Courtesy Polish Wikipedia/Kon/Creative Commons License
Salvia divinorum has hallucinogenic and psychotomimetic properties. Symptoms include agitation and neurologic, cardiovascular, and gastrointestinal effects.
• Snakebite. The venom of the naja naja snake, or Indian cobra, contains neurotoxins that can have opiate-like effects on the central nervous system. The venom can cause blackouts and feelings of well-being and lethargy in people who deliberately have themselves bitten by a cobra (Subst. Abus. 2011;32:43-6). "It boggles my mind what people will do to get high," Dr. Mycyk said.
• Buprenorphine (Suboxone). Clinically used for opioid dependence, this drug is smuggled into prisons by being crushed into a paste that is applied to a drawing or card, or hidden under stamps. A recent study found that 12% of drug contraband in Massachusetts prisons is buprenorphine (Curr. Drug Abuse Rev. 2011;4:28-41). Buprenorphine intoxication causes mild euphoria, somnolence, and possible respiratory depression; laboratory and toxicology screens for illicit drugs would be negative.
Diagnosis
Hospital-based drug screens don’t detect most of the new and evolving designer drugs that result in emergency department visits. "A lot of hospitals have invested in expanded drug-screening panels, but these hospital machines cannot keep up with the creative chemists and users out there," Dr. Mycyk said. So "tox testing is not that helpful for some of these NEW drugs. In fact, it might falsely reassure you."
So, to make the diagnosis, "if the patient is conscious, ask them. Know their language, know the slang. They will tell you. ... They are frightened, and they don’t want to die."
If the patient is delirious or has altered mental status, examine his or her belongings carefully. "Completely examine your patient’s belongings, and you will probably find your answer." Check the small pocket in jeans, Dr. Mycyk suggested. "I’ve been surprised how often I find drug contraband in that small pocket."
Accessing one of the "drug partisan sites" – such as erowid.org, lycaeum.org, shroomery.org, and talktofrank.com – also can be useful if you want to figure out what your patient has taken. However, while it might be helpful to know the agent, focus on symptoms and "treat the patient; don’t treat the product," he said.
Treatment
Deaths from NEW drug abuse most commonly occur due to dysrhythmias, hyperthermia, or metabolic complications. There are no antidotes for any of these NEW drugs, but "symptom-based, goal-directed, supportive therapy will save most of these patients’ lives."
Use common sense, and trust your instincts, Dr. Mycyk said. Get an electrolyte panel if the patient is persistently symptomatic. If a patient is tachycardic and having palpitations, getting an ECG may be appropriate. If they’re overly agitated, it is safe to use benzodiazepines. If they’re dehydrated, give them IV fluids, he said.
It is important to get complete vital signs on these patients, and the most important vital sign is temperature, as elevated body temperature is the best predictor of death in the ED. Degree of tachycardia or tachypnea is not as concerning, he said.
For most of these patients, brief ED observation is fine. However, some of the NEW drugs have long duration of activity; for example, the effects of buprenorphine can last 24-37 hours, so admission might be considered.
All patients with an ED visit for drug use should have counseling before discharge. Simple ED counseling can help, Dr. Mycyk said. "They think a lot of this stuff is safe, and we just need to remind them that it is not safe."
Dr. Mycyk had no significant financial relationships to disclose.