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TAKING A WALK ON THE WILD SIDE OF SUBSTANCE ABUSE Donna Lotzer Clinical Pharmacist TAKING A WALK ON THE WILD SIDE OF SUBSTANCE ABUSE Donna Lotzer Clinical Pharmacist UW Hospital & Clinics WEBBED 2015

WHAT WE WON’T TALK ABOUT • OR MUST WE…(We must) • National Drug Threat WHAT WE WON’T TALK ABOUT • OR MUST WE…(We must) • National Drug Threat Assessment 2007 and 2010 compared • Great Lakes area “Big Five” – Cocaine: 39. 4%/29. 5% – Methamphetamine: 27. 6%/16. 0% – Marijuana: 17. 1%/15. 0% – Heroin: 8. 6%/25. 0% – Controlled Prescription Drugs: 6. 5%/13. 6% www. justice. gov/ndic

NATIONAL MAP OF ABUSE 2010 Stats NATIONAL MAP OF ABUSE 2010 Stats

NATIONAL MAP OF ABUSE 2010 Stats NATIONAL MAP OF ABUSE 2010 Stats

Percentage of State and Local Agencies Reporting High Availability Percentage of State and Local Agencies Reporting High Availability

Objective One: Recognize Unusual Substances of Abuse and the Circumstances Under Which They Can Objective One: Recognize Unusual Substances of Abuse and the Circumstances Under Which They Can Be Used

Who needs drugs? The right mix of espresso, chocolate and minced chicken hearts gets Who needs drugs? The right mix of espresso, chocolate and minced chicken hearts gets me right where I need to be!!

METHODS/CHOICE OF INHALANT ABUSE • Sniffing • Huffing • Bagging • • Propane, butane METHODS/CHOICE OF INHALANT ABUSE • Sniffing • Huffing • Bagging • • Propane, butane Gasoline, paint thinner Acetone, glues Spray paint, correction fluid, degreasers

SYMPTOMS OF INHALANT ABUSE • • • Outward initial signs Sxs of intoxication Ongoing SYMPTOMS OF INHALANT ABUSE • • • Outward initial signs Sxs of intoxication Ongoing problems Terminal events (SSDS) Chronic effects Multisubstance abuse possible/common

GOING FOR THE GOLD • This person has a problem! • Metallic spray paint GOING FOR THE GOLD • This person has a problem! • Metallic spray paint is a favorite of solvent abusers • Meet a repeat multistate offender

GLYBURIDE • • Unintentional party drug? Mistaken for Valium Crushed, snorted Resulted in severe GLYBURIDE • • Unintentional party drug? Mistaken for Valium Crushed, snorted Resulted in severe hypoglycemia!!

Football and Cough Syrup Don’t Mix • Codeine cough syrup • Caught shipping in Football and Cough Syrup Don’t Mix • Codeine cough syrup • Caught shipping in pint water bottles! • Maybe using/abusing? • Used to boost effect of other drugs

AWOL • • • Alcohol With Out Liquid 21 rst century “hookah”! Popular at AWOL • • • Alcohol With Out Liquid 21 rst century “hookah”! Popular at some clubs Promoted for “home use” Shot of booze mixed with oxygen goes directly to one’s bloodstream for maximum effect

“EMBALMING FLUID” • Start with tea, tobacco, MJ • Is it real or PCP? “EMBALMING FLUID” • Start with tea, tobacco, MJ • Is it real or PCP? • Person may refer to smoking “fry”, wet” or “amp”, “happy sticks” or “sherm” • Symptoms of smoking PCP • Symptoms of smoking formaldehyde (!)

HAWAIIAN BABY WOODROSE g, “It’s A ch Churnin a , Stom t Hugging ng HAWAIIAN BABY WOODROSE g, “It’s A ch Churnin a , Stom t Hugging ng Spinni ng, Toile Room d Raci g” Feelin ea H runk Bad D

VIAGRA & CRYSTAL METH COCKTAIL • Targets gay men • Linked to HIV & VIAGRA & CRYSTAL METH COCKTAIL • Targets gay men • Linked to HIV & STD’s • Crystal meth = impotence • Viagra solves that problem for many “Your career took up too much time anyway – a crystal meth habit can suck up your job, your friends, your home and your health in 18 months”

NUTMEG • • Users try because curious, unlikely to repeat Symptoms delayed, long-lasting (>24 NUTMEG • • Users try because curious, unlikely to repeat Symptoms delayed, long-lasting (>24 hrs) Experience nausea, gagging, headache Teens use looking for marijuana-like effects

SAY “CHEESE” PLEASE • Heroin mixed with Tylenol PM • Crush, snort, get high SAY “CHEESE” PLEASE • Heroin mixed with Tylenol PM • Crush, snort, get high & hooked • Affordable, deadly • Ages 13 and up • Nationwide alert by DEA in 2006

RECOMMENDED BY: Physicians, Pharmacists and. . . Dr. Feelgood? ? RECOMMENDED BY: Physicians, Pharmacists and. . . Dr. Feelgood? ?

WHAT ARE THEY AFTER? • Dextromethorphan – Serotonergic activity can produce visual & auditory WHAT ARE THEY AFTER? • Dextromethorphan – Serotonergic activity can produce visual & auditory hallucinations • Antihistamines – Antimuscarinic properties produce visual and tactile hallucinations • Decongestants – Stimulant effects – Replacement for pseudoephedrine • Look for “PE” = phenylephrine

DEXTROMETHORPHAN (DXM) • Availability • Expected symptoms – Drowsiness – GI upset – Stimulant DEXTROMETHORPHAN (DXM) • Availability • Expected symptoms – Drowsiness – GI upset – Stimulant if combos Examples of Clandestine DXM Pills • Symptoms of abuse – Nausea, vomiting – Ataxia, slurred speech – Dizziness, drowsiness – Hallucinations, psychosis – Nystagmus, coma – Withdrawal syndrome

CRUNKING • Briefly hit the news with a fatal case in Hawaii in 2012 CRUNKING • Briefly hit the news with a fatal case in Hawaii in 2012 • Mixes a beverage with cough syrup and narcotic pills • Used by kids to get high • Combination of depressants causes respiratory failure

JIMSON WEED Datura stramonium • Seasonal “high” found in your garden! • Usually seeds JIMSON WEED Datura stramonium • Seasonal “high” found in your garden! • Usually seeds are chewed, sometimes smoked • Hallucinatory, violent behaviors result

ANGELS TRUMPET (Datura inoxia) • Teen victim brewed and drank tea • Same botanical ANGELS TRUMPET (Datura inoxia) • Teen victim brewed and drank tea • Same botanical family as Jimson weed • Contains atropine, scopolamine etc. • Historically called “Jamestown weed” Patrick J. Alexander @ USDA-NRCS PLANTS Database

WHAT IS DMT? • Psychoactive chemical • Causes intense psychedelic effects • Can be WHAT IS DMT? • Psychoactive chemical • Causes intense psychedelic effects • Can be smoked, injected, snorted, or taken orally • Source is many plants – origin in South America • Related to psilocybin

DMT DETAILS • Extremely intense visuals • Short duration (20”) DMT Duration If Smoked DMT DETAILS • Extremely intense visuals • Short duration (20”) DMT Duration If Smoked Total Duration 6 - 20 mins Onset 0 - 1 mins Coming Up 0 - 30 secs Plateau 3 - 15 mins Coming Down 3 - 5 mins After Effects 15 - 60 mins Hangover / Day After --- • Can interact with many Rx drugs – unpredictable • Smoking causes severe lung irritation • Vomiting common • Color-changing vision, buzzing sounds reported • Triggers latent psychiatric problems

SALVIA DIVINORUM (Sage of the Seers) Herb – Legal, abusable Folks “grow their own” SALVIA DIVINORUM (Sage of the Seers) Herb – Legal, abusable Folks “grow their own” • http: //www. all 4 humor. com/videos/funny-videos/salvia-abuse. html

PRESCRIPTION DRUG ABUSE PATTERNS AND TRENDS - 2012 • What are we talking about? PRESCRIPTION DRUG ABUSE PATTERNS AND TRENDS - 2012 • What are we talking about? – Narcotic pain relievers – CNS depressants – Stimulants • Combine with illicit drugs • Falsely lowered perception of risk with Rx abuse • Why abuse them? – – Easy access Cheap, pure “Less harmful” Less likely risk of arrest • How does one get them? – Family and friends – Dealers – Theft from pharmacy

OXYCODONE: Oxy. Contin® True or False: Oxy. Contin® is the #1 misused narcotic for OXYCODONE: Oxy. Contin® True or False: Oxy. Contin® is the #1 misused narcotic for illicit purposes. False: Morphine

ABC NEWS: “PAINKILLER PATCH ABUSE BLAMED FOR DEATHS” • • Fentanyl Tea Bag – ABC NEWS: “PAINKILLER PATCH ABUSE BLAMED FOR DEATHS” • • Fentanyl Tea Bag – Brew up a cup? Fentanyl Rectally – Shove it up where? Fentanyl Chewed – Bite it! Fentanyl Snorted – Up your nose!

FENTANYL MADNESS • • Fentanyl Dermal – Taking the Heat Fentanyl Gel – Up FENTANYL MADNESS • • Fentanyl Dermal – Taking the Heat Fentanyl Gel – Up in Smoke Fentanyl IV – Shooting up the Patch Fentanyl, Cocaine &/or Heroin – Deadly Mix • Fentanyl Oral – Lick your “Perc-o-Pop”

RITALIN GOES TO COLLEGE • Indicated for attention deficit disorder • Used to boost RITALIN GOES TO COLLEGE • Indicated for attention deficit disorder • Used to boost alertness and study longer • Hit the news at UW Madison in 2004 and Marquette in 2006 • Also being used by teens and adults • Source? Diverted from legal prescriptions • Adverse effects are stimulant • Possible risk of cardiac arrhythmias

Objective Two: Appreciate the Sources of Information and the Motivation for Abuse of Unconventional Objective Two: Appreciate the Sources of Information and the Motivation for Abuse of Unconventional Substances in Teens and Adults

You know I don’t think I can face the day today… Motivation? You know I don’t think I can face the day today… Motivation?

WHERE THEY GO – ”SOURCES” • • Wikipedia – Kids & adults alike Erowid WHERE THEY GO – ”SOURCES” • • Wikipedia – Kids & adults alike Erowid – Users head here first!!! Google any term for limitless options You Tube, Twitter, etc.

TEEN-ORIENTED WEBSITE www. whatisdxm. com TEEN-ORIENTED WEBSITE www. whatisdxm. com

“PHARMING” PARTIES • “Trail mix” of drugs available • Social event for any age, “PHARMING” PARTIES • “Trail mix” of drugs available • Social event for any age, especially teens and college kids • Pill-popping frenzy – all participants donate

INHALANT ABUSE VIDEOS • http: //www. youtube. com/watch? v =QXx. Bfmw. Ex. IA • INHALANT ABUSE VIDEOS • http: //www. youtube. com/watch? v =QXx. Bfmw. Ex. IA • http: //www. youtube. com/watch? v =J 618 fx 8 Y 2 u 0&feature=related

THIS WON’T HAPPEN! THIS WON’T HAPPEN!

Website for anyone to buy WHAT? !? Website for anyone to buy WHAT? !?

Objective Three: Understand Utilize the Best Approach to Management of Patients With Symptoms Due Objective Three: Understand Utilize the Best Approach to Management of Patients With Symptoms Due to Atypical or Unknown Substance Abuse

Does anyone think that this would impress a teenager or addict? Would be nice Does anyone think that this would impress a teenager or addict? Would be nice but it is not that easy…

Respect your creativity for thinking outside the box. . • Remember all bets are Respect your creativity for thinking outside the box. . • Remember all bets are off when what you think you are dealing with is an abusable substance. • Let your training and instincts lead the way! • Manage the patient, not the history of exposure…

MANAGEMENT OF INHALANT ABUSE SITUATIONS • We need to do what? ? – Fresh MANAGEMENT OF INHALANT ABUSE SITUATIONS • We need to do what? ? – Fresh air, decontamination – Do NOT stress person – Observation (non-medical OK? ) – Oxygen & EMS transport – CPR/ACLS protocols

MANAGING PHARMING • Unknown pills, in unknown amounts leads to a management dilemma • MANAGING PHARMING • Unknown pills, in unknown amounts leads to a management dilemma • Unexpected, unpredictable for EMS • Fear by medical staff of missing something like acetaminophen – Silent killer 36 - 48 hours out! • Multiple patients from one party… – MUST NOT assume drug exposure is the same for all

TOXIC PLANTS MANAGEMENT • • Woodrose Nutmeg Jimson Weed Salvia Used with permission Jimson TOXIC PLANTS MANAGEMENT • • Woodrose Nutmeg Jimson Weed Salvia Used with permission Jimson Weed Seedpod

NARCOTICS OD MANAGEMENT • Symptoms – Narcotic overdose – Terminal event is respiratory arrest NARCOTICS OD MANAGEMENT • Symptoms – Narcotic overdose – Terminal event is respiratory arrest • Management – Airway priority #1 – Naloxone in large doses (but…) – Supportive care

DEXTROMETHORPHAN MANAGEMENT • • Symptomatic/supportive Naloxone (rare) Benzodiazepines Caution for other ingredients that may DEXTROMETHORPHAN MANAGEMENT • • Symptomatic/supportive Naloxone (rare) Benzodiazepines Caution for other ingredients that may need management(!)

ADDITIONAL RESOURCES FOR HELP • Poison Center at 1 -800 -222 -1222 • National ADDITIONAL RESOURCES FOR HELP • Poison Center at 1 -800 -222 -1222 • National Drug and Alcohol Treatment Referral Service: 800 -662 -HELP • Wisconsin Clearinghouse for Prevention Resources: 800 -248 -9244 or 608 -263 -2797 • National Inhalant Prevention Coalition: 800 -269 -4237 • National Clearinghouse for Alcohol and Drug Information: 800 -729 -6686 or 800 -788 -2800 • My contact information: 608 -265 -8160 – www. uwhealth. org/poison

ONLINE RESOURCES • Medical journals • Websites: – www. inhalants. org – www. inhalant. ONLINE RESOURCES • Medical journals • Websites: – www. inhalants. org – www. inhalant. org – www. theantidrug. com – www. mediacampaign. org – www. samhsa. gov/ – www. drugfree. org – www. backtoschool. drugabuse. gov – www. nida. nih. gov – www. erowid. org