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ICEM 2014

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You should have cashed in big-time. 
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The last several years of returns have been among the best ever.

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Educational Objectives
After evaluating this article participants will be able to:
 
-Identify the critical features of the toxidrome associated with methamphetamines to avoid misdiagnosis
-Incorporate a rational approach to treatment into their practice
-Treat patients more effectively who present with methamphetamine exposure
 
 
 
Case Study
An 18-year-old male snorted a mixture of “ice” methamphetamine crystals in the company of friends at the prom in a small Midwestern high school. The patient became agitated and tremulous within minutes of insufflation. He appeared sweaty and complained of feeling hot. He began speaking nonsensically. Friends were unable to control him as his agitation worsened. He then fell to the ground and began convulsing. Emergency Medical Services (EMS) was contacted.

On arrival to the emergency department, the patient was unresponsive to deep pain. His blood pressure was 185/105 mmHg, heart rate was 152 beats per minute, respirations were shallow at 28 per minute, core temperature was 103.8 F, and room air pulse oximetry was 93%. He continued to experience generalized tonic-clonic extremity movement. Other physical findings included dilated pupils and diaphoretic skin.
    
Amphetamines
Over the past two decades, amphetamine use in the United States has increased at an alarming rate. The clinical syndrome associated with amphetamine toxicity consists of vasoconstriction, tachycardia, and hypertension, associated with agitation and CNS excitation. Benzodiazepine sedation may be required for treating cardiac stimulation. Patients with severe hyperthermia should be treated with aggressive, active cooling. Rhabdomyolysis is treated with volume diuresis and urinary alkalinization.

Routine urine drug screening can be limited confirming amphetamine exposure. Most screens are not specific to amphetamine and false-positive results may occur with over-the-counter products such as pseudoephedrine, phenylpropanolamine or ephedra. In addition, false negatives may result with many of the designer amphetamines such as those with both stimulant (sympathomimetic) and hallucinogenic effects.

Crystal meth is highly addictive resulting in sympathomimetic effects with acute toxicity. Chronic abuse can result in profound malnutrition and weight loss due to the fact users direct all their efforts toward feeding their drug addiction. A common clinical feature is “meth mouth” (AKA Austin Powers teeth) which results from direct chemical effects as well as poor dental hygiene and bruxism. Methamphetamine users have various skin conditions ranging from scabs and rashes to large abscesses from picking at their skin or “skin popping” the drug when intravenous access is limited.

Methamphetamine production and consumption is regional, concentrated primarily in the central Midwest and Western and southwestern United States. Mexican drug traffickers, operating superlabs in Mexico and California, have controlled the production and distribution of most domestic supplies although synthesis of methamphetamines in small-scale laboratories are operated by independent “cooks” who obtain ingredients from local retail and convenience stores are growing exponentially.

Ecstasy
Ecstasy (which also goes as E, X, XTC, rolls, beans and Adam) can be associated with significant unpredictable complications. CNS infarcts, hyperthermia, cerebral edema and hyponatremia have been described. Patients who present to the emergency department following use of MDMA should have a rapid core temperature assessed, complete neurologic exam, rapid cooling as needed and screening for electrolyte abnormalities, such as hyponatremia. The proposed mechanism for hyponatremia is thought to occur via an SIADH effect or by water intoxication as the patients often over-hydrate fearing the lethal effects of dehydration and hyperthermia. There are case reports of patients requiring treatment with 3% hypertonic saline for severe hyponatremia. Other names for ecstasy include “Entactogen” (touching within) and “Empathogen” (feeling for others). It is often used concomitantly with sildenafil (Viagra) for added effects.

Tryptamines (street names DMT; Dimitri) are a class of natural and synthetic hallucinogens that were popular in the sixties. There is currently a new resurgence in several regions; one such drug is Foxy-Methoxy (5-MeO-DIPT) which is a synthetic tryptamine with structure and effects similar to those of psilocybin found in hallucinogenic mushrooms. It has the street names “foxy-methoxy” or “foxy”, most likely because of its reputed aphrodisiac properties. It has gastrointestinal and neurological effects, including nausea, vomiting, diarrhea, restlessness and mydriasis. Larger doses cause perceptual effects similar to those of LSD with “waxiness and plasticity” of the extremities described. It has been supplied as a purple tablet, a capsule or on a sugar cube or blotting paper.

Nexus is a 2C-B newer psychedelic phenethylamine. According to one user, “When I take Nexus, I merge with the music, become one with the crowd, and fuse with the whole of Planet Earth. This isn’t a drug, it’s a trance-dance sacrament.” In regard to its effects, another young man described it as “a cross between the warm, lovey-dovey feeling produced by Ecstasy and the visual patterning you get when you take magic mushrooms”.

Other familiar prescription stimulants abused include methylphenidate (Ritalin) and dextroamphetamine (Adderal). These are commonly prescribed for ADHD in children, but prescription drug diversion by adults has become problematic. They are often taken and abused intranasally or intravenously.

Herbal amphetamine-like stimulants include ephedrine (Ma Huang), which had been ubiquitous in dietary supplements for weight loss and energy drinks. It was originally considered a safe plant-derived “herbal supplement”. However, reports of toxicity including palpitations, tachycardia, syncope, hypertension, psychoses, convulsions, coronary vasospasm, chest pain, acute myocardial infarction, and cerebrovascular ischemia were described. Several deaths due to cardiovascular or cerebrovascular complications were documented. Products containing ephedra are now banned in most US States.

On the international front, metcathione (street name: Cat, Kat or Qat) is a Middle Eastern herbal drug of abuse with amphetamine properties. Hagigat (capsules of 200mg cathione) has been recently marketed as a natural stimulant and aphrodisiac.

Case Outcome
Over the next 16 hours, the patient was admitted to a critical care unit, where he required frequent intravenous doses of lorazepam and midazolam for control of agitation and seizures. Tmax reached 106.2 F and a serum creatinine kinase level peaked at 6,500 international units per liter. Urinalysis was positive for myoglobin and trace red blood cells. Circulating fans, strategic ice packs and aggressive cooling methods were used to control the elevated body temperature.

The patient was discharged from the hospital on day three, alert and with no apparent sequelae. He admitted to past use of “ice” and “ecstasy,” along with ethanol, tobacco and marijuana. He stated that, in the past, he never experienced seizures or syncope following use of these agents. He denied suicidal intent and eventually enrolled in outpatient drug rehabilitation.

The Meth Lab Grocery List
Chemicals, ingredients and equipment used to make crystal meth
  • Dilute HCl (Muriatic acid): Obtained from hardware stores, in the pool section.
  • NaOH (Lye): Obtained from supermarkets in the “drain cleaner” section. “Red Devil Lye” most commonly used.
  • Ethyl Ether (Diethyl Ether): Obtained from engine starting fluid, usually from a large supermarket. Products with “high ethyl ether content” such as Prestone.
  • Desoxyephedrine: Obtained from “VICKS” nasal inhalers. Typically found at any drug or grocery store. Usually 50mg of l-desoxyephedrine per container.
  • Distilled Water: Recommended over tap water.
  • Two large eyedroppers
  • Ten small glass bottles
  • One large glass or porcelain bowl
  • Coffee filters
  • One small jar with a top
  • One Pyrex baking dish
  • One hot plate
Note: please, no smoking during production process



 




     

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