Opioids and Designer Drugs

Designer Drugs of Abuse

Designer drugs of abuse represent a major health risk to those who use them. The toxic effects of these agents are very dangerous when they are correctly identified, but they are especially dangerous because they are often misidentified by emergency room personnel. The three groups of designer drugs are the opiates, amphetamine derivatives and phencyclidine derivatives. Amphetamine derivatives such as MDMA and MDA can cause fatal sequelae including hyperthermia, hypertension, and seizures. No specific antidote exists for these agents. Therefore, their widespread use in certain areas is a major concern. The opiate derivatives M PPP, MPTP and the fentanyl analogues produce a wide range of toxic effects. These agents are much more potent than heroin, and are sometimes sold as heroin unknowingly to the user. The results have been catastrophic, with many fatalities. Arylhexylamines such as phencyclidine and ketamine are becoming more popular as agents of abuse. These drugs may result in fatal toxicity resulting from cardiac arrest, hypertensive emergency, or status epilepticus. Familiarity with the signs and symptoms of toxicity from the designer drugs will expedite the care of these patients.

Accidental methadone ingestion in an infant: case report and review of the literature

INTRODUCTION

We discuss accidental methadone intoxication in an 11-month-old female infant, review the literature, and stress the potential for child abuse among methadone-maintained caregivers.

CASE

An 11-month-old female infant presented with lethargy. Vital signs were normal, and pupils were constricted. Sepsis workup revealed no evidence of bacterial infection. High venous pCO2 suggested respiratory acidosis. Urine toxicology revealed high concentrations of methadone and its metabolites, and the diagnosis of methadone intoxication was confirmed when 0.1 mg/kg intravenous naloxone normalized the child's behavior. Social service agency inquiries found that the child's grandfather had been prescribed methadone for acquired morphine addiction. He carried 5-mg methadone tablets in his pocket and had recently babysat the infant. The patient was subsequently discharged home with pediatric and community services follow-up.

DISCUSSION

Methadone intoxication should be considered in children presenting with lethargy, miosis, and respiratory depression. Seventy-two percent of reported methadone poisoning patients are symptomatic, and unintentional poisoning is a real danger to children because small amounts can be fatal. There are also several case reports where the cause of intoxication was homicide by the parents. Initial management consists of establishing an airway, and naloxone may be indicated, before urine toxicology results are obtained, to help establish the diagnosis. However, if 2 doses do not reverse the child's symptoms, the diagnosis should be questioned. When repeated bolus doses of naloxone are indicated, a continuous infusion may be preferable.

Out-of-hospital care of critical drug overdoses involving cardiac arrest

OBJECTIVES

Death from acute drug poisoning, also termed drug overdose, is a substantial public health problem. Little is known regarding the role of emergency medical services (EMS) in critical drug poisonings. This study investigates the involvement and potential mortality benefit of EMS for critical drug poisonings, characterized by cardiovascular collapse requiring cardiopulmonary resuscitation (CPR).

METHODS

The study population was composed of death events caused by acute drug poisoning, defined as poisoning deaths and deaths averted (persons successfully resuscitated from out-of-hospital cardiac arrest by EMS) in King County, Washington, during the year 2000.

RESULTS

Eleven persons were successfully resuscitated and 234 persons died from cardiac arrest caused by acute drug poisoning, for a total of 245 cardiac events. The EMS responded to 79.6% (195/245), attempted resuscitation in 34.7% (85/245), and successfully resuscitated 4.5% (11/245) of all events. Among the 85 persons for whom EMS attempted resuscitation, opioids, cocaine, and alcohol were the predominant drugs involved, although over half involved multiple drug classes. Among the 11 persons successfully resuscitated, return of circulation was achieved in six following EMS cardiopulmonary resuscitation alone, in one following CPR and defibrillation, and in the remaining four after additional advanced life support.

CONCLUSIONS

In this community, EMS was involved in the majority of acute drug poisonings characterized by cardiovascular collapse and may potentially lower total mortality by approximately 4.5%. The results show that, in some survivors, return of spontaneous circulation may be achieved with CPR alone, suggesting a different pathophysiology in drug poisoning compared with cardiac arrest due to heart disease.

Do Co‐intoxicants Increase Adverse Event Rates in the First 24 Hours in Patients Resuscitated from Acute Opioid Overdose?

BACKGROUND

Patients frequently arrive in emergency departments (EDs) after being resuscitated from opioid overdose. Autopsy studies suggest that multidrug intoxication is a major risk factor for adverse outcomes after acute heroin overdose in patients. If this is true, there may be high-risk drug combinations that identify patients who require more intensive monitoring and prolonged observation. Our objective was to determine the impact of co-intoxication with alcohol, cocaine, or CNS depressant drugs on short-term adverse event rates in patients resuscitated from acute opioid overdose.

METHODS

Data were extracted from the database of a prospective opioid overdose cohort study conducted between May 1997 and 1999. Patients were prospectively enrolled if they received naloxone for presumed opioid overdose. Investigators gathered clinical, demographic, and other predictor variables, including co-intoxicants used. Patients were followed to identify prespecified adverse outcome events occurring within 24 h, and multiple logistic regression was used to determine the association of concomitant drug use on short-term adverse event rates.

RESULTS

Of 1155 patients studied, 58 (5%) had pure opioid overdose and 922 (80%) reported co-intoxicants, including alcohol, cocaine, and CNS depressants. Overall, out of 1056 patients with known outcome status there were 123 major adverse events (11.6%) and 194 minor adverse events (18.4%). After adjustment for age, gender, HIV status, cardiovascular disease, pulmonary disease and diabetes, we found that coadministration of alcohol, cocaine, or CNS depressants, alone or in combination, was not associated with increased risk of death or adverse events during the 24 h follow-up period.

CONCLUSION

In patients resuscitated from acute opioid overdose, short-term outcomes are similar for patients with pure opioid overdose and multidrug intoxications. A history of cointoxication cannot be used to identify high-risk patients who require more intensive ED monitoring or prolonged observation.

Opioid toxicity recurrence after an initial response to naloxone

OBJECTIVE

To determine the frequency and potential predictors of opioid toxicity recurrence after a response to naloxone in adult Emergency Department patients.

METHODS

A retrospective case-control study of naloxone-treated patients with opioid toxicity over an 8-year period. Both the patient response to naloxone and recurrence of opioid toxicity was determined by an expert Delphi Panel. The frequency of opioid toxicity recurrence was compared by the duration of opioid effect, the route of opioid exposure, and the presence of other CNS depressant drugs.

RESULTS

Ninety of 221 (41%) cases with a discharge diagnosis of opioid toxicity were treated with naloxone; six patients were excluded because of a lack of toxicity. There was a response to naloxone in 50% of the 84 cases, and recurrence of toxicity in 31% (95% CI 17-45%) of naloxone responders. The most common opioids were codeine, heroin, propoxyphene, and oxycodone/hydrocodone. Recurrence of toxicity was more common with long-acting opioids (p = 0.04), and was not associated with the route of opioid exposure (p = 0.42), or presence of ethanol and other CNS depressants (p > or = 0.87).

CONCLUSION

Opioid toxicity recurrence after a response to naloxone occurred in approximately 1/3 of adult Emergency Department opioid overdose cases. Recurrence was more common with long-acting opioids and was not associated with the route of opioid exposure. Other clinically useful predictors of toxicity recurrence were not identified.

Nonoperative causes of abdominal pain

In conclusion, it is good practice to consider operative (life-threatening) entities before nonoperative processes in the differential diagnosis of abdominal pain. However, a prudent and educated surgeon considers, even if only briefly, all possibilities before proceeding to operation.

Selective modulation of immune function resulting from in vitro exposure to methylenedioxymethamphetamine (Ecstasy)

Abuse of illicit analogs of methamphetamine (i.e., 'designer drugs') represents a growing problem. One of the most popular methamphetamine analogs is (+/-)-3,4-methylenedioxymethamphetamine (MDMA), commonly known as Ecstasy. The authors demonstrated previously that in vitro exposure to methamphetamine results in modulation of immune functional parameters necessary for host defense. The current study was performed to assess the potential direct (in vitro) immunomodulatory effect of exposure to a modified methamphetamine. Splenocytes or peritoneal macrophages from B6C3F1 mice were cultured in vitro at MDMA concentrations of 0.0001-100 microM. T-cell regulatory function was assessed by anti-CD3-mediated production of IL-2 and IL-4, B-cell function was assessed by quantitating cellular proliferation, natural immunity was assessed by quantitating natural killer (NK) cell activity, T-cell effector function was evaluated as a function of cytotoxic T-lymphocyte (CTL) activity, and macrophage function was assessed by IL-6 tumor necrosis factor (TNF) production. In vitro exposure to MDMA had no effect on B-cell proliferation at any concentration tested. In comparison, in the absence of direct cellular toxicity, production of IL-2 was enhanced at concentrations as low as 0.0001 microM. IL-4 production was not affected by exposure to any concentration of MDMA examined, suggesting a differential alteration in T-helper cell function by this compound. Basal and augmented NK cell function were enhanced at MDMA concentrations between 0.0001 and 1.0 microM when examined at an effector:target ratio of 100:1. CTL induction was significantly suppressed at a concentration of 100 microM. Finally, macrophage production of TNF was slightly suppressed at 10 and 100 microM MDMA, although this inhibition was not statistically significant.

'Designer drugs'. Recognizing and managing their toxic effects

"Adam," "Eve," "ecstasy," "China white." Illicit street drugs such as these are called designer drugs because they are designed to elicit certain effects and to bypass legal classification. Unfortunately, use and abuse of such substances can lead to serious medical problems and even death. Drs Sternbach and Varon describe the best-known compounds and discuss clinical characteristics and management of designer drug intoxication.