Download Barbiturates (ex. phenobarbital)

Pharmageddon:
The Rx Drug
Abuse Crisis
Linda B. Kalin, RN, BS, CSPI
Director
[email protected]
Hotline: 800-222-1222
Office: 712-279-3710
www.iowapoison.org
Increased Media Attention
Disclaimer
 This handout is intended to accompany the lecture for which it was
created and is not a substitute for attending the lecture itself. All
information is intended for use by competent healthcare professionals
and should be utilized in conjunction with pertinent clinical information.
 The author of this lecture and/or handout has checked with sources
believed to be reliable in their efforts to provide information that is
complete and generally in accord with the standards accepted at the
time of publication. In view of the possibility of human error or changes
in medical science, neither the author nor anyone else involved in the
preparation or publication of this work warrants that the information is in
every aspect accurate or complete and they disclaim all responsibility
for any errors or omissions or for the results obtained from the use of
the information contained in this work. Readers are encouraged to
confirm the information with other sources.
Not Just Celebrities
 Overdose deaths involving opioid pain
relievers (OPRs) now exceed deaths
from heroin and cocaine combined1
 Drug deaths now exceed MVA deaths
and nearly 9 out of 10 poisonings
deaths are caused by drugs2
 Enough OPR to medicate every
American with a 5 mg dose of Vicodin
taken every 4 hrs for a month!
1 Overdoses of Prescription Opioid Pain Relievers U.S., 1999-2008 MMWR Nov 2011
2 Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the
United States, 1980–2008. National Center for Health Statistics. 2011
Commonly Abused Rx Drugs
Changing Landscape
 Opioids (painkillers)
 Hydrocodone (Vicodin)
 Oxycodone (Oxycontin)
 Benzodiazepines (sedatives):




Klonopin (Clonazepam)
Xanax (Alprazolam)
Ativan (Lorazepam)
Valium (Diazepam)
 Stimulants (ADHD, weight loss)
Farming
Pharm Parties
Pharming
(aka “skittling”)
 Adderall, Ritalin, Vyvanse
03/04/16
1
Opioids MOA
Diversion
 Opiates bind to specific receptors
(mu, kappa, delta and sigma)
found throughout the body but
notably in the brain, spinal cord
and GI tract
 Mu receptor activation:
  pain (analgesia)
  CNS dopamine action
which produces a state of
euphoria and relaxation
 Many people who die of
painkiller overdoses don’t
have a prescription.
Opioid Use and Abuse
Opioid Pain Relievers
 Some of these Rx’s are
illegally sold or given to
people who use them for
nonmedical reasons (aka
“diversion”).
 As Rx’s have increased,
so have the # of ODs.
 Has increased markedly since 1990
 Morphine
 Coincides with a controversial U.S.
campaign against the undertreatment of
pain  enormous increase in opioid Rxs
 Codeine
 U.S. has 4.6% of the world’s population but
consume 99.93% of the world’s
hydrocodone and 81.57% of its oxycodone1
 All opiates/opioids induce tolerance and are
physically addicting
1
 Heroin
 Hydrocodone (Vicodin®)
 Oxycodone (Oxycontin®)
 Buprenorphine
 Tramadol (Ultram®)
CNS depression (sedation)
Respiratory depression/arrest
Pupil constriction (miosis)
Slurred speech
Impaired attention/memory
Constipation, urinary retention
Nausea
Confusion, delirium
Seizures (tramadol)
Slowed heart rate
03/04/16
 Oxymorphone
(Opana®)
 Fentanyl
 Methadone
 Meperidine
(Demerol®)
2012 World Health Organization’s International Narcotics Control Board
Effects of Opioids










 Hydromorphone
(Dilaudid®)
Passed by Congress as
Title II of Comprehensive
Drug Abuse Prevention
and Control Act of 1970;
signed into law by
President Nixon
I
heroin, marijuana, mescaline, GHB, LSD,
methylfentanyl (China White), MDMA
(Ecstasy), cathinone (khat), methcathinone,
psilocybin, psilocyn, many synthetic drugs
of abuse
II
amphetamine, cocaine, fentanyl, Ritalin,
methadone, oxycodone, morphine,
hydrocodone (Oct 2014)
III anabolic steroids, ketamine, buprenorphine,
some codeine products
IV Rohypnol (penalties C-1), Valium, Xanax,
Darvon, Talwin, Tramadol (Aug 2014)
V Phenergan, Lomotil (diphenoxylate),
pseudoephedrine
2
Hydrocodone/Vicodin & Zohydro
Vicodin contains
HC plus APAP
 Vicodin #1 most prescribed drug
 aka “Pharmaceutical heroin”
 ZohydroER approved 10/25/13
 Abusers crush the pill to bypass
the time-release mechanism-then
chew, snort or inject
 Controversial FDA approval
 First hydrocodone-only opioid
 Potent ER formulation of HC
 Available in 10, 15, 20, 30, 40, 50 mg
Hydrocodone only
Oxycodone (OxyContin)
 Abusers will be able to crush it, chew
or mix it with alcohol; users can also
separate the capsule and snort it or
solubilize with saline and inject
Unintended Consequences
 Enhances the “rush”
 This was the “ultimate score” until
reformulated in Aug 2010
 Oxycodone found in dozens of
other formulations (ex Percocet)
“Speedball”
 Heroin + cocaine in same syringe
 As OxyContin abuse dropped with
the new formulation, heroin abuse
rose1
 Produces intense rush of euphoria
 Combines the effects of both drugs
while negating less desirable effects
 Heroin is easier to use, much
cheaper and easily available
 Heroin cancels out anxiety & paranoia
created by cocaine
 Converted into morphine in brain
 Cocaine negates sedation of heroin use
 Intense euphoria in seconds
 Cocaine wears off far more quickly
 Highly addictive; easy to overdose
 Potentially fatal overdose
1Effect
of Abuse-Deterrent Formulation of OxyContin, N Engl J Med
2012; 367:187-189 July 12, 2012
CDC Health Advisory
Fentanyl
 Potent, synthetic short-acting opioid
(10/26/15)
Increases in Fentanyl-related Overdose Deaths
 80-100X more potent than morphine
 Although can be diverted, most cases
are linked to illicit manufacturing
(fentanyl & fentanyl analogs)
HAN Advisory:
(May 2013) 10,000 pills
of desmethyl fentanyl
seized in Montreal
 Being sold as heroin (much more potent)
2) Improve detection of
fentanyl outbreaks
 Often mixed with heroin and/or cocaine
 Responsible for several deaths
 May require larger doses of naloxone
03/04/16
1) Alert PH depts, HCPs,
MEs & law enforcement
Fentanyl-laced heroin
bags stamped with
“Theraflu”
3) Expand use of
naloxone
3
Opiates: Special Considerations
 Sustained Release or Long Half-Life
 Oxycontin, Methadone
 Opiates Containing Acetaminophen
Medical Use
 Most potent opioid available for medical use
 Schedule II prescription drug
 Hydrocodone: Vicodin, Lorcet, Lortab
 Available in many forms
 Oxycodone: Percocet, Roxicet, Tylox
 Not detected in routine drug screens
 Propoxyphene: Darvocet, Wygesic (still around)
 Keep in secure location; out of children’s reach
 Seizures
 Tramadol, Demerol, Propoxyphene
 EKG Changes
 Propoxyphene (QRS widening)
Special Considerations
 Sustained Release or Long Half-Life
 Oxycontin, Methadone
 Opiates Containing Acetaminophen
 Hydrocodone: Vicodin, Lorcet, Lortab
 Oxycodone: Percocet, Roxicet, Tylox
 Propoxyphene: Darvocet, Wygesic (still around)
 Seizures
 Tramadol, Propoxyphene, Demerol
 Serotonergic activity (drug-drug interactions)
Treatment
 Naloxone (Narcan®) is first-line therapy for
reversing effects of opioid overdose
 Mortality results from respiratory depression
 Naloxone has a shorter duration than
opioid effect
 Re-sedation and  RR/apnea may reappear
 Injectable dosing: start low & titrate up:
0.2 mg  0.4 mg  2 mg  10 mg  R/O other causes
 Tramadol
Naloxone
 FDA approves two new versions of naloxone for
reversing the effects of an opioid overdose
1. Auto-injector, Evzio, approved 04/03/14
2. Narcan nasal spray approved 11/18/15
 Designed to be given outside of healthcare setting
 Alternative for family members, first responders
 Part of targeted strategy to address opioid deaths
 44 states have passed a Naloxone Access Law
 Pending legislation in Iowa
03/04/16
Opioid Withdrawal
 Flu-like syndrome
 Mortality is exceedingly rare
 Symptoms:
 Agitation
 Insomnia
 Muscle aches
 Abdominal cramps
 Lacrimation
 N/V
 Rhinnorrhea
 Mydriasis
 Sweating
 Piloerection
 Yawning
4
The Case
A 51 yo female is brought to the ER after
being found unresponsive by her
husband. An empty bottle of valium was
found at the scene. Patient has a history
of depression. Husband states she has
taken valium for over 10 years. Her HR
is 72, respirs 20 and BP 120/82. IV
access is established.
Do No Harm!
• Flumazenil (Romazicon®) is contraindicated in
virtually all overdoses you’re likely to encounter
 Unknown history
 Benzo dependent
 Poly-drug OD (pro-seizure drugs may be on board)
 Seizure history
 Anything that may predispose to seizures (ex.
hypoxia, low BP, head injury, etc.)
• May be indicated to reverse conscious sedation
Benzodiazepines (BDZ)
 Most benzo names end in "pam" or "am”
 Xanax (alprazolam)  Klonopin (clonazepam)
 Valium (diazepam)  Ativan (lorazepam)
 Sedative prescribed for many indications
 Hallmark: “Coma with stable vital signs” unless
mixed with other CNS or resp depressants
 Deaths rare from benzos alone
 Rapid tolerance; highly addictive
 Withdrawal may be severe (similar to alcohol)
Sedative-Hypnotics
 Used to treat anxiety and sleep disorders
 Mechanism: enhances GABA
 Acts to slow normal brain function
 Benzodiazepines
 Non-benzo hypnotics
 Ambien (zolpidem)
 Sonata (zaleplon)
 Lunesta (eszopiclone)
 Barbiturates (ex. phenobarbital)
 Soma (skeletal muscle relaxant)
Predatory Drugs
 AKA “Date rape drugs”
 Drugs used to facilitate sexual assault,
including rape
 Incapacitates the person
 Difficult to prosecute or recognize:
 May not be aware ingested drug
Many deaths are a result of
“polypharmacy” (abusing more than 1
drug including alcohol)
03/04/16
 Memory impairment
 Drugs are metabolized quickly
5
Most Common Forms of DFSA
 Alcohol
Pharmaceutical Cocktails
 Ketamine
 Drug cocktail that includes at least 1 opioid,
a benzo and carisoprodol
 Gamma-hydroxybutyrate (GHB)
 Abusers say “imitates heroin rush”
 Ecstasy
 “Vegas” Cocktail
 Rohypnol (flunitrazepam):
 “Holy Trinity”
 Hydrocodone
 Oxycodone
 AKA “Forget-me pill”
 Alprazolam
 Alprazolam
 10X more powerful than valium
 Carisoprodol
 Carisoprodol
 Intensifies effects of alcohol and
other drugs
 Cocaine and meth users may use
Quetiapine (Seroquel)
 AKA: Quell, baby heroin, Suzie-Q
 Antipsychotic prescribed for schizophrenia,
bipolar disorders and insomnia
 Recreational value in prison (“Jailhouse Heroin”)
 Abusers ingest the pills simultaneously, commonly
with alcohol to increase the pills effects
ADHD Drugs
 Short term effects:
 Euphoria
  energy/productivity
  concentration and  alertness
 Abusers seek its anxiety-reducing effects and a
“careless state of mind”
  appetite
 Can also be used to come down from a stimulant high
and reduce anxiety during “bad trips”
  wakefuless,  sleep
 Combines with cocaine to form “Q-ball”
 Effects: sedation, heart arrhythmias, coma
Lots of Risks
 NE release causes constriction of blood vessels
  HR,  BP,  temp
 Increased risk of seizures
 Potentially fatal arrhythmias, heart attack, or
stroke
 Psychiatric symptoms: depression, anxiety,
psychosis, and suicidal ideation
Contains powerful
combination of 4 timereleased amphetamines
  libido
 High potential for abuse; may cause
dependence and addiction
The Case
A 28 yo female arrives in ER c/o chest
pain. Her BP is 160/120 and HR 124.
She is agitated, diaphoretic and her
pupils are dilated (mydriasis). While in
the ED, she begins to seizure. Her
boyfriend states she has prior history of
drug abuse. ER physician calls PCC.
How do we treat the seizures?
03/04/16
6
The Case continued…
Dextromethorphan (DXM or DM)
 AKA Robo, skittles, poor man’s PCP
 How do we treat her anxiety/agitation?
 How do we treat her tachycardia?
 How do we treat her hypertension?
 How do we treat her hyperthermia?
 Cheap, easy to get, and legal
 Structurally related to morphine
 OTC use as a cough suppressant
 Abused as a dissociative hallucinogen
 Excess doses can cause symptoms similar to PCP
and ketamine
 Effects vary with the amount taken
What’s on the Net??
 “Slam entire 8 oz bottle of
Robitussin Maximum Strength”
 What to expect with these levels:
– “light buzz” = 300 mg DM
– “strong buzz” = 600 mg DM
– “strongest buzz” = 900 mg DM
Coricidin HBP Cough & Cold*
 AKA: Triple C, Red Devils, Skittles
 Contains 30 mg DM per tab
 Therapeutic dose= 30 mg q 6-8 hr
 Abusers: 250-1500 mg in one dose
 #1 stolen product from pharmacies
 OTC meds are perceived as “no risk”
* Coricidin HBP Cold and Flu® is commonly mistaken
for the Cold and Cough and contains acetaminophen!
What’s on the Net?
Mucinex® becoming popular
4 Plateaus of “Skittling”
1. Mild inebriation
2. Similar to alcohol intoxication:
slurred speech, mild hallucinations
3. Altered state of consciousness,
impaired vision
4. “Out of body” dissociative
sensations; effects like PCP or
ketamine
Contains 600 mg guaifenesin
and 30 mg dextromethorphan
Contains 1200 mg guaifenesin
and 60 mg dextromethorphan
*May also cause N/V, difficulty breathing,  heart rate, seizures, coma
03/04/16
7
Another OTC High
“Sizzurp”
 Diphenhydramine (Benadryl®) and
Dimenhydrinate (Dramamine®)
 AKA purple drank, lean, syrup,
purple jelly, Texas Tea
 Used as a cheap high
 Mixture of Rx-strength cough syrup
containing codeine & promethazine,
Sprite and Jolly Ranchers for flavor
 Anticholinergic (antimuscarinic) effects
develop in overdose
 Watch for QRS and QTc prolongation
 Severe poisoning can lead to serious
cardiac dysrhythmias, coma and death
Just because it’s over-the-counter doesn’t mean it’s safe!
Alcohol Fads
 Vodka Red Bull
(aka “Vod-Bomb”)
 Jell-O Shots/Pudding
Shots
 Drunken Gummies
 Hand Sanitrippin’
 Vaporizing (“smoking”)
 Powdered Alcohol
 DM used if codeine unavailable
 HC-containing cough syrups can be used
 Obtained by Dr shopping, forged Rx’s
and pharmacy theft
 Potential fatal consequences
First Responders
• Never leave the person alone!
• GET HELP! “Better safe than sorry!”
• Turn the person on his/her side and
monitor breathing until help arrives.
• Remember, a person’s BAC can continue
to rise even while he or she is passed out:
Don’t try to guess the level of drunkenness!
• Don’t assume a person is going to be fine
just by sleeping it off!
The Case
A 52 yo F is brought to the ER by her husband
who states she has been very agitated lately,
hasn’t been sleeping well, and has become
confused. She has an elevated temperature,
increased heart rate, elevated blood pressure,
and is diaphoretic. The patient has a seizure in
the emergency room.
What drug(s) could be causing her symptoms?
03/04/16
8