street drugs: update
DESCRIPTION
Street Drugs: Update. Russell Berger, MD Emergency Room Attending Physician Cambridge Health Alliance Associate Director of Medical Toxicology Instructor in Medicine Harvard Medical School. Organizing Principles. Toxidromes Tox Specific Physical Exam EKG. Toxidromes. - PowerPoint PPT PresentationTRANSCRIPT
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Street Drugs: Update
Russell Berger, MDEmergency Room Attending Physician
Cambridge Health AllianceAssociate Director of Medical Toxicology
Instructor in MedicineHarvard Medical School
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Organizing Principles
Toxidromes
Tox Specific Physical Exam
EKG
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Toxidromes
• Opiate---bradypnea, pinpoint pupils
• Anticholinergic-dry and delirious
• Sympathomimetic-wet and crazy
• Sedative Hypnotic-very sleepy
• Serotonergic-AMS, clonus, and dysautonomia
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Opiate overdoses do not always produce pinpoint pupils
• Most reliable sign is a low respiratory rate
• Some opiates produce mydriasis
• Remember pontine pupils
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Anticholinergic
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Sympathomimetic
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Tox Specific Physical Exam
Vital Signs
Mental Status
Pupils
Skin
Reflexes
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Tox EKG
• QRS duration
• QTC duration
• Rhythm and Blocks
• Terminal R in aVR
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If you block Sodium channels…
• You prolong the QRS complex
• >100ms is significant
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If you block Potassium Channels…
• You prolong the QTC
• >450ms is significant
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Some Na Channel Blockers besides TCA’s
• Carbamazepine
• Benadryl
• Flecainide, Procainamide
• Chloroquine
• Propranolol
• Quinine
• Bupivicaine
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Some QTC prolonging Agents
• Seroquel
• Zofran
• Methadone
• Trazodone
• Citalopram
• Erythromycin
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Let me open this story with a little background about myself. I am an extremely intelligent woman. I just graduated with a double degree, I have a high GRE score, and I’ll be working on applying to grad schools shortly. I am not some sort of drug addict, though that does run in my family, but I AM AN EXPERIENCED TRIPPER. Never again. It’s been less than 12 hours since I smoked three or four hits of “incense” and I can confidently say that I have never been through a worse experience in my life.
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Herbal Marijuana
Marketed as K2 or Spice
Popular because not detected on routine drug screens
Frequent use in the military
Cheap, easily accessible, and very potent
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Herbal Marijuana Continued
Packaging will say, “Not for human consumption”
May be referred to as JW compounds, and agonize the CB-1 receptor.
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Effects
Accentuated Cannabis Effects
Psychosis and agitation are common including self-injurious behavior
Dependency issues compared with marijuana
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Treatment
Supportive
PRN benzodiazepines
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• Really, the main questions you should ask yourself before trying DXM are: Am I afraid of my own mind? Am I afraid to look deeply into it? Am I afraid of leaving my body and existence behind? You can expect all of these to happen on an upper-plateau trip, for they most likely will.
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Dextromethorphan (DXM)
• Widely available and cheap
• Not routinely detected on drug screens
• May sometimes get a false positive PCP screen as a clue to exposure.
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Effects
• Rotatory Nystagmus
• Ataxia (lose proprioceptive cues)
• Hyper-reflexia
• Mania and Psychosis
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Treatment
• Supportive
• PRN benzodiazepines
• If serotonergic, can consider cyproheptadine.
• Note: chlorpheniramine is anticholinergic and serotonergic and is frequently mixed with DXM preparations.
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Bath Salts
The Full Ride
Not Exactly a Good Time
Cooking Up My First Trial
An Adventure in Euphoria and tachycardia
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MPDV or Bath Salts
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Bath Salts
Contain stimulant compounds such as MDPV or mephedrone
Produce extreme agitation, delusions, tachycardia, and often violence.
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Treatment
• High doses of ativan are required.
• Intubation may be necessary to control degree of agitation.
• Renal injury from rhabdomyolysis, hyperthermia, and seizure activity may result.
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MDMA
• Produces sympathomimetic toxidrome
• Associated with hyponatremia, practically exclusively found in women.
• Check CK and look for renal injury
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Hyponatremia
Co-peptin is a surrogate marker for ADH. It is used because it is easier to measure than ADH.
Co-peptin levels are elevated in women and not in men when patients are exposed to equal amounts of MDMA.
Thus, MDMA associated hyponatremia may be a function of SIADH.
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What you find clinically
Low serum sodium
High urine sodium
High urine osmolarity
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Jimson Weed
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Another Anticholinergic Agent
Dry
Red
Tachycardic
Delirious
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Cocaine
• When combined with alcohol, mortality increases 20 fold in the first 24 hours.
• Mixed with levamisole
• Between 2007-2011, 5x increase in levamisole contamination
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GHB•
My husband got some liquid GHB for us to try one Friday evening to enhance our evening of sex and intimacy
•This stuff smells and tastes disgusting - I can't think of anything else that tastes even similar! I had to well swill my mouth after knocking back my first dose. I wondered how GHB is used as date rape and not detected in the victim's drink - I know I would have tasted something bad - but then again, maybe 1.5ml in a typical pub/club sized bottle of Red Square or Breezier is more diluted so weaker to taste.
After a short while I started to feel slightly tipsy and then euphoric and horny and then more tipsy and these feelings increased, as so did the same dosage on my hubby. We got very randy with each other and had frantic and incredibly rampant and passionate sex - I experienced heightened sexual arousal and unbelievable orgasms that left me feeling weak and drained, wanting to just lie down and recharge. Within 2 to 3 hours of taking the 1.5ml dose we were feeling like we'd come down off the GHB and were returning to sanity.
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GHB
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Effects
Extreme Sedation
Respiratory Depression
Rapid Sudden Awakening
Withdrawal similar to benzodiazepines and alcohol.
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Treatment
• Supportive
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Review
• Toxidromes
• EKG
• QRS vs QTC
• Some common Street drugs