TAKING A WALK ON THE WILD SIDE OF SUBSTANCE ABUSE

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TAKING A WALK ON THE WILD SIDE OF SUBSTANCE ABUSE

• Donna Lotzer
• Senior Clinical Pharmacist
• UW Hospital Clinics
• March 2007

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WHAT WE WONT TALK ABOUT

• OR MUST WE(We must)
• National Drug Threat Assessment 2007
• Great Lakes area Big Five
• Cocaine 39.4
• Methamphetamine 27.6
• Marijuana 17.1
• Heroin 8.6
• Pharmaceuticals 6.5

www.justice.gov/ndic
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NATIONAL MAP OF ABUSE
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Objective OneRecognize Unusual Substances of
Abuse and the Circumstances Under Which They Can
Be Used
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Who needs drugs? The right mix of espresso,
chocolate and minced chicken hearts gets me right
where I need to be!!
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METHODS/CHOICE OF INHALANT ABUSE

• Sniffing
• Huffing
• Bagging
• Propane, butane
• Gasoline, paint thinner
• Acetone, glues
• Spray paint, correction fluid, degreasers

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SYMPTOMS OF INHALANT ABUSE

• Outward initial signs
• Sxs of intoxication
• Ongoing problems
• Terminal events (SSDS)
• Chronic effects
• Multisubstance abuse possible/common

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GOING FOR THE GOLD

• This person has a problem!
• Metallic spray paint is a favorite of solvent
  abusers
• Meet a repeat multi-state offender

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SOLVENTS AND SEXUAL ASSAULT

• Abducted teenager
• Controlled with solvent-soaked rag
• Assaulted and released
• No evidence to track perpetrator

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GLYBURIDE

• Unintentional party drug?
• Mistaken for Valium?
• Crushed, snorted
• Resulted in severe hypoglycemia!!

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Football and Cough Syrup Dont Mix

• Codeine cough syrup
• Caught shipping in pint water bottles!
• Maybe using/abusing?
• Used to boost effect of other drugs

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AWOL

• Alcohol With Out Liquid
• 21rst century hookah!
• Popular at some clubs
• Promoted for home use
• Shot of booze mixed with oxygen goes directly to
  ones bloodstream for maximum effect

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EMBALMING FLUID

• Start with tea, tobacco, MJ
• Is it real or PCP?
• Person may refer to smoking fry, wet or amp,
  happy sticks or sherm
• Symptoms of smoking PCP
• Symptoms of smoking formaldehyde (!)

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HAWAIIAN BABY WOODROSE
Its A Room Spinning, Stomach Churning, Head
Racing, Toilet Hugging Bad Drunk Feeling
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VIAGRA CRYSTAL METH COCKTAIL

• Targets gay men
• Linked to HIV STDs
• Crystal meth impotence
• Viagra solves that problem for many

Your career took up too much time anyway a
crystal meth habit can suck up your job, your
friends, your home and your health in 18 months
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NUTMEG

• Users try because curious, unlikely to repeat
• Symptoms delayed, long-lasting (gt24 hrs)
• Experience nausea, gagging, headache
• Teens use looking for marijuana-like effects

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SAY CHEESE PLEASE

• Heroin mixed with Tylenol PM
• Crush, snort, get high hooked
• Affordable, deadly
• Ages 13 and up
• Nationwide alert by DEA in 2006

• http//cbs11tv.com/video/?id9268_at_ktvt.dayport.com

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RECOMMENDED BY
Physicians, Pharmacists and ... Dr. Feelgood??
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WHAT ARE THEY AFTER?

• Dextromethorphan
• Serotonergic activity can produce visual
  auditory hallucinations
• Antihistamines
• Antimuscarinic properties produce visual and
  tactile hallucinations
• Decongestants
• Stimulant effects
• Replacement for pseudoephedrine
• Look for PE phenylephrine

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DEXTROMETHORPHAN (DXM)

• Availability
• Expected symptoms
• Drowsiness
• GI upset
• Stimulant if combos

• Symptoms of abuse
• Nausea, vomiting
• Ataxia, slurred speech
• Dizziness, drowsiness
• Hallucinations, psychosis
• Nystagmus, coma
• Withdrawal syndrome

Examples of Clandestine DXM Pills
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JIMSON WEEDDatura stramonium

• Seasonal high found in your garden!
• Usually seeds are chewed, sometimes smoked
• Hallucinatory, violent behaviors result

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ANGELS TRUMPET (Datura inoxia)

• Teen victim brewed and drank tea
• Same botanical family as Jimson weed
• Contains atropine, scopolamine etc.
• Historically called Jamestown weed

Patrick J. Alexander _at_ USDA-NRCS PLANTS Database
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WHAT IS DMT?

• Psychoactive chemical
• Causes intense psychedelic effects
• Can be smoked, injected, snorted, or taken orally
  
• Source is many plants origin in South America
• Related to psilocybin

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DMT DETAILS

• Extremely intense visuals
• Short duration (20)

• Can interact with many Rx drugs unpredictable
• Smoking causes severe lung irritation
• Vomiting common
• Color-changing vision, buzzing sounds reported
• Triggers latent psychiatric problems

"Nothing in this world can prepare one for the
impressions that fill your mind when you enter
the DMT sensorium"
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HEROIN/CLENBUTEROL

• Cases reported in 2005-6
• As close as MN!
• Users believe they have heroin
• Snorting, injecting it
• Spend 2-4 days in ICU
• Think of like an albuterol OD
• Is a veterinary drug

• Not narcotic sxs
• LOOK FOR
• Tachycardia
• Palpitations
• Hyperglycemia
• Hypokalemia
• Hypotension
• Mydriasis
• Agitation
• Tremor

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ECSTASY

• Expected symptoms
• CNS stimulation
• Hallucinations
• Relaxation

• Downside problems
• Heat exhaustion
• Dehydration
• Elevated body temperature
• Seizures
• Anxiety, paranoia
• Cardiovascular
• Muscular (rhabdomyolysis)
• Misc. physical symptoms

www.wcdtf.org/ecstasy.html
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SALVIA DIVINORUM(Sage of the Seers)
Herb Legal, abusable Folks grow their own

• http//www.all4humor.com/videos/funny-videos/salvi
  a-abuse.html

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PRESCRIPTION DRUG ABUSE PATTERNS AND TRENDS - 2007

• Why abuse them?
• Easy access
• Cheap, pure
• Less harmful
• Less likely risk of arrest
• How does one get them?
• Family and friends
• Dealers
• Theft from pharmacy

Vicodin

• What are we talking about?
• Narcotic pain relievers
• CNS depressants
• Stimulants
• Combine with illicit drugs
• Falsely lowered perception of risk with Rx
  abuse

Xanax
Fentanyl
Ritalin
Oxycontin
Darvocet
Oxycodone
"Benzos"
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OXYCODONE OxyContin

• True or False
• OxyContin is the 1
• misused narcotic for
• illicit purposes.
• False Morphine

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OxyContin 12th Graders Percentage of 12th
graders who reported using OxyContin in the year
prior to being surveyed
Read up http//www.npr.org/templates/story/story.
php?storyId5061674
Junior helps himself to Mothers little helpers
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ABC NEWS PAINKILLER PATCH ABUSE BLAMED FOR
DEATHS

• Fentanyl Tea Bag Brew up a cup?
• Fentanyl Rectally Shove it up where?
• Fentanyl Chewed Bite it!
• Fentanyl Snorted Up your nose!

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FENTANYL MADNESS

• Fentanyl Dermal Taking the Heat
• Fentanyl Gel Up in Smoke
• Fentanyl IV Shooting up the Patch
• Fentanyl, Cocaine /or Heroin Deadly Mix
• Fentanyl Oral Lick your Perc-o-Pop

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RITALIN GOES TO COLLEGE

• Indicated for attention deficit disorder
• Used to boost alertness and study longer
• Hit the news at UW Madison in 2004 and Marquette
  in 2006
• Also being used by teens and adults
• Source? Diverted from legal prescriptions
• Adverse effects are stimulant
• Possible risk of cardiac arrhythmias

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• Ever heard of sucking toads?
• This dog is addicted to them!
• Toad-sucking for abuse
• Caused hallucinations, disorientation, dependence
• Possibly a bufo toad?
• Can also cause death (!)

Breaking News!!
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OMIGOSH QUAALUDES??

• Off US market since 1983
• January 2007 DEA reports
• Mimic of Quaalude contains diazepam usually
• Other counterfeit drugs being sold as Xanax,
  Ativan, Ambien, Lexapro contain Haldol (!!)

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Objective TwoAppreciate the Sources of
Information and the Motivation for Abuse of
Unconventional Substances in Teens and Adults
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You know I dont think I can face the day today
Motivation?
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WHERE THEY GO SOURCES

• Wikipedia Kids adults alike
• Erowid Users head here first!!!
• Google any term for limitless options
• My Space and similar
• YouTube videos

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TEEN-ORIENTED WEBSITE
www.dxmstories.com
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PHARMING PARTIES

• Trail mix of drugs available
• Social event for any age, especially teens and
  college kids
• Pill-popping frenzy all participants donate

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INHALANT ABUSE VIDEOS

• http//www.youtube.com/watch?vQXxBfmwExIA
• http//www.cbs2.com/video/?id18885_at_kcbs.dayport.c
  om

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THIS WONT HAPPEN!
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Website for anyone to buy WHAT?!?
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BELIEVE IT OR NOT

• Shoplifting stats
• Health and beauty care items used to be 1
• Included cold meds with pseudoephedrine used to
  make meth
• Replaced by meat as 1 category now (!)

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Objective ThreeUnderstand and Utilize the Best
Approach to Management of Patients With Symptoms
Due to Atypical or Unknown Substance Abuse
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Does anyone think that this would impress a
teenager or addict? Would be nice but it is not
that easy
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Respect your creativityfor thinking outside the
box....

• Remember all bets are off when what you think you
  are dealing with is an abusable substance.
• Let your training and instincts lead the way!
• Manage the patient, not the history of exposure

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MANAGEMENT OF INHALANT ABUSE SITUATIONS

• We need to do what??
• Fresh air, decontamination
• Do NOT stress person
• Observation (non-medical OK?)
• Oxygen EMS transport
• CPR/ACLS protocols

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MANAGING PHARMING

• Unknown pills, in unknown amounts leads to a
  management dilemma
• Unexpected, unpredictable for EMS
• Fear by medical staff of missing something like
  acetaminophen
• Silent killer 36 - 48 hours out!
• Multiple patients from one party
• MUST NOT assume drug exposure is the same for all

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TOXIC PLANTS MANAGEMENT

• Woodrose
• Nutmeg
• Jimson Weed
• Salvia

Used with permission
Jimson Weed Seedpod
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NARCOTICS OD MANAGEMENT

• Symptoms
• Narcotic overdose
• Terminal event is respiratory arrest
• Management
• Airway priority 1
• Naloxone in large doses (but)
• Supportive care

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DEXTROMETHORPHAN MANAGEMENT

• Symptomatic/supportive
• Naloxone (rare)
• Benzodiazepines
• Caution for other ingredients that may need
  management(!)

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ECSTASY MANAGEMENT

• Timeline to help
• Standard ABCs
• Rehydration
• External cooling
• Muscle/kidney supportive care

Ecstasy 5 parts P-ephedrine 1 part Ketamine 0.2
parts
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Talkdowns seldom helpbeing supportive is a
better management tool
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ADDITIONAL RESOURCES FOR HELP

• National Drug and Alcohol Treatment Referral
  Service 800-662-HELP
• Wisconsin Clearinghouse for Prevention Resources
  800-248-9244 or 608-263-2797
• National Inhalant Prevention Coalition
  800-269-4237
• National Clearinghouse for Alcohol and Drug
  Information 800-729-6686 or 800-788-2800
• My contact information 608-265-8160
• ppec_at_uwhealth.org www.uwhealth.org/poison

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ONLINE RESOURCES

• Poison Center at 1-800-222-1222
• Medical journals
• Websites
• www.inhalants.org
• www.inhalant.org
• www.theantidrug.com
• www.mediacampaign.org
• http//ncadi.samhsa.gov/
• www.drugfreeamerica.org
• www.drugfree.org
• www.backtoschool.drugabuse.gov
• www.nida.nih.gov
• www.erowid.org