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Prescription Drug Abuse:
Emerging Drugs of Abuse
Lydia Baltarowich. MD, FACEP,
FACMT
July 10, 2014
Objectives
• Appreciate the significant morbidity and mortality
associated with the current prescription drug abuse
epidemic
• Be familiar with the most common prescription agents and
their methods of abuse
• Recognize the clinical toxidromes associated with the
most common and deadly agents
• Know treatment options for overdose
Emerging Drugs of Abuse
• CDC Data (National Vital Statistics) 1999-2008 showed a
dramatic increase in prescription drug abuse, misuse,
and overdose deaths (MMWR 2011)
• 1999-2008: deaths from opioid prescription pain killers
increased 4-fold
• Since 2004 Rx opioid analgesics account for more ER
visits and deaths than cocaine and heroin; majority listed
as “unintentional
“We have moved from an era of “illicit” street drug abuse
to an era of “legal” prescription drug abuse” (Nelson 2012)
Drug Overdose Deaths 1999-2008
CDC 2011
Emerging Drugs of Abuse
• The prescription opioid epidemic is a major public health problem and
the fastest growing drug problem in the US
• CDC Data 1999-2008 showed a parallel increase in overdose deaths,
prescription sales, & substance abuse treatment admissions related to
opioid prescription pain killers
• Top 5 prescriber of opioids to patients < 39yr:
EP’s, primary care, pediatricians, dentists
• Physician prescriptions are being used as “emerging drugs of abuse”
(CDC MMWR 2011)
Prescription Drug Deaths
Recent Celebrities
• Anna Nicole: 39 yr, died in 2007 from an accidental overdose of at
least nine different prescription drugs
• Heath Ledger: 28 yr died in 2008 from overdose of prescription
drugs, including pain-killers, anti-anxiety drugs, and sleeping pills
• Michael Jackson: King of Pop died in 2009 from a lethal injection of
propofol
• Whitney Houston: died 2012, from drowning in a bathtub after she
ingested a cocktail of cocaine and prescription drugs: more than 12
prescriptions were found in her hotel room
DAWN 2004-2010
Estimated ED visits 2004-2010:
• ED visits for misuse/abuse of pharmaceuticals
increased 115%
• ED visits for non- medical use of narcotic pain relievers
increased 156 % : oxycodone, hydrocodone
• ED visits for stimulant /ADHD drugs increased 196%
• ED visits for benzodiazepines increased 139 %
• ED visits for illicit drugs overall showed no significant
change, except THC
(DAWN Highlights 2012)
AAPCC: NPDS DATA 2007-2012
Categories With Largest Numbers of Deaths
• Analgesics
Opioids > acetaminophen in combination >
acetaminophen alone > salicylates
• Sedatives- hypnotics/ antipsychotics
Alprazolam & quetiapine
•
Antidepressants
Amitriptyline, bupropion, venlafaxine
• Cardiovascular drugs: CaChBlockers, digoxin
• Stimulants and street drugs
Fueling the Prescription Epidemic
Healthcare providers:
• Prescription overabundance from medical providers
• Almost all prescription drugs involved in diversion,abuse, overdoses
come directly or indirectly from the original prescriptions
• Changing philosophy of pain treatment: subjective pain and patient
satisfaction on forefront: JCHO & IOM mandates
well- meaning providers
• Easier to treat pain than addiction
• Aggressive marketing
•
Economics: dealers, diversion, unscrupulous providers
Fueling the Prescription Epidemic
Layperson Perceptions about Rx Drugs:
Safer than street drugs
Not addictive
Improve school & athletic performance
Decrease stress, help sleep
Accessibility:
• Easy access in home medicine cabinets, friends, school
• Internet marketing & selling of drugs without Rx
Cost:
• Cheaper, especially if have insurance
Legal: Prescription drugs vs Illicit
Pill mills, pain clinics and unscrupulous
doctors contribute to the illegal
distribution of legal prescription drugs.
Just about everyone who comes through
the doors walks away with the same
remedy: a prescription for a month-long
supply of powerful opioids
Prescription drugs worth millions to dealers
Street prices for a single tablet of commonly trafficked
drugs, compared to their retail prices:
•
•
•
•
Oxycontin: $50 to $80 on the street, vs. $6
Oxycodone: $12 to $40 on the street, vs. $6 retail
Percocet: $10 to $15 vs. $6
Oxymorphone $ 75
• Vicodin: $5 to $25 vs. $1.50; # 30= 750’s $50
• Tramadol: $1-2 for 50 mg
Street prices taken from the latest data put out by federal law
enforcement agencies; retail prices from pharmacychecker.com.
Internet Pharmacies
• Ryan Haight On-Line Pharmacy Consumer Protection
Act 2008; Implemented 2009
• Amends CSA to prevent illegal distribution of controlled
substances by Internet
• DEA registration & reporting requirements for all Internet
Pharmacies
Physician: Responsibility & Dilemma
Responsibility: treat pain: 5th Vital Sign
• Joint Commission 2000 & patient satisfaction scores
• Institute of Medicine Report 2011: pain under-treated
Dilemma:
• Prevent public health pain killer epidemic
• Balance analgesia with drug diversion
Teen Drug Abuse: Generation Rx
“Generation Rx has arrived” 2004
Teenage illicit drug use declined after
it peaked in 1990’s: Ecstasy use declined
after peaked in 2001 (PATS 2004)
Rx drug use rising among
teens & college students
(PATS 2005/ MTF 2005, 2007)
Generation Rx
Cocaine (9%)
Heroin (4%)
LSD (6%)
Ecstasy (9%)
Methamph (8%)
Ketamine (5%)
GHB (4%)
PATS 2012/ 2013
•
Teen prescription drug misuse and abuse continues to increase since 2008
and is a significant health problem
•
Currently, 1/4 teens (24 percent) admits to having misused or abused a
prescription drug at least once in their lifetime.
Prevalence increasing: 18 % (2008)- 24% (2012)
•
•
Increase in the lifetime misuse and abuse of prescription stimulants with 1/8
teens (13%) now misusing Ritalin or Adderall at least once in their lifetime.
•
•
2013: 4-year increase in the nonmedical use of Adderall by 12th-graders
Prevalence of stimulant misuse: 11% (2008) to 13% (2012) 95% CI
•
1/3 of parents (29 percent) say they believe ADHD medication can improve a
teen’s academic or testing performance
•
Teen misuse and abuse of prescription pain relievers, Vicodin and OxyContin,
has remained stable with one in six (16 percent) teens having misused or
abused prescription pain relievers at least once within their lifetime.
MTF 2012
MTF Trends: 2008-2012
Monitoring the Future (MTF):
“The future is in Adderall”
College Students:
• Adderall prevalence of use increased from 5.7% 2008
to 11% 2012, higher than non-college age mates
• Oxycontin and vicodin declining since 2010
• College students show lower rates of use of illicit drugs
except THC
Commonly Abused Prescription Drugs
• Pain Killers: hydrocodone (vicodin), oxycodone (oxycontin)
• Sedatives: alprazolam, diazepam, clonazepam ,zolpidem
• Stimulants: Adderall, Ritalin
** 2013: 4-year increase in the non medical use of Adderall by 12th-graders
• OTC’s: Dextromethorphan products, antihistamines
(PATS 2004-2012
MTF 2005-2012
DAWN 2007-2011)
Commonly Abused Prescription Drugs
CSA 1970 : Schedules
• Schedule 1: high abuse potential; research only
• Schedule 2: high abuse potential; written rx, 30
day supply, no refills
• Schedule 3 & 4: less abuse potential; verbal rx ;
refills limited to 5 refills/ 6 months
• Schedule 5: antitussives, antidiarrheals
Case 1: “E” or “O” ?
26 yr M found down by friends and could not wake him
up. There were green pills around him so they thought
he took “ E” !
PE: Lethargic, GCS 9; pupils pinpoint,
RR 7, HR 50, BP 90/40 T 35
Neuro: non-focal; Heart/ Lungs/ Abd: + BS
Toxidrome:
Management: A2 B C2 DE’s
Oxycontin
Oxycodone :” Oxy” is
controlled - release oxycodone
10, 20, 40, 80 mg
Oxy’s ,OC’s, Killers, Kicker,Poor Man’s
Heroin, Hillbilly Heroin:
Appalachia highest traffic
Sources: illegal diversion of Rx drug;
“doctor shopping”, theft,
internet distribution
Crush-resistant formulation in 2010
Schedule II
Oxycodone
Oxycodone: high potency (2x’s morphine),
semi- synthetic opioid
Top selling narcotic analgesic since 2001
Majority of oxycodone deaths are due to Oxycontin
Method: crush tablets to defeat time-release matrix,
then snort or inject
Immediate Release: lower dose formulations:
roxicodone or generic oxycodone/: 5,10,20 mg
APAP: percoset, roxicet, tylox
ASA: percodan, roxiprin
Oxycontin mimics
• Analysis of the tablets
indicated that they were a mix
of heroin, caffeine, and
lactose: green coating over a
compressed light brown
powder. Actual OxyContin
tablets have a light green
coating over a compressed
white powder
• Dangers of contraband
products: you don’t know what
you are getting
26
Clinical Pearls
• Opioid toxidrome: miosis, CNS/ respiratory depression
• UDS: opiate immunoassay:
 Natural Opiates: + morphine, codeine, heroin


Semi-synthetics: variable, assay sens & drug concentration
Synthetics: not detected
• Treatment : narcan low dose 0.4 mg IV, IM; titrate dose or infusion
• Long Acting formulations: relapse expected; admit, narcan drip
• Partial response to naloxone: more narcan or co-ingested
sedative
• Addiction/ withdrawal: GI, agitation, diaphoresis, gooseflesh
Oxymorphone: Opana
•
•
•
•
Slang: stop signs, biscuits, octagons, O bomb, blues
“The new oxycontin”: crushed: snort & IV
Formulations: initial: OPANA ER was crushable
Reformulated 2012 but generics exist
•
•
•
•
Oxycodone metabolite, semisynthetic
Efficacy & tolerability like morphine
ETOH+ ER formulations: increase oxymorphone levels
TTP associated with IV use
Vicodin: Hydrocodone + APAP
•
•
•
•
•
•
Most popular Rx “pain killer” abused by teens
Second to marijuana as the ‘drug of choice’
Street prices: $5- $ 25 vs $1.50 (# 30- 750mg $50)
About 50% of teens feel there is no great risk to its use
Potential for APAP toxicity
Vicodin 5mg/ 325 apap; Vicodin ES 7.5mg/ apap 750mg
Lortab, Lorcet, Norco
• Schedule III
• Opioid ototoxicitiy:
methadone and hydrocodone
Acetaminophen
• Most common cause of ALF in US: APAP- opioid combination analgesics
• FDA limits acetaminophen in prescription combination products
at 325 mg and requires liver toxicity warnings: January 2014
• Combination acetaminophen-opioid products: no more than 3gm/ 24h;
patient education regarding dosing should be stressed
• FDA final rule in 2009 on the labeling of all OTC drugs containing
acetaminophen to warn of the risk of liver damage. effective April 2010.
• “Liver warning: Severe liver damage may occur if you take • more than
4,000 mg of acetaminophen in 24 hours • with other drugs containing
acetaminophen • 3 or more alcoholic drinks every day while using this
product.”
Pure Hydrocodone
•
•
•
•
•
ZohydroER:10,15,20-50 mg
No APAP !!!
Abuse potential similar to morphine and oxy
Schedule 2
Capsule Formulation lacks abuse-deterrents, so allows it
to be crushed, chewed, dissolved, snorted, injected
• Extremely potent, hydrocodone opioid that is between five
and 10 times the strength of Vicodin. One capsule could
be fatal to a child
Methadone
• CDC: 1/ 3 of annual Rx drug overdose deaths are from methadone
(1/3 of 15,000)
WHY ?
• Cheap generic used for pain management, not substance abuse rx
• Long ½ life: 8-60 hrs( 24hrs):
• opioid naïve: must titrate doses up from 10-20 mg
• can take 5 days to achieve pain control so patient self medicates
• analgesic effect lasts 4-8 hrs, resp depression longer
• Drug interactions: P450 metabolism
• Dose –dependent QT prolongation > 500msec: torsade,sudden death
• Ototoxicity: tinnitus & hearing loss
Buprenorphine
• Suboxone: buprenorphine and naloxone: prevents IV use
• Tablet or dissolvable sublingual film: “ prison heroin ‘
2 -12 mg buprenorphine with 0.5-3 mg naloxone,
•
•
•
•
Subutex: no naloxone
Schedule III
Better safety profile than methadone, no QT prolongation
Children: delayed, prolonged toxicity
Tramadol
• Tramadol, as synthetic opioid, marketed as a non-controlled
analgesic since1995 under the trade name of Ultram®. Generic,
combination, and extended release tramadol products exist.
• July 2, 2014, DEA final rule placing tramadol into schedule IV
of the Controlled Substances Act. Will become effective
August 18, 2014
• Induces psychic and physical dependence similar to morphine (μopioid)
• Associated with craving, tolerance, and withdrawal symptoms if
discontinued
• Seizures are more likely at high doses > 400 mg/ day
• Serotonergic agent which can cause Serotonin Syndrome, especially
after naloxone administration, which can unmask serotonergic effect
Long- Octing/ ER Opioids
• No place in ED as 1st line treatment for pain
• Not for acute pain or for opiate naïve patient: dose must be titrated,
and can take 5 days to achieve pain control
• Patients tend to self medicate
Abuse: high abuse potential
• ER Formulations desirable: large doses
• Crushed: IV or snorted: rapid onset & rapid fatality
• Tamper-resistent formulations limit crush but you can still swallow pills
Formulations:
• OxyContin: Purdue Pharma created a crush-resistant formulation in
2010; FDA blocked generic version of crushable oxy
• Oxymorphone: tamper resistent OPANA but generics: available
Case 2: Smart Drugs
19 yr F student, brought to ED by friends with headache and palpitations. She
had been studying hard for past 2 weeks during U of D (Dopamine) finals.
Today became restless, talkative, started cleaning everything in her dorm
& then felt like her heart & head were going to explode.
PE: restless, scratching legs constantly, O X 3 HR 160, BP 160/90, T 37
RR 22 Pupils 6mm Talking to self, speech mumbling, paranoid behavior
Neuro exam: non-focal, no tremor or rigidity
Heart/lungs/ abd: +BS
What is the Toxidrome?
DDx:
Management:
Epidemiology
• MTF, PATS, DAWN show increased abuse, misuse of stimulant
ADHD drug: “The future is in Adderall” Smart Drugs
• Performance-enhancing off-label use, rather than abuse as a
recreational drug, is the primary reason that students use stimulants:
• memory enhancement, tests, and study marathons
• Market push behind diagnosis of adult ADHD, similar to that used for
pain killers
• Increased prescribing rates: increased diversion, abuse, misuse,
overdose
Prescription Stimulants
• Dextroamphetamine/ Amphetamine: Adderall / XR
• Slang: Smart Pills, Smurfs, Blue Betties
Blueberries, A-bombs, Black Beauties
• Lisdexamfetamine (Vivanse): pro drug to dextroamphetamine
• Methylphenidate (Mph): Ritalin, Concerta
Ritalin = “kiddee cocaine” / “Vitamin R”/ “R ball”
•
Not an amphetamine
• Abuse Methods: ingest or crush tablets: snort or inject
• Schedule II: high potential for abuse
Prescription Stimulants
Mechanism: Mph & Dextroamphetamine:
Enhance release and block reuptake of NE, D, 5HT
*MPH has little effect on 5HT
Increased dopamine: improves wakefullness, attention & focus
decreases appetite, increases energy
***advantage: “ clean dorm rooms ”
Clinical Pearls
• Sympathomimetic toxidrome:
•
•
•
Alpha/ beta adrenergic: tachy, htn, mydriasis, seizures
DA & 5HT: hyperthermia, rigidity: SS
psych: agitation, hallucinations, paranoia, psychosis
•
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Chronic use: vasculitis, cardiomyopathy, neuropsychstereotypical behavior/
Tweaking: compuslive behavior associated with amphetamine abuse
•
ER Formulations have delayed , prolonged symptoms
•
UDS: amph + : phenethylamine structure, but not methylphenidate
•
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Treatment: aggressive benzos & cooling
Interrupt CV/CNS sympathomimetic toxidrome with benzos
Hyperthermia increase mortality: cooling
•
Addiction/ withdrawal: fatigue, hypersomnia, hyperphaghia
Adderall May Not Make You Smarter, But
It Makes You Think You Are
• Controversial:
According to a study from the University of
Pennsylvania (2010), students who took Adderall
didn’t actually perform better on tests of cognitive
function — they only thought they did
Malenka RC, Nestler EJ, Hyman SE (2009):
Molecular Neuropharmacology: "Therapeutic
(relatively low) doses of psychostimulants, such as
methylphenidate and amphetamine, improve
performance on working memory tasks both in in
normal subjects and those with ADHD. Dopamine
and norepinephrine, but not serotonin, produce the
beneficial effects of stimulants on working memory
“
High on Cough Syrup
Case 3: “Robo-Tripping”
14 yr M brought to ED from school because of bizarre behavior: appears to
be in a trance, says he’s floating
VS HR 120, BP 150/80, T 37, RR 20 pupils 5mm
Alert, oriented X 1, blank stare, visual hallucinations, slurred speech,
cannot move his extremities
Asymptomatic in 12 hrs
Parents later found empty boxes of Coricidin HBP in his room.
Toxidrome: hallucinogen, dissociative,
anticholinergic
“Robo-Tripping”
Toxidrome: hallucinogenic & dissociative
• First plateau: 1.5 to 2.5 mg/kg
– Slight stimulant: restless or drowsy, mydriasis, tachy
• Second plateau: 2.5 to 7.5 mg/kg
– “Stoned”: drowsy or agitated, slurred speech, ataxia, euphoria, LSD
hallucinations, memory disrupted
• Third plateau: at 7.5 to 15mg/kg,
– Strong intoxication, LSD hallucinations
• Fourth plateau: > 15mg/kg (Sigma plateau)
– Similar to ketamine & PCP: trance-like, catatonic state,
dissociative effect
Dextromethorphan
• Over-the-counter cough suppressant: easy access, cheap, legal
• Substitute for illicit Hallucinogens, Dissociative Agents:
PCP/ Ketamine
• Serotonin receptor agonist: blocks 5HT re-uptake: hallucinogen, SS
• NMDA glutamate receptor antagonism results in:
PCP 1 site: dissociative effects (PCP, ketamine)
PCP 2 site: NE, D, 5HT re-uptake inhibition
• UDS: False positive PCP
• Most Popular: Coricidin HBP Cough & Cold
– 30 mg DXM HBr
– 4 mg chlorpheniramine (anticholinergic )
CCC” “Triple C”
“
Concentrated DXM Sources
• DexAlone gelcaps: 30 mg
• DXM/ guaifenesin tablets:
Mucinex DM (ER): 30 mg
• DXM syrups: Delsym:extended release suspension:12 hrs
30 mg DXM/ 5ml (150 ml)
Dextromethorphan
Slang terms
DXM/DM
Robo
Tussin
DEX
Triple C
Red Devils
Skittles
Robo-ing or Robo -Tripping
Robo-shuffle
Prescription Cough Syrup
Promethazine 6.25 mg / Codeine 10 mg per 5 ml
– Codeine is mainly responsible for the euphoria
– Promethazine causes motor impairment, drowsiness
• Highest abuse in South: Texas to Florida
• Schedule V
• “Causes a slow trip, gives u a leaned out kinda feelin”
• Slang: Purple drank, Lean,
Texas Tea, Purple Jelly,
White Cup, Styrofoam Cup,
Promethazine, Codeine
(Urban Dictionary)
“Sizzurp”
The original formula:
Promethazine w/Codeine = Sizzurp
Original Sprite Soda ( fruit flavor soda)
A jolly rancher (flavor additive)
Put it all in a styrofoam cup and enjoy
Styrofoam cups, an iconic symbol of sizzurp
Wayne raps, “You know what’s in my Styrofoam “
Sizzurp is well known in the hip-hop/
rap culture, specifically in Houston,
since 1990’s
Three 6 Mafia's “Sippin' on Some
Sizzurp” and Lil' Wayne's “Me and
My Drank
Case 4: The “Red Pop” Case
18 yr M brought to ED in PEA cardiac arrest after he was found
unresponsive at a party where he was noted to be drinking a
red pop all night mixed with “lean” . Patient was
resuscitated, after 5 days was extubated, but had sequelae
of anoxic cerebral injury: non-verbal, minimally
communicative.
Transferred to Neuro rehab facility.
Drug Screen: opiate positive
Prescription Cough Syrup
Promethazine (Phenergan): phenothiazine antihistamine
• Clinical effects: sedation; anticholinergic, EPS
Codeine
• Opioid agonist
• Metabolism: inactive, requires demethylation to morphine
• 5-7% of caucasian population unable to convert: no CYP2D6
Promethazine and codeine combinations are contraindicated in pediatric
patients < 16 yr
Administration of promethazine with other respiratory depressants has
been associated with respiratory depression and death, in pediatric patients
(FDA Medwatch)
Case 5: Found Down
32 y/o F found unresponsive with an empty bottle of vodka and
unmarked pill bottles next to her
She was last seen yesterday
PE: lethargic, moans and withdraws to pain
VMAS 1
GCS 10
pupils 4 mm
BP 100/60 HR 90 T 36 RR 10 POx 90%
Neuro: non-focal, normal tone; DTR’s 2+
Heart/ Lungs: clear
Abd: soft, BS decreased
Skin: normal
UDS: ETOH 0.20
Toxidrome:
Gaba Receptor Agonists
Sedative-Hypnotic Toxidrome
Benzodiazepines
Z drugs
Alcohols, GHB
Valproic acid
Carisoprodol, meprobamate
Barbiturates
Chloral hydrate
Propofol, Etomidate
“Trinity ”
“Holy Trinity” or “ Houston Cocktail”
• Soma (carisoprodol)350mg
• Alprazolam / Xanax®/ Valium
• Hydrocodone/ Oxycontin/ Tramadol
“Vicosomapraz”
Clinical Pearls: SOMA
•
•
•
Centrally acting muscle relaxant, sedative; meprobamate metabolite
Sedative-hypnotic toxidrome (meprobamate)
Serotonergic: tachy, htn, shivering, tremors, myoclonic jerks, hyperreflexia, clonus,especially after narcan
•
•
Onset of action of carisoprodol is rapid
No awakening; partial response after narcan if “trinity”
•
Lab: neg tox screen, unless “trinity”
•
GABA agonist: addiction/ withdrawal
•
DEA: carisoprodol continues to be one of the
most commonly diverted drugs and abuse is prevalent
• Schedule IV
Case 6:The Pharm Party
These guys went Pharming…
13 & 14 yr M brought to ED after
falling at “the pharm”.
They keep repeating that
they took some “coffins”
PE: Bp 110/60, HR 80, T 36
Drowsy, Ox3,pupils 3mm,
slurred speech, ataxic
Toxidrome?
What are “coffins”
Benzodiazepines
Alprazolam: Xanax 2mg
Zanny bars, coffins, french fries
Blue footballs: 1mg round
Swallowed or crushed/ snorted/ injected
Diazepam, Klonopin: K-pins
Alone or in combination with:
etoh, stimulants, soma, heroin
Toxidrome: cerebellar incoordination/
Sedative-hypnotic
Flumazenil reversal
Lab: poor detection on UDS
Schedule IV
Addiction & withdrawal: occult dependence is common
“Z” Drugs
Non-benzodiazepine hypnotics
Zolpidem: Ambien, Ambien CR
Zaleplon: Sonata
Zopiclone/ Eczopiclone: Lunesta
Most commonly prescribed sleep aid
2013 FDA approved label changes specifying new dosage
recommendations for zolpidem products because of concerns
regarding next-morning impairment (especially women)
Schedule IV
Bind to benzo receptors at GABA A complex
Respond to flumazenil
High toxic to therapeutic ratio
Flumazenil
• Competitive antagonist at BZ receptor on GABA A complex
• Effective for benzo and “Z” drug overdose
• Flumazenil 2 hr half-life: shorter than most benzodiazepines
• Dose:0.2/ 0.3/ 0.5 mg q 30 sec max 3 mg
• Selective Indications:
–
pure benzo induced coma or resp depression
–
reversal of conscious sedation or anesthesia
–
pediatric benzo overdose
• Avoid if:
– chronic benzodiazepine use
– co-ingestants that are proconvulsant, TCA
– if BZD used to control seizures
Other Rx Meds Abuse
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•
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•
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Seroquel (Quetiapine): antipsychotic
Benadryl: anticholinergic; TCA-like
Flexeril: anticholinergic; TCA-like
Clonidine: central alpha2 agonist
opioid toxidrome
Baclofen: sedative
Fentanyl patches
Quetiapine: Seroquel
• Atypical antipsychotic:abused as anxiolytic & sleep aid
• Antihistamine, antimuscarinic, alpha blockade: sedation,
tachy, hypotensive
• K Ch Blocker: “QT iapine “ : QT prolongation
• Dystonic reaction, NMS
• UDS: false + TCA
• 30% of jailed LA inmates in psych services malinger
symptoms to obtain quetiapine
– Sedative, calmative, anxiolytic
Quiz
1) Name the dissociative hallucinogens of abuse
DXM, PCP, Ketamine
2) Which agents have recently been associated with
tinnitus and hearing loss?
Opioids: methadone, hydrocodone
3) Which cough syrup can result in dystonic reactions?
Promethazine/ Codeine
4) Flumazenil is safe in chronic benzo users.
False
Quiz
5) Is Aderrall a scheduled drug?
Schedule II
6) Which opioid is associated with SS?
Tramadol
7) Which sedative is associated with SS?
Soma (Carisoprodol)
8) Which cough syrup ia associated with SS?
DXM
9) Will methylphenidate produce a positive amphetamine
result on UDS ?
Not an amphetamine
Quiz
10) What is concern for treating acute pain in ED
with LA opioids?
Delayed pain control, therapeutic overdose
11) Which neurotransmitters do amphetamines
affect ?
Dopamine, Norepi, Serotonin
12) What are best treatment options for agitation from
prescription stimulants?
Benzodiazepines
Quiz
13) What is Tweaking ( not Twirking) ?
Compulsive behavior associated with
amphetamine abuse
14) What is difference between Schedule 2 and
Schedule 3 category?
Schedule 2: high abuse potential; written rx, 30 day
supply, no refills
Schedule 3 & 4: less abuse potential; verbal rx ;
refills limited to 5 refills/ 6 months