DRUGS OF ABUSE: UNIVERSAL TRUTHS

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DRUGS OF ABUSEUNIVERSAL TRUTHS

• WILLIAM K. MALLON MD FACEP FAAEM
• ASSOCIATE PROFESSOR OF EM
• LACUSC MEDICAL CENTER
• KECK SCHOOL OF MEDICINE AT U.S.C.

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DRUG CULTURES

• Subcultures of drug abuse exist
  internationally
• Clubs, Concerts, Dance Studios,
  Raves
• Surfers, College Campuses,
  Gypsies,
• Motorcycle Gangs, Street Gangs
• Information exchange is VERY VERY rapid
• Chile has DRUG CULTURE continuity with USA
  and Europe
• What happens in Amsterdam creates change in
  Santiago as well as Los Angeles

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DRUGS OF ABUSE

• OLD SCHOOL
• ALCOHOL TOBACCO
• OPIUM HEROIN
• CODEINE
• COCAINE
• MARIJUANA
• LSD
• PHENCYCLIDINE
• PHENOBARBITAL
• QUALUDES

• NEW PLAYERS
• METHAMPHETAMINE
• ECSTASY
• FENTANYL
• OXYCONTIN
• HYDROCODONE
• KETAMINE
• GHB
• VIAGRA
• HUFFING

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POLYPHARMACY RULES

• Anything Alcohol
• Redbull and other energy drinks now common
• Speedball Cocaine Heroin
• Primo Marijuana PCP
• Super Kool Tobacco PCP
• EKG X Ketamine GHB
• Doors and 4s Doriden Tylenol 4
• NEW COMBINATIONS are constant

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ALCOHOL IS UNIVERSAL

• ALL other drug issues are SMALL in cost
  and impact comparison to ETHANOL
• TRAUMA, TRAUMA, TRAUMA
• MVA, Recreational Injuries, Assaults,
  Domestic Violence, Farm Injuries, etc etc
• Alcohol taxation NEVER meets the societal
  costs associated with intoxications
• More LAW Enforcement Issues than all OTHER
  drugs combined..
• SOCIALLY accepted

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D.A.W.N.

• Broad database
• Includes in-patients and clinics and rehab
• Seeks information from users
• Tracks drugs of abuse in the USA / Canada
• RECENT STRONG PERFORMERS
• Methamphetamine
• Ecstasy
• Hydrocodone

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D.A.W.N. SURPRISE

• Increased opiate prescribing was NOT
  associated with increased abuse/addiction
• Early 1990 saw a very low rate of heroin
  abuse despite rises in opiate prescribing
• EM fear of opiate prescription invalid?
• Late 1990s surge in Hydrocodone abuse.
• TIME and NEWSWEEK ran cover stories

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VICODIN DANGERS

• Opiate toxidrome readily recognized
• Narcan reversal, resultant anger/dysphoria
• Against-Medical-Advice Discharge from ED
• DANGER 1 Long half-life possible
  re-sedation
  
• DANGER 2 Total acetaminophen intake
• may exceed
  140mg/kg !!!
• DANGER 3 Heroin induced pulmonary edema
  

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ADDICT AMA RISK

• Wake up and go
• PHC violence
• Titrate to RR6
• Vancouver early
• D/C program
• HIPE predictable
• NOT good
• companionship

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HEROIN TRANSPORT REFUSAL

• 5 year San Diego review of 998 Heroin ODs
• Narcan has a short half-life
• Field D/C safe ?
• But 2 received 3 doses
• Of 998 NO deaths in coroners office NONE
  correlated to the EMS AMA records
• Mandatory transport NOT necessary
• Vilke GM et al, Acad EM 10(8) Aug 2003

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LAYPERSON INFORMATION

• Erowid site (San Francisco based)
• Many unsuccessful attempts to close the
  site and prosecute creators
• Recipes, combinations, paraphernalia details
• Drug information for growers and
  synthesizers and marketing
• Less medical propaganda

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BELLA VISTA

• Cocaine
• Methamphetamine
• Ecstasy
• EVIDENCE OF THESE THREE IS OBVIOUS AT
  THE CLUBS.
• ADS FOR THE LATTER TWO CAN BE FOUND ON
  THE STREETS OF SANTIAGO

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TRANSDERMAL PATCHES

• FENTANYL
• Pinpoint Pupils
• Depressed Respiration
• No Skin Tracks
• Tox Screen (-)
• Euphoric
• Flushed Torso Face
• NARCAN WORKS

• CLONIDINE
• Pinpoint Pupils
• Depressed Respiration
• No Skin Tracks
• Tox Screen (-)
• Lethargic
• Hypotensive
• NARCAN unresponsive

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CRYSTAL METHAMPHETAMINE

• ICE because it burns at low temperatures
• Pure Sympathomimetic
• Cannot be cut during synthesis
• Minimal EUPHORIA, lots of paranoia
• Psychosis evolves from the latter !
• More violent death than medical death (21)
• In the USA suburban first, then urban

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METHAMPHETAMINE

• Increasingly common
• Many related compounds
• Violence commonly associated
• Police think meth is worse than coke
• Long T1/2 more ED presentations
• Cannot ride it out in the ER

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ECSTASY

• Midway between Amphetamine and LSD
• Partly Adrenergic, partly Hallucinogenic
• Younger crowd in general RAVES
• Techno and Trance music
• Ketamine often snorted alongside
• Dehydration and Renal Failure (ATN)
• Hyperthermia, LFT?, and Rhabdomyolysis
• Most users are NOT seen in the ED

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ECSTASY CLINICAL PICTURE

• Young, often below legal alcohol age
• Between MN and 7AM, especially after 2AM
• Chewing Beads or Binky for bruxism
• Light sticks or fluorescent clothing items
• Sweaty and hyperthermic
• Mental status fairly normal unless other
  drugs are on board (ETOH, Ketamine, DMX)
• NO Antidote good supportive care

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BAD ECSTASY

• Blame for bad experiences in the media
  were due to bad ecstasy
• Some TRUTH to assertion
• Ecstasy tablets can be cut with anything
  SUGAR to Dextromethorphan (DMX)
• DMX was the big contaminant in the USA
• Anion gap REVERSAL..
• DMX-HBr Bromide measured as Chloride

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RAVE

• Dance
• Sweat
• Pacifiers
• Chew beads
• Lights/laser
• End at 5-6 AM

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ECSTASY

• Entheogen
• Tactogen
• Enactogen
• Empathogen
• The LOVE DRUG sales pitch again..

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KETAMINE

• Abuse hints at pharmacodynamic effects
• Usually snorted
• Lyophilize liquid Ketamine (often obtained
  from a Veterinarian) back to the powder
  form and sell it
• If you overdose, the party is OVER
• DOWN THE K-HOLE

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KETAMINE

• Safety record for medical usage is
  impressive!
• IM is the method of choice in most EDs
• Even with iatrogenic overdose (500 vs 50mg)
• there have been no lasting negative
  effects
• Medical usage intentionally K-HOLEs the
  patient for a procedure..
• K-HOLE duration is brief 20-30 minutes

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GAMMA HYDROXY BUTYRATE (GHB) ABUSE

• Weight lifters started it..
• Anabolic effects ? (found in brown fat)
• Replaced benzodiazepine as a date-rape
  drug (Rohypnol made illegal)
• Drug screen negative
• AMS, myoclonic jerks unpredictable apnea
• Self extubation at hour 3-4 (short half-life)

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GHB

• GAMMA BUTYROLACTONE (GBL)?GHB
• Available over the internet as a solvent
• Used by the capful
• Colorless and tasteless watch your drink !
• Recipes available to cook it
• Withdrawal state mimics alcohol withdrawal

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HUFFING

• Associated with tagging and graffiti
• Silver and gold paint cost more BUT have
  a lot more propellant
• Silver graffiti is a strong indicator,
  especially when spaces are colored in
• Color-in to empty the can!
• Silver paint in eyebrows and hair
• V-tach /- syncope in a teenager

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TAGGERS AND TAG-BANGERS
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PLACA

• GANG ID
• Monikers
• Used by Police
• NOTORIOUS
• TURF Issues
• dominate
• Often a SET
• Philly script
• Not colored-in

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TOXICOLOGY POCT

• Toxidromes are generally better than testing
• 5-10 false negatives and false positives
  when compared with GC mass spec
• Qualitative testing is NOT a therapy driver
• Multiple products exist Triage Panel DOA
• QuickScreen, Syva Rapid Test, Rapid Drug
  Screen
• Triage performed the best
  
  
• Peace MR et al, J Anal Toxicol Oct
  2000
• Wu AH et al, J Anal Toxicol July-Aug
  1993

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URINE DRUG SCREENS
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TOXICOLOGY POCT

• Does it meet the SAMHSA cutoffs?
• Who? Substance Abuse and Mental Health Services
  Administration.
• 3 products checked against known analytes
• All 3 were adequate for SAMHSA cutoffs
• Negatives might be positive with
  confirmatory testing in 15
• Luzzi VI et al, Clin Chem April 2004
  

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DRUG TESTING

• ALCOHOL is the EXCEPTION
• Serum levels DO REFLECT the clinical
  aspects despite some tolerance issues
• BUT for most drugs of abuse, testing is
  very unreliable both QUALITATIVELY and
  QUANTITATIVELY
• Legal challenges have yielded mixed results

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POLICE, DRUGS AND EMERGENCY MEDICINE

• Violence associated with drugs
• Underage use of alcohol
• Date-rape drug adjuncts
• Driving laws and alcohol (ED samples)
• Import and export with body packing
• Overdoses and secondary medical problems
• Illegal drug sales
• A RELATIONSHIP EVOLVES FROM NEED

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POSSESION WITH INTENT TO SELL 11550
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TYPE 1 PACKETS
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TYPE 2

• BODY PACKERS
• MULES
• GANGS ?
• OBSTRUCTION
• GI PAIN

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13 TH FLOOR JAIL

• Border patrol agents
• DEA and FBI
• Bodypackers
• Notorious crimes
• Newspapers and reporters
• Law enforcement injuries
• Forensic EM

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STILL COMMON

• Almost always smoked now (marketing)
• Occasional speedballer remains
• Coca-ethylene toxicology and longer half-life
  is well known on the street
• Red Bull and malt liquors (8) are common
  ways to cool off a burning throat
• Heat Index study in NYC 93º F
• Uvular burns due to poor pipe screens

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