High-potency heroin often causes overdose in the novice user or in the addict who is surprised by a sudden increase in the heroin’s purity. Adulterants used by dealers to “cut” heroin also can cause illness and death. Quinine, for instance, can cause cardiac arrhythmias. Contaminants such as fentanyl and cholinergic agents such as scopolamine added to enhance the “high” associated with heroin can increase the risk of toxicity or death.
Opioid overdose is characterized by cyanosis and pulmonary edema: slowed breathing, altered mental status, blue lips and fingernail beds, pinpoint pupils, hypothermia, and gasping respirations. In addition to respiratory and cardiac support, treatment with the narcotic antagonist naloxone immediately reverses opioid overdose.
WHERE TO REFER THE ADDICTED PATIENT
To what level of care should you refer the addicted patient from the emergency department—an inpatient medical unit, psychiatric unit/detoxification facility, residential treatment, partial hospitalization, or other model of care? The American Society of Addiction Medicine (ASAM) manual lists disposition recommendations to match individual patients’ clinical criteria. The criteria and levels are listed here as reminders of the issues involved in referring the addicted patient.
ASAM patient criteria
- Alcohol intoxication and/or withdrawal potential
- Biomedical conditions and complications
- Emotional, behavioral, or cognitive conditions and complications
- Readiness to change
- Relapse, continued use, or continued problem potential
- Recovery environment
ASAM levels of care
- Early intervention
- Opioid maintenance therapy
- Outpatient treatment
- Intensive outpatient treatment
- Partial hospitalization
- Clinically managed low-intensity residential services
- Clinically managed high-intensity residential services
- Medically monitored intensive inpatient treatment
- Medically managed intensive inpatient treatment
Source: Mee-Lee D, Shulman GD, Fishman M, et al. ASAM patient placement criteria for the treatment of substance-related disorders (2nd ed, rev). Chevy Chase, MD: American Society of Addiction Medicine, 2001:27-33.
Ecstasy
The drug 3,4-methylenedioxymethamphetamine (MDMA)—also known as Ecstasy, X, and XTC3 —provokes release of dopamine and serotonin into the synapse, causing a sense of blissful open-mindedness, closeness to others, and the ability to “break down (mental) barriers.”14 In the context of “rave” dance parties, MDMA also causes dehydration and hyperthermia, which can lead to rhabdomyolysis, kidney failure, and death.
Life-threatening consequences generally occur only when adequate water is unavailable to a group of intoxicated, dancing teenagers.15 The more common emergency presentations include sudden hypertension, tachycardia, vomiting, depersonalization, panic attacks, and psychosis.16
Immediate treatment includes restoration of normal fluid levels and body temperature, plus reassurance for the non-life-threatening, more common, presentations.
Phencyclidine
Phencyclidine (PCP) and its analogue ketamine—originally developed as anesthetic agents—are no longer used therapeutically because they can cause dissociation, anxiety, and even psychosis. Panic can change to hyperactive behavior, aggressiveness, and violent acts, so the first treatment goal must be to secure the safety of the intoxicated person and others. Chemical restraints such as benzodiazepines are preferred to physical restraints, although some situations may require physical restraint, at least initially.17
PCP affects memory, and often the user is unaware of the agent’s consequences unless he hears descriptions of his behavior from family and friends unfortunate enough to witness the intoxicated state. Coaching by emergency personnel can help the family confront the user with evidence that he needs treatment.
Barbiturates
Physicians prescribe barbiturates such as pentobarbital, phenobarbital, and secobarbital for pain, insomnia, alcohol withdrawal, and anxiety states. Although sometimes useful for acute pain, these drugs can also cause physical dependence, intoxication in overdose, withdrawal seizures, and rebound pain.18
The withdrawal associated with barbiturates—as with withdrawal from other CNS depressants such as alcohol and benzodiazepines—consists of autonomic hyperactivity, confusion, and occasionally seizures.
Overdose, often in combination with alcohol, accounts for most emergency presentations of barbiturate addiction. Supportive treatment—from reassurance and observation to airway support and mechanical ventilation—is required. Since obtundation and coma commonly occur with alcohol/barbiturate combinations, treatment includes monitoring for alcohol intoxication or withdrawal. No antidote exists for barbiturate intoxication.
Alternate medications. If the patient has become addicted to barbiturates prescribed for one of the common indications such as migraine headache, the emergency treater can promote use of a more effective treatment by acknowledging the need to control the headache pain. In managing this pain, the emergency worker can arrange referral:
- to an addiction specialist for treatment of the (now addictive) barbiturate use
- and to a neurologist who can evaluate the patient and prescribe one of many highly effective, nonaddicting headache remedies.
By taking the addiction and the pain seriously, the treater forms an alliance with the patient against the unhealthy consequences of both migraine headaches and addiction.
Benzodiazepines
Often prescribed for anxiety and insomnia, benzodiazepines cause emergency syndromes directly related to their potency, serum half-lives, and lipophilicity. For instance, alprazolam—which is potent, short-acting,19 and highly lipophilic—causes a severe withdrawal syndrome when high doses are stopped abruptly. This withdrawal state includes anxiety, agitation, and autonomic instability and can progress to frank seizures.