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Street Drug OD. Nathanael Wood, MD May 9, 2006. Street Drug Overdoses. Overdoses in General Rock Smack XTC PCP. What is an Overdose?. Not based on dose. Based on Clinical Picture An “Overdose” is any clinically relevant instability from drug ingestion. .
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Street Drug OD Nathanael Wood, MD May 9, 2006
Street Drug Overdoses • Overdoses in General • Rock • Smack • XTC • PCP
What is an Overdose? • Not based on dose. • Based on Clinical Picture • An “Overdose” is any clinically relevant instability from drug ingestion.
Recreational Drugs Popular in the Capital Region Most common in the Emergency Department: • Alcohol • Cocaine and Crack • Heroin and Opioids • Marijuana
Case Study • 24 year old female found seizing. • No medical problems • Vitals: HR 153, BP 205/122, O2 sat 85%, RR 22 • Continues to seize after valium
Cocaine • Andes, Mexico, West Indies, and Indonesia. • Erythroxylon coca • Diminish fatigue at altitude.
Cocaine • Sigmund Freud • 1884: “Über Coca” • “Wonder drug” • Depression • Alcohol dependence Freud became severely addicted.
Cocaine • Most popular street drug • Water-soluble HCl salt • IV • Snorted • Also SC or IM • Slow absorption • Less “rush”
Crack • How to make Crack • Cocaine • Baking soda and water • Boil • Separate • Late 1980s • Smoke vapors • Popping sound • “Rock”
Cocaine: Pathophysiology • CNS Stimulant • Blocks reuptake of norepinephrine and dopamine.
Cocaine: Pathophysiology • Norepenepherine • Sympathetic stimulation • “Fight or Flight” • Pupil dilation • Elevated blood pressure • Tachycardia • Hyperglycemia • Hyperthermia • Cardiac arrhythmias • Seizures
Cocaine: Pathophysiology • Dopamine • Pleasure response • Euphoria • Addiction
Assessment • ABC • If decreased mental status: • Narcan • Finger stick glucose or D50
Cocaine Overdose • Convulsions • Stroke • Chest Pain • Hyperthermia • Hypertension
Convulsions Any route Dose dependent Usually benign Cocaine Overdose • Can be caused by more serious complications like stroke or intracranial hemorrhage.
Convulsions ABC Benzodiazepines Valium Midazolam Avoid restraints* Cocaine Overdose
Cocaine Overdose • Stroke • Bleed or Ischemia • Seconds to 12 hrs
Cocaine Overdose • Stroke • ABC • Rapid transport • Neurosurgery
Cocaine Overdose • Chest Pain • Vasoconstriction • Cardiac ischemia • Angina • MI
Cocaine Chest Pain • Treat them as real • O2, aspirin, nitrates, EKG • NO BETA-BLOCKERS • NO LOPRESSOR (metoprolol) • Benzodiazepines
Cocaine Overdose • Hyperthermia • 114° F • Deadly • Avoid coverings • Avoid restraints • Cooling can be life-saving Treat shivering and psychomotor agitation with benzodiazepines to reduce heat production.
Cocaine Overdose • Hypertension • Alpha-mediated vasoconstriction • DO NOT USE BETA-BLOCKERS • Unopposed alpha stimulation • WORSENS HYPERTENSION! • Use Benzodiazepines • Consider Nitro with medical direction.
Cocaine Overdose • Body Packers • Mules • Transport drugs • Ingested packages • International flights • Well contained packages Breakage of packages can cause severe OD.
Cocaine Overdose • Body stuffers • Ingest drugs they have on them • Concealment • Packages not well made • Rupture easily • Can cause severe overdoses Be suspicious of symptomatic patients in police custody.
Cocaine Overdose • Packers and Stuffers • Treat as OD • ER: bowel decontamination • Surgery
Cocaine Overdose - Overview • ABC • O2, IV, cardiac monitor • Detailed history: • What and how much • Co-ingestions • Fingerstick • Narcan • NO BETA BLOCKERS • Treat chest pain like it’s real • NO BETA BLOCKERS
Cocaine Overdose - Overview • Cooling • Avoid restraints if possible • Use Benzodiazepines • Agitation • Seizure • Hypertension • Shivering when hyperthermic
Heroin • Semisynthetic • Derived from morphine • Opiates / Narcotics family • Opium • Methadone • Hydrocodone • Oxycontin
Heroin • 1874 • Safer, non-addictive substitute to morphine • 1920: Dangerous Drugs Act • Drove it underground • Most frequently abused narcotic in US • Followed by codeine and methadone
Heroin • Pure form • White powder • Bitter taste • Street form • Frequently mixed / cut • Maximize profits • Variety of colors • White to dark brown
Heroin • Impure heroin • Slower absorption • Limits rush when sniffed or snorted • IV injection
100-mg bag in 1980 3.6% pure $3.90 100-mg bag in 1999 38.2% pure $0.80 Heroin South American samples have highest purity, reaching the 90% range. Snorting and smoking are slowly becoming the methods of choice and are especially by the younger users.
Heroin Pathophysiology • CNS effects • Analgesia • Sedation • Euphoria • Respiratory depression
Heroin Pathophysiology • CNS effects • Pupil constriction • Nausea / Vomiting • Cough suppression • Physical dependence
Heroin Pathophysiology • Peripheral effects • Histamine release • Bradycardia • Constipation
Heroin Pathophysiology • Antidote • Narcan
IV use: Onset: 1 minute Rush: few minutes Sedation: 1 hour Half life: 15 to 30 min Heroin
IM / SC / snorted: Not common Slower onset Less rush Heroin
Heroin Overdose • Fatal overdoses • Respiratory depression • Co-ingestion • Alcohol • Cocaine • Antidepressants
Heroin Overdose • Nonfatal complications • Pulmonary edema • Up to 24 hrs after use • Prolonged coma • Rhabdomyolisis • Compartment syndrome
Should be easy to recognize 1. Coma 2. Respiratory depression or apnea 3. Pupil constriction Heroin Overdose
Can be mimicked Stroke ICH (pontine hemorrhage) Hypoglycemia Hypoxia Heroin Overdose
Heroin Overdose • Clinical picture can be confused • Co-ingestions • Adulterants • Preexisting medical conditions
Heroin Overdose • Injection of a highly concentrated sample by an unsuspecting client • Suicide attempt • Co-ingestion As with cocaine, can have body stuffers and body packers, leading to severe overdoses.
Heroin Overdose - Overview • ABC’s • O2, IV, cardiac monitor • Detailed history • What and how much • Co-ingestions • Consider impurities • Fingerstick • Narcan
Cocaine Sympathetic response “Fight or Flight” “Upper” Dilated pupils Agitation Tachycardia Hypertension Heroin Parasympathetic response “Feed or Breed” “Downer” Constricted pupils Sedation Bradycardia Respiratory depression Cocaine vs. Heroin