1. Drugs: Old Friends and New STREET DRUG UPDATE 2014
2. Who am I? Steve Cole [email protected] Ada County
Paramedics for 15 years EMS for 24 years.
3. Disclaimer I have no financial conflicts of interest This
presentation is not a substitute for basic clinical judgment.
Follow your protocols!
4. Before we get started.. Doing your own research Knowing
where to look Staying up to date Educating Yourself.
5. EMS Textbooks SUCK!
6. http://www.samhsa.gov/data/DAWN.aspx Hundreds of
Metropolitan/Suburban Hospitals and Coroners/ME offices across the
US. A DAWN case is any ED visit or death related to recent drug
use. The criteria for inclusion in DAWN are intentionally broad and
simple, with few exceptions Thousands of drugs of all types are
included in DAWN. These include: Illegal drugs of abuse;
Prescription and over-the-counter medications; Dietary supplements;
Non-pharmaceutical inhalants; Alcohol in combination with other
drugs (adults and children) Alcohol alone (age < 21).
7. WWW.EROWID.ORG
8. The Drugs
9. Opioids
10. Epidemiology Opioids of all types are a significant cause
of ED visit (approximately 35%) Heroin accounts for approximately
9% of opioid related visits Heroin has resulted in a 67% increase
of ED related visits from 2004 though 2011 Illicit use of
pharmaceutical opioids accounts for about 26% Oxycodone containing
products had a 158% increase from 2004 through 2011 Source: 2011
DAWN statistics
11. What is Diversion? Diversion is the use of prescribed
substances (Opioids are just one drug class that is often diverted)
for illicit or recreational use. How are Drugs Diverted?
Hospice/Home Health Care Visitors Family Health Care providers
Public Safety Workers Professional Patients.
12. Opioids: What are we talking about? Illicit vs. Legal?
Synthetic vs. naturally occurring opioids? Clinical vs Recreational
use?
13. The Opium Poppy Use/Abuse goes back At least to 4000 BC The
poppy contains numerous opioid alkaloids The most common Opioid
Alkaloids are: Morphine (1-10%) Codeine Thebaine Oripavine
15. Opioid Receptors (Continued) (MU) receptors: Located in the
CNS (Brain/Spinal Cord) AND the digestive tract. CNS depression
Analgesia GI Motility (Constipation) Euphoria (Kappa) Receptors:
Located in CNS Analgesia, Dissascoiation DYSphoria,
16. What is a Toxidrome? syndrome (sindrm/) noun 1. a group of
symptoms that consistently occur together or a condition
characterized by a set of associated symptoms. toxidrome (tksidrm/)
noun 1. a group of signs and symptoms constituting the basis for a
diagnosis of poisoning. In other words: A toxidrome is a syndrome
that specifically relates to a specific toxin Be cautious, many
syndromes/toxidromes are subtle and overlap their symptoms.
Thorough assessment is essential
17. Opioid Toxidrome The Opiate Toxidrome consists of: Altered
mental status Miosis* Unresponsiveness Shallow respirations Slow
respiratory rate Decreased bowel sounds Hypothermia Hypotension* *
these symptoms are very subjective, and may not be present in
polypharmacy overdoses. KEY POINT: Miosis and Hypotension are not
definitive for ruling in or ruling out a opioid overdose.
18. Methods of use: Shooting Skin Popping Muscle Popping
Chasing the dragon Freebasing Dirty Hit Tea With Grapefruit Juice
Tincture Laudanum and Perigoric
19. So why do people overdose? IV opioid use Poly-pharmacy
Overdose Returning to opioid use from abstinence Jail? Detox? The
Weekend Warrior Using opioids alone New supply of Drug
20. Types of Opioids
21. Opium The raw Latex (sap) of the poppy plant Source:
http://www.aaronhuey.com/#/editorial-archive/afghanistan-drug-
war/Opium_032
22. Morphine Naturally occurring in raw opium First isolated in
1804 First IV opioid in 1857 The gold standard by which other
opioids are judged Potent Respiratory / CNS depressant Equipotent
euphoria to Heroin, though slower onset. Intermediate Duration (3-6
hours) Many ER (extended release) formulations
23. Codeine, Hydrocodone Codeine naturally occurs in the poppy
plant Hydrocodone is a semi-synthetic derivative of codeine. Often
taken as a oral tablet or an elixir Often co-ingested with an NSAID
(such as APAP, Motrin or ASA) Norco, Vicodin
24. Heroin Black Tar China White Speed Ball Homicide, Buick,
super Buick, twilight sleep
25. Old verses New
26. Oxycontin/Oxycodone Oxycodone is Another semi-synthetic
Derived from Thebaine Roughly twice as potent as Morphine Also More
potent than Hydrocodone Most often available in Tablet form Like
Hydrocodone, Often co-ingested with an NSAID (such as APAP, Morin
or ASA) Percocet Extended release versions known as Oxycodone
Oxy
27. Oxycontin /Oxycodone 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
28. Methadone Synthetic opioid Comparable with Oxycontin and
Dilaudid. Longer acting than most other Analgesic Typically 4-8
hours Like other prescription opiates, WIDELY Available One study
showed of 18 methadone related deaths: Less than were prescribed
methadone Only three were prescribed methadone through a methadone
tx program
29. Dilaudid Hydromorphone Semi-Synthetic Opioid Technically
found in small quantities in the poppy plant Synthesized in 1924
directly from Morphine Very potent analgesic Very Euphoric Very
potent CNS/ Respiratory Depressant Faster acting than Morphine
(similar to Heroin for rate of onset) 10 times more potent than
Morphine 5 times more potent than Heroin
30. Fentanyl Citrate Very common medically, Increasingly common
recreational abuse Difficult to detect on standard drug assays
Purely Synthetic Potent Analgesic 80-100 times potency of Morphine
Low Euphoric properties Moderate respiratory/CNS depressant Both
pharmaceutical and illicitly prepared Rapid Onset, short Duration
Comes in multiple formulations Typically IV/IM Oral (lollypops)
Transdermal (Duragesic)
31. Duragesic Fentanyl Citrate Synthetic opioid Transdermal
Absorption Used in chronic pain patients 100 times the potency of
morphine Commonly Used for chronic pain Easily Acquired Easily
abused
32. 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 increased
Mortality (Woodall et al, 2007) 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
33. Krocodil
34. Krocodil Desomorphine Synthetic Opioid , first described in
1932 Clandestinely produced and derived from Codeine in a method
similar to Methamphetamine production (Relatively) new trend in
Eastern Europe/Western Asia Since early 2000s Incidence is more
directly related to Heroin use than Prescription opioid use
Important note: Huge difference in pharmaceutical Desomophine and
illicit Krocodil Actual Krocodil is only 5-20% opioid Fast Acting
(similar to Heroin) Short Duration Strong analgesic, Strong
Euphoric 8-10 times analgesia of Morphine, no data on other
properties Potent sedative but Low respiratory depressant
35. Krocodil in the US? Much hype, few questions Production and
availability directly tied to availability of pre-cursers (Codiene)
Typically $30-50 of product will render about $500 of end product
(European/Western Asia Reports) Predictions (also known as educated
guesses): Much hype, most likely will fizzle out Predominantly an
IV drug market Will be misbranded as heroin and mixed with heroin
Will be most common in the users of Black Tar and Low end heroin
out of Mexico We will not see the extensive morbidity and mortality
patterns seen in the former USSR due to the differences in health
care and social safety nets as well as differences in Opioid
use/abuse demographics Will still see some (rare) dramatic cases in
the homeless/forgotten populations
36. Much Hype, Little actual Bite to this Krocodil
37. Poly-Opioid Mixes Increasingly common practice of mixing
one type of opioid (typically Heroin) with another , more potent
opioid. This increases the potency (increasing profit) without
increasing the purity (i.e. the cost) Retains the eurphoric effects
of some opioids while getting the heavier nod of others.
38. Treatment
39. REMEMBER: Opioid overdoses are AMS calls first, opioid
overdoses last A - alcohol, alcohol withdrawal, and anoxia E .
epilepsy and other neurological disorders I - insulin (Hyper or
Hypo-glycemia) O- overdose (Poly-pharmacy?) U - uremia, underdose
of current medications. T- trauma I - infection P - psychiatric S .
stroke, shock states
40. Important note: According to DAWN Data: About 18% of opioid
related cases will also have alcohol. This is about 137% more
common now than 10 years ago. About 10% of opioid related cases
will also involve another pharmaceutical or illicit substance This
is about 84% more common today than 10 years ago Why?
41. Treatment In order to treat an opioid patient we need to
understand HOW opioids kill Primary Causes of Mortality:
Respiratory failure Airway Failure Secondary Causes of Mortality
Aspiration (Rarely) hypothermia and hypotension Situational Factors
MIS-TREATMENT by providers
42. Effect Time Threshold of Respiratory Arrest/Failure
Potential Respiratory Effect of Certain Opioids (i.e. Heroin,
Dilaudid) Potential Respiratory Effect of Other Opioids (i.e.
Morphine, Methadone) NOTE: Sufficient quantities of ANY opioid may
induce respiratory compromise!
43. THIS IS YOUR FIRST LINE TREATMENT AT ALL LEVELS
44. Narcan (Naloxone) Narcan is a Competitive Opioid Antagonist
Synthetic, derived from Thebain since the 1960s Competitive means
it will KICK OFF Opioids from receptors Predominantly works on (MU)
receptors Minimal effects on other opioid receptors It will NOT
work on other CNS depressants (with few exceptions) Clinical
effects last 20-45 minutes depending on circumstances Most opioids
last longer (exception IV fentanyl) Some studies on use in Septic
Shock and other situations
45. Narcan (Naloxone) Ventilation/stimulation first Slow admin
of Narcan, just enough to make them breath ABSOLUTELY NO PUNATIVE
ADMINISTRATION!!! Adult: IV, SL: 0.1-2 mg PRN to a max of 10 mg.*
IN/IM/ETT, IV in cardiac arrest: 2 mg. Pediatrics: 0.01-0.05 mg/kg
IV, IO, IM, SubQ, ET. Repeat PRN. MAX 2 mg/dose High doses may be
needed if drug is synthetic Watch for re-sedation due to Narcans
short duration (about 20-30 minutes)
46. KEY POINT: It should be noted that a response to (or
failure to respond) naloxone is not considered a reliable
diagnostic tool in determining if a patient has consumed opoiods.
Failure to respond to a total dose of 10 mg of naloxone usually
indicates: That poisoning is not due to opioids (or opioids alone);
Or that hypoxic brain damage has occurred. Or that the AMS is not
opioid related at all (A-E-I-O-U-T-I-P-S)
47. Narcan in Cardiac Arrest Poorly studied but very reasonable
In one AHA study: Small study , 36 patients Asytole and PEA were
predominant rhythm. Down times varied but were typically extended.
42% of cardiac arrest patients with a suspected opioid etiology
showed improvement in EKG rhythm s/p Narcan administration 27% had
ROSC by arrival at ER 1% had survival to discharge. Although we
cannot support the routine use of naloxone during cardiac arrest,
we recommend its administration with any suspicion of opioid use.
Due to low rates of return of spontaneous circulation and survival
during cardiac arrest, any potential intervention leading to rhythm
improvement is a reasonable treatment modality. Why? Inhibits the
adverse effects of the opioids in cardiac arrest, specifically
hypotension Narcan may cause a endogenous sympathetic response
(i.e. release of endogenous epinephrine) in the opioid addicted
patient May have indirect, poorly understood antiarrhythmic effects
Source : Resuscitation. 2010 Jan;81(1):42-6. doi:
10.1016/j.resuscitation.2009.09.016. Epub 2009 Nov 13. Naloxone in
cardiac arrest with suspected opioid overdoses. Saybolt MD1, Alter
SM, Dos Santos F, Calello DP, Rynn KO, Nelson DA, Merlin MA.
48. Narcan, OPIOID Withdrawal, and adverse events? OPIOID
WITHDRAWAL IS RARELY FATAL. WHY DO WE HAVE FATAL EVENTS WITH NARCAN
INDUCES WITHDRAWAL? Have you ever heard Narcan causing : Seizures
Cardiac Arrest (VT) Stroke? MOST (not all ) WITHDRAWAL SYNDROMES
ARE RELATED DIRECTLY TO THE EFFECTS OF THE DRUG/SUBSTANCES
INVOLVED. Then WHY do these S/S occur? FOUR REASONS: SYNPATHETIC
RESPONSE HYPOXIA HYPERCARBIA ACIDOSIS
49. Avoiding BAD OUTCOMES SYNPATHETIC RESPONSE EPINEPHERINE
RELEASE! RESPIRATORY DEPRESSION CAUSES: HYPOXIA HYPERCARBIA
ACIDOSIS We Treat Sympathetic response by SLOWING DOWN NARCAN ADMIN
with SMALLER DOSES We treat the RESPIRATORY CAUSES WITH CORRECTIVE
BVM THERAPY!
50. Smaller doses of Narcan? The short time between naloxone
administration and the occurrence of complications, as well as the
type of complications, are strong evidence of a causal link. In
1000 clinically diagnosed intoxications with heroin or heroin
mixtures, from 4 to 30 serious complications can be expected.
Development of ventricular tachycardia or fibrillation; atrial
fibrillation; asystole; pulmonary edema; convulsions; vomiting; and
violent behavior within ten minutes after parenteral administration
of naloxone. Such a high incidence of complications is unacceptable
and could theoretically be reduced by artificial respiration with a
bag valve device (hyperventilation) as well as by administering
naloxone in minimal divided doses, injected slowly. Source:
Osterwalder JJ. Naloxonefor intoxications with intravenous heroin
and heroin mixtures: harmless or hazardous? A prospective clinical
study. J Toxicol Clin Toxicol 34 (1996): 409-416 Cuss FM, Colao CB,
& Baron JH Cardiac arrest after reversal of effects of opiates
with naloxone. Br Med J, 288(1984): 363-364
51. Narcan Infusions? Narcan infusions are a MAINTANANCE
therapy, ideal for LONG transports (20-30 minutes or greater) Many
different methods/compositions/protocols Administer NARCAN as
normal to achieve respiratory and airway stability Mix the TOTAL
effective dose in 100 cc (or 250 cc) NS Set rate to infuse over 1
hour 100 cc Bag: 90 gtts a minute ( 1.5 gtt/sec) 250 cc Bag: 250
gtts a minute (4 gtts / sec) If re-sedation occurs: Evaluate for
other causes Titrate upward for effect Rebolus IV Narcan
52. LAYPERSON/ BLS Narcan?
53. Thoughts IM clinically safer than IN Both should be an
option Protocols/Training should mandate BVM/Airway Management
first
54. NARCAN Treat & Release Criteria Criteria: The patient
can mobilize as usual; The patient has an oxygen saturation on room
air of >92%; 3) have a respiratory rate >10 breaths/min and
35.0C and 50 beats/min and