Intoxication with 3-MeO-PCP alone: A case report and literature review

RATIONALE

3-Methoxyphencyclidine (3-MeO-PCP) is a new psychoactive substance derived from phencyclidine. Although it can lead to severe intoxications, the main manifestations and optimal management have not been well characterized. Here, we report 2 cases of 3-MeO-PCP intoxication in the same patient, and summarize the manifestations of this intoxication reported in literature.

PATIENT CONCERNS

A 17-year-old male purchased a bag of 3-MeO-PCP on the Internet but took an oral dose (200 mg) that corresponds to the less active isomer 4-MeO-PCP. He developed high blood pressure (158/131 mm Hg), tachycardia (100 bpm), and neurological manifestations (confusion, hypertonia, nystagmus, and then agitation). A maculopapular rash appeared, although this may have been related to the administration of midazolam. Hyperlactatemia (2.6 mmol/L) was the main laboratory finding. Seven days later, he returned to the emergency department after sniffing 50 mg of 3-MeO-PCP. High blood pressure, tachycardia, and neurological manifestations (psychomotor impairment and dysarthria) were present but less severe than after the first intoxication.

DIAGNOSIS

In the first intoxication, the blood and urine 3-MeO-PCP concentrations were, respectively, 71.1 ng/mL and 706.9 ng/mL. Conventional toxicity tests were all negative. In the second intoxication, biological samples were not available.

INTERVENTIONS

In the first intoxication, treatment consisted of intravenous hydration and midazolam. The patient was transferred to an intensive care unit for monitoring. After the second intoxication, he was monitored for 12 hours.

OUTCOMES

The patient's condition improved quickly in both cases.

LESSONS

These cases provide additional information on the manifestations of 3-MeO-PCP intoxication. These manifestations are mainly cardiovascular (high blood pressure, tachycardia) and neurological. The fact that second (50 mg) intoxication was less severe than the first (200 mg) is suggestive of a dose-effect relationship for 3-MeO-PCP. The first case also emphasizes the risk of dosing errors caused by the similarity between the names "3-MeO-PCP" and "4-MeO-PCP."

Out with the old, in with the new? Case reports of the clinical features and acute management of two novel designer drugs

Methoxydine (4-MeO-PCP) and Methoxetamine (3-MeO-2-Oxo-PCE) are both commercially produced designer drugs with structural and biochemical similarities to phencyclidine (PCP). Although phencyclidine toxicity is well documented, its recreational use in present times is rare. With the advent of new designer drugs being available widely through internet sites, Acute Physicians should be aware of the clinical features and management of these potential toxins. We present a case of methoxydine ingestion (which to our knowledge has not been previously documented in any medical journals) and a case of methoxetamine ingestion, and discuss their history, contrasting clinical features and acute management.

[Phencyclidine--angel dust]

BACKGROUND

For the first time in ten years, phencyclidine (PCP) has been confiscated in Norway. Physicians should be aware of this substance when treating intoxications.

METHODS

Relevant literature was identified by search in Medline. This review presents the pharmacological properties and effects of phencyclidine as well as symptoms and treatment of phencyclidine intoxication.

RESULTS AND INTERPRETATION

Phencyclidine exhibits hallucinogenic, depressant and stimulant properties. Phencyclidine interacts as an antagonist to the N-methyl-D-aspartate (NMDA) receptor in the central nervous system. Severe NMDA receptor hypofunction can elicit clinical symptoms similar to a schizophrenic episode.

[An expert study of acute poisoning by phencyclidine derivatives]

Described are the results of a complex study of different objects and beverages for the content of synthetic drugs in them, i.e. phencyclidine and tenocyclidine, by using the methods of planar and gas chromatography, UV-spectrometry and mass spectrometry/gas chromatography.

Common drugs of abuse--Part II

Drug abuse affects a significant number of individuals of all ages. Health care practitioners must be knowledgeable about both the physiological effects of such drugs and the impact of drug-seeking behavior on their patients.

Sudden death during arrest and phencyclidine intoxication

Deaths of individuals being arrested are important and complex medicolegal cases. Conclusions regarding the cause and manner of death for such cases must take into account multiple factors that may have played a role, as well as anticipate the forensic issues that will arise. In this article, we review the deaths of 2 individuals in which phencyclidine intoxication was a factor that contributed to death during arrest. Most cases of sudden death during arrest have involved cocaine intoxication; because phencyclidine's pharmacologic properties are quite different from those of cocaine, these cases allow for comparisons to those factors that may have greater importance.

[Analysis of MDMA and PCP by GC-MS from patients admitted to the critical care medical center]

In our country, abuse of methamphetamine has increased. Furthermore, dealings of other drugs by using internet have increased. But, the poison cases of 3,4-methylenedioxymethamphetamine (MDMA) and phencyclidine (PCP) have never been reported in our country. We report an MDMA poison case and a PCP poison case. We could detect MDMA, MDA or PCP by GC-MS from urine and serum of patients admitted to the critical care medical center of Nippon Medical School. Case 1: A 23-year-old foreign female was admitted to our hospital because of disturbance of consciousness. Her friend said that she had been found lying on the floor of the bathroom after taking a tablet. The screening test by Triage showed AMP positive. Not methamphetamine but MDMA and MDA were detected from urine and serum of the patient by GC-MS. Case 2: A 27-year-old foreign female was admitted to our hospital because of restlessness and excitement. Her friend said that she had become restless and excited after taking 15-30 tablets of Tylenol. The screening by Triage showed BZO and PCP positive. Not acetaminophen but PCP was detected in the patient's sample by GC-MS. Drug abuse has expanded to Japan over the border. New responses to abuse drugs with respect to medical treatment and drug analyses should be established.

Evaluation of hair root analysis for acute phencyclidine poisoning and behavior of phencyclidine metabolites in rat hair root

We evaluated the usefulness of hair root analysis to diagnose acute phencyclidine (PCP) poisoning. Male rats were i.p. administered acute poisonous doses (80, 100 and 120 mg/kg) of PCP hydrochloride and the hair roots were plucked out with hair nippers at certain times after administration. The hair root samples were extracted with methanol/HCl. After evaporation of the solvent, the residue was derivatized with N,O-bis(trimethylsilyl) acetamide and analyzed with GC/MS. PCP was detected at high concentrations (up to 181.7 ng/mg) from all samples. The peak concentrations at every dose were observed at 6 h. The concentrations of PCP in the rat hair roots increased dose-dependently in the range of the doses. 1-(1-Phenylcyclohexyl)-4-hydroxypiperidine (PCHP) and trans-1-phenyl-1(4'-hydroxypiperidino)-4-cyclohexanol (t-PCPdiol) were also detected from 5 and 15 min to 48 h after administration, respectively. It is concluded that hair root is a useful specimen for the diagnosis of acute PCP poisoning because PCP, PCHP and t-PCPdiol are detected very soon after administration and a large amount of them is retained in hair root for a long time. PCHP was found from the early stage in hair roots and its concentration was higher than that of t-PCPdiol for 6 h. However, the concentration of t-PCPdiol became higher than that of PCHP after 6 h. These phenomena could be explained by the time lag of production of the primary (PCHP) and the secondary metabolite (PCPdiol).

Anti-phencyclidine monoclonal Fab fragments markedly alter phencyclidine pharmacokinetics in rats

The purpose of these studies was to explore the use of phencyclidine (PCP)-specific high affinity antibodies as a possible treatment for phencyclidine toxicity. High affinity (Kd = 1.8 nM) anti-PCP monoclonal Fab fragments were purified from papain digested anti-PCP immunoglobulin produced in mouse ascites. Control animals (n = 5) received an i.v. bolus dose of 1 mg/kg of PCP, along with a tracer dose of 250 microCi of [3H]PCP. Fab-treated rats (n = 5) also received this PCP dose, but at 2 hr after dosing (when PCP distribution was complete) they received an equimolar dose of anti-PCP Fab (50 mg). Within 5 min after the anti-PCP Fab administration, serum [3H]PCP concentrations increased approximately 60- to 100-fold. Fab treatment caused the [3H]PCP volume of distribution at steady state to decrease from 12.6 +/- 3.0 liters/kg (mean +/- S.D.) in control animals to 0.6 +/- 0.2 liters/kg in the Fab-treated animals (about 5% of control values). Systemic clearance changed from 66.3 +/- 16.9 to 6.8 +/- 2.8 ml/min/kg (about 10% of control values). Because both volume of distribution and systemic clearance decreased to a similar degree, the terminal elimination half-life did not change significantly (3.9 hr in controls vs. 4.9 hr in treated animals, harmonic means). Renal clearance decreased from 1.8 +/- 0.6 to 0.62 +/- 0.17 ml/min/kg after Fab treatment. The anti-PCP Fab caused the percentage of PCP recovered in urine to increase from 2.5 +/- 0.5 to 10.3 +/- 4.7%.(ABSTRACT TRUNCATED AT 250 WORDS)

Protracted phencyclidine coma from an intestinal deposit

Phencyclidine is a common drug of abuse that can be taken orally, intravenously, or by inhalation. We describe a massive overdose of phencyclidine in a patient who swallowed a plastic bag containing the drug. Quantitative serum phencyclidine levels remained persistently elevated for several weeks. On hospital day 20, a plastic bag was passed via the rectum. Subsequently, the patient's serum phencyclidine levels fell in accordance with previously described pharmacokinetics. The patient rapidly recovered neurologic function. Persistently elevated serum drug levels should suggest continued drug absorption from a gastrointestinal deposit. We propose that colonoscopy and esophagogastroduodenoscopy be performed early in this setting.

Diagnosis and management of phencyclidine intoxication

Because phencyclidine intoxication has both psychiatric and physical manifestations, it continues to present a challenge to physicians. Intoxication may be viewed as occurring in three stages. Mild intoxication, the first and most common stage, is manifested primarily by psychiatric signs and symptoms. In the second stage, patients are stuporous to comatose, but they have intact deep pain responses. In the third stage, patients do not respond to deep pain stimuli. Treatment depends on the stage of intoxication.

"Designer drugs"--a current perspective

Since the late 1970s, in an effort to quench the ever burgeoning appetite for pharmacological substances of abuse and to satiate their own need for profit, unscrupulous chemists have set up clandestine laboratories to produce and market new drugs for street sale. Using fairly common industrial chemicals, they have altered or modified preexisting controlled substances such as fentanyl, meperidine, mescaline, amphetamine, and phencyclidine, producing derivatives of these parent compounds that, up until 1986, were able to temporarily elude the guidelines of the Federal Controlled Substances Act due to their new and unique chemical structures. Unsuspecting users continue to use the drugs recreationally. This article will present a comprehensive review of these "Designer Drugs" looking at historical data, pharmacokinetics, treatment, abuse trends, and some of the more recent additions to the social pharmacopoeia.

Analysis of sexual disparity of violent behavior in PCP intoxication

We performed a retrospective chart analysis of 33 patients with an Emergency Department discharge diagnosis of phencyclidine (PCP) intoxication. All 33 cases presented to the Emergency Department between November 1986 and April 1987. Thirty of the 33 patients (91%) were classified as mildly intoxicated (per clinical syndrome as described by Aronow and Done) while the remaining 3 patients (9%) were moderately intoxicated. Two of the patients (6%) required benzodiazepine therapy for agitation while an additional 3 patients (9%) required haloperidol for psychotic symptoms. Twenty-three patients (70%) did not require any medication. Of particular interest was our finding that 11 of the 27 males (41%) required leather restraints for agitation or violent behavior while none of the 6 female patients required leather restraints (Fisher's exact test, p = 0.00078). While nursing perception of physical strength may be a confounder, level of agitation and violent behavior is our primary indication for use of restraints. We believe that there is a sexual disparity in level of agitation and violent behavior induced by PCP. We hypothesize that this may be due to pharmacokinetic factors (such as difference in body fat distribution between the sexes) or biological differences in the central nervous system.

Augmentation of haloperidol by ascorbic acid in phencyclidine intoxication

The authors studied 40 white men with acute phencyclidine (PCP) intoxication. On a random basis, 10 were treated with ascorbic acid, 10 with placebo, 10 with haloperidol, and 10 with a combination of ascorbic acid and haloperidol. While haloperidol was significantly more effective than ascorbic acid, the combination was significantly more effective than either used alone. This combination may have a specific antipsychotic role in the emergency treatment of PCP psychosis.

Drug-specific Fab therapy in drug overdose

The use of digoxin-specific fragments, antigen-binding (Fab) for antidotal therapy of severe digitalis intoxication is rapidly becoming a treatment of choice. Furthermore, studies with this mode of drug-specific therapy using Fab specific for desipramine and for phencyclidine suggest that this treatment may be applicable to a variety of other drugs or drug classes. As Fab technology has advanced, so have laboratory methods for monitoring the efficacy of treatment.

Emergency department management of the intoxicated adolescent

It is widely recognized that many young people will have experiences with alcohol and with psychoactive recreational drugs before emerging from the adolescent years. It is estimated that before leaving ninth grade, one half of the total student population will have had experience with alcohol, and approximately one third with marijuana. Cocaine also is more available to adolescents. For these reasons, the emergency physician is more likely to see teenage patients for drug-related problems.

Hallucinogens

This article describes the various hallucinogens with which adolescents may come in contact. Perspective is provided as to the importance of the various hallucinogens and to their effects on adolescent users.

PCP intoxication in seven young children

Five infants and two young children were treated at a large children's hospital for phencyclidine intoxication. The clinical symptoms and signs were mostly neurologic, including diminished response to tactile and verbal stimuli (100%), ataxia (71%), nystagmus (57%), constricted pupils (57%), depressed sensorium, and stupor associated with a blank, expressionless stare (57%). Notably absent were the behavioral aberrations such as aggression, which are usually seen with PCP intoxication in older children and adults. The possibility of drug intoxication was denied by most of the parents or surrogate parents accompanying these small children and infants for treatment. It is suggested that a systematic investigation for possible PCP exposure, including a urine toxicology screen for PCP (preferably by immunoassay methods), be conducted whenever an infant or child is brought for emergency treatment of unresponsiveness, bizarre behavior, dyskinesis, dystonic posturing, atypical oculomotor and pupil findings, or evidence of hallucinations.

Phencyclidine (PCP) abuse. A close-up look at a growing problem

PCP or "angel dust" is a dissociative anesthetic agent with notoriety as an abuse substance. Numerous members of many subcultures are frequent users of this drug. It is well known in California's psychedelia, along the East Coast, and in the middle- and working-class suburbs of the Midwest. It is important that practitioners become acquainted with the drug and its effects. Persons intoxicated with PCP have murdered their own children and have even jumped out of high-rise apartment buildings. States of florid psychosis lasting for days can follow a brief encounter with PCP. Inadvertent administration of narcotics and barbiturates to patients with acute PCP intoxication can lead to a crisis that could prove to be fatal.

Hair analysis for detection of phencyclidine in newly admitted psychiatric patients

The authors implemented a new procedure for analyzing phencyclidine (PCP) content in hair. They compare the results of analyses of hair with results of analyses of blood and urine in 47 patients newly hospitalized with acute psychiatric illness. Hair analysis identified 11 patients who had used PCP, and blood and urine analyses did not identify any among the sample population. In three patients, the results of hair analysis aided in establishing a diagnosis of PCP intoxication. The authors discuss interpretations of their findings and psychiatric applications of this new technique.

Hemoperfusion of phencyclidine in the dog

Experiments were conducted to determine whether charcoal hemoperfusion (HP) would be useful in severe phencyclidine (PCP) overdose. Dogs were given a single 5 mg/kg injection of PCP. In 6 experiments HP for 2.5 hours was done; and in 6 control experiments, the extracorporeal circuit contained no HP cartridge. The number of seizures, symptoms, duration of coma, and PCP concentrations in the tissues of HP dogs were not different from control. PCP clearance by HP was 67 +/- 16.5 ml/min. PCP recovery by HP was 2.25 +/- 0.25 mg (2.0% of the administered dose). Urinary excretion of PCP was 1.33 +/- 0.46 mg (1.2% of the dose). Volume of distribution of PCP was 21.8 +/- 1.7 L/kg. Due to the high volume of distribution, high lipid solubility and low plasma levels of PCP, HP was not effective in managing PCP overdose in the dog.

Treatment of phenylcyclohexylpyrrolidine (PHP) psychosis with haloperidol

Twenty white males who presented with psychosis were later found to have ingested PHP. Treatment with haloperidol 5 mg IM caused significant improvement while placebo treatment did not. Results of haloperidol treatment of PHP psychosis were similar to previously published reports with phencyclidine (PCP) psychosis.

Pharmacologic approaches to violence

No one drug is specific for the management of violent behavior. Rather, the pharmacologic treatment of aggression is best approached by identifying and treating the underlying psychopathology, with the expectation that the violent behavior will resolve secondarily. Pharmacologic management is probably most successful when other treatment modalities such as family, group, and individual psychotherapies are used concurrently.

Detection of phencyclidine usage by radioimmunoassay of saliva

Paired serum and saliva samples, obtained from 100 emergency department patients suspected of phencyclidine (PCP) intoxication, were analyzed using a specific PCP radioimmunoassay (RIA). Seventy-four of the 100 saliva samples and 75 of the paired serum samples were positive for PCP. The final clinical diagnosis was PCP intoxication in 79 cases. Of these, both serum and saliva tests were positive in 70 cases, only serum was positive in two cases, and both serum and saliva samples were negative in seven cases. The concentration of PCP in the samples did not correlate with the severity of PCP intoxication. In the remaining 21 cases, with no clinical evidence of PCP intoxication, PCP assays were negative in both serum and saliva in 17 cases, three patients had positive saliva and serum tests, and one other patient had a positive PCP saliva assay. Thus, saliva would appear to be as reliable as serum as a specimen for PCP analysis.

Phencyclidine-induced malignant hyperthermia causing submassive liver necrosis

This report describes three male patients arrested for aggressive and combative behavior, characteristic of phencyclidine intoxication, in whom severe hyperthermia, respiratory failure, and coma developed. Two days after the malignant hyperthermic event, serum transaminase levels rose acutely to extremely high levels with concomitant elevations in bilirubin levels and a fall in prothrombin activity. Liver biopsy specimens in two patients showed marked perivenular necrosis and collapse. No specific treatment was directed at the phencyclidine intoxication. Two of the three patients survived. Submassive liver necrosis caused by malignant hyperthermia is an unusual complication of phencyclidine abuse.

Toxicology of drug abuse

Almost all of the drugs of abuse can be identified in bodily fluids, and attempts should be made to do so. These specific drug assays help to document intoxication but do not aid in the emergency management of an acutely intoxicated patient. There are no specific antidotes for the drugs of abuse; symptomatic, detailed medical care is the cornerstone to the successful management of the patient.

The social, psychological and medical management of intoxication

Intoxicated persons appear frequently in substance abuse centers and in general hospital settings. The severity of their condition ranges from mild impairment to coma or delirium. The prominent features of intoxication with the major classes of abused drugs are described. Staff responses to intoxication are discussed. Guidelines are presented for systematic management of this condition.

Comparison of chlorpromazine, haloperidol and pimozide in the treatment of phencyclidine psychosis: DA-2 receptor specificity

Three neuroleptics were used to treat phencyclidine (PCP) psychosis. These included chlorpromazine, a DA-1 and DA-2 dopamine antagonist with noradrenergic effects; haloperidol, a predominantly DA-2 antagonist with noradrenergic effects; and pimozide a predominantly DA-2 antagonist with no noradrenergic activity. Three cohorts of randomly selected young white adult males were studied. Responses to haloperidol and pimozide were statistically equivalent and both were significantly superior to chlorpromazine. These results further support the role of the DA-2 receptor in PCP psychosis and tend to rule out a noradrenergic role. The authors therefore suggest that DA-2 blockers, such as haloperidol or pimozide be employed as treatment of choice in PCP psychosis.