current treatments

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Recreational Drugs in ED Toxidromes and Toxidramas

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  1. Recreational Drugs in EDToxidromes and Toxidramas Angelina Pera ED Registrar

  2. Objectives:Understand the basics Classifying recreational drugs and their toxidromes Case scenarios of some common recreational drugs Discuss their effects and the current treatments - Local and global approaches to the drug law reform

  3. Classification by clinical effects • Stimulant • Entactogenic / empathogenic (ecstasy like) • Hallucinogenic (LSD like)

  4. Stimulant drugs Older: Phenethylamines (e.g. 2C or D-series of ring substituted amphetamines, benzodifurans) Newer: Cathinonesegmephedrone Piperazines e.g. benzylpiperazine (BZP) Action: Inhibit monoamine (especially dopamine) reuptake Tox: Cause a sympathomimetictoxidrome

  5. Entactogenic drugs • e.g. newer: phenylpiperazines, methylone • Effects similar to ecstasy • Sense of intimacy and diminished anxiety • Action: • cause central serotonin release

  6. Hallucinogens • Older: LSD • Newer e.g. 5-MeO-DiPT (DOB) • FLY, DragonFLY • Action: • serotonin receptor agonists • *Most have actions at multiple CNS receptor sites

  7. Case 1 • A 21 yr old woman BIBA after becoming combative at a hotel. She is agitated and reports a man put white powder in her drink • VITALS: pulse 130, RR 24 • blood pressure 154/92, Temp 38, Sat 98% on room air. • OE shouting, agitated • mydriasis, flushed skin, sweating and bruxism • What kind of toxidrome is this?

  8. Sympathomimetic syndrome • Tachycardia • Hypertension • Mydriasis • Diaphoresis • Hyperthermia • Agitation

  9. What drugs might she have taken? • cocaine, amphetamines, methamphetamine • MDMA/ecstasy • - Pt reports it was MDMA • Treatment involves sedation & rehydration

  10. MDMA (Ecstasy) • “Comedown”: fatigue, jaw grinding or clenching, insomnia • Difficulty concentrating, lack of appetite, and dry mouth/thirst

  11. MDMA Toxicity: • Serotonin syndrome • Stimulant psychosis • Hypertensive crisis and CVAs • Hyperthermia with • Rhabdomyalysis • Hyponatraemia – excessive • Intake and increased ADH

  12. Case 2 • 28yr old woman, found by police, partially clothed, at bottom of a steep drop beside the motorway. Restrained • OE: Agitated, abusive • HR 120, BP 140/90 T 37.7 mydriasis • R ankle: swollen, bruised, deformed • Any guesses?

  13. Methamphetamine • Phenethylamineand amphetamine classes • Effect: • Low doses, elevated mood, increase sexual desire, increase alertness, concentration, and energy

  14. Methamphetamine toxicity • Psychosis • Rhabdomyolysis • Cerebral hemorrhage. • Chronic risks: •  STIs, meth mouth, neurotoxicity

  15. Case 3 • Ambulance bring in a 32 yr old man who is apnoeic and unresponsive. Found collapsed in an apartment on K road. • VITALS GCS 8 • pulse 128, RR 4, blood pressure 100/70, sat 82% on room air • What drug might he have taken?

  16. Case 3 Arrives in ED sitting up chatting… After ambulance has given which antidote?

  17. Opioids • opiate- natural alkaloids from opium poppy (Papaversomniferum) • Effects: • analgesia, sedation, respiratory depression, constipation, and a strong sense of euphoria

  18. Opioid Toxicity: • Reduced LOC, miosis, bradycardia and respiratory depression • hypoxia, seizures and muscle spasms, apnea • Flash pulmonary edema (rare) • Antidote Naloxone can reverse apnea and obviate the need for intubation. 0.4mg titrate to RR • Can precipitate withdrawal • Short half life - observation is needed. • naltrexone (longer acting)

  19. BZP 1-benzylpiperazine • –sympathomimetic stimulant, similar to amphetamine • - white powder, capsules or tabs, typical dose 100-250mg • - enhanced neurotransmitter release (NA, DA 5HT) and reuptake inhibition

  20. BZP Toxicity: • Sympathomimetictoxidrome • Metabolic acidosis • Seizures • Long QTc, hyponatraemia, psychosis • Treatment: • early charcoal • treat agitation, seizures, hyperthermia, hypertension

  21. Y-hydroxybutyrate (GHB) • Naturally produced in body, related to the ketone body beta-hydroxybutyrate • Stimulant at lower doses, acts on the GHB receptor • Effects: • euphoria, disinhibition, enhanced sensuality and empathogenicstates • Narrow margin

  22. Y-hydroxybutyrate (GHB) Toxicity: • nausea, dizziness, drowsiness, agitation, visual disturbances, respiratory depression, amnesia, unconsciousness

  23. Cannabis • Dried flowers ofCannabis sativa, • indica, ruderalis • Tetrahydrocannabinol(THC) • Effects: • state of relaxation, euphoria. • philosophical thinking, anxiety and paranoia, tachycardia, postural hypoTand hunger • Greater respiratory burden of CO and tar than tobacco

  24. Synthetic cannabinoids • mimic the effects of cannabis • several cannabinoid families, egK2and Spice • Two major receptors: • CB(1) central nervous system • psychotropic effects • CB(2) T-cells, macrophages, and other parts of the immune system • effects of K2 are much stronger than those usually associated with cannabis

  25. A public health issue: Recreational drug use in NZ: • 2007/2008 New Zealand Alcohol and Drug Use Survey • (16.6%) New Zealanders 16–64 years used in the past year •  cannabis - most popular • 14.6% of adults used in 2007 • methamphetamine use, 2% in 2009 • ecstasy use, 2.6% in 2007.

  26. Experiment 1: Herbal highs in NZ • (new psychoactive drugs) • Synthetic compounds initially designed to avoid contravening drug, medicine, and consumer protection laws • diverse branding and poor quality control led to variation in composition • Many reports of adverse effects

  27. New Zealand’s new psychoactive drug laws 2014 • Regulations apply to synthetic drugs such as ”herbal highs” and synthetic cannabinoids • - retailers require a drug licence for every product • - comply with regulations similar to those of the pharmaceutical industry • Subject to a burden of proof

  28. NZ Psychoactive Substances law • regarded as progressive internationally • has dramatically reduced the number of outlets selling synthetic substances • in line with global trend to decriminalise low risk substances • Eg Cannabis in Uruguay, Colorado

  29. The wider global issues

  30. Global calls for changes to drug policy Former UN Secretary General Kofi Annan And Fernando Henrique Cardoso For the Global Commission on Drug Policy: "'We called on governments to adopt more humane and effective ways of controlling and regulating drugs. We recommended that the criminalisation of drug use should be replaced by a public health approach. "We also appealed for countries to carefully test models of legal regulation as a means to undermine the power of organised crime, which thrives on illicit drug trafficking • United Nations Office on Drugs and Crime (UNODC)

  31. Debate on drug regulation reform • Arguments in favour: • Legal • Current systems for legal classification of drugs inconsistent and historical, rather than based on evidence of their risk • Many countries have successfully regulated alcohol and tobacco, other drugs are not different • Fiscal: • The “war on drugs” is a waste of government resources • (In the US criminal justice system oppose reform out of self interest) • Regulation would bring tax revenues

  32. Debate on drug regulation reform • Moral: • Regulated market would remove power from organised crime and render drug dealers unnecessary • Reduce crime and violence related to drug trafficking • Philosophical: • Humans have always sought altered states of consciousness • trying to eradicate drug use is futile • we must learn to live with them

  33. Those against decriminalising drugs • Create a large black market • Many developing countries are unable to regulate alcohol and tobacco , decriminalising narcotics would be catastrophic • Lead to yet more addicts and more crime • - Portugal • Increase in the use of soft drugs could see users graduate more freely to harder drugs • Drugs could fall more easily into the hands of children

  34. = Greatest Human Miseries Disproportionate effect on poorer countries • Organised crime • Narcoterrorism • Human Trafficking • Child prostitution • Communicable diseases HIV, Hep C

  35. Bibliography • Poisoning with illicit substances: toxicology for the anaesthetist. G.T.C Wong & M.G Irwin Anaesthesia 2013, 68 (Suppl. 1) 117-124 • Clinical toxicology of newer recreational drugs. S.L Hill and S.H.L. Thomas. October 2011, Vol. 49, No. 8 , Pages 705-719 http://informahealthcare.com/doi/abs/10.3109/15563650.2011.615318 • New recreational drugs and the primary care approach to patients who use them . A.R Winstock, & L. Mitcheson. 15 February 2012  BMJ 2012;344:e288 http://www.bmj.com/content/344/bmj.e288 • The Approach to Poisonings l. thibodaux, e. senekal. harvard medical school, bostonmassachusetts • http://www.cdemcurriculum.org/ssm/approach_to/tox.php • 2007/2008 New Zealand Alcohol and Drug Use Survey • http://www.drugfoundation.org.nz/drug-information/drugs-in-new-zealand

  36. Quiz • Which drug to the following refer to? • Acapulco gold • China White • Meow Meow • Horse Tranquiliser • Georgia Home boy/ • Grievous bodily harm

  37. Quiz • The following refer to certaindrug combinations: • candy flipping • hippie flipping • kitty flipping

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