Street Drugs Part 1

Street Drugs every medic should know

SMCAS Ambulance

Jerry Schley

CCEMT-P I/C

Overview

We will review some common principles of caring for the “Pharmacologically gifted”

We will discuss some of the “standard” street drugs that every paramedic should know.

There is no way we can be all inclusive in an hour so bear with me.

And if you think this is going to be boring…try researching it!

Drugs we will cover

Street Opiates

Hyper dynamic DrugsMeth and derivatives

Cocaine

LSD

The Opiates

We will focus on Heroin. There are others similar drugs in this class as well:

MorphineOxycontinFentanylMethadone

BackgroundHeroin - First synthesized from morphine (derived from the poppy plant) in 1874, was not extensively used in medicine until the beginning of this century. Commercial production of the new pain remedy was first started in 1898. While it received widespread acceptance from the medical profession, physicians remained unaware of its potential for addiction for years. It’s abuse was a major cause of the Harrison Narcotic Act of 1914.

BackgroundOne survey in 1999 saw 2% of HS students had used heroin, most (1.1%) under the age of 16. Use is mainly growing in the 30-40 age group (those w/ teenagers)There is some indication that heroin use is slowly increasing to levels seen in the 60’s and 70’s.

BackgroundPure heroin is a white powder with a bitter taste. Most illicit heroin is a powder form which may vary in color from white to dark brown because of impurities left from the manufacturing process or the presence of additives. Pure heroin is rarely sold on the street.. This heroin may be smoked."black tar," has also become increasingly available in the western United States. It is often sold on the street in its tar-like state at purities ranging from twenty to eighty percent. This heroin is most frequently dissolved, diluted and injected.

SlangA "bag" --slang for a single dosage unit of heroin--may contain 100 mg of powder, only a small portion of which is heroin. The remainder could be sugars, starch, powdered milk, or quinine. Traditionally the purity of heroin in a "bag" has ranged from one to ten percent. More recently, heroin purity has ranged from one to ninety-eight percent, with a national average of thirty-five percent. “ chippers" that being the term for non-addicts who use addictive drugs in a controlled fashion

Slang

China White

Red Rum

Homicide, Polo, Super Buick (w/ Scopolamine or Coke)

Dragon

Black Tar

Smack, Scag

Methods of use

Low Purity: almost exclusively was injected either IV, SQ, or IM.

Higher purity: snort or smoke the narcotic.

Availability of high quality heroin is increasing.

Methods of use:

Shooting:

Skin Popping:

Muscle Popping:

Chasing the dragon: Smoking

Freebasing

Dirty Hit:

Methods of use: Oxycontin / MS Contin

Time released capsules, some may have more than 100 mg

Often crushed and snorted, eliminating the “time release”

May be crushed, diluted, and injected like traditional heroin

S/S OF AN OVERDOSEPin Point Pupils

Hypotension

N/V

Respiratory/CNS depression

Aspiration and Hypoxia

Hallucinations

Other s/s? Think poly-pharm involvement

Dirty Needles (“Diabetics”)Cotton balls, Cig FiltersSpoons w/ residueThe bottom of a soda pop can is commonly used as a "spoon" to dissolve the heroin in because it is curved inward like a spoon. The bottom is torn off of a can as close to the bottom as possible.

BASIC TREATMENT

Ventilation/stimulation first

Slow admin of Narcan, just enough to make them breath

Narcan 0.4 mg-2 mg traditional, may need higher doses

High doses may be needed if drug is synthetic

Watch for re-sedation due to Narcan’s short duration

FOCUSED TREATMENT

Due to the multiple drug combinations possible, full ALS is advised (unforeseen drug reactions-speed ball, homicide, etc)

Long Term problemsHIV, HEP-A/B/C, BLOOD POISONING (Septicemia) “Cotton Fever”ENDOCARDITIS TETANUS NECROTIZING FASCIITIS (Flesh-Eating Disease) Associated w/ black tarWOUND BOTULISM TRACKING AND BRUISINGCONSTIPATION, BOWEL OBSTRUCTION

InteractionsCocaine: AKA: SpeedballHeroin is thought to mask/temper some of cocaine's nastier effects“Homicide”, “Super Buick” Heroin, coke, scopolamine- Causes tachycardia, anticholinergic toxicity (remove the heroin via Narcan and the adrenergic and anticholinergic effects combine uninhibited)This is why its very important to give just enough Narcan to regain respiratory function

Some weird things that have been done with a Heroin OD by Junkies

Injected someone with salt water. This is an old junky myth sometimes still used.Injected someone who overdosed on heroin with cocaine or speed, or vice versa. Another old myth.Narcan Used PTA of EMS- Narcan is becoming more and more common among junkies for “emergencies” (some trials are being done in Seattle and Europe)Put ice on their genitals (down their pants) .

Dependence, Detox, and Withdrawalmedical detoxification is usually accomplished by giving decreasing doses of a long-acting opiate like methadone. While not truly physically addictive, Heroin withdrawal is clearly extremely uncomfortable and painful.

The previously suppressed Locus Coeruleus is believed responsible for most of the clinical problems: anxiety, HTN, agitation

TAKE HOME INFORMATOIN

Beware of the curveballs (poly Pharm)

Slow minimal Narcan administration

Hyper-Dynamic Drugs

Hyper-Dynamic Drugs

Hyper-dynamic Drugs: Drugs with severe adrenergic properties…

Meth Amphetamine

Amphetamine,

cocaine (in several forms)

Other drugs that would be similar are Ecstasy, and PMA which are discussed elsewhere.,

Background- Meth and other Amphetamines

“Meth" is methamphetamine, which is a type of amphetamine.

The chemical Methamphetamine is composed of an amphetamine molecule with an additional methyl group attached to its nitrogen (amine group).

For Methamphetamine, the methyl allows it a little better fat solubility and thus better penetration into the brain.

How Long has Meth and other Amphetamines been around?

Jan 18, 1887-Amphetamine was first synthesized by a German chemist

1919- Methamphetamine is first synthesized (in Japan)

WWII -Both Amphetamine and Methamphetamine (by the Japanese mostly)are widely distributed to soldiers to help improve performance. This led to addiction problems in Japan after the war.

BackgroundMethamphetamine is a synthetic stimulant commonly used as a recreational drug. It is legally prescribed as a treatment for ADD under the brand name Desoxyn, for both children and adults.

On the street, it is generally found as an odorless, white or off-white, bitter-tasting powder, though it is also found in pills, capsules and larger crystals.

Methamphetamine production is a relatively simple process, especially when compared to many other recreational drugs.

Slang

Nazi method: a method of quick cooking methMethamphetamine: meth, crystal meth, speed, ice, crank, glass, uppers, yaba, shabu shabu, tweak, go-fast, Hitler's Drug, Crazy MedicineSpeed : any amphetamineJacked: on speed

Slang

Bump: a snorted hit (average 2-4 “bumps”)An intentional binge: with some heavy users injection as much as a gram every 2-4 hours to keep things goingWhat is the difference between crystal and crank? “Crystal" has seven letters, “Crank" only has five.

Methods of use

It is frequently snorted, but is also used orally, smoked, and injected.

Oral use takes about half an hour to produce effects. When smoked, effects are almost instantaneous, and nearly as quick when snorted.

S/S OF AN OVERDOSEHigh last about 6-24 hours. 50% of meth is remains in body at 12 hours. Most effects are from the over stimulation of release of dopamine.Jaw clenching, Agitation, ParanoiaHTN, TachycardiaHyperthermia (lethal levels), DIC, SeizuresVisual, Auditory and tactile hallucinations 'Amphetamine Psychosis‘Serotonin Syndrome?

BASIC TREATMENT

Supportive

VOMIT

ALS (EKG, IV)

FOCUSED TREATMENT

Benzo’s for sedation and seizures0.5-2mg Ativan2.5-10 mg Valium Haldol also an option for just combativeness.

Note: Unresponsive meth users should have a temp checked when feasible for early detection and intervention Active cooling for profound hyperthermia

Long term effectsMethamphetamine is an anorexant, This is considered a benefit for many light users, but in regular or heavy users can lead to malnutrition.

Methamphetamine is also believed to be neurotoxic.It’s use causes damage to the neurons in the dopamine portions of the brain.

Some possible effect on the serotonin producing parts of the brain is also suspected.

Lead Poisoning

Psuedo-Parkinson's D/O

InteractionsThe most commonly (and ambiguously) documented warning of amphetamines (and ecstasy, PMA)is with the use of Monoamine Oxidase Inhibitors (MAOI’s)can be dangerous in combinations with MAOIs, at high doses, or at high frequencies of use.monoamine oxidase inhibitors (MAOIs) Until recently, it was believed that the metabolites of Parnate were Amphetamine and Methamphetamine, which would fit the definition of "sympathomimetic agonists" Recent research does not support the amphetamine metabolite theory. However, there is still a lot to learn about MAOI pharmacology.

Dependence, Detox, and Withdrawal Methamphetamine causes significant tolerance, as well as psychological dependence

strong cravings for more meth, while at the same time being unable to reach a satisfactory high

Withdrawal from high doses can produce severe depression, called the “Crash”

Cocaine

Everybody loves cocaine

“…Woe to you my Princess, when I come, I will kiss you quite red and feed you till you are plump. And if you are forward, you shall see who is the stronger, a gentle little girl who doesn't eat enough or a big wild man who has cocaine in his body."-- Sigmund Freud, On Coca

Background- Cocaine

Cocaine is an alkaloid found in leaves of the South American shrub Erythroxylon coca . It is a powerfully reinforcing psychostimulant.

The drug induces a sense of exhilaration in the user primarily by blocking the reuptake of the neurotransmitter dopamine in the midbrain.

Doctors dispensed cocaine as an antidote to morphine addiction. Unfortunately, some of their patients made a habit of combining both.

BackgroundUntil 1916, one could buy it at Harrods. Cocaine was widely used in tonics, toothache cures and patent medicines; and in chocolate cocaine tablets.

Ryno's Hay Fever and Catarrh Remedy - "for when the nose is stuffed up, red and sore" - was 99.9 per cent pure cocaine.

Prospective buyers were advised - in the words of pharmaceutical firm Parke-Davis - that cocaine "could make the coward brave, the silent eloquent, and render the sufferer insensitive to pain".

Background

Cocaine Hydrochloride is available on the street generally at 30% to 40% purity and retails at prices ranging from $10.00 to $50.00 per quarter gram.

Cocaine metabolites are excreted in the urine and can be detected for between 2 to 4 days after the drug has been consumed.

Slang

rock

cooked cocaine

base, freebase

fat bags

cookies

and kryptonite.

coke

crack

dust

snow

blow

flakes

bloke

Types of Cocaine

Cocaine

Crack

Freebase

Low Potency

MethodsFreebasing: “freebase” either injected or heated and its fumes inhaled through a pipe. Very Elaborate, very dangerousSmoked: Crack converted to smoke via direct flameChasing the dragon –as for heroinSnorting:"snorted into the nose. This results in rapid inhalation of the powder and cutting agents. Cocaine is absorbed rapidly via the mucous membranes into the blood stream. Dabbing:a licked finger is coated with the powder and then placed on the tongue or gums is an alternative method.

Freebasers Hall of Fame

Richard Pryor

Sam Kinison

Nikki Sixx

S/S OF AN OVERDOSETachycardia, cardiac Stimulation , MIHTN Nausea Tremors, insomnia, agitationDilated pupils Headaches, blurred vision Seizures , Strokecerebral vasoconstriction

Twitching (tactile hallucinations)Fever, HyperthermiaImpotence cold sweats Fatigue (when Crashing)Sinus Problems (when snorting)

Acute S/S

Pregnant cocaine users may experience premature labor and abruptio placenta

Just FYI: Cocaine has been reported to produce a prolonged and intense orgasm if taken prior to intercourse…in case you were wondering

BASIC TREATMENTMainly supportive

ALS

Standard therapy for respiratory problems (from smoking)]

steroids very helpful for the respiratory damage

FOCUSED TREATMENTTreat CONFIRMED MI’s per standard guidelines, thrombo’s with caution

NTG’s OK

ACLS –EP recommends spacing out EPI to 5-10 minutes in arrest

Lidocaine with caution

Mag for DysrhythmiasHaldol for combativeness

Benzo’s for sedation and seizures, AND HTN

0.5-2mg Ativan2.5-10 mg Valium

Use anti-Hypertensives with caution as they may worsen coronary ischemia

Alpha specific blockers for HTN (Regitine)Beta Blockers are falling out of favor (may leave alpha effects unopposed)

Long term effectsMultiple Respiratory problems from smoking (COPD)Recurrent snorting of cocaine may result in ischemia, necrosis, and infections of the nasal mucosa, sinuses, and adjacent structures Sterile InfectionsMI’s, Cardiovascular DamageConstipation Vascular damage from HTNIrritability and increased risk of violence are found among heavy chronic users

Interactions-AlcoholWhen combined with alcohol, the cocaine alkaloid yields a further potently reinforcing compound, now known to be cocaethylenealcohol plus cocaine produces more stimulatory l behavior in mice than either drug alone The combination appears to exert more cardiovascular toxicity than either drug alone in humans. Alcohol appears to potentiate cocaine hepatotoxicity in both humans and mice.

Interactions- Heroin and Scopolamine

AKA: SpeedballHeroin is thought to mask/temper some of cocaine's nastier effects“Homicide”, “Super Buick” Heroin, coke, scopolamine- Causes tachycardia, anticholinergic toxicity (remove the heroin via Narcan and the adrenergic and anticholinergic effects combine uninhibited)This is why its very important to give just enough Narcan to regain respiratory function

Dependence, Detox, and withdrawal

Since cocaine withdrawal is generally mild, is mainly psychological in nature.Tolerance to Cocaine builds quickly, thus larger and larger doses are used.Treatment of withdrawal symptoms is generally not required. Depression, bradycardia, sleepiness, fatigue, cocaine craving

Take Home information about Hyper-dynamic Drugs

PROTECT yourself

Betablockers falling out of favor

Benzos for HTN, sedation, SZ

Adrenergic blockers with alpha effects as well as beta 1.

Beware of the poly pharm OD

Beware of the malignant hyperthermia

LSD-d-lysergic acid diethylamide

“For about a week I couldn't walk through the lobby of A-entry at the dorm without getting really scared, because of the goblin I saw there when I was tripping….”

( …User, circa.1971, )

Background

BackgroundDiscovered by Dr. Albert Hofmann in 1938 Extensive study, use, and abuse by the government in the late 40’s. 50’s, and 60’s. (OSS/CIA, US Navy)Some documented cases of CIA Operatives taking it to “Immunize” them selves to its effects in the 60’s.Now that’s job satisfaction!

SlangMany names refer to the carrier or “brand”(image printed on blotter)

Blotter, Sugar, Sugar Cube, “cid, Acid

Bart Simpsons, Barrels, Tabs, Blotter, Heavenly blue, "L", Liquid, Liquid A, Lucy in the sky with diamonds, Microdots, Mind detergent, Orange cubes, Orange micro, Owsley, Paper acid, Sacrament, Sandoz, Sunshine, Tabs, Ticket, Twenty-five, Wedding bells, Windowpane, etc.

SlangHit- DoseBody Kinks- Unexpected physical side effects I.e. nausea, jitters, etcBad trip- A person on LSD who becomes depressed, agitated, or confused may experience these feelings in an overwhelming manner that grows on itself. LSD psychosis: The effects of LSD exacerbate pre-existing psychological problems for several days.

MethodsUsually taken Sublingually or orally on paper (“Blotter”)The solution may also be injected s.c. or i.v.(RARE) The effect is identical with that of oral administration but sets in more rapidly. Usual dose is 50-200 mcg, with “Transcending doses” as high as 500 mcg

How does it work?Similar to other drugs that give hallucinations:It affects the re-uptake of 5-HT similarly to SSRI (serotonin specific reuptake inhibiting) anti-depressants such as fluoxetine (Prozac), sertraline, and paroxetineAgonist (stimulation rather than blocking) properties at the 5-HT2 receptor have been found to fairly universally be associated with other psychedelic drugs such as psilocybin and mescaline, and somewhat in MDMA

S/S OF AN OVERDOSEDilated PupilsVivid Auditory, tactile, and visual perceptionNauseaMild drops in B/PHyperglycemiaPiloerection (Goosebumps)Mild HyperthermiaBradycardiaMay exacerbate pre-existing behavioral tendenciesMild stimulatory effects

After trip effectsInsomnia (common)

“Jitters”

Flashbacks (inconstantly proven and disproven in literature)

BASIC TREATMENT

Supportive

Protect the patient

Calm low key, low light, environment

Calm low key, low light environment

Calm low key, low light environment

Calm low key, low light environment

Oh yes…

Calm low key, low light environment

FOCUSED TREATMENT

Benzo’s for severe agitation (rare)

Dependence, Detox, and withdrawalNo documented physical or psychological dependence

A rapid tolerance is built up (about 3-5 days) that just as rapidly disappears

Take Home Information

Facilitate a low key trip, and all is well

The patients respond to your actions as much as we respond to them

Very little clinical problems from drug, just actions resulting from altered behavior

Anything I missed?