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
Cocaine Overdose
• Convulsions
– Any route
– Dose dependent
– Usually benign
Can be caused by more serious complications like
stroke or intracranial hemorrhage.
Cocaine Overdose
• Convulsions
– ABC
– Benzodiazepines
• Valium
• Midazolam
– Avoid restraints*
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
Heroin
• 100-mg bag in 1980
• 100-mg bag in 1999
– 3.6% pure
– 38.2% pure
– $3.90
– $0.80
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
Heroin
• 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 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
Heroin Overdose
• 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
• 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 vs. Heroin
Cocaine
Heroin
• Sympathetic response
• Parasympathetic response
• “Fight or Flight”
• “Feed or Breed”
• “Upper”
• “Downer”
– Dilated pupils
– Constricted pupils
– Agitation
– Sedation
– Tachycardia
– Bradycardia
– Hypertension
– Respiratory depression
3,4-methylenedioxymethamphetamine
• MDMA
• E
• Ecstasy
• X
• XTC
• Clarity
• Adam
• Stacy
MDMA
• Amphetamine derivative
• 1914: synthesized by
Merck and Company
• 1950’s: US military
– possible brainwashing agent
• 1970’s: Psychiatry
– psychotherapy
– marital counseling
MDMA
• 1980’s: Recreational use spread
– Raves
– Major cities, US and Europe
MDMA - Effects
• Hallucinogenic amphetamine
• Amphetamine (speed) + LSD (acid)
– Empathy
– Euphoria
– Disinhibition
– Increased sensuality
MDMA
• Forms
–
–
–
–
Capsule
Powder
Liquid
Tablets
•
•
•
•
•
Doves
Blue elephants
8½
Bugs Bunny
Ferraris
MDMA
• Long acting
– Duration of action: 8-24 hrs
– Half-life:12-34 hrs.
• Metabolized in the liver and excreted
renally.
• Small subset of the population is missing
the liver enzyme that metabolizes MDMA
– Can be fatal
MDMA
• One tablet
– 50-100 mg
– $20-25.
• Initial effects occur in 30-60 minutes.
• Peak effects occur at 90 min
– May persist 4-8 hrs.
• Tolerance develops rapidly
MDMA
• Often impure
• Substances mixed with MDMA
– Heroin
– Ketamine
– Ephedrine (herbal ecstasy).
MDMA - Effects
• Initial 30 minutes
–
–
–
–
–
–
–
–
Anxiety
Tachycardia
Elevated BP
Diaphoresis
Jaw clenching
Paresthesias
Dry mouth
Increased psychomotor
activity
– Blurred vision
• Within 1 hour
–
–
–
–
–
Relaxation
Euphoria
Empathy
Increased communication.
Increased sensory tactile
enhancement
– Mild visual distortions,
such as halos.
MDMA - Effects
• If too much MDMA is consumed in a single session,
– Restlessness
– Paranoia
– Anxiety
• Following the acute effects of MDMA, “Blues.”
– 24- to 48-hrs
– Lethargy
– Anorexia
– Dysphoria.
– Users often co-ingest to help ease the “Blues"
MDMA - Toxicity
• “Seratonin Syndrome”
– Exacerbated by dancing in hot clubs
– Hyperthermia
– Dehydration
– Muscle breakdown
– Liver toxicity
– Renal Failure
MDMA - Toxicity
• Hyponatremia
– Hyperthermia
– Seratonin syndrome,
– Increased water intake
– Excessive sweating with physical exertion
• Altered mental status
• Seizure
• Coma
MDMA - Toxicity
• Cardiovascular
– Hypertension
– Dysrhythmias
• Stroke and Intracranial bleeds
– Rare
MDMA - Overview
• ABC’s.
• Prehospital care is supportive.
• IV, O2, Frequent vital sign check,
fingerstick glucose.
• Most frequent morbidity/mortality is from
hyperthermia and electrolyte abnormalities.
• Consider benzo’s for anxiety, agitation,
panic reactions, and seizures.
Phencyclidine
• PCP
• Angle Dust
PCP
• 1950’s: Developed for use as a general
anesthetic for surgery.
• 1965: Discontinued because of side effects
of psychotic features, dysphoria, and
extreme agitation.
• 1960’s: Maufactured illegally.
• 1970’s: Popular street drug.
PCP
• White crystalline powder available in
liquid, tablet, or powder forms.
• It can be snorted, ingested orally, injected,
or smoked.
PCP
• Dissociative anesthetic.
• Effects occur in minutes.
• Lasts several hours.
• May last up to 48 hrs with overdose.
PCP - Effects
• Nystagmus (horizontal, vertical, or rotary).
• Hypertension.
• Acute brain syndrome involving confusion,
amnesia, disorientation, and violence.
• Agitation and violent behavior.
• Tachycardia.
• Bizarre behavior including public nudity.
• Hallucinations and delusions.
• Miosis - Often reported with a blank stare
PCP - Rare Effects
– Seizures
– Dystonia
– Ataxia
– Apnea (often seen with co-ingestants)
– Catatonia
– Coma
– Hypertensive crisis
– Intracranial and subarachnoid hemorrhage
PCP – Prehospital Care
• ABC’s
• Supportive care.
• Fingerstick glucose.
• Physical restraints may be required to prevent selfinjury and to protect the medical staff.
• Narcan for depressed mental status (for possible
co-ingestion)
• Benzo’s for severe agitation.