Transcript Slide 1

Nithya Swamy
Resident’s Conference
October 7, 2008
Introduction
 4.7% of the world’s population participate in illicit
drugs
 In the US, of those 12 years or older
 8-9% of individuals in the US abuse illicit drugs
 46.1% have tried it in their lifetime
 Drug use or drug withdrawal can be the cause of a
presenting illness or it can mask an underlying illness
 It is important to recognize the symptoms of drug
intoxication and how to treat it
Goals of Presentation
1.
2.
3.
4.
5.
6.
Drug Use Stats in the US
How Drugs Work
Cases/Common Recreational Drugs
Street Lingo
Drug Effects
Management and Treatment
Drug Use in the US
Drug use at least
once in the last 30
days among those
12 and older
• 22.5 million > 12y were classified with drug abuse or drug dependence. This includes
tobacco, alcohol and illicit drugs.
• 26% American Indian or Alaska Native
• 12.2% for mixed races
• 11.1% Caucasian
• 10.2% Hispanic
• 9.3% African-American
• 6.0% Asian
• Random Scary Fact: By eighth grade, 52 percent of teenagers have consumed alcohol, 41
percent have smoked cigarettes, and 20 percent have used marijuana.
Drug Use in the US
 25-40% of hospitalizations in the US involve substance




abuse
10-16% of outpatients have substance use problems
16,000 deaths/year are due to illicit drug use whether
directly or indirectly (HIV/AIDS, hepatitis,
tuberculosis, homicides, and other violent crimes and
incidental injuries)
Cost: $531 billion dollars annually ($181 billion in illicit
drugs, $168 billion for tobacco and $185 billion for
alcohol)
527000 ER visits each year
Drug Use in the US
 6-7% of senior citizens admitted exhibit symptoms of
alcoholism. Prevalence of problem drinking in the nursing
homes is high as 49%
 In this subpopulation, the majority are women.
 They are more prone to dependence on prescription medications
2/2 overmedication by their own physicians

Opiods for pain and sedative/hypnotics for anxiety or insomnia
 Random Scary Fact #2: Health care workers are at increased risk
of addiction due to high stress jobs and access to drugs.
 Anesthesiologists, surgeons, and emergency room physicians are at
highest risk for drug dependence.
How Drugs Work
 Acute Drug Use:
 Release and Prolonged action of dopamine and serotonin within the
reward circuit.
 Reward Circuit (mesolimbic system)


Addictive drugs lead to the release of dopamine. Dopamine binds to D1 receptor
triggering a signaling cascade that leads to a pleasurable response.
There is also a 2nd cascade activated involving a cAMP dependent PK which activated a
CREB tf which when activated inhibits dopamine release.

In drug users this pathway is chronically active resulting in the need for larger doses to
achieve the same pleasurable response.
DSM IV
SUBSTANCE DEPENDENCIES
303.90 Alcohol
304.40 Amphetamines
304.30 Cannabis
304.20 Cocaine
304.50 Hallucinogens
304.60 Inhalants
305.10 Nicotine
304.00 Opiods
304.70 PCP
304.10 Sedative, Hypnotic or anxiolytic
304.80 Polysubstance dependence
304.90 Other (or unknown) substance
The Drugs
Alcohol
Short Term Effects
 Euphoria: BAC = 0.03 to 0.12%
 Lethargy: BAC = 0.09 to 0.25%
 Confusion: BAC = 0.18 to 0.30%
 Ataxia
 Stupor: BAC = 0.25 to 0.40%
 Anterograde amnesia
 Coma: BAC = 0.35 to 0.50%
 Death: BAC more than 0.50%
 Alcohol->Acetylaldehyde->Acetic Acid->fats, CO2, Water
 Death in the acute phase:
 Alcohol poisoning and respiration depression, loss of gag reflex and
asphyxiation
 Wernicke encephalopathy: ataxia, ophthaloplegia, confusion and impairment of
short-term memory. Lesions in the CNS & PNS. Heavy alcohol use interferes
with thiamine breakdown.

Tx: Thiamine IV/IM
Long Term Effects
 Brain
 Impairs brain development and neurogenesis
 Myopathy in the proximal muscles: 50%
 Polyneuropathy
 Wernicke-Korsakoff:


Korsakoff’s psychosis: progression from Wernicke’s; anterograde and retrograde amnesia, anisocoria,
confabulation, ataxia, tremors & lack of insight.
Long-term tx with thiamine but at this point, may never return to their baseline.
 Heart:
 Dilated cardiomyopathy and CHF

Tx: ACE I, BB, Diuretics, or heart transplant
 GI: mucosal damage
 Inflammation of GI tract
 Impairs esophageal motility, esophagitis, Barrett’s, esophageal Ca, Mallory Weiss
 Steatohepatitis
 Alcoholic hepatitis: Inflammatory response to fatty accumulation: jaundice, ascites,
AST>ALT, encephalopathy, increased PT

Tx: cortiocosteroids, sometimes pentoxyfilline
 Cirrhosis: fibrosis and altered architecture

Portal HTN: gastric & esophageal varices

Coagulopathy

Ascites, encephalopathy and hepatorenal syndrome

Tx: symptomatic: lactulose, vitamin K or FFP, nadalol
Alcohol Withdrawal
 High mortality rate if not effectively treated.
 Alcohol’s primary effect is the stimulation of GABA and
promotes CNS depression
 When abruptly stopped, the CNS undergoes uncontrolled
synapse firing.
 Leads to anxiety, shakiness, diaphoresis, insomnia,
tachycardia, tremor and in more severe cases seizures &
delirium tremens
 DT: autonomic instability, hallucinations
 Treatment: symptomatic and supportive:
 Benzodiazepines followed by taper, vitamin and fluid
replacement
Case
 A 35 year old male presents to the ER and is hyperactive
and tremulous. His girlfriend brought him in for AMS. He
keeps saying he is “the authority of the human mind” and
that because of that, people are trying to kill him. His
girlfriend reports he has not slept much in days.
 Physical Exam:
 H: 5’9; 95lb. T: 103.6, HR: 115, BP: 178/110,
 Pupils are equal but dilated, dry membranes with very poor
dentition
 CV: Irregular rhythm and tachycardic
 What drug has he been taking?
Amphetamines
 Common Amphetamines: (aka Pep Pills, Uppers, Rippers,
Sparklers)
 Amphetamine Sulphate:

Speed, benzedrine, bennies, sulph, whiz, billy
 Dextroamphetamine:

Dexedrine, Dexy’s Midnight Runners, Dexies
 Methamphetamine:

Methedrine, Crank, Crystal Meth, Ice, Meth, Redneck
cocaine, Tina, Geek
 Amphetamines are stimulants that increase levels of the
neurotransmitters: norepinephrine, serotonin and
dopamine.
 It stimulates NT release and at high doses inhibits NT uptake
 Routes: smoking, injection, snorting and rectally
 Intoxication:
 Short term: mydriasis, hyperactivity, increased physical
activity, decreased appetite, tachypnea, tachycardia, irregular
heartbeat, hypertension & hyperthermia.

symptomatic tx with benzos and antipsychotics
 Long term: extreme weight loss, hypoglycemia, severe dental
problems, anxiety, confusion, insomnia, intracerebral
hemorrhage, mood disturbances, and violent behavior. Also,
psychotic features, including paranoia, visual and auditory
hallucinations, and delusions.
 Overdose:
 Sympathetic overload: diaphoresis, tachycardia,
vasoconstriction, hypertension, hyperthermia

Hyperthermia and vasoconstriction can lead to
rhabdomyolysis, renal failure, CV collapse & death.
 Withdrawal:
 7 -10 days



Hypersomnia
Depression
Hyperphagia
 Treatment:
 No medications, primarily behavioral rehab
Chronic use: Noninvasive human brain imaging studies
have shown alterations in the activity of the dopamine
system that are associated with reduced motor
performance and impaired verbal learning. Recent
studies revealed severe structural and functional
changes in areas of the brain associated with emotion
and memory
Case
 A 37 yo female presents drowsy and disinhibited. She keeps
trying to get out of bed and when she does, she is
staggering. She is difficult to understand as her speech is
slurred and she is obviously confused. She becomes more
somnolent and soon becomes difficult to arouse. He
breathing decreases and she requires intubation. Her
husband says “she takes some pills everyday. She has to take
them because if she stops, she has a fit”
 PE:
 T: 95, P: 85, R 18, BP: 76/50
 Eye: lateral nystagmus
 What kind of drug is she on?
Barbiturates
 COMMON BARBITURATES:
 Amobarbital:

Downers, blue heavens, blue velvet, blue devils
 Pentobarbital:
 Nembies, yellow jackets, abbots, Mexican yellows
 Phenobarbital:

Purple hearts, goof balls
 Secobarbital:
 Reds, red birds, red devils, lilly, F-40s, pinks, pink ladies, seggy
 Tuinal:
 Rainbows, reds and blues, double trouble, gorilla pills, F-66s
 Barbiturates are CNS depressants: mild sedation and
anesthesia.
 Anxiolytics, hypnotics and anticonvulsants
 Potentiates inhibitory GABA receptor and a glutamate
receptor
 Upregulates CYP 450 in the liver
 Routes: Oral and IV/IM
 Sx: Respiratory depression, hypotension. Fatigue,
hypothermia, irritability, dizziness, sedation, lateral &
vertical nystagmus, confusion and ataxia.
 Drug users often abuse barbiturates to counteract the
symptoms of stimulants like cocaine or meth
 Commonly abused barbiturates are short acting
 Overdose can lead to respiratory failure and death
 Tx: symptomatic and charcoal
 Withdrawal: 12-20h after the last dose. Symptoms
include anxiety, irritability, elevated heart and
respiration rate, muscle pain, nausea, tremors,
nightmares, insomnia, vivid dreams, hallucinations,
confusion, and seizures
 Tx: stabilization with an intermediate acting barbiturate
like pentobarbital. Newer techniques involve loading
doses of phenobarbital titrated to the clinical or toxic
effects. Eventually they require a gentle taper and rehab
Case
 A 45 year old physician presents complaining of
anxiety, palpitations and profuse sweating. He did not
sleep the night before. He has his sunglasses on and
he’s asking you to whisper b/c anything louder hurts
his years
 PE: He seems anxious and agitated.
 T:98.6, P: 110, R: 33 BP: 150/95
 What drug is he withdrawing from?
Benzodiazepines
 COMMON BENZODIAZEPINES:
 Alprazolam (Xanax)
 Lorazepam (Ativan)
 Clonazepam (Klonopin)
 Diazepam (Valium): Valley Girl
 Triazolam (Halcion)
 Street Names: BZDs, Benzos, Downers, Goofballs,
Heavenly Blues, Robital, Stupefy, Tranx
 Psychoactive drugs with hypnotic, sedative, anxilytic,
anticonvulsant, muscle relaxant and amnesic properties
mediated by slowing of the CNS.
 Tolerance develops quickly and higher doses are required
to achieve the same effect.
 Often, by 4-6 months, benzos have little efficacy
 Benzodiazepines can give rise to physiologic and
psychologic dependence based on the drug's dosage,
duration of therapy and potency.
 Benzos are rarely the sole drug of abuse. An estimated 80
percent of benzodiazepine abuse is part of polydrug abuse,
most commonly with opioids.
 Overdose: respiratory depression, hallucinations, coma.
Mortality rates are not as high as barbiturates
 Tx: supportive; flumazenil is used only for severe cases, as it can
cause acute withdrawal and subsequent seizures.
 Flumazenil should only be used if Benzodiazepines is the only drug
of abuse.
 Withdrawal: Anxiety, tachycardia, hypertension,
diaphoresis, insomnia and sensory hypersensitivity.
 Tx: Taper with a longer acting benzo like chlordiazepoxide
Case
 A 26 year old male presents to the ED complaining of
progressively worsening productive cough and shortness of
breath for 3 days. He does have chest pain but attributes it
to his persistent cough. His sputum is productive of white
foamy sputum.
 When you are assessing him, his breathing becomes more
labored and eventually he has to be intubated. He
progressively becomes hypotensive and requires pressors.
An TTE is done at the bedside and reveals severe dilated
cardiomyopathy with an EF of 15%.
 What is the offending drug?
Cocaine
 Common Street Names:
 Blow, C, California Cornflakes, Nose candy, Coke, Columbian foot
soldiers, Flake., Lady C, snowball, tornado, wicky stick, Showbiz
Sherbert, White Lady, Shnazzle
 Routes:
 Freebase: smoking the base form of cocaine. Absorbed directly into the
bloodstream from the lungs. Rush is more intense than snorting.
 Crack/Cocaine: smokable. Freebase form of cocaine that is made from a
reaction between cocaine and sodium hydroxide.
 Insufflation (snorting, sniffing, blowing)
 Oral: rubbed along gum line: "numbies", "gummers" or "cocoa puffs"
 Strong CNS Stimulant: increase levels of dopamine through the reward
circuit
 Acute:
 Moderate amounts: vasoconstriction, dilates pupils, hyperthermia,
tachycardia, hypertension, euphoria
 Large amounts: Intensify the user’s high, but may also lead to bizarre,
erratic, and violent behavior. Arrhythmias, tremors, vertigo, muscle
twitches, paranoia, or with overdose, cardiac and respiratory arrest
 Chronic:
 bronchospasm, pruritus, fever, diffuse alveolar infiltrates without
effusions, dilated cardiomyopathy, stroke, MI, degradation of septum
nasi, shortness of breath, tooth decay, renal failure
 Withdrawal
 Depressed mood, Fatigue, Generalized malaise, Vivid and unpleasant
dreams, Agitation and restless behavior, Slowing of activity and
Increased appetite
 Low to non-existent mortality; high risk of relapse
 Treatment:
 Supportive, behavioral treatment and detox
Cocaine and ACS





Risk of MI is increased 24-fold in the 1st hour after cocaine use.
6% of patients with cocaine-associated chest pain are having an AMI.
An additional 15% meet the criteria for ACS.
Ischemia may be delayed for up to 24 hrs after use.
Acute:






Vasoconstriction
Immediate and delayed coronary vasoconstriction
Vasoconstriction may be worsened if cocaine is used with tobacco
Hypercoaguability
Platelet activation & aggregation
Increased oxygen consumption
 Chronic:
 Early atherosclerosis and coronary ectasia
 Cardiomyopathy
 EKG: may be normal, non-specific or show ST changes
 56-84% of patients will have an abnormal EKG.
 Up to 43% meet EKG criteria for reperfusion therapy.
Case
 A 17 year old female presents to ED with altered
mental status. She has rapid speech and discussing her
important role in the universe. She is trying to
hug/kiss/grope your male resident.
 PE:
 T: 105, P: 120 R: 25, BP: 140/90
 Difficult to assess as she can’t stop moving, but you do
note she grinding her teeth.
 Her lab values are significant for a Na 115 and a Cr 2.0
MDMA
 Common street names:
 Ecstasy, Adam, Beans, Ex, hug drug,
Jack and Jills, Mandy, Smartees, Sweets,
Vitamin E
 Routes: oral as capsule or tablet
 Semi-synthetic member of amphetamines
 Sub-class of phenylethylamines
 Considered a stimulant, psychedelic, empathogen
(emotional lability)
 Affinity for SERTs (serotonin transporter)


MDMA inhibits the reuptake of serotonin and it reverses the
action of the transporter so that it begins pumping serotonin
into the synapse from inside the cell
Stimulates norepinephrine and dopamine release
 Acute:
 Euphoria, decreased anxiety, intimacy, decreased appetite, urinary retention,
pupil dilation, increased energy, tachycardic, hypertensive, also, oral fixation
such jaw clenching and teeth grinding.
 Danger signs: Hyperthermia, Dehydration, Hyponatremia and Serotonin
syndrome
 Chronic: Serotonergic change
 Overdose: Serious adverse events in MDMA users may be an interaction of the
drug with a preexisting medical condition.
 Risk of adverse event after MDMA consumption is thought to be increased by
preexisting cardiovascular problems, such as cardiomyopathy, hypertension,
viral myocarditis, and congenital cardiac conduction abnormalities
 Neuro: subarachnoid hemorrhage, intracranial bleeding, cerebral infarction due
to MDMA-induced increases in blood pressure may occur in people with
preexisting congenital AVMs or cerebral angiomas.
 Hyperpyrexia: resulting rhabdomyolysis and renal failure
 Hyponatremia: Convulsions
 Tx: SSRIs prevent neurotoxicity. Symptomatic with benzos or dantrolene
Case
 A 42 year old cachectic male presents with a RR of 4
and is unresponsive. His pupils were constricted but
reactive. The paramedics gave him a medication in
which he woke up and reported he took some “cheeba”.
Later, he reported he was freezing and had rigors. He
also had diffuse abdominal cramping, vomiting and
persistent diarrhea.
 Name that drug!
Heroin
 Common Street Names:
 Black, Brown Sugar, Cheeba, Diesel, Hero, Horse, Junk,
Lady H, Poppy, Smack
 Routes:
 IV
 Insufflation
 Smoking
 Other: Speedball or snowball
 Cocaine plus heroin leading to a more intense rush than
one alone
 Synthetic opiod synthesized from morphine
 Crosses blood brain barrier, is converted to morphine
and binds opiod receptors
 Symptoms
 Injection leads to rush of euphoria followed by dry mouth,
periods of wakefulness and sleep, mental slowing. Other
routes have the same symptoms without the intense rush
 Risks:
 Infections, HIV, Hepatitis,
 collapsed veins, endocarditis, pericarditis
 renal insufficiency
 chronic constipation
 pulmonary complications (pneumonia, respiratory
depression).
 Vascular and organ damage from toxic contaminants in
the heroin
 Overdose: Respiratory depression, constricted pupils,
hypotension, coma, delirium, muscle spasticity
 Treatment: Naloxone or Naltrexone
 Withdrawal
 Occurs 6-24h after last dose
 Rebound hyperactivity of the sympathetic nervous system
 Sweating, malaise, anxiety, depression, cramps, excessive
yawning or sneezing, insomnia, chills, rigors, vomiting,
diarrhea, restless leg
 Tx:


longer-acting opiod such as methadone or buprenorphine.
Benzos can be used for symptomatic treatment of anxiety,
insomnia and muscle spasms. Loperamide is used for diarrhea
and Clonidine for hypertension.
Prescription Opioids
 Commonly abused prescription opioids
 OxyContin
 Hydrocodone
 Methadone
 Morphine
 Hydromorphone
 Fentanyl
 Buprenorphine
 Similar symptoms to heroin but lack heroin’s potency
and therefore its severe intoxication and withdrawal.
Case
 A 35 year old male presents with a knife in his left shoulder.
He does not seem to be in pain, but is very agitated and has
to be restrained. According to the police, he started a fight
by attacking a large group of people. On admission, he
continuously yells the aliens are going to abduct him and
that they are talking to him through the TV.
 PE: T: 98.6, P: 122, R: 28, BP: 185/115
 Diffusely erythematous
 Subconjunctival hemorrhage, Dilated pupils, non-reactive
 Dry mucous membranes
 Does not withdraw to pain
PCP
 Common Street Names
 angel dust, illy, water, BrainTree, fry, dumb dust, rocket
fuel, cake, nature boy, love boat, elephant tranquilizer
cornbread, Hairy Jerry, George Jefferson
 Routes:
 Powder: insufflated
 Liquid: dipped on cigarettes and marijuana and smoked.
IV/IM as well.
 Dissociative drug causing hallucinogenic and neurotoxic effects.
 Blocks conscious mind from other parts of the brain.
Depersonalization, derealization and anesthesia.
 NMDA receptor antagonist similar to ketamine and
dextromethorphan.
 Anesthetic
 Associated with memory deficits, psychotomimetic effects similar
to psychosis. Confusion, difficulty concentrating, agitiation,
nightmares, catatonia and ataxia
 Effects:
 Acute: Diaphoresis, HTN, tachycardia. Also, numbness in the
extremities and intoxication, characterized by staggering, unsteady
gait, slurred speech, bloodshot eyes, and loss of balance. More
prone to physical injury as they can’t feel pain.
 Psych: resembles schizophrenia: unpredictable and driven by their
delusions. Auditory hallucinations
 RED DANES: Rage, Erythema, Dilated pupils, Delusions, Amnesia,
Nystagmus, Excitation, Skin Dry.
 Rarely, cardiac failure can result.
Case
 A 68 year old female presents to the ED. She reports
seeing “beautiful colors swirling around” as well as
being able to “smell the lovely music”. She otherwise
will not answer any questions.
 PE: T: 94.7, P 50, R 18 BP 120/80
 Drooling, staring at something/nothing in the air.
 Pupils dilated but sluggishly reactive
 Neuro: Reflexes are 4+ bilaterally
 And the drug is……
LSD
 Common Street Names:
 Acid, Alice, California Sunshine, Trip, Timothy Leary
Ticket, Sugar cubers, Tabs
 Route:
 Tabs, LSD blotter paper dissolved in LSD/Water/Alcohol
solution
 IV/IM
 Synthesized from lysergic acid derived from ergot, a grain fungus that grows on
rye.
 Unknown mechanism of action, but thought to bind dopamine and serotonin
receptors promoting their release
 Physical Sx:
 Hypothermia, fever, hyperglycemia, bradycardia, goose bumps, perspiration,
pupil dilation, saliva production, mucus production, sleeplessness, paresthesia,
euphonia, hyperreflexia, tremors
 Psychological Sx:
 Varies person to person.




Synesthesia
radiant colors, objects and surfaces appearing to ripple or "breathe," colored patterns
behind the eyes, a sense of time distorting, crawling geometric patterns, morphing
objects
loss of a sense of identity, powerful, and sometimes brutal, psycho-physical reactions
interpreted by some users as reliving their own birth.
Lasts 6-14h
 Withdrawal:
 Minimal: Diarrhea, chills, tremors
 Risks: Minimal as it is non-addictive. In patients who take Lithium, SSRIs or
tricyclics with antidepressants, there is an increased risk of a dissociative fugue.
They are unaware of their actions and can harm themselves.
The End
This is your brain after
this presentation.
Any Questions ??????