Street Drugs Part 2

1
Street Drugs Part 2

• 21st Century Street Drugs for the 21st Century
  Street Medic

2
Steve Cole

• Ada County Paramedics
• Boise Idaho

3
Overview

• We will review some common principles of caring
  for the Pharmacologically gifted
• We will discuss 6 of the new drugs that every
  paramedic should know.
• Strangely enough all of these New Drugs have
  been around for decades.
• We will discuss common signs of a RAVE.
• There is no way we can be all inclusive in an
  hour so bear with me.

4
Drugs we will cover

• MDDA (Ecstasy)
• PMA
• GHB analogs
• Rohypnol (roofies)
• DXM
• Ketamine

5
The Rave Culture
6
What is a Rave

• Countryside hideaways set the scene for
  psychedelic parties. The night adorned with
  luminescent tantric and alien banners, lit by
  black and colored lights, lasers and strobes the
  day transforming into a ravers paradise,
  decorated with a colorful array of psychedelia
  and the wonders of mother nature. Here Electronic
  Music and its DJ's unite people in dance
  freedom. Freedom to be who you want, wear what
  you want and to dance as if no one is watching
• ----The internet

7
The Rave Culture

• Generally speaking, Rave applies not just to
  the parties but to an entire subculture
• It is a Multi-National culture, and is seen in
  multi-national cities (Seattle, New York, D.C.,
  Miami, Frankfort (Ger.) etc).
• It has spread to some degree to every City in the
  US.
• Not just Night time Parties at clubs
• Can extend into multi-day events (Burning Man)
• Hallmarked by techno/new age music and
  Psychedelic visual displays.

8
The Rave Culture

• IN SIMPLISTIC TERMS Think the Grateful
  Dead/Hippie ethics meet High energy electronic
  Techno Music, throw in a heavy dose of the
  larger drug culture and that gives you a start.
• As with any sub culture, this group has its
  slang, its distrust for outsiders (especially
  badge carrying authority figures), its Myths
  (dont dial 911).
• To be truly effective, the EMS provider must
  break down barriers, gain trust, to better treat
  the patient.
• An understanding of how these rave parties often
  work will give you a better insight into the
  patients medical condition.

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Anatomy of a Rave
10
Anatomy of a RAVE

• Day or Night
• Tend to be Sponsored (A.K.A. Promoters),
  limits liability on both sides
• Sometimes marketed as Drug Free Teen Dance
  Parties
• If not at a formal club, they tend to be located
  in remote locations to limit outside
  interference.
• Often will have a DJ instead of a band. Some
  DJs are celebrities, called the A-List,
  traveling a Circuit (1000-5000/hr)

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Anatomy of a Rave

• Remember, the overall event doesn't have to be a
  rave to have a strong Raver presence..

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Anatomy of a Rave

• May have multiple Rooms, each with a Theme
  (Jungle-Rave)
• Usually has Multiple Water Venders ()
• May or may not be BYOB
• Any where from 100 to 10,000 (massives)
• Some larger events hire an Private EMS agency to
  stand by, sometimes to limit police involvement.
• More respectable areas may even have a area for
  triage.
• All scenes are a potential volatile environment

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Anatomy of a Rave- Clues

• Light Sticks
• Water/Gatorade Bottles for sale
• H2O shut off in bathroom
• Crash Rooms/Candles/Etc.
• Have Dance Breaks/cool down periods

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Anatomy of a Rave
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Anatomy of a Rave-Common Medical concerns

• Severe Dehydration and Hyperthermia
• Poly-Pharm involvement
• Date Rape
• Multiple Patients (approach with a plan)
• Volatile Crowds

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Interacting with Ravers

• Remember there is a cultural distrust
• Dont be afraid to ask for interpretation of
  slang
• Generally not overtly violent singularly, but
  beware of crowds
• Our attitude and interaction may have a positive
  or negative impact on the crowd.
• Check for a Trip Sitter

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Questions?
18
The Drugs
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MDMA (Ecstasy)-Introduction

• methylenedioxy-n- methylamphetamine
• MDMA is chemically an amphetamine, but
  psychologically its what's known as an
  empathogen-entactogen
• Shares similarities to both mescaline (a
  hallucinogen) and amphetamines (A type of
  Stimulant)

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MDMA (Ecstasy)-STATS

• Average Tablet 300mg  Pure MDMA 100mg 
• One Kilo MDMA 10,000 Tablets 
• Prices Per Dosage 
• .50 to 2.00 at source (Netherlands/Belgium)
  (wholesale). 8.00 bulk quantity U.S.
  (wholesale). 20.00 to 30.00 U.S.
  (retail). (One Kilo MDMA Powder 200,000 -
  300,000

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MDMA (Ecstasy)- How is it used?

• Taken in Tabs
• Effects generally appear within 15-30 minutes.
• Initial effects include a brief "rush" of energy,
  usually described as mild but euphoric.
• After this rush, the high levels off to a plateau
  which lasts 2-3 hours and is followed by a
  gradual "coming down" sensation, culminating in a
  feeling of fatigue. In about 4-6 hours
• MDMA exerts amphetamine-like effects
• These side effects are dose dependent.

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MDMA (Ecstasy) How does it work?

• It MDMA blocks the reuptake of serotonin (5-HT),
  Unlike those drugs MDMA appears to enter the
  neuron, and causes the release of 5-HT as well.
• Thus MDMA is primarily a seritonergic
• MDMA acts on 5-HT similarly to the way
  amphetamines act on dopamine.
• MDMA also agonist effects on 5HT2 muscarinic M1,
  alpha-2 adrenergic and histamine H1 receptors
  (Thus its stimulant effects)
• MDMA also causes some release of dopamine

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MDMA

• MDMA exerts a strong paradoxical effect of
  relaxation which may mask the stimulant side
  effects, followed by a gradual drop.
• Generally, the side effects of MDMA are similar
  to those of amphetamine.
• MDMA also appears to exert an adverse action on
  the immunological response of some individuals,
  particularly with heavy use.

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MDMA (Ecstasy) Toxicity

• MDMA is most often ingested orally, although
  inhalation and injection have been infrequently
  reported.
• The usual dose ranges from 100 to 150 mg.
  Toxicity may be seen at doses as little as 175 mg
• Ecstasy tablets are notoriously impure, often
  containing chemicals other than MDMA (such as
  PMA, PCP,or DXM)
• The Problem is that multiple drug combinations
  (especially stimulants)may lower the toxic
  threshold.
• MAO Inhibitors may lethally potentate this drug.

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MDMA (Ecstasy) Toxicity Mild s/s

• Jaw clenching (Lower Jaw)/teeth grinding, and
  scratching (think Tweekers)
• Nystagmus, Dilated Pupils
• Tremors
• Tachycardia, increased B/P
• Sensation of chills (secondary to elevated temp)
• Auditory Hallucinations (non specific)/sensitivity
  
• Orthostatic s/s, syncope secondary to dehydration

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MDMA (Ecstasy) ToxicityMajor S/S

• Severe Dehydration with Hyponatremia
• Malignant Hyperthermia (Think Heat Stroke, but
  worse)
• Disseminated Intravascular Coagulation (DIC) (may
  have rapid onset)
• Decreased LOC/Coma
• Stroke S/S, Seizures
• Severe Tachycardia, HTN, CHF
• Kidney Failure

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MDMA (Ecstasy) ToxicityTreatment

• Calm low stimulus environment
• VOMIT, Fluid Resuscitation as needed
• Benzodiazepines
• Droperidol 2.5-5mg for sedation/chemical
  restraint IM/IV
• Haldol 5 mg IM/IV
• Consider short acting Beta Blockers for severe
  HTN/Tachycardia (Brevibloc 500 mcg)
• Active cooling if indicated

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MDMA (Ecstasy) What does this mean to me?

• Core Temp if unresponsive
• Fluid Resuscitation
• Watch for DIC, SZ
• P.U.H.A. IF GROSSLY SYMPTOMATIC.

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PMA- Introduction

• Para-methoxyamphetamine, PMA, 4-METHOXYAMPHETAMIN
  E
• Chemically similar to MDMA, first created almost
  25 years ago
• Since its cheaper to make, and uses non
  controlled substances, PMA is often
  misrepresented as MDMA.
• At doses considered safe for MDMA, PMA is
  highly toxic.

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PMA-How is it used?

• PMA is however more toxic than MDMA
• It often appears identical to MDMA, sometimes
  simply thicker.
• Its onset of action is longer (almost 60 minutes)
  compared to MDMA at 15-30 minutes
• Users will re-dose thinking its MDMA and push
  them selves into the toxic range
• Some people think they know their MDMA dose and
  apply this to PMA, thus going toxic
• Substances like Cocaine and Methamphetamine may
  exacerbate the toxic effects of either PMA or MDMA

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PMA- How does it work?

• PMA is over 20 times as potent as MDMA as an
  inhibitor of 5-HT. (in rat studies)
• Like MDMA, PMA blocks the reuptake of serotonin
  (5-HT), Also PMA appears to enter the neuron, and
  causes the release of 5-HT as well.
• PMA acts on 5-HT similarly to the way
  amphetamines act on dopamine.
• PMA also agonist effects on 5HT2 muscarinic M1,
  alpha-2 adrenergic and histamine H1 receptors
  (Thus its stimulant effects)

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PMA- Toxicity

• Street doses of MDMA generally run from 50mg. to
  150 mg. 100mg. or 1/10th of one gram is
  considered an average single dose.
• However the street dose for PMA usually less than
  about 50 mg, with toxic effects seen at even
  slightly higher doses (making toxicity likely)
• When mixed with other drugs (including alcohol)
  or more tablets are taken, the toxic effects
  become more apparent.

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PMA-Toxicity

• With PMA one should not thing about mild vs.
  severe toxicity.
• Think about How much time before the patient
  develops severe toxicity.
• Deaths have been seen with as few as 2-3 tablets
  of PMA.

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PMA -Toxicity

• Hypertension
• Tachycardia and Cardiac arrhythmias,
• Tachypnea
• Severe hyperthermia (as high as 108 degrees F)
• Dehydration (may be severe)
• Renal Failure

• Hallucinations, Behavioral disturbances (similar
  to Ecstasy or LSD)
• Nausea, vomiting
• Erratic eye motion
• Seizures
• DIC
• CHF
• Coma
• Typically any MDMA s/s
• Severe S/S may follow w/in the hour

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PMA- Treatment

• Calm low stimulus environment
• VOMIT, Fluid Resuscitation as needed
• Benzodiazepines
• Droperidol 2.5-5mg for sedation/chemical
  restraint IM/IV
• Haldol 5 mg IM/IV
• Consider short acting Beta Blockers for severe
  HTN/Tachycardia (Brevibloc 500 mcg)

• Active cooling if indicated Treatment is similar
  as for MDMA, generally focused at reducing body
  temperature and response to presenting symptoms.
• Transport should be rapid, as once symptoms
  present, progression to life threatening problems
  may be rapid.
• A recent series of post mortem toxicology screens
  found other types of methamphetamine in 5 of 6
  PMA related deaths

36
PMA-What does this mean to me?

• 1st you identify a probable MDMA/PMA user.
• Then you get a good subjective Hx ,
• By gauging the time of onset of s/s, you can have
  a suspicion for PMA and potential toxicity.
• This combined with the knowledge of PMAs
  Toxicity risk, should help insure the pt. gets
  transported to a medical facility regardless of
  stable presentation.
• Core Temp if unresponsive
• Fluid Resuscitation
• Watch for DIC, SZ
• P.U.H.A. IF GROSSLY SYMPTOMATIC

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DXM- Introduction

• Yes, Its in cough Syrup
• Dextromethorphan acts as a cough suppressant via
  its agonist (activating) activity at mu-opioid
  receptors.
• In Canada Contac CoughCaps (30 mg DXM)
• Related in effects to Ketamine and PCP

38
DXM- How is it used?

• Robo-ing (Old Term from early 90s)
• DXM is available over-the-counter in tablet form
  in several countries as a cough med. Robitussin
  Maximum Strength Cough (not Robitussin DM) syrup
• Users often refer to DXM in plateaus
• Dose of Robitussin Maximum Strength Cough syrup
  is two to five full "shots" using the shot glass
  that comes with the bottle.

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DXM- How does it work?

• DXM is in the same class as ketamine, PCP,
  MK-801, and several other NMDA open channel
  blockers
• Dose ranges from 100-900 mg. Fatal may be in
  excess of 1500 mg, but may be lowered by other
  drugs. Duration is about 2-4 hours, but some
  effects may linger for weeks
• It is classified (generally) as a Dissociative
  Anesthetic
• Some times educated users take a barbiturate or
  benzodiazepine to prevent brain damage while
  taking this drug (Olney's Lesions)

40
DXM- How does it work

• In simple terms, they knock you out by putting
  you 'out of your body
• Effects at low dosage can be similar to alcohol
  producing carefree clumsiness with a touch of
  psychedelic and speedy effect. Intense and
  rhythmic music induces a state of euphoria and
  dancing becomes fun. (thus its rave use)
• On a higher dose imagination can become vividly
  experienced (not always pleasant), feelings of
  dissociation from the body can occur and on very
  high doses profound alterations in consciousness,
  violent outburst, SZ.

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DXM- Toxicity (Acute)

• Dissociative anesthesia/coma/CNS depression
• mild hallucinations, Violent Outbursts/behavior
  control (may last beyond the period of
  intoxication)
• Seizures (lowers the SZ threshold)
• Enhanced auditory perceptions, Tactile sensations
  (crawling skin), Visual disturbances with motion.
  Nausea/vertigo can occur
• DXM has some stimulant effects
• GHB may act synergistically w/ DXM to lower the
  SZ threshold

42
DXM- Toxicity (Acute)

• Hyperthermia
• Histamine Release
• Hypertension
• Tachycardia

43
DXM- Toxicity (Long Term)

• Olney's Lesions vacuoles (essentially, tiny
  holes) in their brains. Specifically, the
  vacuoles showed up in the posterior cingulate
  cortex and retrosplenial cortex
• People who have used dissociatives heavily have
  shown clear evidence of brain damage ranging from
  impaired memory to a schizophrenia-like syndrome.
  
• Many of the impairments correspond exactly to the
  areas of the brain damaged in lab animals.

44
DXM- Coricidin Toxicity

• Coricidin Cough and Cold Caps, 30 mg DXM and 4
  mgs of Chlorphineramine maleate
• Non Specific reports of Respiratory Failure at
  high doses.

45
DXM- Treatment

• VOMIT
• Symptomatic TX.
• Be alert for and (Cautiously) treat hypertension
  or hypotension, and rarely, cardiovascular
  problems
• Restraints (?)
• Avoid Chemical Restraint (Haldol, Droperidol),
  and use Benzodiazepines with caution (Be prepared
  to manage the airway)
• Benadryl may be given for Dystonic reactions, and
  for s/s of histamine release.

46
DXM- What does this mean to me?

• Be Careful, take the same precautions you would
  with a PCP patient.
• ALS eval is a must ( HTN, Hyperthermia,
  Respiratory Depression, and self harm)
• DXM differs from other drugs. Its presentation of
  s/s extend well beyond simple CNS depression and
  hallucinations but into basic cognitive functions
  as well.
• Understanding that DXM effects last well beyond
  the 4 hours of intoxication , and that side
  effects may include Psychotic Breaks will help
  determine deposition of patients.

47
Ketamine- Introduction

• Another Disassociative Amnesiac
• Special K, Vitamin K, new Ecstasy, psychedelic
  heroin, Cat Valium, Ketalar, Ketaject, Super-K,
  breakfast cereal, date rape drug. Slang

48
Ketamine-How is it used

• Used legally as a Veterinary anesthetic
• Illegally used as a Date Rape Drug
• Liquid Ketamine was developed in the early 1960s
  as an anesthetic for surgeries, and was used in
  Vietnam as an anesthetic.
• Powdered Ketamine emerged as a recreational drug
  in the 1970s, and was known as "Vitamin K" in the
  1980s. It resurfaced in the 1990s rave scene as
  "Special K.
• Ketamine is most often injected intramuscularly,
  but can also be taken orally or nasally.

49
Ketamine-What does it do?

• central nervous system depressant
• rapid-acting general anesthetic
• sedative-hypnotic, analgesic, and hallucinogenic
  properties
• Works similar to DXM.

50
Ketamine-Toxicity

• Common recreational doses are between 25mg. and
  500mg. depending on body size and the method of
  administration
• Effects can include delirium, impaired motor
  function, potentially fatal respiratory problems,
  convulsions, and vomiting and out of body
  experiences. (Think DXM)
• The worst problems associated with Ketamine are
  seizures, arrhythmias, respiratory arrest,
  dystonic reactions, coma and cardiac arrest.

51
Ketamine-Toxicity

• The psych effects are similar to LSD, mushrooms
  or Angel Dust (PCP).
• Seizures
• Arrhythmias, cardiac arrest
• Respiratory arrest
• Dystonic reactions
• coma

52
Ketamine-Treatment

• supportive in nature.
• Benadryl for dystonic reactions
• Benzodiazepines are the preferred drug for
  sedation and restraint.
• Use Inapsine and Haldol w/ caution
• Mental health referral is a necessary step for
  all Ketamine overdoses for both substance abuse
  screening and education as well as for
  neuropsychological evaluation for long-term side
  effects (Olney's Lesions) Think DXM

53
Ketamine- What does this mean to me?

• When trying to remember what drug does what,
  remember that PCP, DXM, and Katamine are all
  related neuro-chemically
• Prompt identification and treatment of Ketamine
  overdoses generally result in full recovery of
  most patients.
• Katamine differs from other drugs. Its
  presentation of s/s extend well beyond simple CNS
  depression and hallucinations but into basic
  cognitive functions as well
• When considering destination of these patients,
  consider the Psychiatric capability as well.
• ALS eval is a must ( HTN, Hyperthermia,
  Respiratory Depression, and self harm)

54
GHB Analogs- Introduction

• Gamma-hydroxybutyrate (GHB) may be made in homes
  by using recipes with common ingredients.
• "Liquid Ecstasy," "Georgia Home Boy," "Grievous
  Bodily Harm,
• "liquid ecstasy," do not confuse w/ MDMA
• GBL, GBH, One 4 B

55
GHB analogs How is it used?

• GHB can be produced in clear liquid, or a white
  powder, tablet, and capsule forms, and it is
  often used in combination with alcohol, making it
  even more dangerous
• It is often carried in an eye dropper, or in
  water/Gatorade bottles and passed around.
• Typically measured out in capfuls.
• Occasionally blue food coloring is used to
  identify it at some raves.
• It is occasionally used as a body building aid

56
GHB analogs- what does it do

• At lower doses, GHB has sedative effects, but, as
  the dose increases, GHB effects may result in
  sleep ,eventual coma, respiratory arrest, or
  death.
• It is these effects that make it both a prime
  drug at Raves, and for Date Rape

57
GHB analogs toxicity- mild

• Lethargy, easily aroused with repeated
  stimulation
• Drowsiness, somnolence, dizziness, euphoria
• Confusion (dazed and confused)
• Amnesia, Susceptible to suggestion

58
GHB analogs Toxicity- Severe

• 66 with GCS
• Frequent Vomiting,
• bradycardia,
• Respiratory depression or arrest
• Seizures
• Sudden onset of coma . patients often demonstrate
  extreme SUDDEN combativeness and agitation
  despite such profound CNS and respiratory
  depression
• Death (usually secondary to respiratory failure
  or aspiration)

59
GHB analogs Toxicity

• It is worth noting that alcohol severely
  exacerbates GHBs effects.

60
GHB analogs-Treatment

• Primary Supportive
• Beware of positional Asphyxia, But soft
  restraints are a good Idea
• Due to the risk of sudden airway failure,
  aspiration, and respiratory collapse, these
  patients need aggressive airway monitoring by ALS
  providers

61
GHB analogs-Treatment

• Protect your self
• VOMIT
• Be cautious using respiratory depressants
• Making the decision to tube/not tube is tough,
  these patients do frequently vomit.
• ETT placement is uncommon, but post ETT
  sedation/paralysis and restraint should be
  mandatory in the field

62
GHB analogs- What does this mean to me?

• GHB analogs are unpredictable in clinical course,
  other than duration.
• GHB analogs cause a rapid change in mental and
  respiratory status that makes it difficult to
  plan treatment and care
• GHBs presentation often mimics ETOH abuse and is
  often co-imbibed.

63
Rohypnol Introduction

• Roofies is a common drug used overseas
• It has seen rising use in the US in the Date Rape
  scene.
• It should be noted that similar drugs may be sold
  under this name as well. (Roche)

64
Rohypnol- How is it used

• Frequently used as a date rape drug
• Generally placed illicitly in alcoholic drinks.
• Is odorless/tasteless, and dissolves easily into
  carbonated drinks.
• Clonazepam (A similar US marketed drug) are often
  used as Roofies. Roche

65
Rohypnol- What does it do

• Benzodiazepine, Sedative-hypnotic
• Respiratory depressant
• Antitrade amnesia (Like Versed)

66
Rohypnol-Toxicity

• 1 MG of Rohypnol can impair the pt for up to 8
  hours
• 3 mg of Clonazepam causes significant CNS
  depression and somnolence in 50 of adults on one
  study(with no other drug use) (Comes in .5, 1
  and 3 mg tablets)
• like those produced by other CNS depressants,
  include somnolence, confusion, coma and
  diminished reflexes

67
Rohypnol-Treatment

• Flumazenil is not indicated in patients with
  epilepsy who have been treated with
  benzodiazepines. Antagonism of the benzodiazepine
  effect in such patients may provoke seizures.
• It is also Contraindicated in Poly-Pharm cases.
• Otherwise care is supportive and based on
  Respiratory status.

68
Rohypnol- What does this mean to me?

• Treat these calls and the patients as potential
  criminal cases
• Flumazinil is generally contraindicated in the
  field
• Airway and respiratory concerns are the
  predominate medical problem
• Do not r/o other drug involvement.

69
Summery

• ..Due to the poly-pharmacy drugs that are being
  sold to ravers, all of these patients deserve ALS
  evaluation