Emergency Management of

Drug Overdose

Russell Sharpswain, DO, FACEP, FAAEMDecember 3, 2015

Disclosures

• I have no financial connections or relationships to disclose.

Objectives• Understand current state of drug abuse in the

US• Assessment and initial management of the

patient with suspected drug overdose• Specific presentation and management of the

patient with abuse/overdose of:– Opiates – heroin and prescription pain pills– Marijuana and K2/Spice/synthetic cannabinoids– Stimulants – cocaine and methamphetamine– Hallucinogens – Ecstasy and Mushrooms

Objectives• Making an appropriate disposition on the drug

overdose patient

Drug Abuse…Statistics

• Drug use is on the rise…– 2013 = 9.4% – 2002 = 8.3%

• Mostly driven by increased use of marijuana, while other drugs have held steady

Drug Abuse…Statistics

Drug Overdose – ED Stats

• ED Statistics

Drug Overdose…Statistics

Drug Overdose…Statistics

Drug Overdose…Statistics

Drug Overdose…Statistics

• Most synthetic drug users and abusers under 25 years old

• Many of the synthetic or designer drugs are not easily detected on most ED drug screens

• Many synthetic drugs were readily available until July 2012 when law was passed banning all non-medical synthetic drugs including K2/Spice and “bath salts”

Drug Overdose• Chief complaints can vary widely– Altered mental status• Anxiety• Psychosis

– Nausea and vomiting– Palpitations/chest pain– Dyspnea– Diaphoresis

Drug Overdose• History– HPI = History of present illness• Environment• Witnesses • EMS report• Patient – if possible = Review of systems

– Past medical history

Drug Overdose

• Exam – PRIMARY ASSESSMENT– Vitals– Mental status– Airway– Breathing– Circulation

Drug Overdose• PRIMARY ASSESSMENT– A – Airway• GCS?

– B – Breathing• Respiratory rate

– C – Circulation• Pulses• Rate• Rhythm

Drug Overdose• Assessment and Stabilization– Cardiac monitoring– Continuous oximetry– IV fluids– Close observation

Drug Overdose

• Exam – SECONDARY ASSESSMENT– HEENT– Neck– Chest– Abdomen– Extremities– Skin– Neuro– Psych

Drug Overdose• Emergency Department ASSESSMENT– EKG– Labs• Baseline labs• Drug testing – DON’T BE FOOLED!• Special considerations

– Radiology• X-ray• CT

Drug Overdose• Emergency Department REASSESSMENT

• CANNOT UNDERESTIMATE THE IMPORTANCE OF REASSESSMENT IN THE DRUG OVERDOSE PATIENT!!!

OPIATES

• Heroin• Morphine• Hydromorphone (Dilaudid)• Fentanyl• Hydrocodone (Norco, Vicodin)• Oxycodone (Percocet, Oxycontin)• Codeine• Methadone and Suboxone

OPIATES…Clinical Use

• Pain relief

• Anti-tussive

• Decreased bowel motility

OPIATES…Overdose• Decreased level of consciousness

• Decreased respiratory rate

• Decreased tidal volume

• Decreased bowel sounds

• Miosis (constricted pupils)

• Lesser: urinary retention, urticaria, vomiting,

orthostatic hypotension

Opiate Overdose

• Immediate Treatment:

– AIRWAY

– BREATHING

– CIRCULATION

Opiate Overdose…Treatment• NALOXONE (Narcan)

– Opioid antagonist

– Can be given IV, IM, SQ, Neb, ETT

– Dose from 0.05mg to 2mg depending on clinical

situation

• ARREST: 2mg IV

• Others: 0.05mg to 0.2mg, titrate to effect

Opiate Overdose…Treatment

• NALOXONE (Narcan)

• GOAL: improve respiratory status, not level of

consciousness!

• Overshooting goal with Naloxone can cause

precipitous opioid withdrawal

Opiate Overdose

• Opioid Withdrawal

– Anxiety and Agitation

– Diaphoresis

– Myalgias

– Abdominal cramping

– Nausea and vomiting

– Lesser: Piloerection, yawning, mydriasis, insomnia

Marijuana

• Active ingredient: Delta-9-tetrahydrocannabinol• Can be smoked or ingested• Most commonly used illicit drug in US and Europe

Marijuana

• Symptoms– Impairment of attention and short-term memory, as

well as judgment of time and distance– Conjunctival injection– Increased appetite– Dry mouth– Tachycardia

K2 / Spice

• Synthetic marijuana– Also called Bliss, Black Mamba, Genie, Skunk,

Moon Rocks, and Zohai• In December 2011, National Institute on Drug

Abuse reported 1 in 9 high school students had used K2, making it the 2nd most abused drug by high schoolers

K2 / Spice

• Collection of plants/herbs sprayed with synthetic compound similar to THC – Resembles potpourri– Marketed as “incense you can smoke”

• Readily available until July 2012 when President signed bill making synthetic drugs including K2 illegal

K2 / Spice

• Symptoms– Agitation and anxiety– Tachycardia, chest pain, palpitations– Nausea and vomiting– Diaphoresis, pallor– Seizure / tremors– Paranoia, delusions

K2 / Spice

• Symptoms– Onset 3-5 minutes– Duration 1-8 hours

• Long term effects = Unknown

K2 / Spice

• Assessment– Cardiac monitoring and oximetry– EKG– Labs (as needed)• EtOH or drug screen

– DOES NOT SHOW UP ON STANDARD DRUG SCREEN

• Electrolytes

K2 / Spice

• Treatment = Symptomatic Support– IVF– Anti-emetics– Benzodiazepines– Anti-psychotics

• Disposition– Observe until symptom improvement

Stimulants (sympathomimetics)

• Cocaine• Amphetamine and methamphetamine• Mephedrone = “bath salts”• Ephedrine• Prescription drugs for ADHD, narcolepsy

Stimulants (sympathomimetics)

• Symptoms - Lethal– Signs of poisoning within 2 hours of exposure– Life threatening complications in 2-6 hours– Hypertension (and sequelae)– Cardiac arrhythmia or ischemia/infarction– Hyperthermia– Seizures or strokes

Stimulants (sympathomimetics)

• Symptoms – Non-lethal– Mydriasis– Tachycardia– Diaphoresis– Psychosis, delirium, paranoia– Bruxism

Stimulants (sympathomimetics)• Assessment– Vital signs• Core body temperature

– EKG and cardiac monitoring– Labs: BMP• Total CK• Drug screen• Other treatable ingestions

Stimulants (sympathomimetics)

• Treatment– PRE-HOSPITAL: Manage airway and control

agitation, blood glucose– ED: Symptomatic Support– Recognize and treat:• Hypoglycemia• Cardiac arrhythmia• Seizures

Stimulants

• Treatment– IVF– Benzodiazepines– Ketamine– Avoid physical restraints if possible– HTN – nitroprusside or nitroglycerin

Ecstasy

• MDMA = 3-4 methylenedioxymethamphetamine• Molly, Adam, E, Roll, X, XTC• Synthetic drug with hallucinogenic and stimulant

properties

Ecstasy

• Usually in pill form, often branded• Often mixed with many other drugs (ketamine,

ephedrine, methamphetamine, dextromethorphan, caffeine, and cocaine)

Ecstasy

• Younger people using at raves, parties, and concerts to “enhance senses”

• Peak use in 2000/2001– Decreased use overall, but recent studies show

increased use in 8th and 10th graders

Ecstasy

• Effects– Intensely pleasurable feelings and sensations– Enhanced self-confidence and energy– Peacefulness, acceptance, empathy– Feelings of closeness and desire to touch others

Ecstasy• Symptoms– Nausea and vomiting– Diaphoresis, blurred vision– Palpitations, tachycardia, hypertension – Teeth clenching, seizures, muscle cramps– Anxiety, depression, confusion– Dehydration, renal or hepatic dysfunction

Ecstasy

• Long-term effects– Disrupt metabolism and temperature regulation– Renal, liver, and cardiovascular failure– Problems with learning and memory– Rate of addiction 43%

Ecstasy• Assessment– Cardiac monitoring and oximetry– EKG– Body temperature– Labs as needed• Electrolytes, hepatic and renal function• EtOH• Drug screen

Ecstasy• Treatment = Symptomatic Support– IVF– Anti-emetics– Benzodiazepines– Anti-psychotics

Ecstasy• Treatment = REASSESSMENT– Hyperthermia– Mental status change– Cardiovascular stability

• Disposition– Home if symptoms improved and stable– Admit if unstable

Mushrooms

• Psychedelic mushrooms = “Magic mushrooms”– PSILOCYBIN causes hallucinations– Also known as shrooms, boomers, caps, Liberty

Cap, silly putty, Simple Simon• Grown in US, Mexico, UK, South America• Normally dried and eaten, but can be brewed

into a tea

Mushrooms

• Symptoms• Onset: 20 minutes• Duration: up to 6 hours– Hallucinations or distorted perceptions– Synesthesia– Intense fear or delusions– Changes in personality

Mushrooms

• Symptoms– Increased or decreased appetite– Nausea and vomiting– Dilated pupils– Tachycardia– Muscle relaxation or weakness, ataxia

• Long-term: flashbacks, psychosis, memory impairment, tolerance

Mushrooms

• Assessment– Cardiac monitoring and oximetry– EKG– Labs as needed based on symptoms– EtOH and drug screen

Mushrooms

• Treatment = Symptomatic Support– IVF– Anti-emetics– Benzodiazepines– Anti-psychotics– Quiet room with little sensory stimulation

Drug Overdose – Disposition?

• How do you know when it’s OK to send the patient with a drug overdose home?

Drug Overdose – Disposition?

• Opiates– No automatic need for prolonged observation or

admission after naloxone administration (CJEM, 2001)

Drug Overdose – Disposition?

• Normalization or Stabilization of vital signs• Resolution or Improvement of symptoms • Return to baseline mental status– If not returned to baseline mental status, sober

adult present to take responsibility for patient

Drug Overdose – Disposition?• Expected duration of drug effect has passed• If suspected to be intentional drug overdose,

psych assessment

Drug Overdose – Disposition?• Have to use clinical and ethical judgment in

some cases, as there is no clear black and white answer about who can safely go home, and who needs further observation

Drug Overdose - Summary

• Abuse of opiates and synthetic drugs is a growing problem in the US and around the world

• Principles of managing most drug overdose cases are similar regardless of what drug is causing symptoms

• Most synthetic drugs do not show up on routine drug screens

Drug Overdose - Summary

• Many drug overdose cases involve multiple different drugs, intentionally or otherwise

• Reassessment during observation of the drug overdose patient is very important

• The best treatment is often symptomatic care• Use sound clinical judgment when deciding

the disposition of the drug overdose patient

And always remember…

Drug Overdose

• Questions?

References• Tintinalli JE, et al. Emergency Medicine: a comprehensive study guide. 5th

Ed. 2000.• www.uptodate.com. Opioid intoxication in adults. 1/10/10.• Emergency Medicine Practice. Toxicology Update: a rational approach to

managing the poisoned patient. Volume 3 Number 8. August 2001.• K2 Drug Facts, online at http

://www.k2drugfacts.com/pdf/NewsPDF/ObamaSignsLegislation.pdf• The Partnership at Drugfree.org online at

http://www.drugfree.org/drug-guide/k2-spice and http://www.drugfree.org/drug-guide/ecstasy

• Businessinsider.com at http://www.businessinsider.com/15-maps-that-show-how-americans-use-drugs-2013-9

• http://mic.com/articles/80091/which-drug-is-your-state-most-addicted-to-this-map-reveals-a-disturbing-trend

References

• Traub SJ, Hoffman RS, Nelson LS. “The ‘ecstasy’ hangover: hyponatremia due to 3,4 – methylenedioxymethamphetamine.” Journal of Urban Health: Bulletin of the New York Academy of Medicine. Vol. 79. Dec 2002.

• Emedicine.com: Sympathomimetic toxicity at http://emedicine.medscape.com/article/818583-overview• Abovetheinfluence.com online at

http://www.abovetheinfluence.com/facts/drugsecstasy • National Institute on Drug Abuse online at

http://www.drugabuse.gov/publications/drugfacts/mdma- ecstasy and https://www.drugabuse.gov/related-topics/trends-statistics/overdose - death-rates and https://www.drugabuse.gov/publications/drugfacts / nationwide-trends• eMedicine through Medscape, Sympathomimetic toxicity, online at

http://emedicine.medscape.com/article/818583- overview• Mother Nature Network online at

http://www.mnn.com/family/protection-safety/stories/synthetic-marijuana-can-cause-unusual-side-effects-in-teens#