Download Chemical Dependency

POSSIBLE OVERDOSE
CARE OF POSSIBLE OVERDOSES
• Intoxicated
• Opioid Dependent
• Opioid Withdrawal
• Benzodiazepine Dependent
• Cocaine Dependent
• Recreational Drug User
DEFINITIONS
• Addiction: continuing use of substance despite threatening and/or adverse
consequences
• Tolerance: ability to use increased amounts of substance with diminishing
intoxication effect; needing to use more of a drug to gain same effect
• Physical Dependence: habitual use of drug where negative physical withdrawal
symptoms result from abrupt discontinuation
ALCOHOL WITHDRAWAL
• Occurs when alcohol is no longer available to receptor sites in the brain
• Onset at 6-8 hours after last drink
• Peaks 24-36 hours after last drink
• Withdrawal can be
FATAL
ALCOHOL WITHDRAWAL SYMPTOMS
• Tremors
• Diaphoresis
• Tachycardia
• Elevated BP
• Fever
• Irritability
• Restlessness
• Anxiety
• Intense craving for Alcohol
SYMPTOMS CONTINUED
• Abdominal cramping
• Muscle pain
• Hallucinations
• Confusion
• Delirium
• Paranoia
• Seizures
• Status Epilepticus
• Coma
• Death
DELIRIUM TREMENS (DTS)
• Most intense and serious symptom
• Mortality rate up to 35% untreated
• Elements of DTs
•
agitation, tremulousness, autonomic instability, auditory and visual hallucinations,
hyperpyrexia, disorientation, confusion, seizure death
CRITICALLY ILL
• Cognitive difficulties & psychotic symptoms such as hallucinations may be
difficult to recognize, especially in intubated patients
• Agitation may lead to use of Benzos which can mask alcohol related problem
• May reoccur in subsequent admissions
TREATMENT OF ALCOHOL WITHDRAWAL
• Provide safe, calm environment
• Observe patient frequently
• Be aware of fall risk
• Adequate nutrition and hydration
• Monitor vital signs
• Monitor physical status
• Diaphoresis?
• Tremors?
• Anxiety?
BENZODIAZEPINES/THIAMINE
• Benzos replace ETOH on receptor sites
•
Decrease tremors, muscle cramping and anxiety
•
Lower BP and Pulse
•
Facilitate rest
• May deficient due to poor nutrition
• Thiamine necessary to metabolize glucose
• Irreversible brainstem & cerebellar damage can result from IV glucose
administered in Thiamine deficient patient (Wernicke’s encephalopathy)
TREATMENT GOALS
• Safe detoxification
• Preserve patient dignity
• Prevent Delirium Tremens
• Encouragement of ongoing treatment for alcoholism
BENZODIAZEPINE DEPENDENCE
• Sudden withdrawal can be dangerous, potentially fatal
• Can cause DTs
• Gradual reduction of daily dose
• 10% every 2-4 weeks if not being medically monitored daily
WITHDRAWAL SYMPTOMS
• Elevated heart rate
• Elevated BP
• Insomnia
• Restlessness
• Anxiety
• Headaches
• Muscle spasm and cramps
• Can progress to: seizures, coma, death delirium tremens
ONSET/DURATION
• Depends on half life of Benzodiazepine
• Usually 24-48 hours
• Delayed up to 3 weeks
• Post acute as long as 2 months or longer
OPIOID DETOX
• Not life threatening
• Very uncomfortable
• Resembles bad case of flu
• Treat symptoms
•
Clonidine
•
Robaxin
•
Bentyl
•
Immodium
•
Ibuprofen
COCAINE WITHDRAWAL
• No physical dependence
• Intense craving
• Depression
• Suicide
• Somnolence
DRUGS OF ABUSE
• Bath Salts
•
May appear as white or off-white powder or crystals
•
May be ingested, insufflated (snorted or inhaled) or smoked
•
Contents produce clinical effects akin to those of amphetamines or other
stimulants
•
Sympathomimetic effects: increased BP/P, diaphoresis, agitation
•
If hallucinations are part of presentation, a quiet environment devoid of auditory
and visual stimulation may help, benzodiazepine
DRUGS OF ABUSE
• Synthetic Cannabinoids
•
Sold as white or off-white powder or combined with plant products
•
Spice, K2, Chill Zone, Sensation, Chaos, Aztec Thunder, Red Merkury
and Zen are common brand names
•
They may be ingested or insufflated or smoked when mixed with plant
products
•
Clinical effects reported as variable sometimes mild, but there are
reports of paranoia and agitation resulting in self harm
•
Supportive care and a quiet environment devoid of stimulation in
addition to benzodiazepines
DRUGS OF ABUSE
• Salvia divinorum
•
Hallucinogenic herb
•
Can be smoked, ingested, brewing in tea or using as tincture (dissolving in alcohol
and drinking)
•
Kappa opioid receptor angonism causing sedation, analgesia, GI hypomotility,
aversion and depression
•
If hallucinations are present, a quiet environment devoid of auditory and visual
source of stimulation
•
Naloxone to treat opioid effects
INSUFFLATION
• To blow something such as air, powder or gas into the lungs of prescription
drugs such as opioids (e.g. Oxycodone, Percocet, Vicodin, methadone and
buperonorphine), stimulants (e.g. Adderall) and other psychoactive
medications
• Clinical affects will correspond to drug insufflated
• Remember to perform a thorough nasal and oropharyngeal exam for signs of
nasopharyngeal necrosis
ENERGY DRINKS
• Contain caffeine and may be consume in excessive quantities resulting in
caffeine toxicity
• Clinical effects may include mild nausea, or protracted vomiting
(corresponding to dose ingested), cardiac dysrhythmias or seizures
• Supportive care should include intravenous fluid resuscitation, antiemetics
and sympatholytics
METHOXETAMINE (MXE)
• Analog of ketamine, and both drugs have structural similarity to PCP
• Clinical effects mirror those of ketamine and other dissociative anesthetics
• Physical findings may include nystagmus, altered mental status (some users
report out of body experiences) and significant analgesia
• Care is supportive
PIPERAZINE
• Initially designed as an antihelminthic (drug that rids body of parasitic worms),
but was discovered to have stimulant properties
• BZP, CPP, MeBP, MeOPPm MeP and TFMPP are types
• Historically have been abused in nightclubs as alternatives to ecstasy and other
amphetamines
• Sympathomimetic clinical effects may be similar and supportive care involves
intravenous fluid resuscitation and benzodiazepines
ACETYL FENTANYL
• Used by intravenous drug users
• Street names: Apache, China girl, china white, dance fever, friend, goodfella,
jackpot, murder 8, TNT and Tango and Cash
• Fentanyl’s potency is significantly greater than that of morphine and heroin
• Clinicians treating possible overdoses should consider increasing doses of opioid
antagonist, may be necessary to reverse opioid effects of respiratory depression
DEXTROMETHORPHAN (DXM)
• One of the active ingredients in over-the-counter cough suppressing medications
• Abuse has been referred as “Robotriping” in reference to Robitussin, and using
“Skittles” or “Triple C’s” because of the red pill formulation in Coricidin
• Clinical effects mimic those of ketamine including nystagmus and supportive care
should include checking for salicylate or acetaminophen as cough syrup
preparations are often co-formulated
• If co-formulated with diphenhydramine look for evidence of diphenhydramine
tricyclic antidepressant-like sodium channel cardiac activity ( QRS prolongation
and/or abnormal R wave in aVR)
• Treatment involves intravenous sodium bicarbonate
CODEINE CONTAINING COUGH SYRUP
• Referred to as Syrup, Purple Drank, Sizzurp, and Lean
• Goal of mixing ethanol with codeine-containing syrup is to become intoxicated
and narcotized
• Treatment should include supportive care, airway management, and possible
Naloxone
• Investigation for evidence of salicylate toxicity and acetaminophen is also
indicated, as cough syrup products are often co-formulated with these
ingredients
ECSTASY OR MDMA (“MOLLY”)
• Enjoys continued popularity as “Molly” among amphetamine enthusiasts
• Sympathomimetic effects may also include signs of serotonin syndrome
(hyperthermia, hypertension, tachycardia, altered mental status, ophthalmic clonus,
hyperreflexia, clonus and/or muscle rigidity) and bruxism (grinding of teeth)
• Supportive care includes intravenous resuscitation, benzodiazepines as needed for
sedation and possible coding in severe cases of hyperthermia
• May also cause hyponatremia or lead to excessive water intake
POINTS TO REMEMBER
• Be non-judgmental
• Pain is subjective
• Right to pain relief
• Right to be treated with dignity and respect
• Long term narcotics = increased tolerance
• Long term narcotics = physical dependence with or without addiction
• Tolerance decreases quickly after narcotic cessation
• Cause for overdose when use resumed after period of abstinence
REMEMBER
• Give meds as needed
• Monitor patient frequently
• Monitor: VS, I&O, and physical status
• Document response to med
• Supportive environment