Street Drugs Part 1

1
Street Drugs Part 1

• Street Drugs every medic should know

2
Ada County Paramedics

• Steve Cole

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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 boringtry
  researching it!

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Drugs we will cover

• Street Opiates
• Hyper dynamic Drugs
• Meth and derivatives
• Cocaine
• LSD

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The Opiates

• We will focus on Heroin. There are others
  similar drugs in this class as well
• Morphine
• Oxycontin
• Fentanyl
• Methadone

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Background

• Heroin - 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.
• Its abuse was a major cause of the Harrison
  Narcotic Act of 1914. 

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Background

• One 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 60s and
  70s.

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Background

• Pure 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. 

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Slang

• A "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

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Slang

• China White
• Red Rum
• Homicide, Polo, Super Buick (w/ Scopolamine or
  Coke)
• Dragon
• Black Tar
• Smack, Scag

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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.

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Methods of use

• Shooting
• Skin Popping
• Muscle Popping
• Chasing the dragon Smoking
• Freebasing
• Dirty Hit

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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

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S/S OF AN OVERDOSE

• Pin 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 Filters
• Spoons w/ residue
• The 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.

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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 Narcans short
  duration

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FOCUSED TREATMENT

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

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Long Term problems

• HIV, HEP-A/B/C,
• BLOOD POISONING (Septicemia) Cotton Fever
• ENDOCARDITIS
• TETANUS
• NECROTIZING FASCIITIS (Flesh-Eating Disease)
  Associated w/ black tar
• WOUND BOTULISM
• TRACKING AND BRUISING
• CONSTIPATION, BOWEL OBSTRUCTION

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Interactions

• Cocaine AKA Speedball
• Heroin 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

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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) .

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Dependence, Detox, and Withdrawal

• medical 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

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TAKE HOME INFORMATOIN

• Beware of the curveballs (poly Pharm)
• Slow minimal Narcan administration

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Hyper-Dynamic Drugs
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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.,

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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.

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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.    

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Background

• Methamphetamine 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.

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Slang

• Nazi method a method of quick cooking meth
• Methamphetamine meth, crystal meth, speed, ice,
  crank, glass, uppers, yaba, shabu shabu, tweak,
  go-fast, Hitler's Drug, Crazy Medicine
• Speed any amphetamine
• Jacked on speed

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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 going
• What is the difference between crystal and crank?
• Crystal" has seven letters, Crank" only has
  five.

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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.

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S/S OF AN OVERDOSE

• High 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, Paranoia
• HTN, Tachycardia
• Hyperthermia (lethal levels), DIC, Seizures
• Visual, Auditory and tactile hallucinations
• 'Amphetamine Psychosis
• Serotonin Syndrome?

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BASIC TREATMENT

• Supportive
• VOMIT
• ALS (EKG, IV)

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FOCUSED TREATMENT

• Benzos for sedation and seizures
• 0.5-2mg Ativan
• 2.5-10 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

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Long term effects

• Methamphetamine 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.Its 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

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Interactions

• The most commonly (and ambiguously) documented
  warning of amphetamines (and ecstasy, PMA)is with
  the use of Monoamine Oxidase Inhibitors (MAOIs)
• 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.

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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

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Cocaine
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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

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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.

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Background

• Until 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".

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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.

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Slang

• rock
• cooked cocaine
• base, freebase
• fat bags
• cookies
• and kryptonite.

• coke
• crack
• dust
• snow
• blow
• flakes
• bloke

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Types of Cocaine

• Cocaine
• Crack
• Freebase
• Low Potency

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Methods

• Freebasing freebase either injected or heated
  and its fumes inhaled through a pipe. Very
  Elaborate, very dangerous
• Smoked Crack converted to smoke via direct flame
• Chasing the dragon as for heroin
• Snorting"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.
• Dabbinga licked finger is coated with the powder
  and then placed on the tongue or gums is an
  alternative method.

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Freebasers Hall of Fame

• Richard Pryor
• Sam Kinison
• Nikki Sixx

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S/S OF AN OVERDOSE

• Tachycardia, cardiac Stimulation , MI
• HTN
• Nausea
• Tremors, insomnia, agitation
• Dilated pupils
• Headaches, blurred vision
• Seizures , Stroke
• cerebral vasoconstriction

• Twitching (tactile hallucinations)
• Fever, Hyperthermia
• Impotence
• cold sweats
• Fatigue (when Crashing)
• Sinus Problems (when snorting)

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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
  intercoursein case you were wondering

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BASIC TREATMENT

• Mainly supportive
• ALS
• Standard therapy for respiratory problems (from
  smoking)
• steroids very helpful for the respiratory damage

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FOCUSED TREATMENT

• Treat CONFIRMED MIs per standard guidelines,
  thrombos with caution
• NTGs OK
• ACLS EP recommends spacing out EPI to 5-10
  minutes in arrest
• Lidocaine with caution
• Mag for Dysrhythmias
• Haldol for combativeness

• Benzos for sedation and seizures, AND HTN
• 0.5-2mg Ativan
• 2.5-10 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)

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Long term effects

• Multiple 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 Infections
• MIs, Cardiovascular Damage
• Constipation
• Vascular damage from HTN
• Irritability and increased risk of violence are
  found among heavy chronic users

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Interactions-Alcohol

• When combined with alcohol, the cocaine alkaloid
  yields a further potently reinforcing compound,
  now known to be cocaethylene
• alcohol 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.

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Interactions- Heroin and Scopolamine

• AKA Speedball
• Heroin 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

52
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

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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

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LSD-d-lysergic acid diethylamide
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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, )
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Background
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Background

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

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Slang

• Many 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.

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Slang

• Hit- Dose
• Body Kinks- Unexpected physical side effects I.e.
  nausea, jitters, etc
• Bad 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.

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Methods

• Usually 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

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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 paroxetine
• Agonist (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

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S/S OF AN OVERDOSE

• Dilated Pupils
• Vivid Auditory, tactile, and visual perception
• Nausea
• Mild drops in B/P
• Hyperglycemia
• Piloerection (Goosebumps)
• Mild Hyperthermia
• Bradycardia
• May exacerbate pre-existing behavioral tendencies
• Mild stimulatory effects

63
After trip effects

• Insomnia (common)
• Jitters
• Flashbacks (inconstantly proven and disproven in
  literature)

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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

65
FOCUSED TREATMENT

• Benzos for severe agitation (rare)

66
Dependence, Detox, and withdrawal

• No documented physical or psychological
  dependence
• A rapid tolerance is built up (about 3-5 days)
  that just as rapidly disappears

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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

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Anything I missed?