STREET DRUGS :

DOWN AND DIRTY

BROUGHT TO YOU BY YOUR FAVORITE DRUG FIENDS!

Revision Info

• Revised 06-13-05• For more information, contact

– Steve Cole– colemedic@hotmail.com

Where our motto is :

OBJECTIVES

• Quick intoduction to the drug culture

• Quick review of the following drugs:– Heroin and Oxycontin– MDMA and PMA– DXM– GHB

The Rave…

The Rave Culture

• Generally speaking, “Rave” applies not just to the parties but to an entire subculture

• Not just “Night time” Parties at clubs

• Can extend into multi-day events (Burning Man)

• Hallmarked by techno/new age music and Psychedelic visual displays.

Anatomy of a Rave

Anatomy of a RAVE• Day or Night• Tend to be “Sponsored” (A.K.A.

“Promoters”), limits liability on both sides

• Sometimes marketed as “Drug Free Teen Dance Parties”

• If not at a formal club, they tend to be located in remote locations to limit outside interference.

• Often will have a DJ instead of a band. Some DJ’s are celebrities, called the “A-List”, traveling a “Circuit” ($1000-5000/hr)

Anatomy of a Rave

• Remember, the overall event doesn't have to be a rave to have a strong Raver presence…..

A RAVE CAN BE ANYWHERE

Anatomy of a Rave- Clues

• Light Sticks• Water/Gatorade Bottles for sale• H2O shut off in bathroom• Crash Rooms/Candles/Etc.• Have Dance Breaks/cool down periods• In Idaho we are mainly seeing these in

remote locations.

Lights are Captivating

• Three or more work on one X user’s eyes, up close & personal. Some lights are very bright.

• It’s called “Eye Candy”

More “Eye Candy”• Glow sticks of all sizes• Special mouthguards

– Protect from swallowing mini glow sticks

– Also less visible than the pacifiers

Why Face Masks & Vicks?

• The sensation of breathing is intensified by the menthol (eucalyptus) in vapor rub products. This will be slathered on their upper lips or in face masks. Or inhalers will be used.

• Remember, many report things like “being burned by a cigarette feels good.” It’s all about sensation

It’s About Sensation• Many carry personal

vibrators. Notice the “x” & “e” & butterfly beads. Butterfly is a common emblem for Ecstasy.

• Every touch feels good.• They may rub each other with

things like Tiger Balm or with hair brushes or gloves with the “gripper dots” to intensify touch.

Vibration of the music through the balloon feels good too.

Drug Paraphernalia

• MDMA causes “bruxism”—teeth grinding & involuntary jaw locking; damages teeth.

• Pacifiers, lollipops, mouthguards & other things to suck help reduce this.

• Hidden compartments

GHB Test KITS

False SecurityFalse SecurityFalse SecurityFalse Security

Harm Reduction• Web sites

– www.dancesafe.org– www.erowid.org

WWW.EROWID.ORG

• www.dancesafe.org• Non Profit• Drug testing kits• Drug warnings• Drug testing and postings• HARM REDUCTION

What To Expect

Anatomy of a Rave-Common Medical concerns

• Severe Dehydration and Hyperthermia

• Poly-Pharm involvement

• Date Rape• Multiple Patients

(approach with a plan)

• Volatile Crowds

Interacting with Ravers• Remember there is a

cultural distrust• Don’t be afraid to ask

for interpretation of slang

• Generally not overtly violent singularly, but beware of crowds

• Our attitude and interaction may have a positive or negative impact on the crowd.

• Check for a “Trip Sitter”

Safety• Hazards: Uncontrolled

Scenes– Patients– Environment– Bystanders – Weapons – CLAN LABS

• Tactics learned from law enforcement community– Staging– Isolation and Control – Scoop and swoop– Travel in Packs

SAFETY for the PT.

• Pt safety poses an extreme challenge for EMS– Drug

Interactions– Rapid Changes– Restraint

The Drugs

Heroin and Oxycontin

Opiate Abuse

Heroin

• Black Tar• China White• Speed Ball• Homicide, Buick,

super Buick, twilight sleep

Methods of use: • Shooting:

• Skin Popping:

• Muscle Popping:

• Chasing the dragon: Smoking

• Freebasing

• Dirty Hit:

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• Becoming much more common

Methadone• Reportedly Harder to

“kick” than Heroin• Like other prescription

opiates, WIDELY Available

• One study showed of 18 methadone related deaths:– Less than ½ were

prescribed methadone– Only three were

prescribed methadone through a methadone tx program

Duragesic• Fentanyl Citrate• Transdermal Absorbtion• Used in chronic pain

patients• 100 times the potency of

morphine• Fastest growing method

of opiate abuse• Commonly Used for

chronic pain• Synthetic opioid• Easily Acquired• Easily abused

Duragesic- methods of abuse• Almost 70 fold increase in use from 1995-2002

(DAWN)• Rate of use is increasing.• Street price between $10-100/PATCH• Methods of abuse

– Topical– Injected– Chewed

• Oral Conversion– Up to 50% may be lost in conversion, so it is often frozen

first.– Preservatives may cause liver problems– 25 ug/hr = 2.5 mg avail– 50 ug/hr = 5 mg avail– 75 ug/hr = 7.5 mg avail– 100 ug/hr = 10 mg avail

S/S OF AN OPIATE 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 or similar improvised device

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 Narcan’s short

duration (about 20-30 minutes)

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

Some weird things that have been done with a Heroin OD by Junkies

• Injected someone with salt water or Milk 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) .• Placed in a cold shower

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

MDMA and PMA

Introduction• methylenedioxy-n-

methylamphetamine (MDMA)– MDMA is *chemically* an amphetamine,

but psychologically its what's known as an empathogen-entactogen

– Shares similarities to both mescaline (a hallucinogen) and amphetamines

• Para-methoxyamphetamine, ( PMA) , 4-METHOXYAMPHETAMINE – Chemically similar to MDMA, first

created almost 25 years ago– Since its cheaper to make, and uses

non controlled substances, PMA is often misrepresented as MDMA.

– At doses considered “safe” for MDMA, PMA is highly toxic.

PMA• Use is identical to MDMA, PMA is more toxic than

MDMA• It often appears identical to MDMA, sometimes

simply thicker.• Its onset of action is longer (almost 60 minutes)

compared to MDMA at 15-30 minutes• Users will re-dose thinking its MDMA and push them

selves into the toxic range• Some people think they know their MDMA dose and

apply this to PMA, thus going toxic• Substances like Cocaine and Methamphetamine

may exacerbate the toxic effects of either PMA or MDMA

PMA and MDMA

• Taken in tabs although inhalation and injection have been infrequently reported.

• Effects generally appear within 15-30 minutes (MDMA) or almost 60 minutes (PMA).

• The usual dose ranges from 100 to 150 mg. Toxicity may be seen at doses as little as 175 mg

MDMA/PMA how It Looks

• Powder• Pressed pills• Capsules (may not be full)• Wide range of logos• Wide variety of colors & shapes• Nicknames reflect logos & colors• Designed to look “innocent” &

thus “harmless.”

“Euros”

MDMA/PMA Packaging• Because of their small size, MDMA pills

may be easily hidden. They may simply be mixed in with other candies, such as Skittles, M&Ms, etc. Pez containers are common too.

MDMA /PMA Toxicity Mild s/s• Jaw clenching (Lower Jaw)/teeth grinding, and

scratching (think Tweekers)• Nystagmus, Dilated Pupils• Tremors• Tachycardia, increased B/P• Sensation of chills (secondary to elevated

temp)• Auditory Hallucinations (non

specific)/sensitivity• Orthostatic s/s, syncope secondary to

dehydration

MDMA/PMA ToxicityMajor S/S• Severe Dehydration with Hyponatremia• Malignant Hyperthermia (Think Heat

Stroke, but worse)• Disseminated Intravascular Coagulation

(DIC) (may have rapid onset)• Decreased LOC/Coma• Stroke S/S, Seizures• Severe Tachycardia, HTN, CHF• Kidney Failure

MDMA/PMA Basic Tx

• Calm low stimulus environment• VOMIT (standard ALS)• Fluid Resuscitation as needed for

hypotension, dehydration, and/or orthostatic s/s

• Active cooling if indicated• Core Temp if unresponsive

Long Term effects

• More prolonged “burn out” or “crash periods” up to a week later

• Dental Damage• Depression for

weeks• Renal failure

MDMA Focused Tx• Benzodiazepines

– Ativan 0.5-2 mg– Valium 2.5-10 mg

• beta blockers have fallen out of favor (like Brevibloc), Consider an adrenergic blocker w/ alpha blocker properties as well.

Take Home Information

• Core Temp if unresponsive• Fluid Resuscitation• Sedation PRN• Watch for DIC, SZ• P.U.H.A. IF GROSSLY

SYMPTOMATIC.

DXM- Introduction• Yes, its in cough syrup OR COUGH

TABS (CORICIDIN)”TRIPPLE C”• Dextromethorphan acts as a cough

suppressant via its agonist (activating) activity at mu-opioid receptors.

• In Canada: Contac CoughCaps (30 mg DXM)

• Related in effects to Ketamine and PCP

DXM

• Yes, its in cough syrup OR cough tabs (CORICIDIN)”TRIPPLE C”

• Dextromethorphan acts as a cough suppressant via its agonist (activating) activity at mu-opioid receptors.

• In Canada: Contac CoughCaps (30 mg DXM)• Related in effects to Ketamine and PCP

DXM- How is it used?• “Robo-ing” (Old Term from

early 90’s) • DXM is available over-the-

counter in tablet form in several countries as a cough med. Robitussin Maximum Strength Cough (not Robitussin DM) syrup

• Users often refer to DXM in “plateaus”

• Dose of Robitussin Maximum Strength Cough syrup is two to five full "shots" using the shot glass that comes with the bottle.

DXM- Coricidin Toxicity• Coricidin Cough and

Cold Caps, 30 mg DXM and 4 mgs of Chlorphineramine maleate

• Chlorphineramine maleate is an anti-cholinergic drug like scopolamine.

• Non Specific reports of “Respiratory Failure” at high doses.

DXM- Coricidin Toxicity

• Robo-Walk• Robo-Itch• Robo-Talk• Psychosis• Dialated Pupils

DXM- Treatment• VOMIT• Symptomatic TX.• Be alert for and (Cautiously) treat hypertension

or hypotension, and rarely, cardiovascular problems

• Restraints (?)• Avoid Chemical Restraint (Haldol,

Droperidol),Benzo’s are preferred (Be prepared to manage the airway)

• Benadryl may be given for Dystonic reactions, and for s/s of histamine release.

DXM- What does this mean to me?• Be Careful, take the same precautions you

would with a PCP patient.• ALS eval is a must ( HTN, Hyperthermia,

Respiratory Depression, and self harm)• DXM differs from other drugs. Its presentation

of s/s extend well beyond simple CNS depression and hallucinations but into basic cognitive functions as well.

• Understanding that DXM effects last well beyond the 4 hours of intoxication , and that side effects may include “Psychotic Breaks” will help determine deposition of patients.

BREAK?

GHB

GHB Analogs- Introduction• Gamma-

hydroxybutyrate (GHB) may be made in homes by using recipes with common ingredients.

• "Liquid Ecstasy," "Georgia Home Boy," "Grievous Bodily Harm,

• “Liquid ecstasy," do not confuse w/ MDMA

• GBL, GBH, One 4 B

Recognizing GHB

AKA: GHB, G, Jib, Scoop, Liquid E, Liquid X, Woman’s Viagra, Grievous Bodily Harm, Easy Lay, Gamma 10, Salty Water, GH Buddy, Aminos, Blue Nitro, Blue Thunder, Thunder Nectar, Renewtrient, Revivarant, Remforce, Firewater, Invigorate, Xyrem (research product), sodium oxybate, Fantasy & One4B (NZ)

So Many Names….

• Tranquili G, Midnight Blue, Verve, Rejoov, Somax, SomatoPro, Flower Power, Puritech, Alcover, G-riffick, Eclipse, GHGold, Soap, Vita G, Dormir, Enliven, FX, Serenity, Inner G, Zen, White Magic Cleaner, Weight Belt Cleaner, Ink Jet Cartridge Cleaner, Plant Food, Fingernail Polish Remover, Paint Stripper.

There are more than 80 known names for GHB and its equally deadly analogs.

GHB analogs –How are they used?

• GHB can be produced in clear liquid, or a white powder, tablet, and capsule forms, and it is often used in combination with alcohol, making it even more dangerous

• It is often carried in an eye dropper, or in water/Gatorade bottles and passed around.

• Typically measured out in capfuls.• Occasionally blue food coloring is used to

identify it at some raves.• It is occasionally used as a body building

aid

Other GHB Products

Efforts to Avoid Detection

• GHB & its analogs are NOT protected by the Dietary Supplement & Heath Education Act of 1994.

• Unapproved for human use.

• “Misbranded” drugs.• May be listed as

“weight belt cleaner” or other solvent use or plant growth formula—trying to avoid detection

Efforts to Avoid Detection

• Acetone free Nail Polish

GHB- No longer Just for Rapists

• Recreational Use• Muscle Gain• Those under

mandatory drug testing

• Elderly

What To Expect

Typical Drinks To Hide GHB

Any Substance can be used to hide a GHB Analog!

Typical GHB ContainersTypical bottles for hiding GHB--

film canisters, hair spray, liquid candy bottles, food coloring, breathe mint containers (may be liquid LSD or G), vanilla bottles, Gatorade, pump hand lotion bottles.

Recognizing ContainersANY container

that will hold a liquid.

GHB addicts have hidden it in engine compartments, attics, etc.

Billy Idol: Famous GHB’er

Billy almost died in 1993 from (then legal) GHB in front of a L.A. Night club

Nick Nolte

GHB analogs - What does it do

• At lower doses, GHB has sedative effects, but, as the dose increases, GHB effects may result in sleep ,eventual coma, respiratory arrest, or death.

• It is these effects that make it both a prime drug at Raves, and for Date Rape

GHB analogs toxicity- mild

• Lethargy, easily aroused with repeated stimulation

• Drowsiness, somnolence, dizziness, euphoria

• Confusion (dazed and confused)• Amnesia, Susceptible to

suggestion

GHB analogs Toxicity- Severe• 66% with GCS <9, ½ of these may have

GCS at 3! • Frequent Vomiting, • Bradycardia, • Respiratory depression or arrest• Seizures • Sudden onset of coma . Patients often

demonstrate extreme SUDDEN combativeness and agitation despite such profound CNS and respiratory depression

• Death (usually secondary to respiratory failure or aspiration)

GHB

• ALCOHOL IS THE MOST COMMON DRUG CO CONSUMED IN GHB RELATED DEATHS

GHB analogs-Treatment

• Primary Supportive• Beware of positional Asphyxia, but

soft restraints are a good idea• Due to the risk of sudden airway

failure, aspiration, and respiratory collapse, these patients need aggressive airway monitoring by ALS providers

GHB analogs-Treatment• Protect your self• VOMIT• Be cautious using respiratory depressants• Making the decision to tube/not tube is

tough, these patients do frequently vomit.• ETT placement is uncommon, but post ETT

sedation/paralysis and restraint should be mandatory in the field

Difficulty in Prosecution

• Sort Duration• Amnesia clouds

recall• Often pro-sexual

appearing behavior

• Lack of :– Credible witness– Evidence

GHB analogs- What does this mean to me?

• GHB analogs are unpredictable in clinical course, other than duration.

• GHB analogs cause a rapid change in mental and respiratory status that makes it difficult to plan treatment and care

• GHB’s presentation often mimics ETOH abuse and is often co-imbibed.

“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, )

Background

Background

• Discovered by Dr. Albert Hofmann in 1938

• Extensive study, use, and abuse by the government in the late 40’s. 50’s, and 60’s. (OSS/CIA, US Navy)

• Some documented cases of CIA Operatives taking it to “Immunize” them selves to its effects in the 60’s.

• Now that’s job satisfaction!

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.

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.

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

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

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

After trip effects

• Insomnia (common)

• “Jitters”• Flashbacks

(inconstantly proven and disproven in literature)

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

FOCUSED TREATMENT

• Benzo’s for severe agitation (rare)

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

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

Summary• The scariest things about these drugs are

the uncertainties involved in poly-pharm overdoses, unknown ingredients, etc…

• Careful case by case assessment and treatment is more important than a cook-book approach.

• Knowing the onsets, durations, and warning signs is as essential as knowing the actual effects of a drug.

Anything I

missed?

These Drugs in in Boise?

Seattle Wa., July 2002Caffeine (83.3%) MDA (16.7%)

Houston, TX July, 2002Caffeine (9.1%)MDA (90.9%)

Kuna Idaho, April 2002MDA (100 %)

Lewiston Idaho, May 2002MDMA (75.0%) Ephedrine/Pseudoephedrine (25.0%)

Summary

• “..Due to the poly-pharmacy drugs that are being sold to ravers, all of these patients deserve ALS evaluation…”

• Knowing your onsets and durations will help you a lot .

Don’t let this pt….

…turn out like this:

And don’t miss this!

QUESTIONS???QUESTIONS???

Supplemental information follows:

Samantha Reid, Age 15GHB induced death at a party

The 4 guys who gave the GHB to her are serving 5 ½ -15 years in prison

No alcohol was involved

Melanie Sidone, 15 at the time, was in a coma for 17 hours

Erick Limmer, 26, Owned the apartment that the GHB overdose took place in. CONVICTED!

Daniel Brayman, a senior, was one of two boys who picked up the freshman girls took

them to the Party…CONVICTED!

Nicholas Holtschlag, 18, allegedly handed drinks that were poisoned with GHB to

Melanie Sindone and Samantha Reid. CONVICTED!

Joshua Cole deliberately slipped the GHB into the girls non alcoholic drinks.

CONVICTED!