Street Drugs: Update

1. Street Drugs: Update Russell Berger, MD Emergency Room Attending Physician Cambridge Health Alliance Associate Director of Medical Toxicology Instructor in Medicine Harvard Medical School

2. Organizing Principles Toxidromes Tox Specific Physical Exam EKG

3. Toxidromes • Opiate---bradypnea, pinpoint pupils • Anticholinergic-dry and delirious • Sympathomimetic-wet and crazy • Sedative Hypnotic-very sleepy • Serotonergic-AMS, clonus, and dysautonomia

4. Opiate overdoses do not always produce pinpoint pupils • Most reliable sign is a low respiratory rate • Some opiates produce mydriasis • Remember pontine pupils

6. Anticholinergic

7. Sympathomimetic

8. Tox Specific Physical Exam Vital Signs Mental Status Pupils Skin Reflexes

9. Tox EKG • QRS duration • QTC duration • Rhythm and Blocks • Terminal R in aVR

12. If you block Sodium channels… • You prolong the QRS complex • >100ms is significant

13. If you block Potassium Channels… • You prolong the QTC • >450ms is significant

14. Some Na Channel Blockers besides TCA’s • Carbamazepine • Benadryl • Flecainide, Procainamide • Chloroquine • Propranolol • Quinine • Bupivicaine

15. Some QTC prolonging Agents • Seroquel • Zofran • Methadone • Trazodone • Citalopram • Erythromycin

16. Let me open this story with a little background about myself. I am an extremely intelligent woman. I just graduated with a double degree, I have a high GRE score, and I’ll be working on applying to grad schools shortly. I am not some sort of drug addict, though that does run in my family, but I AM AN EXPERIENCED TRIPPER. Never again. It’s been less than 12 hours since I smoked three or four hits of “incense” and I can confidently say that I have never been through a worse experience in my life.

17. Herbal Marijuana Marketed as K2 or Spice Popular because not detected on routine drug screens Frequent use in the military Cheap, easily accessible, and very potent

18. Herbal Marijuana Continued Packaging will say, “Not for human consumption” May be referred to as JW compounds, and agonize the CB-1 receptor.

19. Effects Accentuated Cannabis Effects Psychosis and agitation are common including self-injurious behavior Dependency issues compared with marijuana

20. Treatment Supportive PRN benzodiazepines

21. Really, the main questions you should ask yourself before trying DXM are: Am I afraid of my own mind? Am I afraid to look deeply into it? Am I afraid of leaving my body and existence behind? You can expect all of these to happen on an upper-plateau trip, for they most likely will.

22. Dextromethorphan (DXM) • Widely available and cheap • Not routinely detected on drug screens • May sometimes get a false positive PCP screen as a clue to exposure.

23. Effects • Rotatory Nystagmus • Ataxia (lose proprioceptive cues) • Hyper-reflexia • Mania and Psychosis

24. Treatment • Supportive • PRN benzodiazepines • If serotonergic, can consider cyproheptadine. • Note: chlorpheniramine is anticholinergic and serotonergic and is frequently mixed with DXM preparations.

25. Bath Salts The Full Ride Not Exactly a Good Time Cooking Up My First Trial An Adventure in Euphoria and tachycardia

26. MPDV or Bath Salts

27. Bath Salts Contain stimulant compounds such as MDPV or mephedrone Produce extreme agitation, delusions, tachycardia, and often violence.

28. Treatment • High doses of ativan are required. • Intubation may be necessary to control degree of agitation. • Renal injury from rhabdomyolysis, hyperthermia, and seizure activity may result.

29. MDMA • Produces sympathomimetic toxidrome • Associated with hyponatremia, practically exclusively found in women. • Check CK and look for renal injury

30. Hyponatremia Co-peptin is a surrogate marker for ADH. It is used because it is easier to measure than ADH. Co-peptin levels are elevated in women and not in men when patients are exposed to equal amounts of MDMA. Thus, MDMA associated hyponatremia may be a function of SIADH.

31. What you find clinically Low serum sodium High urine sodium High urine osmolarity

32. Jimson Weed

33. Another Anticholinergic Agent Dry Red Tachycardic Delirious

34. Cocaine • When combined with alcohol, mortality increases 20 fold in the first 24 hours. • Mixed with levamisole • Between 2007-2011, 5x increase in levamisole contamination

36. GHB • My husband got some liquid GHB for us to try one Friday evening to enhance our evening of sex and intimacy • This stuff smells and tastes disgusting - I can't think of anything else that tastes even similar! I had to well swill my mouth after knocking back my first dose. I wondered how GHB is used as date rape and not detected in the victim's drink - I know I would have tasted something bad - but then again, maybe 1.5ml in a typical pub/club sized bottle of Red Square or Breezier is more diluted so weaker to taste. After a short while I started to feel slightly tipsy and then euphoric and horny and then more tipsy and these feelings increased, as so did the same dosage on my hubby. We got very randy with each other and had frantic and incredibly rampant and passionate sex - I experienced heightened sexual arousal and unbelievable orgasms that left me feeling weak and drained, wanting to just lie down and recharge. Within 2 to 3 hours of taking the 1.5ml dose we were feeling like we'd come down off the GHB and were returning to sanity.

37. GHB

38. Effects • Extreme Sedation • Respiratory Depression • Rapid Sudden Awakening • Withdrawal similar to benzodiazepines and alcohol.

39. Treatment • Supportive

40. Review • Toxidromes • EKG • QRS vs QTC • Some common Street drugs