Street Drugs of Abuse Timothy B. Erickson, MD Professor: Department of Emergency Medicine University of Illinois @ Chicago
Case #1 History • A 25 yr old male is found unresponsive by friends at an inner city night club called the “Passion Pit”. He is brought to your ER by paramedics.
Physical Exam • Gen: Disheveled appearance, shallow breathing, responds to painful stimuli • Vitals: P=56 RR=6 BP=110/70 T=95 • Head: NC/AT • Eyes: Pinpoint pupils • Neck: Nontender no deformity • Lungs: Poor inspiratory effort, CTA
Physical Exam • CV: Bradycardic RRR S1S2 no m’s • Abd: Soft with hypoactive BS • Rectal: Normal tone (-)Heme • G/U: Half-melted ice cubes placed on groin by friends at nightclub • Neuro: Moves all 4 ext, nonfocal • Skin: Cool, Arms with needle tracks
Case Discussion • What are your priorities when managing this patient?
Management Priorities • Airway • Breathing • Circulation • Assess for signs of trauma • Antidote administration
Case Summary • Comatose patient • Pinpoint (miotic) pupils • Depressed respiratory drive • Bradycardia • Hypothermia
Opioid Overdose • Heroin • Methadone • Codeine • Morphine • Fentanyl • Demeral • Propoxyphene
NALOXONE • Indicated in comatose patients with suspected drug overdose • Restrain patient prior to administration • Dose: 2-10mg IVP • Short half life (T1/2) • Naloxone drip may be required
Clinical Course • After administration of 2mg of naloxone, the patient becomes more alert and begins to verbalize with spontaneous respiratory activity. • His vital signs are stable with NSR noted on the cardiac monitor.
Clinical Course • Laboratory data including ECG and CXR are unremarkable. • The toxicology screen is positive for opiates.
Clinical Course • The patient denies suicidal ideations and admits to frequent chronic IV heroin abuse claiming “I just had a bad cut tonight.” • He becomes more uncooperative and demands to be discharged….
Case#2 History • The patient is a 28 yr old male who presents in police custody complaining of chest pain. He has no prior history of cardiac disease. • The patient was arrested at the local international airport for combative behavior while standing in line near the security area.
Case Physical Exam • Gen: Patient is very agitated, clutching his chest • Vitals: P= 140 BP= 220/130 RR= 28 T=103.2 F • Eyes: Pupils equal: 7mm • Lungs: CTA • Ht: RRR S1S2 2/6 systolic murmur
PHYSICAL EXAM • Abd: Distended with diffuse tenderness, hyperactive BS • Ext: Good pulse, no cyanosis, no needle tracks • Neuro: No focal defs • Skin: Diaphoretic
Clinical Course • The patient now admits to swallowing several “condoms full of cocaine” before boarding the plane from Columbia to the U.S.
Drug Smugglers • Describe the difference between a “Body Packer” and a “Body Stuffer”
Packers and Stuffers • Body Packers: Drug smugglers who ingest large amounts of pure illegal contraband methodically wrapped in order to deliver “the goods” across international borders. • Body Stuffers: Individuals who “swallow the evidence” during drug raids (poorly wrapped but less pure).
Cocaine • Cocaine hydrochloride= usual street preparation • Freebase cocaine(cocaine alkaloid)= cocaine is extracted with alkaline (buffered ammonia) and solvent is added(acetone). Freebase pops or cracks when heated hence the term “crack” • Rock of crack= cocaine hydrochloride heated with baking soda until a rock is formed-these are smoked in paraphernalia • Speedball-heroin laced with cocaine-no narcan
Cocaine Toxicity (Sympathomimetic) • Hypertension • Tachycarida • Hyperthermia • Diaphoresis • Anxiety • Seizures • CVA/Intracranial bleed • Myocardial infarction
Gastric Decontamination • Activated charcaol • Polyethlene glycol solution (aka: Go-lytely) • Surgical removal
Cocaine & Chest Pain • Oxygen • Benzodiazepines • Nitroglycerin • B-Blockers- contraindicated • Hypertension control • Thrombolytic Agents (TPA) • Cath Lab / Angioplasty
Clinical Course • The patient’s chest pain and hypertension resolves with large doses of NTG and benzodiazepines • The patient is administered activated charcoal and PEG solution by the ER physician.
Clinical Course • Because of the ST segment elevations on ECG, the cardiologist elects to give TPA. • Since thrombolytics were given, the general surgeon refuses to take the patient to the OR for an exploratory lap and removal of the cocaine packets.
Clinical Course • The patient subsequently develops seizure activity, worsening hyperthermia, rhabdomyolysis, and intracranial hemorrhage. • He expires 48 hrs after admission
Case #3 History 17 y/o CF presents to the community hospital emergency department at 2:00AM with “fever and strange behavior” as per her parents. While waiting to be examined, the patient has a witnessed tonic-clonic seizure lasting 1 minute in duration.
No PMH; No medications ; NKDA • Vitals: T=104.2F P=120 BP=100/90 RR=28 • PE: Gen: restless, agitated, confused HEENT: pupils 6mm & reactive, MMM CV: RRR, no MRG Lungs: CTA Abd: Soft, (+)BS, mild tenderness Skin: warm, dry, no rashes Neuro: No focal defs
DIAGNOSTIC STUDIES • CBC: WNL • Lytes: 120/3.9/87/21 • Serum Osm=234, Urine Osm=261 • Urine Na: 82 • U/A: large blood (-)RBCs • CPK: 3,300 • CT head: normal
Earlier that night: •Urine Tox Screen: + Amphetamines + Cannabis - EtOH, ASA, APAP
Ecstasy = MDMA • 3,4 methylenedioxymethamphetamine • X, E, M, XTC, Rolls, Adam, Bean, Hug Drug
MDMA Properties and Mechanism of Action • Designer drug from the essential oil of the sassafras tree • Ring substituted amphetamine • Pharmacological effects are a blend of amphetamines and mescaline • Structure resembles natural neurotransmitters of Epi, DA • Biological actions and effects resemble those of Epi, DA, and serotonin
Pharmacodynamics • Increases the net release of monoamine neurotransmitters (5-HT, NE, DA) from their axon terminals • MDMA binds to and blocks the serotonin reuptake transporter – flooding the terminals with 5-HT • Similar, weaker action on DA reuptake • Amphetamine like increase in NE • Increase in 5-HT and DA = mental effects • Increased NE=physical amphetamine effects
MDMA analogues • MDA (3,4-methylenedioxyamphetamine) – “Love Drug” - similar in effect, more stimulating, twice as neurotoxic • MDE (N-ethyl-methylenedioxyamphetamine) “Eve” – more introspective experience • MMDA (3-methoxy-4,5-methylenedioxyamphetamine) – closed eye hallucinations, “brain movies” • MBDB (N-methyl-1-(1,3-benzodioxol-5-yl)-2-butanamine) – effects similar to MDA
MDMA History • 1912 – first synthesized by Merck • 1914 – patented by Merck – manufactured as an appetite suppressant, never marketed • 1950’s- studied by US Army as potential agent in psychological warfare • 1970 – used in psychotherapy, “penicillin for the soul” • 1977 – class A illegal drug in UK • 1985 – Schedule I illegaldrug in U.S.
Trends in Ecstasy Use • DEA seizures of Ecstasy Tablets: • 1996 – 13,342 tablets • 2000 – 949,257 tablets • 2001 - >4,000,000 tablets in 8 months
Ecstasy Use by Students, 2000 (NIDA Studies) Perceived availability by 12th graders 51.4% (40.1%)
MDMA Production and Sales • Street value = $25 per pill • Wholesale price = $2-$8 per pill • Production cost = 2-5 cents per pill • Majority of production and distribution linked to well organized crime networks in Europe (Amsterdam, Germany, UK) and Israel • Smaller labs all over US and Europe
Areas of Usage • Highest at raves, dance clubs (as high as 91% of clubbers in dance scene in Scotland) • Dramatic increase in college use, suburban teens, house parties Millroy, CM, JRSM February 1999
Physical CLUES • Glowsticks or lights • Lollipops • Pacifiers • Vick’s Vapor Rub and Nasal Inhaler • Fuzzy Mittens
Methods of Administration • Mainly PO – stamped tablets, capsules • Intra-nasal – rapid absorption of crushed tablets or opened capsules • Intra-rectal – faster absorption than PO • Recreational usage varies from ½ pill to as much 15 pills in a 6 hour span