Transcript record cerebral academy

DRUG MISUSE IN THE EMERGENCY
CLINIC
March 2016
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Appreciate dynamic nature of recreational drug scene and rapid
emergence of new psychoactive medications
Appreciate the need to remain up-to-date with merging patterns
Recognise that most cases require support and symptomatic care
Be aware of available antidotes and indications for use
Recognise the importance of asking all patients about substance
use
Recognise the attendance at ED provides opportunities for brief
intervention and health promotion advice
Be aware if of available local addiction services to signpost
individuals
Recreational drug use is the use of any psychoactive drug for
pleasure
These include:
 Traditional illicit drugs e.g. cannabis, cocaine, ecstasy
(MDMA), amphetamine
 Plants with psychoactive properties e.g. khat, psilocybin
mushrooms
 Novel psychoactive substances (NPS) (legal highs) are
analogues of and mimic the effects of e.g. stimulants like
cocaine and MDMA but are not safe. This poses considerable
challenges to ED are limited data on health risks are available
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13,917 hospital admissions (not including all Emergency
Department episodes) coded with a primary diagnosis of
recreational drug toxicity (HSCIC 2014).
7,104 admissions to hospital with a primary diagnosis of a
drug-related mental health and behavioural disorder (HSCIC
2014).
2,248 deaths attributed to drugs controlled by the Misuse of
Drugs Act 1971, in 2014 for England and Wales. (ONS 2015)
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Acute toxicity
Injuries
Psychiatric complications
Withdrawal
Show geographical variability due to trends and availability
Young people reporting problems with NPS tend to present at
acute service such as ED departments.
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Acute intoxication: signs and symptoms dependent on the
drug
Main groups are depressants or stimulants
Often little or no history is available
Important to gather as much information as possible
Usually from the paramedics
Detailed advice is available form the National Poisons
Information Service by telephone or password for online
access
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Heroin, methadone, oxycodone, codeine, dihydrocodeine
Opiates are powerful analgesics and used in medical practice for
this
Prone to misuse due to euphoric and addictive properties
Excess opiate exposure by oral ingestion, inhalation,
intravenous/intramuscular and transdermal routes
ED attendance as result of: respiratory depression, coma, collapse
Deep vein thrombosis, blood borne viruses, accidental arterial
puncture, withdrawal syndrome
Failure to treat and recognise toxicity can lead to death from
respiratory depression
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Naloxone is an opiate receptor antagonist
Short half life of 1.5 hours so risks relapse of opiate toxicity
Indications for use includes respiratory depression
Naloxone should be titrated to response as it may trigger
acute withdrawal in opiate dependent patients
Naloxone should be administered intravenously if possible
Can also be administered intramuscularly but difficult to
titrate a response
Patients should be observed and monitored, & may need an
infusion
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Significant risk of overdose due to small amounts required for
intended effect ie euphoria and relaxation
The difference between intended effect and overdose is very
little eg 0.5.mls
Overdose results in collapse, respiratory depression &
possible arrest
Risk increased with alcohol and other depressants
Severe toxicity leads to coma, respiratory arrest, seizures,
death if supportive care ie monitoring, intubation and
ventilation is not provided
No antidote exists
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Physical dependence may develop with chronic use
Withdrawal symptoms include agitation, tremor, seizures,
hallucinations and psychosis
High doses of benzodiazepines and intubation/ventilation
may be required to manage withdrawal
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Sedative/hypnotic
Toxicity includes drowsiness, ataxia, slurred speech, reduced
consciousness
Potentiation of symptoms with alcohol or other CNS
depressants which may lead to vomiting and respiratory
depression
Severe toxicity leads to hypotension and bradycardia
Patients with supra-therapeutic doses of benzodiazepines,
should be considered for activated charcoal
ED provides supportive care and close monitoring of
respiratory rate, and intubation and ventilation if needed
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Flumazenil is a benzodiazepine antagonist
Generally used to iatrogenic benzodiazepine overdose
Its use in pre-hospital overdose is not advised unless under
the expertise of the national poisons unit
Flumazenil in mixed overdose may reduce seizure threshold
and result in difficulties controlled fits if they occur
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Amphetamines, ecstasy (MDMA), cocaine, mephedrone,
benzylpiperazine, novel psychoactive substances
Symptoms include anxiety, palpitations, chest pain, sweating,
disorientation, agitation, hallucinations, delusions, psychosis.
Examination may elicit tachycardia, hypertension,
hyperpyrexia, neuromuscular excitability, clonus, dilated
pupils, seizures, altered GCS
There is no antidote
Supportive care should be initiated using ABC approach
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Patients may have tachycardia and hypertension: treat with
benzodiazepines
Patients may complain of chest pain; treat with benzodiazepines
Chest pain due to coronary artery spasm, acute myocardial infarction,
aortic dissection
Pneumothoraces result from snorting stimulants
Patients should have a 12 lead ECG and chest x-ray
Temperature should be monitored, & if over 38 degrees, active
cooling may be needed
Serotonin syndrome may develop: hyperpyrexia, tachycardia,
neuromuscular hyperactivity
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Limited use in ED
Majority of patient should be managed symptomatically
Routine toxicology identifies a limited number of substances
NPS will only be tested in a specialist laboratory
Results may not be immediately available so will not influence
management
Risk of false positives due to cross reactivity with prescribed
drugs or drugs used during resucitation
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Does the patient have any other history including ED
attendance related to substance use?
Head injury: patients should be assessed according to NICE
guidelines and have an CT scan if needed. On discharge they
should be given written advice
Self harm: enquire if patient took substance to harm
themselves or to have a good time and record response
Patients who admit to self harm should have a psychiatric
assessment before discharge
FURTHER POINTS (contd)
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Immunizations: tetanus status should be documented in
patients with sustained cuts, lacerations, abrasions
Victimization: patients may be at risk of sexual assault whilst
under the influence of drugs. Ask the patient if this is a
possibility
Drug and other substance use history: explore patterns of
drug use and gather whether they feel it is problematic.
Contact local drug services if needed
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Airway – ensure it is clear and normal respiratory rate and pattern
Breathing – what is respiratory rate and oxygen saturation; equal
air entry bilaterally; any added sounds
Circulation – perform 12 lead ECG; what is pulse rate and blood
pressure
Disability – is patient alert; is there evidence of head injury; is
patient moving all 4 limbs equally; assess tone and check for
clonus
Exposure – check patient for other injuries, “track marks” evidence
of venous punctures
Glucose – check glucose
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Advisory Council on the Misuse of Drugs (2011). Consideration of the Novel Psychoactive Substances (‘Legal Highs’)
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National Treatment Agency (2013) Falling drug use: the Impact of treatment. www.nta.nhs.uk/falling-drug-use.aspx
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