Emergency Management of Drug Overdose Russell Sharpswain, DO, FACEP, FAAEM December 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 B – Breathing 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 Radiology 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 Long term effects = Unknown 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 Disposition 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 Disposition 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#