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Drugs Of Abuse

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  1. Drugs Of Abuse Core Rounds, Feb 6, 2003 A.F. Chad, MD, CCFP M. Yarema, MD, FRCP

  2. Case #1 • 24 yo M • Car chase -> Pulled over by Crockett & Tubbs • “I’m F__kin’ High!!” • “I took a bunch of blow!!!” • Agitated, sweating,, aggressive, h/a & cp • Cuffed -> collapse -> no pulse • EMS -> CPR, tubed, pulse, Tx to Hospital • Now What?

  3. Case #2 • 19 yo M • Out “dancing and Partying” • Glow sticks & Soother & bottled water • Euphoric, sl agitation • Tachy, mydriatic, hyperthermic, brown urine • What now?

  4. Case # 3 • 21 yo “Hot Chick” • “Girls Night Out” • Dude with earrings, sideburns, soul patch & silver sequined cowboy hat buys her a drink • She feels “off” • Sluggish -> LOC • Friends freak-> Sonny & Rico (who happened to be there undercover) escort to FHH • What now?

  5. Case # 4 • Same creepy dude looking for love (after getting shut down by “Hot Chick”) • Buys drink for previous 21 yo “Hot Chick’s” “Sweet looking friend” • Drink tastes fine • She becomes sleepy, “out of it”, separated from friends • Wakes up in strange apt. • No memories of night out • What’s up?

  6. Case # 5 • 32 yo Cletus from Spokane • EMS called re explosion inside trailer • He comes out agitated, aggressive, wielding axe • “detained” by our Miami Vice heroes and escorted to FHH • Tachy, HTN, psychotic • What’s up?

  7. Case # 6 • 18 yo F • Dancing all night • Ate some powder given by a Kellogg’s rep • Feels like she’s floating • Nystagmus, “out of it” • What’s up?

  8. Outline • Cocaine • History, pharmacology, presentation, complications, treatment • MDMA • History, pharmacology, presentation, complications, treatment • GHB • History, pharmacology, presentation, complications, treatment • Methamphetamine • History, pharmacology, presentation, complications, treatment • Ketamine • History, pharmacology, presentation, complications, treatment • Flunitrazepam • History, pharmacology, presentation, complications, treatment

  9. USA Controlled Substances Act 1984

  10. A couple general approach slides

  11. COCAINE Blow

  12. Cocaine • From Coca Leaves • Use noted from 2000 B.C. • 1859 Spanish MD’s use as Rx • 1863 French wine with 6mg cocaine sold • 1884 William Stewart Halsted does 1st Cocaine nerve block • Halsted: 1st cocaine impaired MD on record • 1893 cocaine related deaths noted • 1914 Harrison Narcotics Act bans non-Rx cocaine

  13. Cocaine in the USA (New Springsteen hit?) • 2000: 926,000 new users • average age of 1st time users: 20 years • 27.8 million (12.%) Americans ages 12 or older tried cocaine at least once • 4.2 million (1.9%) used cocaine in the past year • 1.7 million (0.7%) used cocaine w/i the month • peak use in 1985: 5.7 million Americans ( 3% of the population)

  14. Rock, Blow, Snow • benzoylmethylecgonine • leaves of Erythroxylon coca: shrub indigenous to Peru, Bolivia, Mexico, West Indies and Indonesia • crystalline alkaloid: C17H21NO4 • Commonly in cocaine HCl form • Ester-type local anaesthetic

  15. Jimmy Crack Pipe & He Don’t Care • Remove HCl via ether extraction = crack • Frees the basic cocaine molecule = “free basing” • Crack -> cracking sound when smoked • Vaporizes @ 98 degs C -> no ruining • Allows for smoking a bowl

  16. Cocaine Pharmacology • 1st - blocks norepinephrine uptake • 2nd - causes norepinephrine release • 3rd - moderate release and reuptake blockade of dopamine & serotonin • Has Na+ & K+ channel blockade effects

  17. Cocaine Pharmacology • Fat soluble -> easily crosses BBB • Stimulates CNS esp in Limbic area with dopamine -> “high as a frikkin’ kite” • metabolized by hepatic esterases and plasma pseudocholinesterase • benzoylecgonine & ecgonine methylester are active metabolites

  18. Cocaine: How Can You do it? • ALL mucous membranes • IV (100% bioavailability) • Eaten (20-30% bioavailability) • poor absorption in stomach, good in duodenum • Smoked (crack) (20-30% bioavailability) • 1 inch line = 25-100mg coke • Spoon = 5-25mg coke • LD50 = 1 gm (po)

  19. When am I gonna Get High? • Inhalation • 7 s onset, 1-5 min peak, 20 min duration, 40-60 min half-life • IV • 15 s onset, 3-5 min peak, 20-30 min duration, 40-60 min half-life • Nasal • 3 min onset, 15 min peak, 45-90 min duration, 60-90 min half-life • Oral • 10 min onset, 60 min peak, 60 min duration, 60-90 min half- life

  20. When Coke Alone Ain’t Enough • EtOH: Metabolite • Ethylbenzoylecgonine (cocaethylene) Increases T1/2 and Lowers LD50 • Nicotine • increases sympathetic response • Heroin • speedball = IV/smoke heroin, then smoke crack, moderates withdrawal -> higher doses

  21. 3 Phases of Toxicity • Phase I - Early stimulation • CNS: Mydriasis, headache, bruxism, nausea, vomiting, vertigo, nonintentional tremor ,tics, preconvulsive movements, pseudohallucinations • CVS - HTN / HypoTN, tachy / brady, pallor • Respiratory - Increased rate & Vt • Temperature - Elevated • Behavioral - Euphoria, elation garrulous talk, agitation, apprehension, excitation, restlessness, verbalization of impending doom, emotional instability

  22. 3 Phases of Toxicity • Phase II - Advanced stimulation • CNS: Malignant encephalopathy, seizures and status, decreased responsiveness, increased DTR, incontinence • CVS: HTN, tachy; ventricular dysrhythmias, weak, rapid, irregular pulse and hypotension; peripheral cyanosis • Respiratory: Tachypnea, dyspnea, gasping, irregular breathing • Temperature: Severe hyperthermia

  23. 3 Phases of Toxicity • Phase III - Depression and premorbid state • CNS: Coma, areflexia, pupils fixed and dilated, flaccid paralysis, and loss of vital support functions • CVS: Circulatory failure, cardiac arrest (ventricular fibrillation or asystole) • Respiratory: Respiratory failure, gross pulmonary edema, cyanosis, agonal respirations,

  24. Cocaine: Not so safe • CVS • CNS • Respiratory • Packers / Stuffers • Other

  25. Cocaine Dysrhythmias • ST, SVT, A.Flutter, A.Fib, VT, V.Fib, AVB, Asystole, long QT ->TdP • Like a type 1A Na+ blocker (procainamide, quinidine) • Direct SNS overload? • Cardiotoxic -> arrythmogenic foci • Accelerated atherosclerosis

  26. Rx Cocaine Dysrhythmias • Depends on Rhythm • NO B-blocker, procainamide, quinidine • NaHCO3 may be of help • Beckman KJ, Parker RB, Hariman RJ, et al. Hemodynamic and electrophysiological actions of cocaine: Effects of sodium bicarbonate as an antidote in dogs. Circulation 1993;83:1799-1807. • Benzos if 2nd to increased catacholamines • Lidocaine is safe if indicated • Shih RD, Hollander JE, Burstein JL, et al. Clinical safety of lidocaine in patients with cocaine-associated myocardial infarction. Ann Emerg Med 1995;26:702-706.

  27. Coke: close to the Heart • Vasoconstriction, plt clumping, thrombi • Higher O2 demand • Direct myocardial toxicity • Goldfrank LR, Hoffman RS. The cardiovascular effects of cocaine. Ann Emerg Med 1991;20:165-175. • Accelerated atherogenesis • Minor RL Jr, Scott BD, Brown DD, et al. Cocaine-induced MI in patients with normal coronary arteries. Ann Intern Med 1991; 115:797-806.

  28. Coke Chest Pain • Most common complaint post coke use • 6% will have MI (rookies or crack heads) • Often classic sounding cp • ECG non-diagnostic in 60% • CK-MB and TNT NOT increased by coke alone (cardiac event) • CK increased (rhabdo)

  29. Coke & CP • Need observation x 12 hours (consensus) • 33% develop bad stuff • Serial ECG & enzymes • 0.2% problems post 12 hours • Hollander JE. The management of cocaine-associated myocardial infarction. N Engl J Med 1995;333:1267-1272.

  30. Coke & CP • Is 6 hours good enough? • 197 pts • Check enzymes 0, 3, 6 hrs • If all N + no ECG changes -> OK • Kushman SO, Storrow AB, Liu T et al. Cocaine-associated chest pain in a chest pain center. Am J Cardiol 2000;85:394-396.

  31. MI with your Coke? • Same Rx as normal but NO B-blockers!!!! • phentolamine or verapamil? • Hollander JE, Carter WA, Hoffman RS. Use of phentolamine for cocaine-induced myocardial ischemia. N Engl J Med 1992;327:361. • Benzos as good as NTG as good as both • Weber JE, Chudnofsky CR, Boczar M, et al. Cocaine-associated chest pain: How common is MI? Acad Emerg Med 2000;7:873-885.

  32. Thrombolysis & Coke? • Crap? • Hollander JE, Burstein JL, Hoffman RS, et al. Cocaine-associated MI: Clinical safety of thrombolytic therapy. Cocaine Associated Myocardial Infarction (CAMI) Study Group. Chest 1995;107: 1237-1241. • Good? • Mueller PD, Benowitz NL, Olson KR. Cocaine. Emerg Med Clin North Am 1990;8:481-493. • Be REALLY Careful? • Hollander JE, Wilson LD, Leo PJ, et al. Complications from the use of thrombolytic agents in patients with cocaine associated chest pain. J Emerg Med 1996;14:731-736.

  33. Well, we have Angio in Calgary • Case reports suggest ok • Shah DM, Dy TC, Szto GY, et al. PTCA and stenting for cocaine-induced AMI: A case report and review. Catheter Cardiovasc Interv 2000;49:447-451.

  34. Coke Shake • Seizures in 2-10% • Stoke not uncommon • Need CT • BENZOS!!!! • Phenobarb • GA

  35. Strokey Cokey • Most common cause of stroke in young • 60% users get h/a post use • Stroked pts usually h/a 3-6 hours post • Can cause SAH, ischemia, ICH, vasculitis • NEED CT +/- LP if concerned

  36. Crack Lung • Distinct entity 1-12 hours post smoking • fever, dyspnea, hemoptysis, hypoxia, chest pain, infiltrates, respiratory failure • Rx steroids (eosinophils on Bx) • Other Resp Problems • Upper airway burn, epiglotitis, asthma, pneumothorax, pneumomediastinum, noncardiogenic pulmonary edema, pulmonary hemorrhage/infarction

  37. Snow Stuffers • Hiding it from Crockett & Tubbs • Quickly ingested, not prepared • Toxicity!!! • AC + whole bowel irrigation

  38. Put it in my Crack Pack • Packers = well prepared packets of drug • Large amounts • Bowel obst, sudden death (bag bursts) • + tox screen (95% sensitive) • Xray, contrast, CT • NO SCOPE!!! • AC -> polyethylene glycol -> clear fluid • Admit until all packets out • Surgery if concerns

  39. Other • Rhabdo • Normal Rx • Excited Delirium • Loss of pregnancy • Hyperthermia • Dopaminergic regulated

  40. Pepsi vs Coke • ABCD!!! • Need monitors, IV’s, Tubes, O2 • Remove any residual cocaine from nasal use. • Protect the patient from hypoglycemia, • Rely on clinical findings re toxidrome • Reassurance if the patient is oriented. • Avoid physical or pharmacological restraints if possible. • Symptoms usually abate by 6 hours unless complications arise or coingested with longer acting agent (amphetamines)

  41. Pepsi vs Coke • CBC, lytes, coags, glucose, U/A, CK, TNT, Bhcg, ABG, creatinine, tox screen • CXR • ECG • CT +/- LP • Fancy tests • NB: Urine screen for cocaine metabolites detects use within past 3-4 days, sometimes as long as 3 weeks

  42. Pepsi Drugs • BENZOS!!!! • As much as needed!!!! • Epi? • Still use in arrest • Lido? • Theoretically can worsen • B-Blockers? • BAD -> uncontrolled A stim • Even labetalol has 7:1 beta:alpha effect ratio