Street Drugs: Update

Russell Berger, MDEmergency Room Attending Physician

Cambridge Health AllianceAssociate Director of Medical Toxicology

Instructor in MedicineHarvard Medical School

Organizing Principles

Toxidromes

Tox Specific Physical Exam

EKG

Toxidromes

• Opiate---bradypnea, pinpoint pupils

• Anticholinergic-dry and delirious

• Sympathomimetic-wet and crazy

• Sedative Hypnotic-very sleepy

• Serotonergic-AMS, clonus, and dysautonomia

Opiate overdoses do not always produce pinpoint pupils

• Most reliable sign is a low respiratory rate

• Some opiates produce mydriasis

• Remember pontine pupils

Anticholinergic

Sympathomimetic

Tox Specific Physical Exam

Vital Signs

Mental Status

Pupils

Skin

Reflexes

Tox EKG

• QRS duration

• QTC duration

• Rhythm and Blocks

• Terminal R in aVR

If you block Sodium channels…

• You prolong the QRS complex

• >100ms is significant

If you block Potassium Channels…

• You prolong the QTC

• >450ms is significant

Some Na Channel Blockers besides TCA’s

• Carbamazepine

• Benadryl

• Flecainide, Procainamide

• Chloroquine

• Propranolol

• Quinine

• Bupivicaine

Some QTC prolonging Agents

• Seroquel

• Zofran

• Methadone

• Trazodone

• Citalopram

• Erythromycin

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.

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

Herbal Marijuana Continued

Packaging will say, “Not for human consumption”

May be referred to as JW compounds, and agonize the CB-1 receptor.

Effects

Accentuated Cannabis Effects

Psychosis and agitation are common including self-injurious behavior

Dependency issues compared with marijuana

Treatment

Supportive

PRN benzodiazepines

• 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.

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.

Effects

• Rotatory Nystagmus

• Ataxia (lose proprioceptive cues)

• Hyper-reflexia

• Mania and Psychosis

Treatment

• Supportive

• PRN benzodiazepines

• If serotonergic, can consider cyproheptadine.

• Note: chlorpheniramine is anticholinergic and serotonergic and is frequently mixed with DXM preparations.

Bath Salts

The Full Ride

Not Exactly a Good Time

Cooking Up My First Trial

An Adventure in Euphoria and tachycardia

MPDV or Bath Salts

Bath Salts

Contain stimulant compounds such as MDPV or mephedrone

Produce extreme agitation, delusions, tachycardia, and often violence.

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.

MDMA

• Produces sympathomimetic toxidrome

• Associated with hyponatremia, practically exclusively found in women.

• Check CK and look for renal injury

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.

What you find clinically

Low serum sodium

High urine sodium

High urine osmolarity

Jimson Weed

Another Anticholinergic Agent

Dry

Red

Tachycardic

Delirious

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

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.

GHB

Effects

Extreme Sedation

Respiratory Depression

Rapid Sudden Awakening

Withdrawal similar to benzodiazepines and alcohol.

Treatment

• Supportive

Review

• Toxidromes

• EKG

• QRS vs QTC

• Some common Street drugs