Download But before we begin

But before we begin,
Let’s spend time looking at drugs and chemicals
What’s Out There ( Illicit and Legal )
How Does it Work
How Do You Use it
• Let’s not overlook:
•
Tobacco & Alcohol
• Not only the synergistic effects of
nicotine & ethanol but smoking now
becomes a vehicle for other drugs
(marijuana & black tar heroine)
How Would You Treat Acute Intoxication
Numerous drugs are “stimulants” – legal and illicit –
and induce effects as by stimulating the Sympathetic
NS
Cocaine
Ephedra
COCAINE
Caffeine
1 kg
Cocaine brick
Pharmaceutical (Prescription) Stimulants
Attention Deficit Disorder
Adderal
Weight Control
Phenterimine
Narcolepsy
Modafinil
Illicit Amphetamines
MDMA
Methamphetamine
Processing cocaine
HAD COCAINE UNTIL 1903
Powder or Rock: it’s an ACID or a BASE
The Origins of Cocaine:
Legal sales up to 1914
Incas / Mayans / Aztecs: ceremonial rites
Spanish Conquistadors of SA brought to Europe
Active alkaloid isolated n 1860
Touted as a “general cure-all”, Sigmund Freud a noted enthusiast of its use
Architect Bartholdi: Inspired design of the Statue of Liberty
The alkaline crystal is stabile to heat = volatilization
COCAINE TODAY: 20mg lowest reported lethal intake
1 ounce = 30 grams
“dime” = 1/10 ounce = 3 grams
“eight ball” = 1/8 ounce = 3.75 grams
“quarter” = 1/4 ounce = 7.5 grams
Single rocks can cost $10 to $100 depending on weight
Purities:
leaves 0.2 – 0.9 %
powder 15 – 25 %
free base 40 – 60 %
crack 40 – 85 %
Recognizing the ACUTE SYMPATHOMIMETIC CRISIS
Neurologic:
agitation, seizures, muscle rigidity
Cardiac:
tachyarrhythmias, hypertension
ischemia and acute MI
Hyperthermia
core Temps > 105 = fatality
Rhabdomyolysis
rise in CK levels
Gastrointestinalhepatic failure, emesis, abdominal pain,
ischemic gut
Metabolic Acidosis, Hypoglycemia, Hyperkalemia
ABCs – Control Airway
Control Agitation / Seizures: IV Benzos
Hydrate / Alkalinize if High CPKs
Vasodilators if severe hypertension
Mechanical Cooling
Methamphetamine: powder, crystals, or tablets
Meth Labs
Can be ingested, snorted, smoked, injected
Mobile or Fixed
Combustible
Toxic
Booby-Trapped
Armed
Convert OTC stimulants into Methamphetamine
Utilize readily available chemicals and equipment
+
=
Acetone (nail polish remover)
Isopropanol (Rubbing alcohol)
Ephedrine or pseudoephedrine (OTC Cough / Cold)
Sulfuric acid (drain opener)
Ether (Engine starter fluid / aerosol)
Iodine tablets (OTC)
Methanol (Heet/gasoline additives)
Lithium batteries
Red phosphorous (matches)
Muriatic acid HCL (toilet bowl cleaners)
Anhydrous ammonia (fertilizers)
NaOH - Red Devil lye
Salt (table or rock)
Sodium metal
Trichloroethane (solvents)
Toluene (glue, wood stripper)
Numerous ways with “meth” to get yourself to the morgue
Aspiration
SYMPATHOMIMETIC TOXIDROME
Stroke
Hyperthermia
Enhanced central catecholamine stimulation
HIV
Seizures
Sepsis
Homicide
Agitated – Alert – “Intense” - Irritable
Elevated Heart Rate and Blood Pressure
Sweating
Dilated Pupils
Enhanced Muscle Tone and Hyper-reflexive
Following the “high”
May see overwhelming
psychosis / paranoia / delusions
Liver Failure
Trauma
Cardiac Arrest
Cardiomyopathy
Designer Amphetamines
phen-ethyl-amine
\fen-'eth-al-a-,men\
Any of a series of compounds containing a phenethylamine skeleton
and modified by chemical constituents
in the molecule.
The Schulgens report on the synthesis
and experiences with 177 PIHKALs
19 are identified as “important”
The Most Common “Club-drug” used is MDMA
3, 4 methylenedioxymethamphetamine
aka: “E”, Ecstasy, XTC, the hug-drug, Adam, and M&Ms
2C-B
DOB
MDA
MEM
TMA
2C-D
DOI
MDE
MJ
2C-T-2
DOM
MDMA
MMDA
TMA-2
2C-T-7
M (mescaline)
MDOH
Methamphetamine
TMA-6
MDMA is only produced in:
HI-TECH,
CLEAN,
QUALITY CONTROLLED,
EXPERTLY STAFFED
Acute Effects of MDMA
Altered Mental Status
Agitation / Coma
clandestine labs !
Found in trunks of cars, basements,
garages, and kitchen sinks
Tachycardia – SVT
Hypertension
Seizures
Excessive Serotonergic
stimulation of
CNS and Spinal 5HT receptors
HYPERPYREXIA and
DEHYDRATION
Diaphoresis
Muscle Rigidity
(rhabdomyolysis)
CONSEQUENCES OF
MDMA ABUSE
Acute Hepatic Failure and
Disseminated Intravascular Coagulopathy
Excessive sweating – core body temp
•Serotonin mediated
•Environmental
•Promoters
Seen in individuals with core temps > 105
Clinical Course and Pathology
similar to Environmental Heat Injury
ALMOST ALWAYS FATAL !
> 105 F
Ephedra ephedra sinensis
MA HUNAG
So what is Herbal Ecstasy ?
A number of different “legal” stimulants of which
the most common is Ephedra
Marketed as
a diet aid
Marketed for the
all-night party
Ephedra is a potent sympathomimetic drug, capable of
inducing Hypertensive crisis, tachyarrhythmias, seizures,
CVA, and myocardial ischemia
Diet products with Ephedra
Blocker
Stacker
Stinger
Hydroxycut
ThermaSlim
A very common herbal sympathomimetic
Protected by Dietary Substance Act of 1994
Numerous FDA – Med Watch Reports of toxicity
with therapeutic dosing
(plus other alkaloids)
Chitosol
TrimSpa
Xenedrine
TriLean
Thermbuterol
BetaLean
Metabolife
Metabohealth
Tone n Tighten
Cheat and Eat ….just to name a few
New Dietary Agents on the WEB
A unique patented formula of
EPHEDRA
Contains: leptogluterin
CAFFEINE
SALICYALTE
A natural way to enhance
fat-burning neuro-hormones
Zn, Cr,
B Vitamins to LBA / UBA
And overcome genetic
predisposition
Abuse of ADD Drugs
Ritalin
Cylert
Adderall
(methylphenidate)
(pemoline)
(d/l amphetamine)
One last “upper”
Herbal Sympathomimetics for
Sexual Performance
Tabs are crushed and
snorted like cocaine
Effects same and as severe
as any other Amphetamine
YOHIMBINE: alpha agonist
Opiates derived from the poppy plant
10 % ( 10 grams per 100 grams of “gel” ) is MORPHINE
0.5 % ( 500 mgs per 100 grams of “gel” ) is CODEINE
Papaver somniferum
The opium poppy plant is restricted for sale, growth,
and distribution by the United States DEA
GARDEN PLANT
OPIUM POPPY
Heroin
Morphine
Opium
Opiates essentially all have the same chemical structure
“phenacethrene ring”
Morphine
Codeine
Heroin
Oxycodone
Red rock, white powder, black tar: OPIUM
Brown and White powder: HEROIN
Ready for Delivery
Hydrocodone
Hydromorphone
Butorphanol
Oxymorphone
Origins of Heroin – first synthesized in 1874
Commercial preparation in 1870s by Bayer
Bayer stopped production in 1913 (addiction)
Harrison Narcotic Act of 1914
1924: federal law made any use / possession illegal
How is heroin abused today ?
NIDA Reports that 85 % is done by Inhalation
Goodbye needles !!! We can smoke it !!!
A widely-prescribed
tonic and “cure-all”
Black tar heroin
Street Heroin: 1 – 80 % pure, with 35 % average purity
(powdered milk, sugar, quinine, sorbital, fentanyl …)
$500 source
$100,000 profit
What are there other opiate drugs ?
OXYCODONE
THE TWO MOST FREQUENTLY
ABUSED ORAL OPIATES
Fentanyl
MORPHINE
DEXTROMETHORPHAN
Meperidine
Propoxyphene
Methadone
Each of these 4 are readily abused, NONE detect on Opiate Drug Screens
On the horizon…
• Cheeze or “starter heroin”
Mixture of crushed powder, usually
acetaminophen and
diphenhydramine (agitation,
confusion & hallucinations) laced
with heroin
PREFERRED ROUTE:
CRUSH AND INHALE
AKA: SKITTLES
Almost any sedative can be used
Almost every sedative has been documented
Any sedative potentiates Ethanol effects
NONE are easily detected
Downers and Date Rape
How to Not Be Victim
What to do if suspected
Don’t leave drinks unattended
Get Medical Attention ASAP
Don’t stay at parties alone, always
be with someone you trust
Void and Save the sample
(needed if crime investigation)
Don’t drink anything with
Unusual taste, sight, odor
Don’t destroy evidence
Don’t intentionally mix
Drugs and Ethanol
Seek help from a counselor
No One Invites This Crime !
Don’t accept drinks (nonalcoholic)
From strangers
Sedative – Hypnotic “spiking” of alcoholic beverages
GHB (BL, BD)
Gamma hydroxy butyrate
Similar in structure and
Function to GABA
Looks like water
Liquid or powder
Substance G, Great Home Buys, Liquid Soap, Easy Lay
Georgia Home Boy, Grievous Body Harm
Contact Police / Authorities
Don’t deny what happened
GHB was an over-the-counter Dietary Supplement
Promoted for:
Exercise
Endurance
Weightlifting
Insomnia
Anxiety
Child birth
Numerous Reports of
Coma / Apnea / Death
Reported Use in assaults
Can’t purchase GHB, BL, or BD
Products sold for human consumption
How is GHB used and Dosed ?
500 mg to 2 grams per dose
5cc – 20 cc liquid or as a powder
Water soluble – no odor / taste / clear
Toxic effects of GHB include:
GHB: March 2000, DEA Schedule 1
Motor Incoordination
Drowsiness – Amnesia
Disinhibition
Still available for purchase as a
nonpharmaceutical chemical and available
via the Internet on numerous sites
Coma / Apnea / Bradycardia
What else is used in assaults ?
NUTMEG
Choral Hydrate
Hallucinogens: Relatively MILD
Effects
Not available in US – sold in Mexico
All are potent Sedatives / Amnestics
None detect on Routine Tox Screens
tetrahydrozoline
Salvia divinorum
Potent Hallucinogen / Dissociative
Ketamine
Black Market Sales – Clandestine Produced
Sold as Crystal Powder: hits are 25 – 50mg
Inhaled / Smoked – Use of “K” surpassed PCP
• RECREATIONAL USE - Ketamine has become
a drug of abuse. Common effects include
tachycardia, altered mental status, anxiety,
palpitations, slurred speech, hallucinations,
nystagmus, mydriasis, mild hypertension and
chest pain. Confusion, vomiting and memory loss
are less common. Rarely seizures, polyneuropathy,
or respiratory arrest may occur. Death is rare
following ketamine abuse or overdose.
Ketamine
cont.
STREET USE - Ketamine can be administered by the intravenous,
intramuscular oral or inhalational routes; it may also be smoked. It is most
commonly taken in powdered form and either mixed in a drink or snorted
(Graeme, 2000).
INHALANTS:
Asphyxiants
Methemoglobin
Butyl nitrite
– 1) Then and now
» a) Ketamine was used as a general anesthetic in the late 1960's, but
emergence reactions (vivid and disturbing hallucinations) have limited its
clinical use. The drug is now most frequently used for short-term sedation
during clinical procedures; most frequently used in the pediatric population
(Weiner et al, 2000).
» b) The drug began to be abused shortly after it was developed because of its
similar effects to PCP, but with a shorter duration of action. Its abuse was
initially limited to healthcare workers and animal trainers, but has now
become a street drug of abuse that has been used at rave parties in North
America and the United Kingdom (Weiner et al, 2000; Weir, 2000).
» 2) Ketamine has become popular in the teen and young adult
culture because of its unique combination of hypnotic, analgesic
and amnesic effects with limited respiratory depression. It can
produce a "dissociative" effect which is characterized by analgesia
and amnesia without causing a loss of consciousness (Weir, 2000).
Nitrous Oxide
Bagging:
Complete submersion of the face
Highest Risk of Asphyxiation
SNIFFING
HUFFING
Child Abuse in Central America
Structural Similarities
Dimethyl Ether
CH3 O CH3
Acetone
CH3 C CH3
O
Trichloroethanol
CCl3 CHOH
Trichloroethylene
CCl2H CClH2
Halothane
Tetrafluoromethane
F
F C F
F
Br F
H C C F
Cl F
DEATH: Acute
* TRAUMATIC
* VENTRICULAR ARRHYTHMIA
* HYPOXIA:
Suffocation
Apnea
Seizure
Laryngo / Bronchospasm
Fatality > 24 Hours After Admission
CEREBRAL EDEMA
ASPIRATION PNUEMONITIS /
SEPSIS
RHABDOMYOLYSIS
Direct Toxin
Traumatic
RENAL
FAILURE
Who uses what? Hard to say
but….
• Stimulants or sympathomimetics
•
Party goers or people wanting
increased energy (students, busy
parents)
• Opiates or depressants
•
People who are anxious or want to
“chill”
• Experimentation or malicious intent
• So what’s pharming?
Resources
•
•
•
•
www.erowid.com
www.streetdrugs.org
www.drugfree.org
www.justthinktwice.com
Cathy Smith -Coordinator
Wisconsin Poison Center
[email protected]
414-266-2630