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Street Drugs Part 1

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Title: Street Drugs Part 1


1
Street Drugs Part 1
  • Street Drugs every medic should know

2
Ada County Paramedics
  • Steve Cole

3
Overview
  • We will review some common principles of caring
    for the Pharmacologically gifted
  • We will discuss some of the standard street
    drugs that every paramedic should know.
  • There is no way we can be all inclusive in an
    hour so bear with me.
  • And if you think this is going to be boringtry
    researching it!

4
Drugs we will cover
  • Street Opiates
  • Hyper dynamic Drugs
  • Meth and derivatives
  • Cocaine
  • LSD

5
The Opiates
  • We will focus on Heroin. There are others
    similar drugs in this class as well
  • Morphine
  • Oxycontin
  • Fentanyl
  • Methadone

6
Background
  • Heroin - First synthesized from morphine (derived
    from the poppy plant) in 1874, was not
    extensively used in medicine until the beginning
    of this century.
  • Commercial production of the new pain remedy was
    first started in 1898. While it received
    widespread acceptance from the medical
    profession, physicians remained unaware of its
    potential for addiction for years.
  • Its abuse was a major cause of the Harrison
    Narcotic Act of 1914. 

7
Background
  • One survey in 1999 saw 2 of HS students had used
    heroin, most (1.1) under the age of 16. Use is
    mainly growing in the 30-40 age group (those w/
    teenagers)
  • There is some indication that heroin use is
    slowly increasing to levels seen in the 60s and
    70s.

8
Background
  • Pure heroin is a white powder with a bitter
    taste. Most illicit heroin is a powder form which
    may vary in color from white to dark brown
    because of impurities left from the manufacturing
    process or the presence of additives. Pure heroin
    is rarely sold on the street.. This heroin may be
    smoked.
  • "black tar," has also become increasingly
    available in the western United States. It is
    often sold on the street in its tar-like state at
    purities ranging from twenty to eighty percent.
    This heroin is most frequently dissolved, diluted
    and injected. 

9
Slang
  • A "bag" --slang for a single dosage unit of
    heroin--may contain 100 mg of powder, only a
    small portion of which is heroin. The remainder
    could be sugars, starch, powdered milk, or
    quinine. Traditionally the purity of heroin in a
    "bag" has ranged from one to ten percent. More
    recently, heroin purity has ranged from one to
    ninety-eight percent, with a national average of
    thirty-five percent. 
  • chippers" that being the term for non-addicts
    who use addictive drugs in a controlled fashion

10
Slang
  • China White
  • Red Rum
  • Homicide, Polo, Super Buick (w/ Scopolamine or
    Coke)
  • Dragon
  • Black Tar
  • Smack, Scag

11
Methods of use
  • Low Purity almost exclusively was injected
    either IV, SQ, or IM.
  • Higher purity snort or smoke the narcotic.
  • Availability of high quality heroin is
    increasing.

12
Methods of use
  • Shooting
  • Skin Popping
  • Muscle Popping
  • Chasing the dragon Smoking
  • Freebasing
  • Dirty Hit

13
Methods of use Oxycontin / MS Contin
  • Time released capsules, some may have more than
    100 mg
  • Often crushed and snorted, eliminating the time
    release
  • May be crushed, diluted, and injected like
    traditional heroin

14
S/S OF AN OVERDOSE
  • Pin Point Pupils
  • Hypotension
  • N/V
  • Respiratory/CNS depression
  • Aspiration and Hypoxia
  • Hallucinations
  • Other s/s? Think poly-pharm involvement
  • Dirty Needles (Diabetics)
  • Cotton balls, Cig Filters
  • Spoons w/ residue
  • The bottom of a soda pop can is commonly used as
    a "spoon" to dissolve the heroin in because it is
    curved inward like a spoon. The bottom is torn
    off of a can as close to the bottom as possible.

15
BASIC TREATMENT
  • Ventilation/stimulation first
  • Slow admin of Narcan, just enough to make them
    breath
  • Narcan 0.4 mg-2 mg traditional, may need higher
    doses
  • High doses may be needed if drug is synthetic
  • Watch for re-sedation due to Narcans short
    duration

16
FOCUSED TREATMENT
  • Due to the multiple drug combinations possible,
    full ALS is advised (unforeseen drug
    reactions-speed ball, homicide, etc)

17
Long Term problems
  • HIV, HEP-A/B/C,
  • BLOOD POISONING (Septicemia) Cotton Fever
  • ENDOCARDITIS
  • TETANUS
  • NECROTIZING FASCIITIS (Flesh-Eating Disease)
    Associated w/ black tar
  • WOUND BOTULISM
  • TRACKING AND BRUISING
  • CONSTIPATION, BOWEL OBSTRUCTION

18
Interactions
  • Cocaine AKA Speedball
  • Heroin is thought to mask/temper some of
    cocaine's nastier effects
  • Homicide, Super Buick Heroin, coke,
    scopolamine- Causes tachycardia, anticholinergic
    toxicity (remove the heroin via Narcan and the
    adrenergic and anticholinergic effects combine
    uninhibited)
  • This is why its very important to give just
    enough Narcan to regain respiratory function

19
Some weird things that have been done with a
Heroin OD by Junkies
  • Injected someone with salt water. This is an old
    junky myth sometimes still used.
  • Injected someone who overdosed on heroin with
    cocaine or speed, or vice versa. Another old
    myth.
  • Narcan Used PTA of EMS- Narcan is becoming more
    and more common among junkies for emergencies
    (some trials are being done in Seattle and
    Europe)
  • Put ice on their genitals (down their pants) .

20
Dependence, Detox, and Withdrawal
  • medical detoxification is usually accomplished by
    giving decreasing doses of a long-acting opiate
    like methadone.
  • While not truly physically addictive, Heroin
    withdrawal is clearly extremely uncomfortable and
    painful.
  • The previously suppressed Locus Coeruleus is
    believed responsible for most of the clinical
    problems anxiety, HTN, agitation

21
TAKE HOME INFORMATOIN
  • Beware of the curveballs (poly Pharm)
  • Slow minimal Narcan administration

22
Hyper-Dynamic Drugs
23
Hyper-Dynamic Drugs
  • Hyper-dynamic Drugs Drugs with severe adrenergic
    properties
  • Meth Amphetamine
  • Amphetamine,
  • cocaine (in several forms)
  • Other drugs that would be similar are Ecstasy,
    and PMA which are discussed elsewhere.,

24
Background- Meth and other Amphetamines
  • Meth" is methamphetamine, which is a type of
    amphetamine.
  • The chemical Methamphetamine is composed of an
    amphetamine molecule with an additional methyl
    group attached to its nitrogen (amine group).
  • For Methamphetamine, the methyl allows it a
    little better fat solubility and thus better
    penetration into the brain.

25
How Long has Meth and other Amphetamines been
around?
  • Jan 18, 1887-Amphetamine was first synthesized by
    a German chemist
  • 1919- Methamphetamine is first synthesized (in
    Japan)   
  • WWII -Both Amphetamine and Methamphetamine (by
    the Japanese mostly)are widely distributed to
    soldiers to help improve performance. This led to
    addiction problems in Japan after the war.    

26
Background
  • Methamphetamine is a synthetic stimulant commonly
    used as a recreational drug. It is legally
    prescribed as a treatment for ADD under the brand
    name Desoxyn, for both children and adults.
  • On the street, it is generally found as an
    odorless, white or off-white, bitter-tasting
    powder, though it is also found in pills,
    capsules and larger crystals.
  • Methamphetamine production is a relatively simple
    process, especially when compared to many other
    recreational drugs.

27
Slang
  • Nazi method a method of quick cooking meth
  • Methamphetamine meth, crystal meth, speed, ice,
    crank, glass, uppers, yaba, shabu shabu, tweak,
    go-fast, Hitler's Drug, Crazy Medicine
  • Speed any amphetamine
  • Jacked on speed

28
Slang
  • Bump a snorted hit (average 2-4 bumps)
  • An intentional binge with some heavy users
    injection as much as a gram every 2-4 hours to
    keep things going
  • What is the difference between crystal and crank?
  • Crystal" has seven letters, Crank" only has
    five.

29
Methods of use
  • It is frequently snorted, but is also used
    orally, smoked, and injected.
  • Oral use takes about half an hour to produce
    effects. When smoked, effects are almost
    instantaneous, and nearly as quick when snorted.

30
S/S OF AN OVERDOSE
  • High last about 6-24 hours. 50 of meth is
    remains in body at 12 hours. Most effects are
    from the over stimulation of release of dopamine.
  • Jaw clenching, Agitation, Paranoia
  • HTN, Tachycardia
  • Hyperthermia (lethal levels), DIC, Seizures
  • Visual, Auditory and tactile hallucinations
  • 'Amphetamine Psychosis
  • Serotonin Syndrome?

31
BASIC TREATMENT
  • Supportive
  • VOMIT
  • ALS (EKG, IV)

32
FOCUSED TREATMENT
  • Benzos for sedation and seizures
  • 0.5-2mg Ativan
  • 2.5-10 mg Valium
  • Haldol also an option for just combativeness.
  • Note Unresponsive meth users should have a temp
    checked when feasible for early detection and
    intervention
  • Active cooling for profound hyperthermia

33
Long term effects
  • Methamphetamine is an anorexant, This is
    considered a benefit for many light users, but in
    regular or heavy users can lead to malnutrition.
  • Methamphetamine is also believed to be
    neurotoxic.Its use causes damage to the neurons
    in the dopamine portions of the brain.
  • Some possible effect on the serotonin producing
    parts of the brain is also suspected.
  • Lead Poisoning
  • Psuedo-Parkinson's D/O

34
Interactions
  • The most commonly (and ambiguously) documented
    warning of amphetamines (and ecstasy, PMA)is with
    the use of Monoamine Oxidase Inhibitors (MAOIs)
  • can be dangerous in combinations with MAOIs, at
    high doses, or at high frequencies of
    use.monoamine oxidase inhibitors (MAOIs)
  • Until recently, it was believed that the
    metabolites of Parnate were Amphetamine and
    Methamphetamine, which would fit the definition
    of "sympathomimetic agonists"
  • Recent research does not support the amphetamine
    metabolite theory. However, there is still a lot
    to learn about MAOI pharmacology.

35
Dependence, Detox, and Withdrawal
  • Methamphetamine causes significant tolerance, as
    well as psychological dependence
  • strong cravings for more meth, while at the same
    time being unable to reach a satisfactory high
  • Withdrawal from high doses can produce severe
    depression, called the Crash

36
Cocaine
37
Everybody loves cocaine
  • Woe to you my Princess, when I come, I will
    kiss you quite red and feed you till you are
    plump. And if you are forward, you shall see who
    is the stronger, a gentle little girl who doesn't
    eat enough or a big wild man who has cocaine in
    his body."-- Sigmund Freud, On Coca

38
Background- Cocaine
  • Cocaine is an alkaloid found in leaves of the
    South American shrub Erythroxylon coca . It is a
    powerfully reinforcing psychostimulant.
  • The drug induces a sense of exhilaration in the
    user primarily by blocking the reuptake of the
    neurotransmitter dopamine in the midbrain.
  • Doctors dispensed cocaine as an antidote to
    morphine addiction. Unfortunately, some of their
    patients made a habit of combining both.

39
Background
  • Until 1916, one could buy it at Harrods. Cocaine
    was widely used in tonics, toothache cures and
    patent medicines and in chocolate cocaine
    tablets.
  • Ryno's Hay Fever and Catarrh Remedy - "for when
    the nose is stuffed up, red and sore" - was 99.9
    per cent pure cocaine.
  • Prospective buyers were advised - in the words of
    pharmaceutical firm Parke-Davis - that cocaine
    "could make the coward brave, the silent
    eloquent, and render the sufferer insensitive to
    pain".

40
Background
  • Cocaine Hydrochloride is available on the street
    generally at 30 to 40 purity and retails at
    prices ranging from 10.00 to 50.00 per quarter
    gram.
  • Cocaine metabolites are excreted in the urine and
    can be detected for between 2 to 4 days after the
    drug has been consumed.

41
Slang
  • rock
  • cooked cocaine
  • base, freebase
  • fat bags
  • cookies
  • and kryptonite.
  • coke
  • crack
  • dust
  • snow
  • blow
  • flakes
  • bloke

42
Types of Cocaine
  • Cocaine
  • Crack
  • Freebase
  • Low Potency

43
Methods
  • Freebasing freebase either injected or heated
    and its fumes inhaled through a pipe. Very
    Elaborate, very dangerous
  • Smoked Crack converted to smoke via direct flame
  • Chasing the dragon as for heroin
  • Snorting"snorted into the nose. This results in
    rapid inhalation of the powder and cutting
    agents. Cocaine is absorbed rapidly via the
    mucous membranes into the blood stream.
  • Dabbinga licked finger is coated with the powder
    and then placed on the tongue or gums is an
    alternative method.

44
Freebasers Hall of Fame
  • Richard Pryor
  • Sam Kinison
  • Nikki Sixx

45
S/S OF AN OVERDOSE
  • Tachycardia, cardiac Stimulation , MI
  • HTN
  • Nausea
  • Tremors, insomnia, agitation
  • Dilated pupils
  • Headaches, blurred vision
  • Seizures , Stroke
  • cerebral vasoconstriction
  • Twitching (tactile hallucinations)
  • Fever, Hyperthermia
  • Impotence
  • cold sweats
  • Fatigue (when Crashing)
  • Sinus Problems (when snorting)

46
Acute S/S
  • Pregnant cocaine users may experience premature
    labor and abruptio placenta
  • Just FYI Cocaine has been reported to produce a
    prolonged and intense orgasm if taken prior to
    intercoursein case you were wondering

47
BASIC TREATMENT
  • Mainly supportive
  • ALS
  • Standard therapy for respiratory problems (from
    smoking)
  • steroids very helpful for the respiratory damage

48
FOCUSED TREATMENT
  • Treat CONFIRMED MIs per standard guidelines,
    thrombos with caution
  • NTGs OK
  • ACLS EP recommends spacing out EPI to 5-10
    minutes in arrest
  • Lidocaine with caution
  • Mag for Dysrhythmias
  • Haldol for combativeness
  • Benzos for sedation and seizures, AND HTN
  • 0.5-2mg Ativan
  • 2.5-10 mg Valium
  • Use anti-Hypertensives with caution as they may
    worsen coronary ischemia
  • Alpha specific blockers for HTN (Regitine)
  • Beta Blockers are falling out of favor (may leave
    alpha effects unopposed)

49
Long term effects
  • Multiple Respiratory problems from smoking (COPD)
  • Recurrent snorting of cocaine may result in
    ischemia, necrosis, and infections of the nasal
    mucosa, sinuses, and adjacent structures
  • Sterile Infections
  • MIs, Cardiovascular Damage
  • Constipation
  • Vascular damage from HTN
  • Irritability and increased risk of violence are
    found among heavy chronic users

50
Interactions-Alcohol
  • When combined with alcohol, the cocaine alkaloid
    yields a further potently reinforcing compound,
    now known to be cocaethylene
  • alcohol plus cocaine produces more stimulatory l
    behavior in mice than either drug alone
  • The combination appears to exert more
    cardiovascular toxicity than either drug alone in
    humans.
  • Alcohol appears to potentiate cocaine
    hepatotoxicity in both humans and mice.

51
Interactions- Heroin and Scopolamine
  • AKA Speedball
  • Heroin is thought to mask/temper some of
    cocaine's nastier effects
  • Homicide, Super Buick Heroin, coke,
    scopolamine- Causes tachycardia, anticholinergic
    toxicity (remove the heroin via Narcan and the
    adrenergic and anticholinergic effects combine
    uninhibited)
  • This is why its very important to give just
    enough Narcan to regain respiratory function

52
Dependence, Detox, and withdrawal
  • Since cocaine withdrawal is generally mild, is
    mainly psychological in nature.
  • Tolerance to Cocaine builds quickly, thus larger
    and larger doses are used.
  • Treatment of withdrawal symptoms is generally not
    required.
  • Depression, bradycardia, sleepiness, fatigue,
    cocaine craving

53
Take Home information about Hyper-dynamic Drugs
  • PROTECT yourself
  • Betablockers falling out of favor
  • Benzos for HTN, sedation, SZ
  • Adrenergic blockers with alpha effects as well as
    beta 1.
  • Beware of the poly pharm OD
  • Beware of the malignant hyperthermia

54
LSD-d-lysergic acid diethylamide
55
For about a week I couldn't walk through the
lobby of A-entry at the dorm without getting
really scared, because of the goblin I saw there
when I was tripping.

( User, circa.1971, )
56
Background
57
Background
  • Discovered by Dr. Albert Hofmann in 1938
  • Extensive study, use, and abuse by the government
    in the late 40s. 50s, and 60s. (OSS/CIA, US
    Navy)
  • Some documented cases of CIA Operatives taking it
    to Immunize them selves to its effects in the
    60s.
  • Now thats job satisfaction!

58
Slang
  • Many names refer to the carrier or brand(image
    printed on blotter)
  • Blotter, Sugar, Sugar Cube, cid, Acid
  • Bart Simpsons, Barrels, Tabs, Blotter, Heavenly
    blue, "L", Liquid, Liquid A, Lucy in the sky with
    diamonds, Microdots, Mind detergent, Orange
    cubes, Orange micro, Owsley, Paper acid,
    Sacrament, Sandoz, Sunshine, Tabs, Ticket,
    Twenty-five, Wedding bells, Windowpane, etc.

59
Slang
  • Hit- Dose
  • Body Kinks- Unexpected physical side effects I.e.
    nausea, jitters, etc
  • Bad trip- A person on LSD who becomes depressed,
    agitated, or confused may experience these
    feelings in an overwhelming manner that grows on
    itself.
  • LSD psychosis The effects of LSD exacerbate
    pre-existing psychological problems for several
    days.

60
Methods
  • Usually taken Sublingually or orally on paper
    (Blotter)
  • The solution may also be injected s.c. or
    i.v.(RARE) The effect is identical with that of
    oral administration but sets in more rapidly.
  • Usual dose is 50-200 mcg, with Transcending
    doses as high as 500 mcg

61
How does it work?
  • Similar to other drugs that give hallucinations
  • It affects the re-uptake of 5-HT similarly to
    SSRI (serotonin specific reuptake inhibiting)
    anti-depressants such as fluoxetine (Prozac),
    sertraline, and paroxetine
  • Agonist (stimulation rather than blocking)
    properties at the 5-HT2 receptor have been found
    to fairly universally be associated with other
    psychedelic drugs such as psilocybin and
    mescaline, and somewhat in MDMA

62
S/S OF AN OVERDOSE
  • Dilated Pupils
  • Vivid Auditory, tactile, and visual perception
  • Nausea
  • Mild drops in B/P
  • Hyperglycemia
  • Piloerection (Goosebumps)
  • Mild Hyperthermia
  • Bradycardia
  • May exacerbate pre-existing behavioral tendencies
  • Mild stimulatory effects

63
After trip effects
  • Insomnia (common)
  • Jitters
  • Flashbacks (inconstantly proven and disproven in
    literature)

64
BASIC TREATMENT
  • Supportive
  • Protect the patient
  • Calm low key, low light, environment
  • Calm low key, low light environment
  • Calm low key, low light environment
  • Calm low key, low light environment
  • Oh yes
  • Calm low key, low light environment

65
FOCUSED TREATMENT
  • Benzos for severe agitation (rare)

66
Dependence, Detox, and withdrawal
  • No documented physical or psychological
    dependence
  • A rapid tolerance is built up (about 3-5 days)
    that just as rapidly disappears

67
Take Home Information
  • Facilitate a low key trip, and all is well
  • The patients respond to your actions as much as
    we respond to them
  • Very little clinical problems from drug, just
    actions resulting from altered behavior

68
Anything I missed?
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