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Drugs of Abuse

Drugs of Abuse. Otto F. Sabando DO Program Director Emergency Medicine Residency St. Joseph’s Regional Medical Center Paterson NJ www.emresidency.info. Marijuana (tetrahydrocannabinol(THC)). Epidemiology Most frequently utilized illegal substance in US (20 million Americans)

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Drugs of Abuse

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  1. Drugs of Abuse Otto F. Sabando DO Program Director Emergency Medicine Residency St. Joseph’s Regional Medical Center Paterson NJ www.emresidency.info

  2. Marijuana (tetrahydrocannabinol(THC)) • Epidemiology • Most frequently utilized illegal substance in US (20 million Americans) • Adolescent use on the rise • History • Cultivated for thousands of years for ritual, medicinal, fiber

  3. Pathophysiology and Pharmacology • After smoking, effects to brain within 15 seconds • Specific cannaboid receptors? • Perception and cognition • Pain modulation • Effects peak 10-30min and may last 1-4hrs. THC is lipophylic and highly protein bound

  4. Clinical Effects • Psychologic • Alterations in sensation, perception, cognition and psychomotor function • Danger with acute toxicity • Loss of motor skills and judgment • Alcohol and marijuana use impair further the motor skills and judgment

  5. Clinical Findings • On exam • Tachycardia, psychotic, muscle tremors, weakness, and bronchodilitation • Urinary retention, decreased testosterone, increased appetite, conjunctival injection • Dyspnea and chest pain • Pneumothorax and pneumomediastinum

  6. Treatment • No known cases of lethal marijuana intoxication • Supportive care • Benzodiazepines for agitation due to psychosis

  7. Wet • Marijuana dipped in Formaldehyde • Enhances the effects of marijuana • Causes major psychotic reaction similar to PCP • Treatment is 4 point restraints with administration of benzodiazepines

  8. Drugs of Abuse • PCP and Ketamine

  9. History and Epidemiology • PCP first discovered in 1926 • 1950’s Parke Davis • Serenyl use 1963 • Rapidly discontinued • 10%-30% incidence post-op psychosis and dysphoria • 1967 Sernylan for veterinary use • 1970’s recreational use seen • “the PeaCe Pill”, angel dust, crystal joints (CJs) • 1977-78 epidemic proportions • Mid 1980’s the Controlled Substance Analogue Enforcement Act 1986 • Lead to a drop in use

  10. History and Epidemiology • Ketamine entered clinical practice in 1970 • One tenth to one-twentieth the potency of PCP, shorter duration of action and less emergence reaction than PCP • Ketamine abuse noted in 1971 • 1980’s increase use amongst professional's • Most abused drug by doctors and other health care workers • “Date rape Drug” • Rave parties

  11. Pathophysiology and clinical manifestations

  12. Clinical Manifestations • Neuro • Nystagmus (rotary, horizontal, vertical) ataxia, altered gait • Dystonic reactions: opisthotonos, torticollis, tortipelvis, and risus sardonicus • Cardiac: • Severe hypertension, Intracranial bleed • No prodysrhythmic effects

  13. Clinical Manifestations • Lanrygospasm with ketamine use • 0.017% • Cholinergic and anticholinergic manifestations • Miosis, Mydriasis, blurred vision, profuse diaphoresis, hypersalivation, bronchospasm, bronchorrhea, urinary retention • Hyperthermia • Encephalopathy, rhabdomyolysis, myoglobinuria, liver function abnormalities

  14. Management • Supportive care • Activated charcoal if orally ingested • Quiet room • Decrease sensory stimulation • 4 point restraints • Sedation with midazolam is preferred

  15. Drugs of abuse Cocaine

  16. Case • A 24 y.o. male runs into the ED complaining of chest pain for the last 30 minutes. The pain is substernal, sharp and constant. The patient is diaphoretic and short of breath. He admits to binging cocaine over the last two days. The route of cocaine ingestion is intranasal.

  17. Case • PE: VS: T101.2 F oral, P:120, R: 22, BP 150/100, Pulse ox 100% • Gen: Thin, anxious, and in moderate distress • Eyes: Pupils 6mm and reactive • CV: tachycardic no murmurs • Lungs: BLCTA • Neuro: GCS 15 • Skin: diaphoretic, flushed and warm

  18. Case • Monitor • Oxygen • S/L nitro • ASA • EKG Sinus tachycardia • PCXR – Neg • Labs: CBC, CMP, CPK, CE, Troponin, U/A, Urine Tox • Ativan 2 mg

  19. Cocaine • History • Inca Empire 5000 yrs, a divine plant • 1859 recognized for anesthetic properties • 1892 Coca Cola tonic for the tired elderly • 1906 U.S. controlled cocaine use • 1980’s cocaine epidemic

  20. Cocaine • Clinical manifestations • Hyperthermia • Neurologic effects • Stroke • Seizure (especially IV and crack cocaine) • Cocaine “wash out” • Cardiac effects: • MI risk increased 24-fold in the hour following cocaine use

  21. Cocaine • Chest pain atypical (hours to days) • Q wave and non Q wave infarctions can be seen equally • Dysrhythmias can be seen in high dosages. Low dosages can cause bradycardia. • Cardiomyopathy- chronic cocaine use • “stunned myocardium”

  22. Cocaine • Endocarditis and DVT are associated with IV use. • Aortic dissection • Pulmonary and upper airway effects • Asthma exacerbations, PTX, pneumomediastinum, pulmonary edema • Crack smoking • Rhabdomyolysis lead to ARF, hypotension and hyperthermia • “Crack eye” : corneal abrasion, ulcerations • central retinal artery occlusion and bilateral blindness from diffuse vasospasm.

  23. Cocaine • Gastrointestinal • Highly sensitive to catecholamine • “Body packers” vs. “body stuffers” • Uterus: • Placental abruption 2nd and 3rd trimester • Intrauterine growth retardation • Breast milk • Cocaine can be passed

  24. Cocaine • Management • Benzodiazepine (Ativan) and cooling measures decreases mortality • Utox: cocaine last for three days • CP Protocol • Uncontrolled HTN • Tx with calcium channel blocker or phentolamine • Dysrhythmias • Tx with calcium channel blocker, sodium bicarb, lidocaine, amioderone??

  25. Cocaine • EM Pearl • Never treat the patient with a beta-blocker!!! • Unopposed alpha-adrenergic agonism leads to worsening vasoconstriction

  26. Drugs of abuse Opiates

  27. Opioid’s • History • Used medicinally since 1500 BC • 1804 Morphine isolated from opium • 1898 heroin synthesized and marketed by Bayer as antitussive • 1999 208,000 Americans use heroin

  28. Opioids

  29. Case • 54 y.o. female BIBA from the beach. The patient is noted to be unconscious. EMS arrived and intubated the patient. Accucheck was 176 • On arrival to the ED the patient is intubated and does not respond to painful stimuli. V.S. T:99R P:72, R:8,BP:140/80, Pulse ox: 100%. • PE: Eyes pupils are constricted. • CV: normal, Resp: BLCTA, Neuro: GCS 3 • Pt. was immediately given 0.2 mg of narcan IV and pulled her ET tube out. • Patient admitted to taking 6 percocet pills this am and robitussin for her migraine

  30. Opiate Receptors

  31. Opioids • Clinical effects • CNS depression leading to hypotension, bradycardia and hypothermia • With MAOI’s and Meperidine (Libby Zion 1984), tramadol and dextromethorphan • Seizures • Propoxyphene, Meperidine, or tramadol • EKG: QT prolongation with LAAM or high dose methadone. • Pulmonary: respiratory depression • Pulmonary edema

  32. Opioids • Clinical effects • Gastrointestinal • Increase smooth muscle tone and depress gut motility leading to constipation and obstipation

  33. Opioids • Lab and bed side testing • Finger stick • CXR • Acetaminophen and pregnancy testing • Urine drug screen • Opiates • Meperidine or methadone not detected • False positive- fluoroquinolones • Dextromethorphan, false positive PCP

  34. Opioids • Treatment • Respiratory support is lifesaving and critical • Naloxone/Narcan • Start slow: 0.05 mg IV • Redose as needed with observation for signs of withdrawal (i.e. Diaphoresis, piloerection,

  35. Opioids • Special situations • Oxycontin (oxycodone hydrochloride) • Crushed for snorting or IV use • More drug than Percocet, up to 160 mg/pill • Epidemic deaths (Maine, Kentucky, Virginia and Florida) • Treatment: requires high amount of narcan

  36. Opioids • Atypical opioid's • Dextromethorphan • Movement disorders, hallucinations, serotonin syndrome, sedation • Opiod findings may or may not be present • Lomotil (diphenoxylate+atropine) • Present with opiod or anticholinergic findings • Adult patients with OD or children with single tablet ingestion, monitor for 24hrs • Naloxone reverses only the opiod component

  37. Opioids • Atypical opioid's • Fentanyl and its analogues • Short acting with potencies of up to 6000 times that of morphine • Clonidine and other central alpha 2 agonists • Clinical syndromes indistinguishable from opioid's • 50% of children with Clonidine toxicity respond to Naloxone

  38. Opioids • Demerol (Meperidine) • Normeperidine, toxic, renally eliminated hepatic metabolite. • Increases noted with accumulated doses and renal insufficiency • Delirium, tremors and intractable seizures • Acts on serotonin receptor • Blockade of presynaptic reuptake may produce serotonin syndrome • Muscle rigidity, hyperthermia, altered mental status

  39. Opioid's • MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine) • Introduced in 1982 • Incorrect heating of synthetic mixture (MPPP) • Selectively destroyed dopamine-containing cells of the substantia nigra by inhibiting mitochondrial oxidative phosphorylation • “frozen addicts”, acute severe parkinsonian symptoms • Invaluable in experimental model for study of Parkinson's disease

  40. Other facts • Body packers • Mules from other countries • Rupture of packets • Cocaine • Ischemic bowel, emergent surgery • Opiates (i.e. heroin) • Airway management with Naloxone • Body stuffer • On the run criminals ingesting the drug sale of the day • Usually benign course.

  41. Drugs of Abuse • Amphetamines

  42. Case • 19 y.o. male is BIBA for severe agitation. The patient was reported to be using “X” at a dance club and became severely agitated. • The patient continues to be agitated with the following vital signs: T:103.4 F oral, P:120, R:18, BP:170/100, Pulse ox 97% room air.

  43. Case • Physical exam • Gen: agitated and confused • Eyes: pupil: 6mm and reactive b/l • Neck: supple no masses • CV: tachycardic • Lungs: BLCTA • Ext: no cyanosis, clubbing, edema • Neuro: Confused, normal DTR’s, good strength B/L • Skin: flushed and diaphoretic

  44. Amphetamine • Methylyenedioxymethamphetamine • (MDMA) i.e. Ecstasy, X, E, XTC, Adam, M&M • History • Synthesized in 1912, rediscovered 1965 • Most widely used amphetamine by college students • 1980’s used by psychiatrist’s to enhance psychotherapy now banned • Epidemic in the Mid-West

  45. Amphetamine • Current use: • Dose range: 50-150 mg or 1-2 pills per party (content can vary from 0-200mg) • Many users are knowledgeable in pharmacology of drug • Common in “rave” party's

  46. Amphetamine • Clinical effects • Effects 15-60 minutes, last for 1-6 hrs. Effects may be present for 40 hrs! • Enhances pleasure, heightens sexuality, jaw clenching (use of pacifiers), insomnia, loss of appetite, poor concentration, memory problems. • Acute large ingestions present with sympathetic effect (amphetamine) can cause death (hyperthermia, Dysrhythmias, rhabdomyolysis)

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