Update on Drugs of Abuse Trends in Florida

Melissa Parsons, MDDepartment of Emergency Medicine

University of Florida College of Medicine-Jacksonville

Learning Objectives

1. Understand general trends for drugs of abuse in Florida

2. Become familiar with toxidromes

3. Recognize excited delirium syndrome and factors that increased morbidity/mortality

NO FINANCIAL DISCLOSURES

CASE 1

CASE 1

CASE 1

• What do you want to do now?

RSI ?

Naloxone ?

OPIOIDS

Opioids

TOXIDROME• CNS sedation

• Hypothermia

• Hypotension

• Hyporeflexia

• Bradycardia

• Miosis (pinpoint pupils)

• Respiratory depression

• Seizures – Meperidine (Demerol), Tramadol

• Rigidity, myoclonus – Fentanyl

Opioids

Management

• Supportive• Naloxone

– Indication: reverse respiratory depression

– Adults: 0.4mg—2mg

– Pediatrics <5 years 0.1 mg/kg

– Max 10 mg

– May need high doses for fentanyl

– IV, SC, IM, IN, IO

– Half life: 1 hour

Spike in deaths due to heroin and fentanyl

447

538

0

100

200

300

400

500

600

2006 2007 2008 2009 2010 2011 2012 2013 2014

De

ath

s fr

om

he

roin

an

d f

en

tan

yl

Heroin

Fentanyl

Florida Medical Examiners Commission Annual Drug Reports 2007-2014

Crack down on “pill mills” and opioid prescribing

208

271250

230

150

10978 93

11995

48 57

108

199

447

0

50

100

150

200

250

300

350

400

450

500

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

He

roin

De

ath

sNumber of Heroin Deaths in Florida: 2000-2014

2014 Florida Medical Examiners Commission Annual Drug Report

Fentanyl

• Synthetic opiate– 100 times more powerful than

morphine

– 30-50 times more powerful than heroin

• “Breaking Bad” “Blue Drop” “Theraflu” “China White”

• Imported from Mexico and China

Fentanyl

CASE 2

CASE 2 – Patient feels like this…

CASE 2

• What do you do now?

•Let her refuse transport?

•Sedate her?

CANNABINOIDSSYNTHETIC CANNABINOIDS

Cannabinoids Compounds found in the marijuana plant THC is the most psychoactive (strong hallucinogen). Street names: “ganja,” “MJ,” “ragweed,” “reefer” and “grass.

Clinical Effects Psychological

Alterations in perception, feelings of well-being, increased appetite

Physiological Acute: Increased HR and BP Chronic: Decreased HR and blood

pressure Decreased coordination Delay in psychomotor skills CNS depression (especially peds) Slurred speech Rare: apnea, cyanosis, hypotonia

Marijuana Ingestion

• Marijuana Wax, “Budder,” or Butane hash oil, or “Ear wax hash”

90% THCMarijuana wax

20% THCMarijuana joint

Marijuana or “Vap” pens

Synthetic Cannabinoids…

Abuse of Synthetic Drugs an Epidemic

Abuse of Synthetic Drugs an Epidemic

• 2012 Synthetic Drug Abuse Prevention Act – Places 26 synthetic drugs including types of

cannabinoids and cathinones under Schedule 1

– Illegal drug makers have 100s more to take their place

– NO quality control (Russian Roulette)

– Often products labeled “not for human consumption”

• Unknown chemicals• Unknown potency• Constantly changing

Russian Roulette

Mystery packages

Drug makers constantly producing new synthetic cannabinoids products to evade laws on older compounds… impossible to keep up.

2015: >30 compounds

Synthetic Cannabinoids

• Synthetic chemicals sprayed onto dried plants

• They are 5-45 times more potent than THC and more toxic to brain and the heart

Synthetic Marijuana is a misnomer

Marijuana User

Synthetic Cannabinoid User

Man decapitated his wife, killed two dogs, cut off his left hand, and gouged his right eye out

Man kills two women using a knife and tomahawk while trying to find the ‘portal to

hell” in their backyard shed

Synthetic Cannabinoids

Symptoms:• Seizures• Psychosis

– Patients without psych history– Paranoia, agitation and anxiety – Suicidal or homicidal ideation

• CV events– Tachycardia and

tachydysrhythmias– MI– Stroke

• Respiratory failure• Acute kidney injury• Hyperthermia• Hyperemesis

Management:• Supportive care• Sedation

– Benzodiazepines – Ketamine– Avoid antipsychotics

• IVFs for AKI or rhabdomyolysis• Low stimulus environment

Risk Factors for increased mortality:1. New Psychosis/ Excited delirium with use

• Trauma or injury• Restraint procedures by law enforcement

• Chemically sedate… avoid restraints2. Pre-existing cardiovascular conditions3. Co-ingestions

CASE 3

CASE 3

• What do you want to do now?

EXCITED DELIRIUM SYNDROME

Excited Delirium Syndrome

Clinical Features:

• Hyper-aggression/agitation – Catecholamine surge and acidosis

– Superhuman strength

• Autonomic dysfunction

• Hyperthermia

• Acidosis

• Rhabdomyolysis, hyperkalemia

• Acute kidney injury

• Can be difficult to recognize and manage in prehospital setting.

• May mimic other medical conditions

• Attempt de-escalation techniques

• Personal safety issue for first responders

Excited Delirium Syndrome

• Management:

– Agitation: chemical and physical restraint

– Hyperthermia: Active and passive cooling

– Hypoxia: Airway support

– Acidosis: IVF, Bicarb if severe

– Rhabdo/Hyperkalemia: IVF, Calcium chloride, Bicarb

Excited Delirium Syndrome

KETAMINE: • 4-5 mg/kg IM or 2 mg/kg IV• Rare side effects

• Increased oral secretions, • Laryngospasm, • Hypertension, • Distress from emergence phenomena

BENZO’s: • Effective. • Potential for respiratory depression

ANTIPSYCHOTICS: • Potential lethal side effects• Increased QTc & risk for sudden

death• Anticholinergic syndrome

Management of Excited Delirium Syndrome

MDMASYNTHETIC CATHINONES

3,4-methylenedioxymethamphetamine (MDMA)

• Ecstasy

– Often adulterated with caffeine, methamphetamine, and other harmful drugs

– Typically in tablet form

• Molly

– Slang for "molecular"

– Supposedly a “purer” form of MDMA sold as powder or capsule

Synthetic Cathinones

• Synthetic chemicals related to cathinone, an amphetamine-like stimulant found naturally in the Khatplant.

Synthetic Cathinones

• MDPV (Methylenedioxypyrovalerone)– most common synthetic cathinone found in the

blood and urine of ED patients reportedly taking "bath salts”

• Alpha-PVP

• Methylone

• Ethylone

• Butylone

• Many more

United Way of Broward County Commission on Substance Abuse Annual Drug Trends Report June 2015

United Way of Broward County Commission on Substance Abuse Annual Drug Trends Report June 2015

Alpha-PVP aka Flakka

Special considerations:• Paranoia• Pursued or chased• Extreme hyperthermia (105-106)• Excited Delirium Syndrome

8 Duval2 Clay 1 St Johns 1 Putnam

http://interactive.sun-sentinel.com/flakka-case/

Number of Flakka Cases in Florida 2015

http://interactive.sun-sentinel.com/flakka-case/

“In recent weeks in Florida, this new drug has led to a man trying to break down the door to a police station, a man impaling himself while trying to scale a fence, and an armed and naked man shouting about hallucinations from a rooftop” – CBS

Synthetic CathinonesClinical effects

CNS: Euphoria

Decreased need for food and sleep

Increase in alertness and awareness

Heightened sexual desire

Anxiety/agitation

Paranoia

Violent behavior

Hallucinations (auditory or tactile)

Suicidal thoughts

Excited Delirium Syndrome (ExDS)

Synthetic CathinonesClinical Effects

Cardiovascular: Hypertension Tachycardia Chest pain

Hyperthermia Hyponatremia Nausea/Vomiting Liver failure Kidney failure Rhabdomyolysis Compartment syndrome

Synthetic Cathinones

• Self-harm and bizarre/at risk behavior without evidence of psychosis or depression is the

SECOND leading cause of death with use

Take Home Points

• Florida is seeing increased heroin/fentanyl use as opioid prescription drugs become harder to acquire– You may need larger doses of naloxone to reverse synthetic opioids

like fentanyl.

– Don’t give up if 0.4mg doesn’t work…

• Higher potency forms of marijuana and synthetic forms of cannabinoids can lead to more severe clinical effects– Synthetic cannabinoids do NOT equal marijuana

Take Home Points

• New synthetic drugs constantly being produced, which are potentially more toxic and dangerous.– It doesn’t matter what the compound is…treat them symptomatically

• Control of agitation/psychosis in Excited Delirium Syndrome is high priority to reduce mortality. – Use chemical sedation.

– Avoid restraints.

– Don’t forget to cool their hyperthermia.

– Get labs to check for end-organ dysfunction.

THE END