Talk i gave at ICEN in Melbourne on Street Drugs - clinical update for the emergency nurse.

1. Street Drugs
Kane Guthrie FCENA

2. Clinical Update
• Synthetic canabinoids
• Designer amphetamines
• Nurofen plus abuse

3. Street Drugs - Australia
ED’s biggest bain remains:
– ETOH
– Smoking
Emerging concerns:
– Prescription drug abuse
– Synthetic derivatives of old

4. Street Drugs in ED
• Resource intent
• Challenging personas
Stats:
• Amphetamines in ED 1.2% presentations
(Gray, 2007, MJA)
• July 2010-12 Vic ambulance
• 318% increase in amphetamine related call
outs
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(Helibourne, 2013, MJA)

5. The Web

6. Big Business/Clever People

7. Case 1
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28 female
Known polysubstance abuse
Presents agitated, & diaphoretic
Vitals: BP 172/89, HR 128, RR 30, Temp 37.9
Given IVIH, IV Diazepam – symptoms settle
• Admits to smoking “spice”

8. Synthetic Canabinoids
• “K2” “Spice” – “legal Marijuana”
• Typically sold – “incense” “room fresheners”
• Labeled - not for human consumption
• Sold OTC or Internet - $20-30

9. Synthetic Canabinoids
• Difficult to detect
Contains:
• Herbs/vegetables sprayed chemicals
• Target CB1 receptors in brain
Generally smoked
– Can be injected (tea), baked (cookies)

10. The Symptoms
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Agitation - Psychosis
Tachycardia
Hypertension
Arrhythmia's
Metabolic derangements
Seizures

11. ED Management
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Supportive care
Give Benzo’s – agitation, anxiety
Monitor temp
Fluids – dehydration
Look for co-ingestions

12. Case 2
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22 male BIB Police
Found - agitated, palpitations, paranoid
Smoke some “Crystals”
Brought it of the net!
Vitals: BP 185/96, HR 142, Temp 38.2

13. Designer Amphetamines
• Mephedrone.
• “Meow-Meow”, “Bath Salts”
• Synthetic derivative – cathinone
– Derived leaves Khat plant

14. Mephedrone
Synthetic stimulant:
• Euphoric & psychostimulant effects
• Similar to MDMA, Cocaine, Methamphet
• Illegal in Australia
– Easily available over net!

15. Mephedrone
Presents:
– Clear white powder
– Crystals (bath salts), capsules , pills
Taken:
– Ingested, injected, smoked
Cost:
$20-$50 a hit!

16. Mephedrone
• Short half life – 30-90mins
• Effects last 2-4 hours
• Results in compulsive re-dosing
Causes pronounced peripheral vasoconstriction

18. ED Management
• Supportive care
– Hydration, bladder care
• Give benzo’s - agitation, HR, HT, temp
• Monitor Temp >39 risk MOF
• Monitor for seizures, hyponatraemia
• Caution with antipsychotics

19. Case 3
• 35 female
Presents to ED with 2/52 hx:
– Weakness
– Thirst
– Nausea
• Appears dehydrated, generalised weakness in
all 4 limbs.

20. Blood Gas

21. Her ECG

22. Further History
• Admits to using 4g Nurofen+/day
• Addicted to opioids

23. Nurofen Plus Abuse
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Emerging problem
Its all about the codeine
Cheap – available OTC
Each tablet 200mg nurofen/12.8mg codeine
Reports pt’s abusing 60-100 tablets/day

24. The Issues
• Renal tubular acidosis
• Metabolic complications:
– Hypokalaemia
– Hyperchloraemia
– Hypophosphataemia
• GI Bleeds

25. Renal Tubular Acidosis
Essentially failure of:
– H+ excretion or
– HCO3 reabsorption
Causes:
– Chronic renal disease, autoimmune, genetic,
– Drugs – lithium, ibuprofen, toluene

26. ED Management
• Treat medical complications
• Often require ICU/HDU
• Electrolyte replacement
– K, Mg
• Surgery/scopes - if bleeding
• Opioid withdrawal
• Excellent supportive care

27. Remember
‘”Every Turkey has a terminal event””
“Always consider medical causes”

28. Further Info/Resources

29. Street Drugs in 2013
• Countless new agents
– Cheap & easily available
• Generally structurally variants of old
• Toxicity somewhat predictable
• Management principles largely the same

30. Questions

31. Thankyou