From the Street to the Pharmacy: Illicit Drugs and Reversal Agents
Heather Powell, PharmDPGY2 Internal Medicine Pharmacy Resident
Clement J. Zablocki Veterans Affairs Medical CenterGolden Peters, PharmD, BCPS
Associate Professor, Department of Pharmacy PracticeSt. Louis College of Pharmacy
Conflict of Interest/disclosures
• Heather Powell and Golden Peters declare no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria
Pharmacist Objectives
At the conclusion of this program, the pharmacist will be able to:
• Compare and contrast illicit street drugs based on mechanism of action, physiologic and neurologic effects.
• Identify and describe the implications that illicit street drugs may have on prescription medications and disease states.
• Recognize important signs and symptoms of illicit drug overdose.
• Discuss the utility of the naloxone injection kit and nasal spray in patients with opioid use, addiction and/or heroin use.
Technician Objectives
At the conclusion of this program, the pharmacy technician will be able to:
• Compare and contrast illicit street drugs based on mechanism of action, physiologic and neurologic effects.
• Identify and describe the implications that illicit street drugs may have on prescription medications.
• Recognize important signs and symptoms of illicit drug overdose.
• Discuss the utility of the naloxone injection kit and nasal spray in patients with opioid use, addiction and/or heroin use.
Pretest Question #1
• Which of the following is true regarding the AHA/ACC 2014 statement on the use of cocaine and beta-blocker usage in patients presenting with non-ST-segment elevation acute coronary syndromes?
A. ACS in patients with cocaine use should be treated in the same matter as patients without cocaine use unless there is presence of acute cocaine intoxication
B. Beta-blockers use cannot be recommended due to the potential to provoke or exacerbate coronary vasospasm
C. ACS in patients with acute cocaine intoxication should be treated with beta-blockers
D. None of the above
Pretest Question #2
• AJ is a 21 yo female who presented to the ER with confusion/agitation, hypertension, diaphoresis, tremor, and myoclonus. The only prescription medication she takes is fluoxetine 60 mg q AM. It is discovered she drank an entire bottle of dextromethorphan and took ecstasy prior to coming. What diagnosis is most likely based on her story?
A. Heat StrokeB. Serotonin SyndromeC. Neuroleptic Malignant SyndromeD. Meningitis
Pretest Question #3
• Which is a sign/symptom of an overdose with opioids, stimulants and hallucinogens?
A. Fever
B. Miosis
C. Agitation
D. Convulsions
Pretest Question #4
• Which statement below does not accurately represent Evzio® (naloxone) auto-injector?
A. When administering, hold for 5 seconds
B. FDA approved for opioid overdose reversal
C. Special training is required prior to dispensing
D. Clothing does not need to be removed for administration
Background
• Economic Impact
• Legal cost for illicit drugs
– $40 billion
Health Care Overall
Tobacco $130 billion $295 billion
Alcohol $25 billion $224 billion
Illicit Drugs $11 billion $193 billion
Drugabuse.gov. Statistics. 2014.Source: www.youtube.com/watch?v=ZnQB7SqIESg
National Survey on Drug Use and Health. Behavioral Health Trends. 2014
Illinois Statistics
• Illicit drug use in the past month (> 12 years old) (2014)
State Percent (%)
Illinois 9.55
Iowa 6.27
Indiana 9.12
Missouri 9.27
Wisconsin 8.31
National Average 9.27
Samhsa.gov. Reports by geography. 2014.Source: www.sircon.com/stateInformationCenter/illinois.jsp
ILLICIT DRUG BASICS:What are they, what do they do, and why should I be concerned?
Source: http://www.aarp.org/health/health-insurance/info-2014/medicare-changes-for-2015.html
Narcotics
• Opioids
Physiologic Effects Neurologic Effects
Pain relief ↓ tension
Cough suppression ↓ anxiety
Constipation ↓ aggression
Miosis ↑ drowsiness
Respiratory depression ↑ inability to concentrate
Pruritus ↑ apathy
Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88.Source: www. pixabay.com/en/diet-pills-medication-pharmacy-sick-1328802/
Narcotics
• Routes of Administration: Oral, Injected, Sniffed, Inhaled, Rectal• Street Names
– Morphine: Dreamer, Emsel, First Line, God’s Drug, Hows, M.S., Mister Blue, Morf, Morpho, and Unkie
– Codeine: Cody, Sippin Syrup, Sizzurp, Lean– Heroin: Big H, Black Tar, Chiva, Hell Dust, Horse, Negra, Smack, and Thunder– Oxycodone: Hillbilly Heroin, Kicker, oc, ox, Roxy, Perc, oxy– Hydrocodone: Hydro, Norco, Vikes– Hydromorphone: D, Dillies, Dust, Footballs, Juice, Smack– Meperidine: Demmies, Pethidine, Mapergan– Fentanyl: Apache, China girl, China white, Dance Fever, Friend, Goodfella, Jackpot, Murder 8, TNT,
Tango, Cash– Methadone: Amidone, Chocolate Chip Cookies, Fizzies, Maria, Pastora, Salvia, Street Methadone,
Wafer
Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88.
Narcotics
• Mechanism of Action: Bind to mu-opioid receptors in the CNS causing inhibition of the ascending pain pathways
Source: https://www.lexisnexis.com/legalnewsroom/workers-compensation/b/recent-cases-news-trends-developments/archive/2014/10/01/
Narcotics
• Drug-Drug or Drug-Disease Considerations
– Skin and soft tissue infections – “krokodil”
– Respiratory depression with concomitant depressants
– Endocarditis
Drugs.Indiana.edu. Drug Information. 2016.Source: www. pixabay.com/en/nile-crocodile-crocodylus-niloticus-245013/https://www.youtube.com/watch?v=CqRbmG1edV0
Stimulants
• Cocaine, Phencyclidine (PCP), Synthetic cathinones (bath salts), Amphetamines/Methamphetamine, Dextromethorphan
Physiologic Effects Neurologic Effects
↓ appetite ↑ self-esteem
↑ mental/physical performance ↑ wakefulness
↑ BP/HR Psychosis
↑ insomnia Exhilaration
Physical exhaustion
Rhabdomyolysis
Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88.Karch S. Drug Abuse Handbook. Boca Raton, Fla.: CRC Press; 1998.
Stimulants - Cocaine
• Routes of Administration:
– Powdered – snorted or injected
– Cocaine base (crack) – smoked
• Street Names: Coca, Coke, Crack, Flake, Snow, Soda Cot
Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88.Source: www. pixabay.com/en/drugs-death-cocaine-drug-risk-1276787/
Stimulants - Cocaine
• Mechanism of Action: Blocks reuptake of catecholamines(dopamine and NE) at presynaptic α- and β-adrenergic terminals of the heart muscle, vascular smooth muscle, and central and peripheral nervous systems sympathomimetic effects in dose-dependent fashion
Lange RA, Cigarroa RG, Flores ED, et al. Ann Intern Med. 1990; 112:897-903.Source: http://thesource.com/2015/11/03/ireland-to-decriminalize-weed-cocaine-and-heroine/
Stimulants - Cocaine
• Cocaine Specific Effects
– Rapid neurologic onset followed by a cocaine “crash”
– Restlessness and panic attacks
Karch S. Drug Abuse Handbook. Boca Raton, Fla.: CRC Press; 1998.Source: www.pixabay.com/en/drugs-cocaine-user-addiction-908533/
Stimulants - Cocaine
• Drug-Drug or Drug-Disease Considerations
– Cardiovascular disease
• Endocarditis
• Accelerated atherosclerosis
• Acute Coronary Syndrome– Is it safe to use beta-blockers for ACS in patients who use cocaine?
Schurr JW, Gitman B, Belchikov Y. Pharmacotherapy. 2014; 34(12)1269-1281.McCord J, Jneid H, Hollander JE, et al. Circulation. 2008; 117:1987-1907. Lange RA, Cigarroa RG, Flores ED, et al. Ann Intern Med. 1990; 112:897-903Source: http://www.medscape.com/viewarticle/859042
Stimulants - Cocaine
• Beta-blocker Controversy– Beta-blockers may potentiate cocaine-induced coronary vasoconstriction by
blocking beta-receptors in the coronary vasculature leaving alpha-receptors unopposed
– ACC/AHA 2008: Recommends against the use of beta-blockers due to the potential to provoke or exacerbate coronary vasospasm (Strength of Recommendation: Class IIIc)
– ACC/AHA 2014 UA/NSTEMI: ACS in patients with cocaine use should be treated in the same matter as patients without cocaine use unless there is presence of acute cocaine intoxication (Level of Evidence: C)
Schurr JW, Gitman B, Belchikov Y. Pharmacotherapy. 2014; 34(12)1269-1281.Amsterdam EK, Wenger NK, Brindis RG, et al. JACC. 2014; 64(24):2645-2687. Lange RA, Cigarroa RG, Flores ED, et al. Ann Intern Med. 1990; 112:897-903.Amsterdam EA, et al. JACC. 2014; 64(24):2714-2715.
Stimulants - Cocaine
Drug Receptor affinity Comments
Propranolol Β1, β2 Concerns of coronary artery vasospasm
Labetalol Β1, β2, α1 α-antagonism reduces potential unopposed α effects
Carvedilol Β1, β2, α1 Less potent at α compared to labetalol.
Metoprolol Β1Cardioselective
Less unopposed α due to lack of β2 antagonism
Esmolol Β1 Cardioselective
Schurr JW, Gitman B, Belchikov Y. Pharmacotherapy. 2014; 34(12)1269-1281.
Stimulants - Cocaine
• Pulmonary disease:
– “crack lung” or lung thrombosis
• Skin and soft tissue infections:
– cutaneous vasculitis from levimasole
Shah R, Patel A, Mousa O, Manocha D. QJM. 2015. Muirhead TT, Eide MJ. NEJM. 2011; 364:354. Source: www.qjmed.oxfordjournals.org/content/early/2015/04/13/qjmed.hcv064
Stimulants - Methamphetamine
• Routes of Administration: Oral, Injected, snorted, smoked
• Street Names: Bennies, Black Beauties, Crank, Ice, Speed, Uppers
Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88.
Stimulants - Methamphetamine
• Mechanism of Action: Noncatecholamine sympathomimetic amines promote release of dopamine and norepinephrine from presynaptic nerve terminals and block their reuptake by competitive inhibition
Karch S. Drug Abuse Handbook. Boca Raton, Fla.: CRC Press; 1998.Source: http://www.recovery.org/topics/methamphetamine-recovery/
Stimulants - Methamphetamine
• Drug-Drug or Drug-Disease Considerations
– May exacerbate or precipitate movement disorders
– Extensive tooth decay
– Skin and soft tissue infections due to formication
– Acute Coronary Syndrome
– Endocarditis
Source: Powerpoint (Office 2010) [Computer Software]. Redmond, WA: Microsoft
Stimulants – Dextromethorphan
• Routes of Administration: Oral
• Street Names: Robo-tripping, Poor Man’s PCP, Dex, CCC, DXM, Skittles, Velvet, Robo
Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88.Source: Powerpoint (Office 2010) [Computer Software]. Redmond, WA: Microsoft
Stimulants – Dextromethorphan
• Mechanism of Action: Dissociative anesthetic via nonselective serotonin reuptake inhibitors, sigma-1 receptor agonism, and NMDA receptor antagonism at high doses
Karch S. Drug Abuse Handbook. Boca Raton, Fla.: CRC Press; 1998.Source: Powerpoint (Office 2010) [Computer Software]. Redmond, WA: Microsoft
Stimulants - Dextromethorphan
• Dextromethorphan Specific Effects:
– 1st plateau: euphoria, auditory changes, change in perception of gravity
– 2nd plateau: intense euphoria, vivid imagination, closed-eye hallucinations
– 3rd/4th plateau: altered consciousness, out-of-body experiences, temporary psychosis
Karch S. Drug Abuse Handbook. Boca Raton, Fla.: CRC Press; 1998.
Stimulants - Dextromethorphan
• Drug-Drug or Drug-Disease Considerations
– Serotonin syndrome
– Co-ingestant toxicity (antihistamines, alpha-1 adrenergic decongestants, or acetaminophen)
Karch S. Drug Abuse Handbook. Boca Raton, Fla.: CRC Press; 1998.
Marijuana
• Routes of Administration: Oral, Inhaled
• Street Names: Pot, Grass, Dope, MJ, Mary Jane, Doobie, Hooch, Weed, Hash, Reefers, Ganja, Dank
Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88.Source: www.pixabay.com/en/mortar-herbs-pistil-medicine-1031156/
Marijuana
• Mechanism of Action: Via cannabinoid receptor CB1 activation, THC causes release of acetylcholine, glutamate, GABA, NE, and dopamine
Karch S. Drug Abuse Handbook. Boca Raton, Fla.: CRC Press; 1998.Ashton CH. The British Journal of Pyschiatry. 2001; 178(2): 101-106.
Marijuana
Physiologic Effects Neurologic Effects
Tachycardia without effect on BP ↓ attention
↑ supraventricular and ventricular ectopic activity
↓ concentration
↓ testosterone in men ↓ short-term memory
Corneal vasodilation ↓ anxiety
Intraocular pressure reduction ↑ appetite
Slurred speech Agitation
Nystagmus Euphoria
Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88.Ashton CH. The British Journal of Pyschiatry. 2001; 178(2): 101-106
Marijuana
• Drug-Drug or Drug-Disease Considerations
– Used for chronic severe pain, refractory nausea/vomiting, anorexia, cachexia, glaucoma, seizures
– Pulmonary disease/cancer risk
Horn JR, Hansten PD. Pharmacy Times website. 2014. Ashton CH. The British Journal of Pyschiatry. 2001; 178(2): 101-106Source: www.pixabay.com/en/seedling-cannabis-marijuana-1062908
Hallucinogens
• Ecstasy/MDMA, Synthetic cannabinoids, Ketamine, Lysergic acid diethylamide (LSD), Psilocybin
Physiologic Effects Neurologic Effects
Pain relief ↓ tension
Cough suppression ↓ anxiety
Constipation ↓ aggression
Miosis ↑ drowsiness
Respiratory depression ↑ inability to concentrate
Pruritis ↑ apathy
Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88.
Hallucinogens – Ecstasy/MDMA
• Routes of Administration: Oral, snorted, injected
• Street Names: Adam, Beans, Clarity, Disco Biscuit, E, Ecstasy, Eve, Go, Hug Drug, Lover’s Speed, MDMA, Peace, STP, X, XTC, Molly
• Mechanism of Action: Indirect serotonin agonist (increases amount of serotonin released into the synapse), enhances release of dopamine, and may inhibit monoamine oxidase
Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88.Karch S. Drug Abuse Handbook. Boca Raton, Fla.: CRC Press; 1998.Source: Powerpoint (Office 2010) [Computer Software]. Redmond, WA: Microsoft
Hallucinogens – Ecstasy/MDMA
• Ecstasy/MDMA Specific Effects– Both a stimulant and a psychedelic
– Produces energizing effect and enhanced tactile experience enjoyment
• Drug-Drug or Drug-Disease Considerations– Serotonin Syndrome
– Hyperthermia
– Hyponatremia
Karch S. Drug Abuse Handbook. Boca Raton, Fla.: CRC Press; 1998.Source: Powerpoint (Office 2010) [Computer Software]. Redmond, WA: Microsoft
Drug Class Substance Examples Physiologic Effect Neurologic Effect
Narcotics Opioids
Pain reliefCough suppression
MiosisRespiratory depression
Constipation Pruritis
↓ tension, anxiety, aggression↑ drowsiness, apathy, inability to
concentrate
Stimulants
Cocaine/CrackMethamphetaminesDextromethorphan
Synthetic cathinones(bath salts)
Phencyclidine (PCP)
↓ appetite↑ mental/physical performance, BP/HR, and
insomniaPhysical exhaustion
Rhabdomyolysis
↑ self-esteem, wakefulnessPsychosis
Exhilaration
Cannabinoids Marijuana
↓ testosterone in men↑ supraventricular and ventricular ectopic
activityTachycardia without effect on BP
Corneal vasodilationSlurred speech
Nystagmus
↓ attention, concentration, short term memory, and anxiety
↑ appetiteDysphoriaAgitationEuphoria
Drug Class Substance Examples Physiologic Effect Neurologic Effect
Hallucinogens
MDMA (ecstasy)Synthetic cannabinoids
KetamineLysergic acid diethylamide
(LSD)Psilocybin
↑ HR/BPMydriasis
Distortions of thought associated with time and spaceVisual color changes
Flashbacks to time of abuse
DepressantsBarbiturates
Gamma hydroxybutricacid (GHB)
↓ muscle spasms, BP, RRSlurred speech
Loss of motor coordinationWeaknessHeadache
LightheadednessBlurred vision
Nausea/vomiting
↓ anxiety, reaction time, mental function/judgement
SedativeSeizure prophylaxis
AmnesiaConfusion
SIGNS AND SYMPTOMS OF AN OVERDOSE
What you can look for…Source: www.thesilverpen.com/inspired-living-celebrating-life/prescription-painkiller-overdose/
Opioid/Narcotics/Heroin
• Signs/Symptoms of an overdose:
– Confusion
– Convulsions
– Unconsciousness
– Slowed breathing
– Cold, clammy skin
– Extreme drowsiness
– Constricted (pinpoint) pupils
Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88.Source: www. floridarecoverygroup.com/florida-suffering-from-a-surge-in-heroin-overdoses/
Stimulants
• Signs/Symptoms of an overdose:
– Fever
– Stroke
– Seizures
– Agitation
– Convulsions
– Cardiovascular collapse
Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88.Source: www.coub.com/view/37k1zrjSource: www.tvlistings.zap2it.com/tv/breaking-bad/EP01009396?aid=zap2it
Marijuana/Cannabis
• Signs/Symptoms of an overdose:
– No death from overdose has been reported
Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88.Source: www.hightimes.com/read/illinois-becomes-20th-state-legalize-medical-marijuanaSource: www.blog.hrusa.com/blog/illinois-medical-cannabis-pilot-program/
Hallucinogens
• Signs/Symptoms of an overdose:– Coma
– Seizures
– Convulsions
– Respiratory arrest
– Respiratory depression
• Overdose is rare– Death usually occurs from a suicide, accidents and dangerous
behaviors
Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88.Source: www. drugs-forum.com/forum/showthread.php?t=115682
OPIOID OVERDOSE TREATMENT KITS
Narcan® (naloxone) Nasal Spray
Evzio® (naloxone) Auto-injector
Source: www.legacyfreedom.com/drug-overdose-statistics-facts/
Disclaimer!!!
• This presentation is NOT the same as the course offered by IPhA– Illinois State Opioid Antagonists Training Program
• K. Gable, C. Herndon, J. Kerr and G. Reynolds
• On-demand web-based program at IPhA.org• Benefits:
– Gain certification, allowing for pharmacists to dispense naloxone without a prescription• First responders, school nurses, or any individual at risk of overdose
• Requirements:– Licensed Illinois pharmacist– Complete certification course– CPR certified IPhA.org. Program registration. 2016
Source: www.ipha.org/isoatp-registration
Overdose Statistics
• National– Opioid and heroin overdose deaths
• 2014 – 28,647 deaths– Quadrupled since 2000
• Illinois– Opioid and heroin overdose deaths
• 2013 – 1579
• 2014 – 1705
– Percent increase: 8.3%**statistically significant increased from 2013 to 2014
CDC. Drug overdose data. 2016.
Antidote
• Naloxone– Antidote for opioid/heroin overdose
– Competitive mu opioid receptor antagonist
– Reverses all signs/symptoms of opioid intoxication
– Parenteral, intranasal, pulmonary administration• No bioavailability after oral administration
– Onset of action• < 2 minutes
– Duration of action• 20 – 90 minutes
Boyer EW. NEJM. 2012;367:146-55.Thomas SA. US Pharm. 2015;40(3):HS2-HS6.
Opioid Overdose Rescue Kits
• Evzio® (naloxone) Auto-injector– FDA approved in 2014 for opioid overdose reversal– Special training to use the device is not required– Automated
• Once cap is removed, audible administration instructions are provided by the device
– Rapidly delivers a single dose of naloxone (0.4mg)– Can be repeated if needed– Each prescription contained a training device– Injection site
• Outer thigh muscle– Do not need to remove clothing
Thomas SA. US Pharm. 2015;40(3):HS2-HS6.Source: www.evzio.com/hcp/
Opioid Overdose Rescue Kits
• Evzio® (naloxone) Auto-injector
– AdministrationTrainer
Source: www.evzio.com/hcp/Source: www.paindr.com/preventing-opioid-overdose-deaths-with-evzio-2/Source: www..methadone.us/blog/evzio-for-reversal-of-opioid-overdose/
Opioid Overdose Rescue Kits
• Evzio® (naloxone) Auto-injector
– Administration
PL Detail-Document. Pharmacist’s Letter/Prescriber’s Letter. 2016.Source: www.evzio.com/hcp/about-evzio/how-to-use-evzio.php
Opioid Overdose Rescue Kits
• Narcan® (naloxone) Nasal Spray
– FDA approved in 2015 for opioid overdose reversal
– Special training to use the device is not required
– Administer nasal spray in one nostril while patient is lying on their back
– Rapidly delivers a single dose of naloxone (4mg)
– Can be repeated if needed
– No needle
– Contains two blister packed, single-use nasal sprays
– Narcan parenteral formulation is no longer available
Thomas SA. US Pharm. 2015;40(3):HS2-HS6.Source: www.narcannasalspray.com/
Opioid Overdose Rescue Kits
• Narcan® (naloxone) Nasal Spray
– Administration
Source: www.nphotos.prnewswire.com/medias/switch.doPL Detail-Document. Pharmacist’s Letter/Prescriber’s Letter. 2016.
Posttest Question #1
• Which of the following is true regarding the AHA/ACC 2014 statement on the use of cocaine and beta-blocker usage in patients presenting with non-ST-segment elevation acute coronary syndromes?A. ACS in patients with cocaine use should be treated in the same matter as
patients without cocaine use unless there is presence of acute cocaine intoxication
B. Beta-blockers use cannot be recommended due to the potential to provoke or exacerbate coronary vasospasm
C. ACS in patients with acute cocaine intoxication should be treated with beta-blockers
D. None of the above
Posttest Question #2
• AJ is a 21 yo female who presented to the ER with confusion/agitation, hypertension, diaphoresis, tremor, and myoclonus. The only prescription medication she takes is fluoxetine 60 mg q AM. It is discovered she drank an entire bottle of dextromethorphan and took ecstasy prior to coming. What diagnosis is most likely based on her story?
A. Heat StrokeB. Serotonin SyndromeC. Neuroleptic Malignant SyndromeD. Meningitis
Pretest Question #3
• Which is a sign/symptom of an overdose with opioids, stimulants and hallucinogens?
A. Fever
B. Miosis
C. Agitation
D. Convulsions
Pretest Question #4
• Which statement below does not accurately represent Evzio® (naloxone) auto-injector?
A. When administering, hold for 5 seconds
B. FDA approved for opioid overdose reversal
C. Special training is required prior to dispensing
D. Clothing does not need to be removed for administration
References
• National Institute on Drug Abuse (NIH). Trends & Statistics. Available at: https://www.drugabuse.gov/related-topics/trends-statistics. Accessed June 28, 2016.
• Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Retrieved from http://www.samhsa.gov/ data/. Accessed June 28, 2016.
• National Institute on Drug Abuse (NIH). Drug Facts: Nationwide Trends. Available at: https://www.drugabuse.gov/publications/drugfacts/nationwide-trends. Accessed June 28, 2016.
• Substance Abuse and Mental Health Services Administration (SAMHSA). Reports by geography. Available at: http://www.samhsa.gov/data/reports-by-geography?tid=632&map=1. Accessed June 28, 2016.
• Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88. Available at: http://www.dea.gov/pr/multimedialibrary/publications/drug_of_abuse.pdf. Accessed January 13, 2016.
• Karch S. Drug Abuse Handbook. Boca Raton, Fla.: CRC Press; 1998.• Lange RA, Cigarroa RG, Flores ED, et al. Potentiation of cocaine-induced coronary vasoconstriction by beta-
adrenergic blockade. Ann Intern Med. 1990; 112:897-903.• Schurr JW, Gitman B, Belchikov Y. Controversial therapeutics: the β-adrenergic antagonist and cocaine-
associated cardiovascular complications dilemma. Pharmacotherapy. 2014; 34(12)1269-1281.
References
• McCord J, Jneid H, Hollander JE, et al. Management of cocaine-associated chest pain and myocardial infarction. Circulation. 2008; 117:1987-1907.
• Amsterdam EA, et al. 2014 ACA/AHA guideline for the management of patients with non-ST-elevation acute coronary syndromes. JACC. 2014; 64(24):2645-2687.
• Shah R, Patel A, Mousa O, Manocha D. Crack lung: cocaine induced lung injury. QJM. 2015. , hcv064; DOI: 10.1093/qjmed/hcv064
• Muirhead TT, Eide MJ. Toxic effects of levamisole in a cocaine user. NEJM. 2011; 364:354. • Ashton CH. Pharmacology and effects of cannabic: a brief review. The British Journal of Psychiatry. 2001;
178(2): 101-106.• Horn JR, Hansten PD. Drug interactions with marijuana. Pharmacy & Healthcare Communications, LLC.
Pharmacy Times website. 2014. Available at: http://www.pharmacytimes.com/publications/issue/2014/December2014/Drug-Interactions-with-Marijuana. Accessed June 26, 2016.
• CDC. Injury prevention & control: opioid overdose. Available at: http://www.cdc.gov/drugoverdose/data/statedeaths.html. Accessed June 28, 2016.
• Boyer EW. Management of opioid analgesic overdose. NEJM. 2012;367:146-55.• Thomas SA. Opioid overdose rescue kits. US Pharm. 2015;40(3):HS2-HS6.• PL Detail-Document, Naloxone for opioid overdose: FAQ. Pharmacist’s Letter/Prescriber’s Letter. January
2016.
From the Street to the Pharmacy: Illicit Drugs and Reversal Agents
Heather Powell, PharmDPGY2 Internal Medicine Pharmacy Resident
Clement J. Zablocki Veterans Affairs Medical CenterGolden Peters, PharmD, BCPS
Associate Professor, Department of Pharmacy PracticeSt. Louis College of Pharmacy
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