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Cocaine, Amphetamines, and other Sympathomimetics

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Amphetamines

Methamphetamines

Crystal, ice, tina, crank, meth

Heavy users are ‘tweakers’

Synthesized from ephedrine

formication (bugs under skin), bruxism (jaw grinding)

Benzedrine-ice is the smoked form. Causes release of serotonin and dopamine in the CNS, periphral norepi release.

Cocaine

(Comprehensive Review Crit Care Med 2003 31:6)

 

Cocaine+Alkaline Solution+Ether=Freebase which can be smoked

Crack=extracted c sodium bicarb and water.

Blocks reuptake of biogenic amine neurotransmitters (NE, DA, 5-HT)

Reverse tolerance for seizures and paranoid ideation

Hyperthermia, Lung sx in smokers, DIC, Rhabdo

Can cause acute abd from intra-abd hemorrhage or ischemia (~19 hrs after use)

Mydriasis, Grinding of teeth (Bruxism), AMI, SAH, Seizures, Mesenteric Ischemia, Placental abruption.

Use bicarb for ventricular dysrhythmias.  Do not use Lido as increases seizure potential

Crack Lung-acute pulmonary infiltrates

Can cause widened QRS

Use benzos then nitroprusside

Crack dance-hemiballismus from same

Neuro-Can cause stroke:  ischemic from cocaine vasospasm, thrombotic, or hemorrhagic from cocaine hypertension causing the rupture of an aneurysm.  Can precipitate tonic/clonic as well as focal seizures.  This can be from direct CNS stim or hyperthermia.  Can also cause seizure kindling.  Cocaine related accumulation of dopamine in the basal ganglia can lead to tourette’s, tardive dyskinesia, choreoathetosis, dystonia, and the classic akathisia/chorea known as the crack dance.

Pulmonary-epistaxis and nasal septal perfs.  Bronchospasm and asthma exacerbation.  Can act as a hapten leading to hypersensitivity pneumonitis (crack lung)  Pulmonary hemorrhage.  Noncardiogenic pulmonary edema.  Chronic cocaine use can lead to pulmonary hypertension and cor pulmonale.  Pneumomediastinum and pneumothorax are well known complications of cocaine use.

Cardiac-increased heart rate/bp and svr can lead to ischemia.  Chronic cocaine use accelerates atherosclerotic disease.  Dilated cardiomyopathies.

GI-mesenteric ischemia or ischemic colitis from vasospasm  Pyloric and prepyloric ulcers.

Renal-can cause acute renal infarction from vasospasm

Vascular-can lead to arterial thrombosis due to decreased protein C and antithrombin III levels.  Aortic dissection

Pyschiatric-cocaine associated delirium

 

Chest Pain

Cocaine-induced is within approx. 1 hr of cocaine use. Pt intoxicated with sympathomimetic toxidrome. B-blockers contraindicated. Phentolamine 1-2 mg aliquots if nitro and ativan do not work

alt dosing: 5-10 mg Q 15 minutes

 

Cocaine-assoc. is a patient who uses cocaine and has chest pain, but not within acute intox. B-blockers are probably fine in these patients

 

cocaine may accelerate athero by 20 years. Shown in rabbits to cause plt aggregation.

 

1 of every 4 nonfatal MIs in patients aged 18-45 is related to frequent cocaine use. Approximately 6% of patients with cocaine-associated chest pain sustain an acute MI (Am J EM, 11/07, pg. 1015).

Dysrhythmia from Cocaine Review Art

Amphetamine Analogues

Methylenedioxymethamphetamine (MDMA)

X, Ecstasy, E, XTC, Adam

Peaks in 90 minutes, lasts 4-6 hours

75-150 mg normal dose

Causes serotonin release and block of reuptake, also alpha/beta adrenergic.

Hyperthermia (Up to 43) probably from central serotoninergic mechanism as well as increased muscle activity, hyponatremia if increased free water uptake (also possibly ADH effect from serotonin effects), possibly rhabdomyolysis.  HTN, Narrow Complex tachycardias (procainamide)

Though more likely it is a B3 receptor effect from released and no uptake of norepi. In animal model, carvedilol was able to both prophylax and treat this effect. (Crit Care Med 2005;33:1314)

Liver failure can also be seen.  It is unknown if NAC has a role in treatment.

Benzos, active cooling

If patient is taking MAOIs can provoke hypertensive crisis, Agony after Ecstasy

MDA (Love Pill)/MDEA (Eve)

Also cause norepinephrine release, very similar to MDMA

MPH (Methylphenidate, Ritalin)

Associated c fatalities when tabs are crushed then drug is injected or sniffed

Can also cause talc emboli when injected

Metcathinone (Cat, Khat, Jeff)

Naturally contained in leaves of catha edulis in Arabia

Synthetic version is #1 drug of abuse in Russia, Seen in US in Michigan

Similar effects to meth

Ephedrine

Naturally found in Chinese herbal medicine ‘ma-huang’

Similar to methamphetamines except peripheral effects are much more prominent than central, hence users may use life threatening amounts in the attempt to get same high.

Arylhexamines

Phencyclidine (PCP)

PeaCePill, aka Sherman, dust, soma, goon

When mixed c pot=killer weed, diluted in embalming fluid (formaldehyde)=wet or illy

Nystagmus, groucho eyes (dilated, staring, roving pupils)

Hypoglycemia

Hypethermia, diaphoresis not common, Muscle rigidity, can lead to rhabdo

give haldol and ascorbic acid

Give activated charcoal no matter the route of use, as PCP accumulates in the stomach

Ketamine can test false positive on urine screen.  Test will stay positive for 4 weeks

Ketamine

Special K, Vitamin K, Fort Dodge

Anxiety, chest pain, and palpitations are most common presenting symptoms.  Tachycardia and HTN from sympathomimetic effects are most common signs.

Dextromethorphan

DM, Robo

In cough suppressants

Bizarre movements

CNS depression

 

From the Poison Review:

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TPR Podcast Episode #6

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New Club Drugs

October 6, 2014, 11:52 pm

TPR Podcast Episode 6: I’ve Tripped and I Can’t Get Down

Written by Theresa Kim, MD

Synthetic Cathinones

o   examples: mephedrone, methedrone, MDPV, methylone

o   “bath salts” generally contained one or more synthetic cathinones

o   Schneir et al performed a comprehensive analysis of the composition of “bath salts”, finding great variability in components and concentrations

  • Synthetic cathinones release norepinphrine, dopamine, serotonin

o   Norepinephrine > sympathomimetic manifestations

o   Serotonin > serotonin syndrome, hallucinations

o   Dopamine > abuse potential

  • Routes: oral , nasal, parenteral
  • Effects: euphoria, agitation, paranoia, tachycardia, sweating, confusion, chest pain, palpitations, restlessness
  • Complications: hyponatremia, hyperpyrexia, serotonin syndrome, rhabdomyolysis, agitated delirium, multi-system failure
  • Treatment: supportive

o   chemical restraint, aggressive cooling if indicated, fluids, anticipate potential complications

Piperazines

  • purely synthetic compounds with no naturally occurring form
  • piperazine was initially produced/licensed in the 1950s as a veterinary anti-helminthic drug
  • examples: BZP, MDBZP, TFMPP
  • generally stimulate actions of norepinephrine, dopamine, and serotonin
  • route: usually ingestion in pill or loose powder form
  • effects similar to those of MDMA and amphetamines: anxiety, palpitations, sweating, confusion, agitation, vomiting, hallucinations, hyperventilation
  • can cause false positive results on amphetamine screen
  • complications: seizures, metabolic acidosis, hyponatremia, hyperthermia, multi-organ failure, psychosis, seizures
  • treatment: supportive
  • Symptoms commonly persist > 24 hrs

Gamma-Hydroxybutyric Acid (GHB)

  • colorless oily chemical
  • GABA analogue
  • effects: CNS depression, disinhibition, nausea, dizziness, agitation, urinary incontinence, aggression
  • Complications: coma, respiratory depression, rhabdomyolysis
  • relatively short duration (generally < 3 hours)
  • treatment: supportive

Methoxetamine

  • Structural analogue of ketamine
  • often (mistakenly) touted as “bladder friendly”
  • street names include MXE, mexxy, KMax, rolfcoptr,” legal” ketamine, minx, jipper
  • NMDA receptor antagonist
  • routes: insufflation, oral, sublingual, rectal, paranteral routes reported
  • effects: similar to ketamine
  • Animal studies show that prolonged exposure of mice to methoxetamine results in renal toxicity and bladder fibrosis in a similar way that ketamine has been known to do
  • treatment: supportive

Synthetic Cannabinoids

  • synthetic versions of , delta-9-tetrahydrocannabinol (THC), the active psychoactive component found in marijuana
  • action: cannabinoid receptor agonism
  • route: usually smoked or vaporized
  • effects: euphoria, altered perception, cognitive slowing
  • Complications: cases of acute kidney injury, myocardial infarction, and psychosis have been reported
  • treatment: supportive

25C-NBOMe

  • derivative of the psychedelic compound phenethylamine 2C-C MOA: partial agonist of 5-HT2A receptor
  • routes: sublingual, buccal, inhalation
  • Complications: vasoconstriction, serotonin syndrome, hyperthermia, hypertension, metabolic acidosis, rhabdomyolysis, seizures, renal failure, disseminated intravascular coagulation
  • treatment: supportive

 

Bibliography

Bersani, F.S., Ornella, C., Albano, G., Valeriani, G., Santacroce, R., Posocco, F.B.M., Cinosi, E., Simonato, P., Martinotti, G., Bersani, G., Schifano, F. (2014). 25C-NBOMe: preliminary data on pharmacology, psychoactive effects, and toxicity of a new potent and dangerous hallucinogenic drug. Biomed Research International.

 

Feuer, A. (2014, Aug 15). A year after drug deaths, the electric zoo music festival tries again. The New York Times.

 

Schneir, A., Ly, B.T., Casagrande, K., Darracq, M., Offerman, S.R., Thorton, S. , Smollin, C., Vohra, R., Rangun, C., Tomaszewski, C., Gerona, R.R. (2014). Comprehensive analysis of “bath salts” purchased from California stores and the internet. Clinical Toxicology 52, 651-658

 

Smith, C., & Robert, S. (2014). ‘Designer drugs’: update on the management of novel psychoactive substance misuse in the acute care setting. Clinical Medicine 14(4), 409-415.

 

Zawilska, J.B. (2014). Methoxetamine – a novel recreational drug with potent hallucinogenic properties. Toxicology Letters.

– See more at: http://www.thepoisonreview.com/2014/10/06/episode-6-im-tripping-and-i-cant-get-down/#sthash.QFODHdRf.dpuf

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