Wasted…How Times Have Changed.

1. Wasted…How Times Have Changed. Kasandra Botti, DO, FACEP Medical Director, Department of EMS Mount Nittany Medical Center March 8, 2014

2. Overall Program Objective • Become familiar with some of the new drugs of abuse – how they are used, expected toxidrome/symptoms, and emergency treatment. • Review some of the old drugs of abuse and the new creative ways they may be abused.

3. Is there a problem? 2002

4. Heroin laced with painkiller Fentanyl takes toll in PennsylvaniaBy Rosa Flores, CNNupdated 5:32 PM EST, Sat February 1, 2014

5. Is there a drug problem • Fake Drugs Seized in State College Drug Raid • By: Jeff Preval • Updated: February 23, 2012 • STATE COLLEGE, CENTRE COUNTY - Fake drugs, recently banned in Pennsylvania have been seized in Centre County. In a raid Wednesday night, involving three State College businesses, synthetic marijuana, bath salts and other narcotic paraphernalia were reportedly seized. The charge for selling these substances is considered a felony. The Centre County district attorney says the joint investigation involved stores in State College, as well as, Schuykill and Berks County. Products were seized from Jamaica Junction, Dragon Chasers Emporium and Grasshoppers in State College.The investigation continues. Wearecentralpa.com

6. Is there a drug problem • Drug-Deal Incident Preceded Fatal Stabbing in Lemont, Police Documents Show • by Adam Smeltz on January 17, 2012 4:52 PM • A small-time drug transaction gone awry led to the fatal stabbing of a College Township man late Monday, a State College police investigation suggests.The victim, identified as Tyler Vaughn Struble, 20, of 831 Henszey St., had suffered a deep laceration to his neck area when police arrived at his Lemont home shortly after 10 p.m. He was pronounced dead later at Mount Nittany Medical Center.Authorities have charged Tyler Steven Marlatt, 20, of 821 Southgate Drive, State College, with first-, second- and third-degree murder in connection with Struble's death. Marlatt also is charged with robbery and aggravated assault. Statecollege.com

7. All the RAVEPartygoers commonly using alcohol, ecstasy, bath salts, synthetic marijuana

8. Is there a problem • Avicii on November 17, 2011 – 31 patients transported from the Bryce Jordan Center to the Emergency Department. • Sebastian-Ingrosso on Feb. 23, 2012 – 10 patients transported from the BJC to the Emergency Department. • DayGlow on April 11, 2012 – 27 patients transported and on April 12, 2012 - 31 patients transported from the BJC to the Emergency Department

9. Is there a problem? • October 2012, Calder Commons: Penn State cheerleader Paige Raque falls from balcony • December 2012, Sigma Alpha Mu: Female falls from window • Nov. 16, 2013, Penn Tower: Student killed after falling from ninth-floor balcony • Nov. 22, 2013, The Palmerton: Student falls from second-floor balcony at The Palmerton • Jan. 19, 2014, The Palmerton: Another student falls from second-floor balcony

11. Designer Drugs • Synthetic derivatives of federally controlled substances created by slightly altering the molecular structure of existing drugs. • Produced illegally in clandestine labs for illicit use.

12. Synthetic Marijuana

13. Synthetic Marijuana Common Names: K2, Spice, Blaze Cost: $30-$40 for a 3 gram bag Route of Administration: smoking, snorting, or swallowing

14. Synthetic Marijuana • Emerged as a problem in 2009 • A blend of plant and herbal materials that have been sprayed with chemicals • One in nine high school seniors have gotten high on synthetic marijuana • Calls to poison control centers in 2011 about 7000, up from 2900 in 2010

15. Synthetic Marijuana Desired Effects: Marijuana-like high and calming effect Adverse Effects: excessive sweating, agitation, tachycardia, aggression, restlessness, confusion, inability to speak, and STROKE

16. Emergency Medicine NewsJanuary 2014 • Strokes caused by Spice • Thought to be embolic etiology • Siblings in Florida • 26 year old male – slurred speech and weakness to the right side of his body – given TPA • 19 year old female – severe aphasia with weakness to the right side of her body – she was left completely disabled with right hemiparesis and expressive aphasia.

17. Synthetic Marijuana • Intoxication? • Neurological Signs?

18. Synthetic Marijuana • Treatment: • Supportive care • Treatment of associated symptoms • Benzodiazepines for agitation, aggression • IV Fluids for dehydration

19. Bath Salts

21. Bath Salts Common Names: White Lightning, Cloud 9, Ivory Wave, White Dove Cost: $40 for 500mg Route of Administration: Snorting, swallowing, smoking, injecting

22. Bath Salts DesiredEffects: Increased alertness; diminished requirement for food or sleep; regarded as synthetic cocaine Adverse Effects: hypertension, sweating, chest pain tachycardia, extreme paranoia, increased suicidal thoughts, necrotizing fasciitis

23. Bath Salts • Number of calls to poison control centers in 2011 was about 6100, up from 304 in 2010. • Bath Salts accounted for 23,000 of 2.5million drug-related visits to the ED in 2011. • Evade FDA regulation by printing warning label, “ Not for Human Consumption.”

24. Bath Salts • Treatment: • Supportive care • Treatment of associated symptoms • Benzodiazepines for agitation, paranoia, restlessness, and seizures • Maintain patient and staff safety • TIME

25. Ecstasy Proper Name: 3, 4-Methylenedioxymethamphetamine Common Name: MDMA, XTC, Adam, E Cost: $20 to $30 per dosage unit retail Route of Administration: Swallowing, snorting, smoking, injecting

26. Ecstasy Desired Effects: profoundly positive feelings, empathy for others, elimination of anxiety, and extreme relaxation; suppress the need to eat, drink, or sleep. Adverse Effects: diaphoresis, bruxism, jaw clenching, paresthesias, hyperthermia, fatal dysrythmia and Hyponatremia which can cause cerebral edema, confusion, and seizures.

27. Ecstasy • MDMA causes massive serotonin release. Coupled with dancing and dehydration, the hyperthermia is greatly exaggerated. • Many users will have pacifiers in their mouth because of bruxism

28. MDMA • Treatment: • Supportive care • Treatment of associated symptoms • Hyperthermia – cooling with ice packs and a fan, ice-lavage; antipyretics are not useful • Benzodiazepines for agitation or seizures • Admission if evidence suggests presence of significant hyperthermia, altered mental status, seizures, severe hyponatremia, respiratory depression, or acute renal failure secondary to rhabdomyolysis.

29. Molly

30. Molly’s Plant Food • Molly’s Plant Food is a synthetic hallucinogenic amphetamine marketed as a “plant food” that contains ingredients that produce highs similar to Ecstasy.

31. Excited Delirium • Acute onset of agitated behavior which may result in death.

32. . Excited Delirium • Bizarre and violent behavior, most commonly violence towards glass • Removal of clothing, public nudity (even in cold weather) • Aggression • Hyperactivity • No pain perception • Hyperthermia • Paranoia • Hallucination • Incoherent speech or shouting • Grunting or animal-like sounds • Incredible strength or endurance (typically noticed during attempts to restrain victim)

33. Excited Delirium • Other medical conditions that can resemble excited delirium are panic attack, hyperthermia, diabetes, head injury, delirium tremens, and hyperthyroidism.

34. Excited Delirium • Treatment Suggestions for Excited Delirium: • Cooled IV fluids • Chemical Sedation (Ketamine) • ECG Monitoring • Pulse Oximetry • Sodium Bicarbonate administration

36. Date Rape Drugs

37. GHB and GBL Proper Name: Gamma-hydroxybutyric acid, gamma-butyrolactone Common Name: GHB, GBL Other Street Name(s): Grievous Bodily Harm, scoop, liquid ecstasy, cherry meth, growth hormone booster, liquid x, and Georgia homeboy. Cost: $10 per bottle, which usually contain 10 “hits” Desired Effects: Initially marketed as a fat-burner and a growth hormone promoter; now used as a hallucinogenic, euphoric, and sleep aid

38. GHB and GBL • Physical Characteristics: • GHB generally comes in pure powder form or mixed with water. • GBL is a precursor to GHB. GBL is a solvent found in floor cleaning products, nail polish, and superglue removers. • Described by users as, “alcohol-free, hang over free high with potent prosexual effects.” • FDA approved for treatment of narcolepsy. • First used by body builders for the euphoric effect during marathon weight lifting sessions.

39. GHB and GBL • Harmful Effects: • GHB quickly produces moderate amnesia but does not produce analgesia or muscle relaxation. • Bradycardia, decreased systemic vascular resistance, and hypotension. • CNS depression is the hallmark of GHB use. • Myoclonic jerks often confused with seizure activity. • Sporadic violent agitation. • Hypotension occurs in 10% of GHB ingestions. • Burns to lips and oropharynx may represent caustic injury from concomitant lye ingestion.

40. Rohypnol Proper Name: Flunitrazepam (Rohypnol) Common Name: Roofies Other Street Name(s): In South Florida, street names include “circles,” “Mexican valium,” “rib,” “roach-2,” “roofies,” “roopies,” “rope,” “ropies,” and “ruffies.” In Texas, flunitrazepam is called “R-2,” or “roaches.”Cost: $5 or less per tablet Desired Effects: Produce profound intoxication, boost the high of heroin, and modulate the effects of cocaine

41. Rohypnol • Physical Characteristics: • Flunitrazepam—marketed under the trade name Rohypnol—is manufactured worldwide, particularly in Europe and Latin America to treat severe sleep disorders • However, the drug is neither manufactured nor approved for medical use in the United States. • Described as 10X more potent than valium.

42. Rohypnol • Harmful Effects: • It has physiological effects similar to diazepam. • Paradoxically, although the drug is classified as a depressant, flunitrazepam can induce excitability or aggressive behavior in some users. • Dizziness, confusion, drowsiness, blurred vision, unresponsiveness, anxiety, agitation

43. The Usual…and the not so usual way of abusing common drugs.

44. Alcohol: The old standby Just New Flavors

45. 2010 Monitoring the Future • Nearly half of all college students (44%) report having been drunk in the prior 30 days. • About one in eight college students (13%) reported having 10 or more drinks in a row at least once in the prior two weeks, and one in twenty (5%) reported 15 or more drinks in a row.

47. State Patty’s Day 2012 Over 48 hours…66 patients presented to the ER with Alcohol intoxication or Alcohol Overdose AVERAGE BAC 282.9

48. New Ways to Abuse Alcohol • Ethanol Tampon: more alcohol absorption without consuming a large amount of fluid or calories

49. New Ways to Abuse Ethanol

50. Neknomination