Patients with substance abuse present as unconscious, hyperstimulated, or psychotic as a result of an overdose. Acute management includes basic life support, sedation, and treatment of other side effects of the drug. Naloxone is used to reverse the effects of opioid overdose. Hypo/Hyperthermia is treated accordingly. Cases of drug ingestions require GI decontamination using activated charcoal. Aggressive behavior is treated through pharmacological interventions. Incidents of drug abuse can be decreased through parental monitoring and supportive family relationships.
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Track marks can be a helpful physical sign to recognize drug abuse


Overview

Acute management of drug overdose involves basic life support protocols based on individual needs. GI decontamination and pharmacological interventions are then used to reverse the side effects of abused drug, treat aggressive behaviors, and manage temperature related variations. History, examination, and investigations are taken alongside resuscitation approach. There is a difference in the drug-related vocabulary of health practitioners and drug abusers. It is, therefore, important for a health care provider to have an idea of these locally used names.

History

  • Age of the patient
  • Gender
  • Drug history
  • Type of drugs used
  • Dosage
  • Route of administration
  • Type of drug abuse e.g. recreational, accidental, self-poisoning, deliberate.
  • Timing of drug abuse
  • Other drugs are taken along with the substance of abuse such as alcohol, caffeine, tobacco.

Examination

Vital signs

  • Heart rate
  • Blood pressure
  • Temperature
  • Respiratory rate
  • Oxygen saturation

Physical signs of drug abuse

  • Smell
  • Changes in skin texture
  • Pressure sores
  • Rhinitis
  • Bruising
  • Track marks
  • Phlebitis
  • Cellulitis
  • Nasal septal damage

Neurological examination

  • Glasgow coma scale
  • Pupils (dilated or constricted)
  • Muscle tone
  • Reflexes
  • Movement of limbs
  • Fasciculations
  • Other signs of trauma or injury

Investigations

  • Blood glucose levels
  • ECG
  • ABGs
  • Human chorionic gonadotropin (hCG) blood test in women of childbearing age
  • Screening of paracetamol levels in the case of self-poisoning

Patients with drug abuse usually present with one of the following 3 states:

1. Unconscious patients

These patients are more likely to be affected by CNS depressants like opiates and benzodiazepines. Airway support is the priority in these patients.

2. Hyper-stimulated patients

Amphetamine, cocaine and other stimulants produce hyperstimulation. Priority for these patients is sedation and cardiovascular and neurological assessment.

Patients with acute psychotic conditions

Exposure to stimulants and cannabinoids may result in acute psychotic episodes. These patients are a risk to staff and themselves. Chemical sedation with short-acting benzodiazepines and antipsychotics is a priority.

Outpatient management of drug abuse cases

  • Counseling
  • Setting quit dates
  • Follow-up appointments
  • Psychological interventions (therapy)
  • Structured day programs

Indications for inpatient management

  • Detoxification
  • Failure of sufficient outpatient therapy
  • Danger to self or others
  • Severe medical or psychiatric morbidity

Management of specific drugs overdose

Amphetamines & Cocaine

Toxidrome

  • CNS-related symptoms: euphoria, psychosis, seizures, hallucinations, delirium, agitation
  • Hyperthermia
  • Serotonin toxicity
  • Neuromuscular excitation
  • Diaphoresis
  • Flushing
  • Tachycardia
  • Nausea, vomiting, and diarrhea
  • Mydriasis
  • Hypertension
  • Myocardial dysfunction
  • Arrhythmias

Complications

  • Seizures
  • ACS
  • Rhabdomyolysis
  • Hypertension
  • Hyperthermia
  • Serotonin toxicity
  • Shock
  • Arrhythmias
  • Hypernatremia

Management

  • Acute coronary syndrome (ACS): aspirin, nitrates, opiate analgesics, benzodiazepines
  • Benzodiazepines for agitation seizures, and hypertension.
  • Inotropes and crystalloid infusion for hypotensive shock
  • Sodium bicarbonate and amiodarone for arrhythmias
  • IV fluids and ice packs to treat hyperthermia

Ecstasy (MDMA)

3, 4-Methylenedioxymethamphetamine is a drug used as a recreational activity. It is an amphetamine derivative and has serotonergic activity. The effect of MDMA are as follows:

  • Enhanced empathy
  • Intimacy
  • Positive mood

Acute poisoning of Ecstasy presents as:

  • Bruxism
  • Hypertension
  • CNS and Neurological excitement
  • Hypernatremia as a result of increased vasopressin release
  • Delirium
  • Convulsions
  • Hyperthermia
  • Palpitations

Treatment of Ecstasy overdose is similar to that of amphetamine overdose.

Hypernatremia is treated by using hypertonic saline.

Opiates

Less than 10 breaths per minutes along with Miosis and semi-conscious state is most likely to be due to opiate poisoning.

Opiate toxidrome

  • CNS depression may present with symptoms ranging from drowsiness to coma
  • Respiratory depression
  • Hypercapnia (hypercarbia)

Complications

  • Respiratory failure
  • Hypothermia
  • Rhabdomyolysis
  • Aspiration pneumonitis
  • Pulmonary edema (Non-cardiogenic)

Management

  • Oxygen and respiratory support take priority in all patients suspected of opiate poisoning.
  • Naloxone to reverse the effects of opioid poisoning
  • Supportive care including IV fluids, re-warming in the case of hypothermia, and maintenance of normoglycemia.

Cannabis

Acute cannabis intoxication has the following clinical features:

  • Anxiety
  • Disorientation
  • Depersonalisation
  • Altered mood
  • Memory impairment
  • Paroxysmal atrial fibrillation
  • Attention deficit
  • Orthostatic hypotension
  • Tachycardia and palpitations

Complications

  • Hyperemesis gravidarum
  • Agitation
  • Psychosis

Management

Acute cannabis toxicity is usually NOT a serious problem. Symptoms resolve within 4-12 hours of ingestion.

  • Reassurance is often sufficient in acute cannabis toxicity.
  • Anti-emetics for nausea and vomiting
  • Anti-psychotics
  • Benzodiazepines to treat agitation

Other Illegal Drugs

γ-Hydroxybutyrate causes rapid onset CNS depression. However, it has a short duration of action, and supportive management is enough.

An overdose of psychoactive substances such as cathinone presents with symptoms similar to that of amphetamines and is treated in a similar manner.

Cannabinoids poisoning is treated similarly to that of cannabis.

Methods of Gastrointestinal Decontamination

1. Activated charcoal

Indication:

Patient presents within one hour of ingestion of a toxic substance

Contraindications:

  • Decreased level of consciousness.
  • Abused drug has a low binding affinity for activated charcoal,g., lithium
  • GI bleeding or perforation risk

2. Gastric lavage

Indication:

It is used in extraordinary situations where a potentially toxic amount of medication has been consumed.

Contraindications:

  • Compromised airway
  • Ingestion of strongly acidic or alkaline substance
  • GI bleeding or perforation risk

Complications of Substance Abuse

  • Drug overdose leading to serious morbidity and mortality
  • Risk of endocarditis, hepatitis, and HIV with IV drug abuse
  • Addiction: criminal acts to sustain drug activity, theft, prostitution

Prevention of Substance Abuse

  • Guidance on substance abuse
  • Parental awareness
  • Monitoring of Adolescents activities
  • Positive self-esteem
  • Supportive family relationships
  • Parents as positive role models
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