STREET DRUGS / OVERDOSEPresented By:

Steven Jones, NREMT-PCLEMC Training Officer

Drug Abuse

Drug Abuse:Self administration of drug or drugs in manner not in accordance with accepted medical or social patterns

Drug Abuse

• Psychological Dependency (Habituation)• Drug necessary to maintain user’s

sense of well-being• Physical Dependency

• Physical symptoms if intake reduced

Drug Abuse

• Compulsive Drug Use• Preoccupation with obtaining drug• Rituals of preparing, using drug as important as

drug effects• Tolerance

• Increasing doses needed to obtain drug effect

Drug Abuse• Addiction

• Includes• Psychological dependence• Physical dependence• Compulsive use• Tolerance

• Plus, complete absorption with obtaining, using drug to exclusion of all else

Drug Abuse

• Suspect drug-related problem in patients with:• Altered LOC• Bizarre behavior• Seizures

Drug Abuse

• Ask EVERY patient about recreational drugs.• Be non-judgmental.• Keep drug box/cabinet secured.• Use discretion.• If held up, give them what they want!

Narcotics

• Opium• Opium derivatives• Synthetic opium substitutes

Narcotics

• Examples• Opium• Morphine• Heroin• Codeine• Dilaudid

• Oxycodone (Percodan)

• Meperidine (Demerol)• Propoxyphene

(Darvon)• Talwin• Fentanyl

Narcotics• Effects

• Analgesia• CNS depression

• Euphoria• Drowsiness• Apathy

• Antidiarrheal action• Antitussitive action

Narcotics• Overdose

• Mild to Moderate• Lethargy• Pinpoint pupils• Bradycardia• Hypotension• Decreased

bowel sounds• Flaccid muscles

Severe Respiratory depression Coma Aspiration Seizures with certain

compounds (meperidine, propoxyphene, tramadol)

Narcotics

• Overdose• Management

• Support oxygenation/ventilation• Vascular access• Narcan 2.0 to 4.0 mg

• Improve respirations• Do NOT awaken completely• Restrain before giving

Narcotics

• Associated Dangers• Skin abscesses• Phlebitis• Sepsis• Hepatitis• HIV• Endocarditis

• Adulterant toxicity

• “Cotton fever”• Malnutrition• Tetanus• Malaria

Narcotics• Withdrawal

• Insomnia• Restlessness• Irritability• Anorexia• Tremors• Back, extremity pain

• Watery eyes• Yawning• Rhinorrhea• Sneezing• Diarrhea• Diaphoresis

Resembles Severe Influenza

Narcotics• Withdrawal

• Lasts 7 to 10 days• NOT life threatening

Sedative-Hypnotic Drugs

Categories• Barbiturates• Benzodiazepine• Barbiturate-like non-barbiturates• Chloral hydrate

Mechanism of Action• Most overdoses of sedative-hypnotics are

from benzodiazepines, barbiturates• Both enhance effects of gamma-

aminobutyric acid (GABA)• GABA enhancement results in down-

regulation of CNS activity

Sedative-Hypnotics• Use more then a week leads to tolerance

to effects on sleep patterns• Withdrawal after long term results in

“rebound” increase in frequency of occurrence, duration of REM sleep.

• In high doses, sedative-hypnotics depress CNS to point of Stage III or general anesthesia

Sedative-Hypnotics

• Tolerance• Happens with all sedative-hypnotics• Appears very quickly even during short-term use.• Discontinuation will bring receptor response back

to normal after drug has been metabolized• Withdrawal symptoms may take up to a week to

see in some patients

Chloral Hydrate

• “Micky Finn” when mixed with alcohol• Rapidly absorbed, acts quickly• Drowsiness, sleep• Alcohol, chloral hydrate compete for metabolism by

same enzyme• Prolonged action for both when mixed• Not commonly abused

Barbiturates• Introduced in 1903• Replaced older sedative-hypnotics• Quickly became major health problem• In 1950’s-60’s barbiturates were

implicated in overdoses; were responsible for majority of drug-related suicides

Barbiturates

• Short-acting• Amytal• Pentathiol

• Intermediate-acting• Nembutal• Seconal• Tuinal

• Long-acting• Phenobarbital

Barbiturates

• Initial overdose presentation • Slurred speech• Ataxia• Lethargy • Nystagmus• Headache • Confusion

Barbiturates• As overdose progresses

• Depth of coma increases• Patient anesthetized with loss of neurologic

function• EEG may mimic brain death

• Respiratory depression occurs• Peripheral vasodilation occurs

• Hypotension, shock• Hypothermia

• Blisters (bullae) form on skin

Barbiturates• Early deaths

• Respiratory arrest• Cardiovascular collapse

• Delayed deaths• Acute renal failure• Pneumonia• Pulmonary edema• Cerebral edema

Barbiturates• Overdose management

• Secure airway• Support oxygenation/ventilation• IV with NS• Prevent heat loss secondary to vasodilation• Bicarbonate to alkalinize urine (long-acting only)

Barbiturates

• Withdrawal signs/symptoms• Apprehensiveness• Anxiety• Tremulousness• Diarrhea• Nausea• Vomiting• Seizures

Barbiturate-like, non-barbiturates• Examples

• Doriden (glutethimide)• Quaalude (methaqualone)• Placidyl (ethchlorvynol)• Noludar

• Overdose produces sudden, prolonged apnea• Highly addictive• Withdrawal resembles barbiturate withdrawal• Only Placidyl, Doriden remain available in U.S.

Placidyl (ethchlorvynol)• “Pickles”, “jelly beans”, “Mr. Green Jeans”• Produces vinyl-like odor on breath• Concentrates in CNS, slow hepatic metabolism• Half-life >100 hrs• Prolonged deep coma (100 to 300 hrs), hypothermia,

respiratory depression, hypotension, bradycardia• EEG is flatline (asystole)• Keep patient on life support for a few days; they wake

up, are ok

Doriden (gluthethimide)

• Abused in combination with codeine• “sets”, “hits”, “loads”, “fours and doors”• Prolonged coma (average 48 hours)• Hypotension, shock common• Anticholinergic signs: dilated pupils, tachycardia, dry

mouth, ileus, urinary retention, hyperthermia

Benzodiazepines

Benzodiazepines

• Developed due to overdoses, deaths related to barbiturates, barbiturate-like non-barbiturates

• Relatively few deaths• In 1993, prescription rate for barbiturates dropped to

one-sixth that of benzos

Benzodiazepines• Examples

• Valium (diazepam)• Ativan (lorazepam)• Versed (midazolam)• Librium (chlorodiazepoxide)• Tranxene (chlorazepate dipotassium)• Dalmane (flurazepam)• Halcion (triaxolam)• Restoril (temazepam)• Xanax (Alprazolam)

Benzodiazepines

• Adverse Effects• Weakness• Headache• Blurred vision• Vertigo• Nausea• Diarrhea• Chest pain

Benzodiazepines

• Overdoses• Relatively safe taken by themselves, even in

overdose• Can be lethal with other CNS depressants

especially alcohol • Look like other CNS depressant overdoses• Antidote is Romazicon (flumazenil)

• Not approved in CLEMC protocols• Only recommended in known, controlled

situations• Can lead to seizures that cannot be controlled

Benzodiazepines• Produce withdrawal syndrome similar to

barbiturate withdrawal

Benzodiazepine-like non-benzos• BuSpar (buspirone)

• Used for generalized anxiety disorder• Less sedating than diazepam• Less potentiation by other CNS

depressants• Ambien, Stilnox (zolpidem)

• Used for short-term insomnia treatment• Toxic effects similar to benzos

Neuroleptics• Antipsychotics, major tranquilizers• Used in treatment of schizophrenia, other psychoses• Examples

• Haldol• Mellaril• Thorazine• Stellazine• Compazine

Neuroleptics

• Extrapyramidal muscle contractions (dystonias)• Bizarre, acute, involuntary movements, spasms of

skeletal muscles• Reversible with Benadryl

Neuroleptics

• Acute Overdose Presentation• CNS depression• Hypotension• Anticholinergic symptoms: flushing, dry mouth,

hyperthermia, tachycardia, urinary retention• Ventricular arrhythmias, including Torsades• Seizures

Neuroleptics

• Acute Overdose Management• ABCs• Fluid, vasopressors for hypotension• Lidocaine for ventricular arrhythmia• Magnesium Sulfate for Torsades• Diazepam for seizures

Neuroleptics

• Neuroleptic malignant syndrome• Life-threatening reaction• Signs, symptoms

• Hyperthermia• Muscular rigidity• Altered LOC• Tachycardia, hypotension

Neuroleptics

• Neuroleptic malignant syndrome• Management

• ABCs• Oxygen• Assist ventilation, as needed• Benzodiazepines• Rapid cooling• Volume for hypotension

Stimulants

• Examples• Cocaine• Amphetamines

• Benzedrine (bennies, beans)• Dexedrine (dexies, copilots)• Methamphetamine (crystal meth, ice)

• CLOSELY WATCH BODY TEMPERATURE! PREPARE FOR RAPID COOLING.

• Ephedrine• Caffeine• Ritalin (Adderal)

Stimulants

• Produce • euphoria• hyperactivity• alertness• sense of enhanced energy• anorexia

Stimulants• Overdose signs/symptoms

• Euphoria, restlessness, agitation, anxiety• Paranoia, irritability, delirium, psychosis• Muscle tremors, rigidity• Seizures, coma• Nausea, vomiting, chills, sweating, headache• Elevated body temperature• Tachycardia, hypertension• Ventricular arrhythmias

Stimulants• Overdose complications

• Hyperthermia, heat stroke • Hypertensive crisis• CVA• Acute MI• Intestinal infarctions• Rhabdomyolysis• Acute renal failure

Stimulants

• Chronic effects• Weight loss• Cardiomyopathy• Paranoia• Psychosis• Stereotypic behavior: picking at skin

(“cocaine bugs”)

Stimulants• Overdose management

• Oxygen, monitor, IV• Valium for sedation• Hypertension control

• Avoid beta-blockers, including labetolol (Why?)• Body temperature reduction

Stimulants• Withdrawal

• Drowsiness• Profound depression (“cocaine blues”)• Increased appetite• Abdominal cramps, diarrhea, nausea• Headache

Hallucinogens

Hallucinogens

• Examples• Indole hallucinogens

• LSD (acid)• Morning-glory

seeds• Psilocybin• DMT

• Amphetamine-like hallucinogens

• Peyote• Mescaline• DOM• MDA• MDMA (ecstasy)

Hallucinogens

• Produce altered/enhanced sensation• Effects highly variable depending on patient• Increased dose does not intensify effect• Toxic overdose virtually impossible

Hallucinogens• Some patients may experience “bad trips”• Depends on surroundings, emotional state• Signs and symptoms

• Paranoia, fearfulness, combativeness• Anxiety, excitement• Nausea, vomiting• Tachycardia, tachypnea• Tearfulness• Bizarre Reasoning

Hallucinogens

• Moderate Intoxication• Tachycardia• Mydriasis• Diaphoresis• Short attention span• Tremor• Hypertension• Hyperreflexia• Fever

Hallucinogens

• Life-threatening toxicity (rare)• Seizures• Severe hyperthermia• Hypertension, arrhythmias• Obtunded, agitated, or thrashing about• Diaphoretic, hyperreflexic• Untreated hyperthermia can lead to hypotension,

coagulopathy, rhabdomyolysis and multiple organ failure

Hallucinogens

• Management of “bad trip”• Rule out other causes of hallucinations

• Hypoglycemia• Alcohol, drug withdrawal• Infection

• Quiet, supportive environment• Benzodiazepines, haldol for agitation, anxiety

Phencyclidine (PCP)

• Street names• Angel dust• Peace Pill• Hog • Krystal• Animal tranquilizer

• Used as veterinary anesthetic

Phencyclidine (PCP)

• Actions• Dissociative anesthesia• Generalized loss of pain perception• Little or no depression of airway reflexes or

ventilation• CNS-stimulant, anticholinergic, opiate, and alpha-

adrenergic effects

Phencyclidine (PCP)

• Low Doses• Lethargy, euphoria, hallucinations• Slurred speech• Blank stare• Insensitivity to pain• Midposition to dilated pupils• Vertical and horizontal nystagmus• Occasionally bizarre or violent behavior

Phencyclidine (PCP)

• Localized dystonic reactions

• Wide-eyed coma• Rigidity• Seizures

• High Doses• Diaphoresis• Salivation• Hypertension• Tachycardia• Hyperthermia

Phencyclidine (PCP)

• Treatment• Maintain airway• Assist ventilations, as needed• Treat coma, seizures, hypertension, hypothermia

as needed• Quiet environment• Sedation if needed to control agitation

• Geodon• Benzodiazepines

Inhalants• “Huffing” - the dangerous practice of

inhaling volatile chemicals to produce euphoric effects.

Inhalants• Examples

• Hydrocarbons (solvents, paints, aerosols)• Gases (freon, halon fire extinguishing agent)• Metallic paints (“huffing”)

“Huffing” is becoming increasingly popular among younger children.

Inhalants• Effects

• Dysrhythmias including VF• CNS depression• Seizures• Respiratory irritation• Epinephrine may increase risk of dysrhythmias

• Treatment• Oxygen• Treat symptomatically

Inhalants

“Date rape” drugs• Flunitrazepam (Rhohypnol)• Gamma hydroxybutyrate (GHB)

Flunitrazepam (Rhohypnol)

• Street names• Rophies• Roofies• R2• Roofenol

• Roche• Roachies • La rocha• Rope• Rib

Flunitrazepam (Rhohypnol)• Benzodiazepine• Similar to Valium but 10x more potent• Produced, sold legally in Europe, South America• Uses

• Short-term treatment of insomnia• Sedative hypnotic• Preanesthetic medication

Flunitrazepam (Rhohypnol)• Effects

• Disinhibition and amnesia• Onset within 30 minutes, peak within 2 hours, may

persist 8 hours or more• Frequently abused with alcohol or other drugs• Enhances high produced by heroin

Flunitrazepam (Rhohypnol)• Adverse Effects

• Drowsiness• Dizziness• Confusion• Decreased BP• Memory impairment• GI disturbances• Excitability, aggressive behavior

Flunitrazepam (Rhohypnol)• Management of overdose

• Lethal overdose very unlikely• Oxygenate, ventilate• Intubate if necessary to control airway• Vascular access• ECG• Fluid for hypotension• Dextrostick (rule out hypoglycemia)• Treat trauma resulting from assault

Flunitrazepam (Rhohypnol)

• Withdrawal• Headache• Anxiety, tension• Numbness, tingling

of extremities• Restlessness,

confusion• Loss of identity

• Hallucinations• Delirium• Seizures (up to a

week after cessation)• Shock• Cardiovascular

collapse

Flunitrazepam (Rhohypnol)• Management of withdrawal

• Oxygen/ventilation• Intubate if necessary• EKG• Vascular access• Fluid for hypotension• Dextrostick• Diazepam for seizures

Gamma hydroxybutyrate (GHB)• Street names

• Cherry meth• Liquid X• Liquid ecstacy

• Originally developed as anesthetic• Banned in 1991 because of side effects• Promoted as aphrodisiac

Gamma hydroxybutyrate (GHB)• Effects

• Odorless, nearly tasteless• Tremors• Seizures• Death

THE END