EMS “Street Drug” Review and Management of Overdose

1. EMS “Street Drug” Review and Management of Overdose SILVER CROSS EMS SYSTEM JANUARY 2014

2. Objectives • Review of the commonly used “street drugs” • How to identify a patient that is possibly on these drugs • Common side effects of these drugs • EMS management of safety considerations • Overdose situations: management and clinical assessment decision-making • SMO: overdose review • Medication review: Narcan • Skill review: insertion of the oropharyngeal and nasopharyngeal airways

3. Common “Street Drugs”that EMS is increasingly facing • Methamphetamine • Common Club Drugs: • MDMA (Methylenedioxy-methamphetamine) • GHB (Gamma-hydroxybutyric acid) • Heroin

4. Methamphetamine • Other names for methamphetamine: • Ice • Meth • Tina • Geep • Chalk Dust • Ice Cream • LA Glass

5. Methamphetamine • Methamphetamine is a highly addictive stimulant. • Generally lasting 12 hours, this high is 250 times more stimulating to the dopamine receptors in the brain than the high from endorphins from exercise, eating, and even sex. • These receptors wear out after a period of time, becoming damaged. The person has no way to feel good from eating, sex, or anything pleasurable and seeks out more of the drug.

6. These people may go into a deep sleep for two to four days, appearing to be deceased. • This puts them at risk for rhabdomyolosis, a break down of muscle tissue. The proteins floating in the bloodstream from this breakdown clog the kidneys and cause kidney failure. Depending on the extent of the damage, the patient could end up on permanent dialysis.

7. How is Meth ingested? • Swallowing -20-30 Minutes to feel the effects -This method has the least risks due to the vomiting mechanism when toxins are ingested -Meth can be put in water, juice, and commonly is placed in gel caps and taken orally. -“Parachuting” is wrapping the meth in toilet paper and swallowing it. This delays the onset, and makes the high come on more slowly and evenly. This can also be done with a baggie and a small puncture. Considered a “harm reduction technique.” Crystal Meth Recovery Services, Meth Memo 2013

8. How is Meth Ingested? • Smoking • 7-10 Seconds to feel the effects • Entered through the lungs which may lead to breathing difficulties • Usually crystal meth is smoked in glass pipes, similar to how crack cocaine is used. Crystal Meth Recovery Services, Meth Memo 2013

9. How is Meth Ingested? • Shooting Up • 15-30 seconds to feel the effects • Injected into the veins, or “the works.” • This is where abscesses and skin infections begin to develop. • Injection bypasses the filtering mechanism by the body: the vomiting mechanism is bypassed and this directly circulates in the bloodstream. • The sharing of needles spreads diseases such as Hepatitis, HIV, and many antibiotic-resistant bacteria. • Improperly drawn-up meth can create an air bubble in the syringe and subsequently cause an air embolus resulting in cardiac arrest. Crystal Meth Recovery Services, Meth Memo 2013

10. How is Meth Ingested? “Bumping” or snorting • Onset of 3-5 minutes • Most common ingestion method • Can cause nose bleeds, respiratory problems, • and abscesses can form on the nose and face. Crystal Meth Recovery Services, Meth Memo 2013

11. How is meth ingested? • “Booty Bump” • Onset of 10-15 seconds • Needleless syringe is used to administer liquid meth into the rectum. • The drug is absorbed by the blood vessels in the lining of the rectum. • Sometimes used in conjunction with prostitution, this can cause injury and disease when used as a “professional adjunct” for these patients for alternate routes of intercourse. • Often used in patients who have septum issues from snorting or loss of veins from injecting. Crystal Meth Recovery Services, Meth Memo 2013

12. How is Meth Ingested? • “Hot Rail” • Onset of 7-10 seconds. A glass stem is heated until the tip is red hot, then placed over a bump (a small pile of the drug) and the vapor is inhaled through the nose. Crystal Meth Recovery Services, Meth Memo 2013

13. Effects of Meth… • Immediate Effects • Elation • High energy and feeling of acuity, insomnia • GI distress (vomiting/ diarrhea) • Sweating • Anorexia • Agitation, irritability, talkativeness, panic, compulsive fascination with repetitive tasks, violence, confusion • Increased sex drive, making this a popular club drug • Hypertension, hyperthermia, tachycardia, glucose level instability, bronchodilation • Vasoconstriction

14. “Faces of Meth” • Faces of Meth is an internet finding with hundreds of results. • Meth causes muscle wasting and anorexia, and in combination with the toxins it is “cut” with, causes a severe result in the aging process and is often the cause of sores on the face and skin. Tooth loss is also a common side effect of meth use… • Here are some “before and after” photos. • Most of these photos are taken within a six-month to two-year period:

15. “Faces of Meth” http://photos.oregonlive.com/oregonian/2011/05/faces_of_meth_7.html

16. “Faces of Meth” http://photos.oregonlive.com/oregonian/2011/05/faces_of_meth_7.html

17. “Faces of Meth” http://photos.oregonlive.com/oregonian/2011/05/faces_of_meth_7.html

18. Meth and the teeth… Meth affects the top teeth first, and subsequent damage spreads to the gum tissue, dissolving the roots.

19. EMS and Meth… Treating the patient experiencing agitation and insomnia…

20. EMS and meth • Be aware the lack of sleep causes the brain to work incorrectly. When combined with the toxins of meth, this patient can become very agitated. • Use caution and protect yourself from exposure to bodily fluids from an agitated patient and paraphernalia in the pockets. • Ask for police assistance when dealing with a violent patient, however, make an attempt at calming these patients. The tachycardia and hypertension in combination with further agitation can cause cardiac arrest. • Use restraint techniques safely. Use of soft restraints is preferred over police handcuffs to reduce injury and professional liability. • Call ahead for medical control direction for the agitated patient if necessary.

21. EMS and meth • Obtain IV access if possible. • Maintain airway control, being aware of loose teeth, piercings, and vomit that potentially could enter the airway. • If patient is seizing, follow Code 35 for the ALS/BLS SMO’s for Seizures. ALS providers can administer Versed if applicable. • Monitor patient for hypertension, hyperthermia, and cardiac arrhythmias. Be sure to monitor patient’s glucose level

22. Meth Overdose • Myocardial infarction • “The approach to the patient with methamphetamine-induced cardiac ischemia should be no different than standard of care ACS treatment. Nitrates, beta-blockers, aspirin, heparin, and morphine should be administered if indicated. • Based on the latest American College of Cardiology Foundation/American Heart Association guidelines, methamphetamine- and cocaine-using patients with chest pain and suspected ACS should also receive sublingual nitroglycerin.” Methamphetamine Toxicity Treatment & Management (2013). John R Richards, MD, FAAEM; Chief Editor: Asim Tarabar, MD.

23. MDMA • 9 million users worldwide • Most common club drug • Often seen at raves and industry parties

24. MDMA • ECSTASY • Adam • Cadillac • Beans • California Sunrise • Clarity • E • Essence • Elephants • Eve • Hug • Hug Drug • Love Drug • Love pill • Lover’s speed • Molly • Roll • Scooby snacks • Snowball • X • XE • XTC STREET NAMES

25. MDMA • “Ecstasy was originally developed by Merck pharmaceutical company in 1912. In its original form, it was known as “MDMA.” It was used in 1953 by the US Army in psychological warfare tests, and then resurfaced in the 1960s as a psychotherapy medication to “lower inhibitions.” It wasn’t until the 1970s that MDMA started being used as a party drug. • By the early 1980s, MDMA was being promoted as “the hottest thing in the continuing search for happiness through chemistry,” and the “in drug” for many weekend parties. Still legal in 1984, MDMA was being sold under the brand name “Ecstasy,” but by 1985, the drug had been banned due to safety concerns.” Drugfreeworld.com (2013)

26. MDMA • Onset form pill ingestion is roughly 20 minutes to one hour. • Duration is anywhere from 3 to 6 hours. • Patient has feeling of well-being, extreme euphoria, significantly enhanced sense of touch and other senses such as sound perception, along with a boost in energy. Some individuals even experience mild hallucinogenic effects while on the drug. The enhanced tactile experiences individuals experience while on the drug has earned it the nickname "the love drug". • Some Ecstasy users feel ill and experience stiff joints and muscles, a stiff jaw, extreme thirst, sleep disturbances, depression and paranoia. www.ecstasy.ws/e-overdose.htm (2014)

27. MDMA and EMS Actual overdose is rare, and what EMS needs to consider is the effects of the drug Hyperthermia and low sodium levels (hyponatremia) are the biggest problems EMS faces. Monitoring patient’s temperature and glucose levels are mandatory. Establishing an IV of NS will help restore sodium and prevent further dehydration. Take caution when touching patients, as they have increased tactile sensations. Actual overdose is treated following SMO protocol for overdose, maintaining airway and following ACLS guidelines for cardiac arrhythmias.

28. GHB • Rohypnol • It has been a concern for the last few years because of its abuse as a "date rape" drug. • People may unknowingly be given the drug that, when mixed with alcohol, can incapacitate victims and prevent them from resisting sexual assault. • Also, Rohypnol can be lethal when mixed with alcohol and/or other depressants. https://www.k-state.edu/media/webzine/Didyouhearyes/GHBfacts.html

29. GHB • This drug is a sedative-hypnotic, causing amnesia. • It can cause respiratory depression in large amounts. • GHB is usually taken orally. • It is sold as a light-colored powder that easily dissolves in liquids or as a pure liquid packaged in vials or small bottles. • In liquid form, it is clear, odorless, tasteless, and almost undetectable when mixed in a drink. GHB is typically consumed by the capful or teaspoonful at a cost of $5 to $10 per dose. • The average dose is 1 to 5 grams and takes effect in 15 to 30 minutes, depending on the dosage and purity of the drug. Its effects last from three to six hours. https://www.k-state.edu/media/webzine/Didyouhearyes/GHBfacts.html

30. GHB and EMS • The most likely situation with this drug arises in an unintentional ingestion. • Be careful to preserve evidence if patient feels they were sexually assaulted. • Take caution with patient’s emotions, as they may be fragile due to amnesia and experience severe anxiety. • Treatment of the side effects is necessary, and due to “cocktail mixes” Narcan may be given to counteract other drugs mixed with GHB.

31. GHB Overdose • Side effects of mild to severe overdose: • Nausea • Vomiting • Delusions • Depression • Vertigo • Hallucinations • Seizures • Respiratory distress • Loss of consciousness • Slowed heart rate • Lowered blood pressure • Amnesia • Coma • GHB can become addictive with sustained use.

32. Heroin • Heroin use is on the rise! • Has a “city drug” stigma, however many suburban departments are seeing huge increases of the drug in higher socioeconomic areas • 30 Deaths are accounted to heroin in Will County in 2011 • Chicago and the metro surrounding areas have the highest rate of ER visits due to heroin abuse

33. Heroin and EMS • While many EMS providers are familiar with overdoses and the heroin patient, important reminders of care can make for a better patient outcome and safer situations for EMS Many reports of EMS providers having a problem with a patient requesting a refusal after Narcan is administered. Call medical control for direction!

34. Heroin Overdose • Symptoms • Airways and lungs • Apneic • Shallow breathing • Slow and labored breathing • Eyes, ears, nose, and throat • Dry mouth • Extremely small pupils, sometimes as small as the head of a pin ("pinpoint pupils") • Tongue discoloration • Cardiac • Hypotension • Weak pulse • Bradycardia • Skin • Cyanosis • Notable track marks/difficulty establishing an IV • Stomach and intestines • Constipation • Spasms of the stomach and intestinal tract • Nervous system • Coma • Delirium • Disorientation • Drowsiness • Muscle spasticity

35. SMO Review:Code 33Drug Overdose

36. Drug of the MonthNarcan(naloxone) • Opioid antagonist • Counters the effects of opiate overdoses: • Heroin • Morphine • Vicodin • Codeine • Oxycodone • Fentanyl • Methadone

37. Narcan(naloxone) • May be administered intranasally (ALS or BLS) • IV, IM, and IO (with medical direction) are all ALS administration routes for Narcan • Given in 2mg increments every five minutes, up to 6mg • Opioid withdrawal syndrome may occur in some patients given large doses of Narcan. • Severe side effects of Narcan: • Emesis and aspiration, agitation, hypo- and hypertension, cardiac arrhythmias, dyspnea, pulmonary edema, encephalopathy, seizures, coma, and death. • Narcan reduces constipation, and in repeat doses can cause explosive diarrhea.

38. Skill review:Nasopharyngeal airway • Nasopharyngeal airway skill review: • Your EMT textbook might have explained that the proper way to measure is from the tip of the nose to the ear lobe. True. • But you can grab the right size on the first try most of the time with this rule: • Big adults – grab the 8-9mm (24-27 french). • Regular sized adults get a 7-8mm (21-24 french). • Small adults get a 6-7mm (18-21 french). • Kids start at 5mm and work down. • When deciding if a patient is “big” or “regular” use their height as a guide, not their weight. Patient height is the most accurate predictor of correct NPA sizing. Taken from: theemtspot.com (2014)

39. Considerations for nasopharyngeal airway insertion • Indicated in cases of respiratory depression/arrest and: • Intact gag reflex • No signs of facial trauma • Signs of drug overdose • Do not force NPA into the nostril as this may cause unnecessary edema and trauma. • Use NRB or AMBU to assist patient with adequate oxygenation and ventilation. • Choose larger nostril • Lubricate to reduce trauma to soft tissues

40. Nasopharyngeal Airway Insertion http://www.atitesting.com/ati_next_gen/skillsmodules/content/airway-management/equipment/devices.html

41. Skill Review:Oropharyngeal Airway • Prevents the tongue from occluding/covering the epiglottis • Indicated in the patient with: • No gag reflex • Excessive secretions and frequent suctioning is needed • Larger tongue/tongue occluding the airway

42. Skill review:Oropharyngeal Airway Insertion http://www.atitesting.com/ati_next_gen/skillsmodules/content/airway-management/equipment/devices.html

43. System Policy Update: LVAD ProtocolManual Page 300-78

44. Thank you for your time and attention! Silver Cross EMS System January 2014