update on drugs of abuse trends in florida
TRANSCRIPT
Update on Drugs of Abuse Trends in Florida
Melissa Parsons, MDDepartment of Emergency Medicine
University of Florida College of Medicine-Jacksonville
Learning Objectives
1. Understand general trends for drugs of abuse in Florida
2. Become familiar with toxidromes
3. Recognize excited delirium syndrome and factors that increased morbidity/mortality
Opioids
TOXIDROME• CNS sedation
• Hypothermia
• Hypotension
• Hyporeflexia
• Bradycardia
• Miosis (pinpoint pupils)
• Respiratory depression
• Seizures – Meperidine (Demerol), Tramadol
• Rigidity, myoclonus – Fentanyl
Opioids
Management
• Supportive• Naloxone
– Indication: reverse respiratory depression
– Adults: 0.4mg—2mg
– Pediatrics <5 years 0.1 mg/kg
– Max 10 mg
– May need high doses for fentanyl
– IV, SC, IM, IN, IO
– Half life: 1 hour
Spike in deaths due to heroin and fentanyl
447
538
0
100
200
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500
600
2006 2007 2008 2009 2010 2011 2012 2013 2014
De
ath
s fr
om
he
roin
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Heroin
Fentanyl
Florida Medical Examiners Commission Annual Drug Reports 2007-2014
Crack down on “pill mills” and opioid prescribing
208
271250
230
150
10978 93
11995
48 57
108
199
447
0
50
100
150
200
250
300
350
400
450
500
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
He
roin
De
ath
sNumber of Heroin Deaths in Florida: 2000-2014
2014 Florida Medical Examiners Commission Annual Drug Report
Fentanyl
• Synthetic opiate– 100 times more powerful than
morphine
– 30-50 times more powerful than heroin
• “Breaking Bad” “Blue Drop” “Theraflu” “China White”
• Imported from Mexico and China
Cannabinoids Compounds found in the marijuana plant THC is the most psychoactive (strong hallucinogen). Street names: “ganja,” “MJ,” “ragweed,” “reefer” and “grass.
Clinical Effects Psychological
Alterations in perception, feelings of well-being, increased appetite
Physiological Acute: Increased HR and BP Chronic: Decreased HR and blood
pressure Decreased coordination Delay in psychomotor skills CNS depression (especially peds) Slurred speech Rare: apnea, cyanosis, hypotonia
Abuse of Synthetic Drugs an Epidemic
• 2012 Synthetic Drug Abuse Prevention Act – Places 26 synthetic drugs including types of
cannabinoids and cathinones under Schedule 1
– Illegal drug makers have 100s more to take their place
– NO quality control (Russian Roulette)
– Often products labeled “not for human consumption”
• Unknown chemicals• Unknown potency• Constantly changing
Russian Roulette
Mystery packages
Drug makers constantly producing new synthetic cannabinoids products to evade laws on older compounds… impossible to keep up.
2015: >30 compounds
Synthetic Cannabinoids
• Synthetic chemicals sprayed onto dried plants
• They are 5-45 times more potent than THC and more toxic to brain and the heart
Synthetic Marijuana is a misnomer
Synthetic Cannabinoid User
Man decapitated his wife, killed two dogs, cut off his left hand, and gouged his right eye out
Man kills two women using a knife and tomahawk while trying to find the ‘portal to
hell” in their backyard shed
Synthetic Cannabinoids
Symptoms:• Seizures• Psychosis
– Patients without psych history– Paranoia, agitation and anxiety – Suicidal or homicidal ideation
• CV events– Tachycardia and
tachydysrhythmias– MI– Stroke
• Respiratory failure• Acute kidney injury• Hyperthermia• Hyperemesis
Management:• Supportive care• Sedation
– Benzodiazepines – Ketamine– Avoid antipsychotics
• IVFs for AKI or rhabdomyolysis• Low stimulus environment
Risk Factors for increased mortality:1. New Psychosis/ Excited delirium with use
• Trauma or injury• Restraint procedures by law enforcement
• Chemically sedate… avoid restraints2. Pre-existing cardiovascular conditions3. Co-ingestions
Excited Delirium Syndrome
Clinical Features:
• Hyper-aggression/agitation – Catecholamine surge and acidosis
– Superhuman strength
• Autonomic dysfunction
• Hyperthermia
• Acidosis
• Rhabdomyolysis, hyperkalemia
• Acute kidney injury
• Can be difficult to recognize and manage in prehospital setting.
• May mimic other medical conditions
• Attempt de-escalation techniques
• Personal safety issue for first responders
Excited Delirium Syndrome
• Management:
– Agitation: chemical and physical restraint
– Hyperthermia: Active and passive cooling
– Hypoxia: Airway support
– Acidosis: IVF, Bicarb if severe
– Rhabdo/Hyperkalemia: IVF, Calcium chloride, Bicarb
Excited Delirium Syndrome
KETAMINE: • 4-5 mg/kg IM or 2 mg/kg IV• Rare side effects
• Increased oral secretions, • Laryngospasm, • Hypertension, • Distress from emergence phenomena
BENZO’s: • Effective. • Potential for respiratory depression
ANTIPSYCHOTICS: • Potential lethal side effects• Increased QTc & risk for sudden
death• Anticholinergic syndrome
Management of Excited Delirium Syndrome
3,4-methylenedioxymethamphetamine (MDMA)
• Ecstasy
– Often adulterated with caffeine, methamphetamine, and other harmful drugs
– Typically in tablet form
• Molly
– Slang for "molecular"
– Supposedly a “purer” form of MDMA sold as powder or capsule
Synthetic Cathinones
• Synthetic chemicals related to cathinone, an amphetamine-like stimulant found naturally in the Khatplant.
Synthetic Cathinones
• MDPV (Methylenedioxypyrovalerone)– most common synthetic cathinone found in the
blood and urine of ED patients reportedly taking "bath salts”
• Alpha-PVP
• Methylone
• Ethylone
• Butylone
• Many more
Alpha-PVP aka Flakka
Special considerations:• Paranoia• Pursued or chased• Extreme hyperthermia (105-106)• Excited Delirium Syndrome
8 Duval2 Clay 1 St Johns 1 Putnam
http://interactive.sun-sentinel.com/flakka-case/
Number of Flakka Cases in Florida 2015
http://interactive.sun-sentinel.com/flakka-case/
“In recent weeks in Florida, this new drug has led to a man trying to break down the door to a police station, a man impaling himself while trying to scale a fence, and an armed and naked man shouting about hallucinations from a rooftop” – CBS
Synthetic CathinonesClinical effects
CNS: Euphoria
Decreased need for food and sleep
Increase in alertness and awareness
Heightened sexual desire
Anxiety/agitation
Paranoia
Violent behavior
Hallucinations (auditory or tactile)
Suicidal thoughts
Excited Delirium Syndrome (ExDS)
Synthetic CathinonesClinical Effects
Cardiovascular: Hypertension Tachycardia Chest pain
Hyperthermia Hyponatremia Nausea/Vomiting Liver failure Kidney failure Rhabdomyolysis Compartment syndrome
Synthetic Cathinones
• Self-harm and bizarre/at risk behavior without evidence of psychosis or depression is the
SECOND leading cause of death with use
Take Home Points
• Florida is seeing increased heroin/fentanyl use as opioid prescription drugs become harder to acquire– You may need larger doses of naloxone to reverse synthetic opioids
like fentanyl.
– Don’t give up if 0.4mg doesn’t work…
• Higher potency forms of marijuana and synthetic forms of cannabinoids can lead to more severe clinical effects– Synthetic cannabinoids do NOT equal marijuana
Take Home Points
• New synthetic drugs constantly being produced, which are potentially more toxic and dangerous.– It doesn’t matter what the compound is…treat them symptomatically
• Control of agitation/psychosis in Excited Delirium Syndrome is high priority to reduce mortality. – Use chemical sedation.
– Avoid restraints.
– Don’t forget to cool their hyperthermia.
– Get labs to check for end-organ dysfunction.