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DRUGS OF ABUSE: UNIVERSAL TRUTHS

DRUGS OF ABUSE: UNIVERSAL TRUTHS. WILLIAM K. MALLON MD FACEP FAAEM ASSOCIATE PROFESSOR OF EM LAC+USC MEDICAL CENTER KECK SCHOOL OF MEDICINE AT U.S.C. . DRUG CULTURES. Subcultures of drug abuse exist internationally: Clubs, Concerts, Dance Studios, Raves

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DRUGS OF ABUSE: UNIVERSAL TRUTHS

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  1. DRUGS OF ABUSE:UNIVERSAL TRUTHS WILLIAM K. MALLON MD FACEP FAAEM ASSOCIATE PROFESSOR OF EM LAC+USC MEDICAL CENTER KECK SCHOOL OF MEDICINE AT U.S.C.

  2. DRUG CULTURES • Subcultures of drug abuse exist internationally: Clubs, Concerts, Dance Studios, Raves Surfers, College Campuses, Gypsies, Motorcycle Gangs, Street Gangs • Information exchange is VERYVERY rapid • Chile has DRUG CULTURE continuity with USA and Europe • What happens in Amsterdam creates change in Santiago as well as Los Angeles

  3. OLD SCHOOL : ALCOHOL & TOBACCO OPIUM & HEROIN CODEINE COCAINE MARIJUANA LSD PHENCYCLIDINE PHENOBARBITAL QUALUDES NEW PLAYERS : METHAMPHETAMINE ECSTASY FENTANYL OXYCONTIN HYDROCODONE KETAMINE GHB VIAGRA HUFFING DRUGS OF ABUSE

  4. POLYPHARMACY RULES • Anything + Alcohol • “Redbull” and other energy drinks now common • “Speedball” = Cocaine + Heroin • “Primo” = Marijuana + PCP • “Super Kool” = Tobacco + PCP • “EKG” = X + Ketamine + GHB • “Doors and 4’s” = Doriden + Tylenol # 4 • NEW COMBINATIONS are constant

  5. ALCOHOL IS UNIVERSAL • ALL other drug issues are SMALL in cost and impact comparison to ETHANOL • TRAUMA, TRAUMA, TRAUMA • MVA, Recreational Injuries, Assaults, Domestic Violence, Farm Injuries, etc etc… • Alcohol taxation NEVER meets the societal costs associated with intoxications • More LAW Enforcement Issues than all OTHER drugs combined….. • SOCIALLY accepted

  6. D.A.W.N. • Broad database • Includes in-patients and clinics and rehab • Seeks information from users • Tracks drugs of abuse in the USA / Canada • RECENT STRONG PERFORMERS : Methamphetamine Ecstasy Hydrocodone

  7. D.A.W.N. SURPRISE • Increased opiate prescribing was NOT associated with increased abuse/addiction • Early 1990 saw a very low rate of heroin abuse despite rises in opiate prescribing • EM fear of opiate prescription invalid? • Late 1990’s surge in Hydrocodone abuse…. • TIME and NEWSWEEK ran cover stories

  8. VICODIN DANGERS • Opiate toxidrome readily recognized • Narcan reversal, resultant anger/dysphoria • Against-Medical-Advice Discharge from ED • DANGER #1: Long half-life = possible re-sedation • DANGER #2: Total acetaminophen intake may exceed 140mg/kg !!! • DANGER #3: Heroin induced pulmonary edema

  9. ADDICT AMA RISK • Wake up and go • PHC violence • Titrate to RR=6 • Vancouver “early” D/C program • HIPE predictable • NOT good companionship

  10. HEROIN TRANSPORT REFUSAL • 5 year San Diego review of 998 Heroin ODs • Narcan has a short half-life • Field D/C safe ? • But 2% received 3 doses • Of 998 NO deaths in coroners office NONE correlated to the EMS AMA records • Mandatory transport NOT necessary Vilke GM et al, Acad EM 10(8): Aug 2003

  11. LAYPERSON INFORMATION • Erowid site (San Francisco based) • Many unsuccessful attempts to close the site and prosecute creators • Recipes, combinations, paraphernalia details • Drug information for growers and synthesizers and marketing • Less medical “propaganda”

  12. BELLA VISTA • Cocaine • Methamphetamine • Ecstasy EVIDENCE OF THESE THREE IS OBVIOUS AT THE CLUBS…. ADS FOR THE LATTER TWO CAN BE FOUND ON THE STREETS OF SANTIAGO

  13. FENTANYL: Pinpoint Pupils Depressed Respiration No Skin Tracks Tox Screen (-) Euphoric Flushed Torso + Face NARCAN WORKS CLONIDINE: Pinpoint Pupils Depressed Respiration No Skin Tracks Tox Screen (-) Lethargic Hypotensive NARCAN unresponsive TRANSDERMAL PATCHES

  14. CRYSTAL METHAMPHETAMINE • “ICE” because it burns at low temperatures • Pure Sympathomimetic • Cannot be “cut” during synthesis • Minimal EUPHORIA, lots of paranoia • Psychosis evolves from the latter ! • More violent death than medical death (2:1) • In the USA: suburban first, then urban

  15. METHAMPHETAMINE • Increasingly common • Many related compounds • Violence commonly associated • Police think meth is worse than coke • Long T1/2 : more ED presentations • Cannot “ride it out” in the ER

  16. ECSTASY • Midway between Amphetamine and LSD • Partly Adrenergic, partly Hallucinogenic • Younger crowd in general : RAVES • Techno and Trance music • Ketamine often snorted alongside • Dehydration and Renal Failure (ATN) • Hyperthermia, LFT↑, and Rhabdomyolysis • Most users are NOT seen in the ED

  17. ECSTASY: CLINICAL PICTURE • Young, often below legal alcohol age • Between MN and 7AM, especially after 2AM • “Chewing Beads” or “Binky” for bruxism • Light sticks or fluorescent clothing items • Sweaty and hyperthermic • Mental status fairly normal unless other drugs are on board (ETOH, Ketamine, DMX) • NO Antidote : good supportive care

  18. “BAD” ECSTASY • Blame for “bad experiences” in the media were due to “bad” ecstasy • Some TRUTH to assertion • Ecstasy tablets can be cut with anything : SUGAR to Dextromethorphan (DMX) • DMX was the big contaminant in the USA • Anion gap REVERSAL….. • DMX-HBr : Bromide measured as Chloride

  19. RAVE • Dance • Sweat • Pacifiers • Chew beads • Lights/laser • End at 5-6 AM

  20. ECSTASY • “Entheogen” • “Tactogen” • “Enactogen” • “Empathogen” • The “LOVE DRUG” sales pitch again…..

  21. KETAMINE • Abuse hints at pharmacodynamic effects • Usually snorted • Lyophilize liquid Ketamine (often obtained from a Veterinarian) back to the powder form and sell it • If you overdose, the party is OVER : “DOWN THE K-HOLE”

  22. KETAMINE • Safety record for medical usage is impressive! • IM is the method of choice in most EDs • Even with iatrogenic overdose (500 vs 50mg) there have been no lasting negative effects • Medical usage intentionally K-HOLE’s the patient for a procedure….. • K-HOLE duration is brief : 20-30 minutes

  23. GAMMA HYDROXY BUTYRATE (GHB) ABUSE • Weight lifters started it….. • Anabolic effects ? (found in brown fat) • Replaced benzodiazepine as a “date-rape” drug (Rohypnol made illegal) • Drug screen negative • AMS, myoclonic jerks & unpredictable apnea • Self extubation at hour 3-4 (short half-life)

  24. GHB • GAMMA BUTYROLACTONE (GBL)→GHB • Available over the internet as a “solvent” • Used by the “capful” • Colorless and tasteless : watch your drink ! • Recipes available to “cook” it • Withdrawal state mimics alcohol withdrawal

  25. HUFFING • Associated with tagging and graffiti • Silver and gold paint cost more BUT have a lot more propellant • Silver graffiti is a strong indicator, especially when spaces are “colored in” • Color-in to empty the can! • Silver paint in eyebrows and hair • V-tach +/- syncope in a teenager

  26. TAGGERS AND TAG-BANGERS

  27. PLACA • GANG ID • Monikers • Used by Police • “NOTORIOUS” • TURF Issues dominate • Often a “SET” • “Philly” script • Not colored-in

  28. TOXICOLOGY POCT • Toxidromes are generally better than testing • 5-10% false negatives and false positives when compared with GC mass spec • Qualitative testing is NOT a therapy driver • Multiple products exist : Triage Panel DOA QuickScreen, Syva Rapid Test, Rapid Drug Screen • Triage performed the best… Peace MR et al, J Anal Toxicol Oct 2000 Wu AH et al, J Anal Toxicol July-Aug 1993

  29. URINE DRUG SCREENS

  30. TOXICOLOGY POCT • Does it meet the SAMHSA cutoffs? • Who? Substance Abuse and Mental Health Services Administration…. • 3 products checked against known analytes • All 3 were adequate for SAMHSA cutoffs • Negatives might be positive with confirmatory testing in 15% Luzzi VI et al, Clin Chem April 2004

  31. DRUG TESTING • ALCOHOL is the EXCEPTION • Serum levels DO REFLECT the clinical aspects despite some tolerance issues • BUT for most drugs of abuse, testing is very unreliable both QUALITATIVELY and QUANTITATIVELY • Legal challenges have yielded mixed results

  32. POLICE, DRUGS AND EMERGENCY MEDICINE • Violence associated with drugs • Underage use of alcohol • Date-rape drug adjuncts • Driving laws and alcohol (ED samples) • Import and export with body packing • Overdoses and secondary medical problems • Illegal drug sales A RELATIONSHIP EVOLVES FROM NEED

  33. POSSESION WITH INTENT TO SELL: 11550

  34. TYPE 1 PACKETS

  35. TYPE 2 • BODY PACKERS • MULES • GANGS ? • OBSTRUCTION • GI PAIN

  36. 13 TH FLOOR JAIL • Border patrol agents • DEA and FBI • Bodypackers • Notorious crimes • Newspapers and reporters • Law enforcement injuries • Forensic EM

  37. STILL COMMON • Almost always smoked now (marketing) • Occasional “speedballer” remains • Coca-ethylene toxicology and longer half-life is well known on the “street” • Red Bull and malt liquors (8%) are common ways to cool off a burning throat • Heat Index study in NYC : 93º F • Uvular burns due to poor pipe screens

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