Illicit Drugs and Reversal Agents

From the Street to the Pharmacy: Illicit Drugs and Reversal Agents

Heather Powell, PharmD PGY2 Internal Medicine Pharmacy Resident Clement J. Zablocki Veterans Affairs Medical Center Golden Peters, PharmD, BCPS Associate Professor, Department of Pharmacy Practice St. Louis College of Pharmacy Conflict of Interest/disclosures

• Heather Powell and Golden Peters declare no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria Pharmacist Objectives

At the conclusion of this program, the pharmacist will be able to: • Compare and contrast illicit street drugs based on mechanism of action, physiologic and neurologic effects. • Identify and describe the implications that illicit street drugs may have on prescription medications and disease states. • Recognize important signs and symptoms of illicit drug overdose. • Discuss the utility of the naloxone injection kit and nasal spray in patients with opioid use, addiction and/or heroin use. Technician Objectives

At the conclusion of this program, the pharmacy technician will be able to: • Compare and contrast illicit street drugs based on mechanism of action, physiologic and neurologic effects. • Identify and describe the implications that illicit street drugs may have on prescription medications. • Recognize important signs and symptoms of illicit drug overdose. • Discuss the utility of the naloxone injection kit and nasal spray in patients with opioid use, addiction and/or heroin use. Pretest Question #1

• Which of the following is true regarding the AHA/ACC 2014 statement on the use of cocaine and beta-blocker usage in patients presenting with non-ST-segment elevation acute coronary syndromes?

A. ACS in patients with cocaine use should be treated in the same matter as patients without cocaine use unless there is presence of acute cocaine intoxication B. Beta-blockers use cannot be recommended due to the potential to provoke or exacerbate coronary vasospasm C. ACS in patients with acute cocaine intoxication should be treated with beta- blockers D. None of the above Pretest Question #2

• AJ is a 21 yo female who presented to the ER with confusion/agitation, hypertension, diaphoresis, tremor, and myoclonus. The only prescription medication she takes is fluoxetine 60 mg q AM. It is discovered she drank an entire bottle of dextromethorphan and took ecstasy prior to coming. What diagnosis is most likely based on her story?

A. Heat Stroke B. Serotonin Syndrome C. Neuroleptic Malignant Syndrome D. Meningitis Pretest Question #3

• Which is a sign/symptom of an overdose with opioids, stimulants and hallucinogens?

A. Fever B. Miosis C. Agitation D. Convulsions Pretest Question #4

• Which statement below does not accurately represent Evzio® (naloxone) auto-injector?

A. When administering, hold for 5 seconds B. FDA approved for opioid overdose reversal C. Special training is required prior to dispensing D. Clothing does not need to be removed for administration Background

• Economic Impact

Health Care Overall Tobacco $130 billion $295 billion Alcohol $25 billion $224 billion Illicit Drugs $11 billion $193 billion

• Legal cost for illicit drugs – $40 billion

Drugabuse.gov. Statistics. 2014. Source: www.youtube.com/watch?v=ZnQB7SqIESg National Survey on Drug Use and Health. Behavioral Health Trends. 2014 Illinois Statistics

• Illicit drug use in the past month (> 12 years old) (2014)

State Percent (%) Illinois 9.55 Iowa 6.27 Indiana 9.12 Missouri 9.27 Wisconsin 8.31 National Average 9.27

Samhsa.gov. Reports by geography. 2014. Source: www.sircon.com/stateInformationCenter/illinois.jsp What are they, what do they do, and why should I be concerned? ILLICIT DRUG BASICS:

Source: http://www.aarp.org/health/health-insurance/info-2014/medicare-changes-for-2015.html Narcotics

• Opioids Physiologic Effects Neurologic Effects Pain relief ↓ tension Cough suppression ↓ anxiety Constipation ↓ aggression Miosis ↑ drowsiness Respiratory depression ↑ inability to concentrate Pruritus ↑ apathy

Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88. Source: www. pixabay.com/en/diet-pills-medication-pharmacy-sick-1328802/ Narcotics

• Routes of Administration: Oral, Injected, Sniffed, Inhaled, Rectal • Street Names – Morphine: Dreamer, Emsel, First Line, God’s Drug, Hows, M.S., Mister Blue, Morf, Morpho, and Unkie – Codeine: Cody, Sippin Syrup, Sizzurp, Lean – Heroin: Big H, Black Tar, Chiva, Hell Dust, Horse, Negra, Smack, and Thunder – Oxycodone: Hillbilly Heroin, Kicker, oc, ox, Roxy, Perc, oxy – Hydrocodone: Hydro, Norco, Vikes – Hydromorphone: D, Dillies, Dust, Footballs, Juice, Smack – Meperidine: Demmies, Pethidine, Mapergan – Fentanyl: Apache, China girl, China white, Dance Fever, Friend, Goodfella, Jackpot, Murder 8, TNT, Tango, Cash – Methadone: Amidone, Chocolate Chip Cookies, Fizzies, Maria, Pastora, Salvia, Street Methadone, Wafer

Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88. Narcotics

• Mechanism of Action: Bind to mu-opioid receptors in the CNS causing inhibition of the ascending pain pathways

Source: https://www.lexisnexis.com/legalnewsroom/workers-compensation/b/recent-cases-news-trends- developments/archive/2014/10/01/ Narcotics

• Drug-Drug or Drug-Disease Considerations – Skin and soft tissue infections – “krokodil” – Respiratory depression with concomitant depressants – Endocarditis

Drugs.Indiana.edu. Drug Information. 2016. Source: www. pixabay.com/en/nile-crocodile-crocodylus-niloticus-245013/ https://www.youtube.com/watch?v=CqRbmG1edV0 Stimulants

• Cocaine, Phencyclidine (PCP), Synthetic cathinones (bath salts), Amphetamines/Methamphetamine, Dextromethorphan Physiologic Effects Neurologic Effects ↓ appetite ↑ self-esteem ↑ mental/physical performance ↑ wakefulness ↑ BP/HR Psychosis ↑ insomnia Exhilaration Physical exhaustion Rhabdomyolysis Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88. Karch S. Drug Abuse Handbook. Boca Raton, Fla.: CRC Press; 1998. Stimulants - Cocaine

• Routes of Administration: – Powdered – snorted or injected – Cocaine base (crack) – smoked • Street Names: Coca, Coke, Crack, Flake, Snow, Soda Cot

Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88. Source: www. pixabay.com/en/drugs-death-cocaine-drug-risk-1276787/ Stimulants - Cocaine

• Mechanism of Action: Blocks reuptake of catecholamines (dopamine and NE) at presynaptic α- and β-adrenergic terminals of the heart muscle, vascular smooth muscle, and central and peripheral nervous systems  sympathomimetic effects in dose- dependent fashion

Lange RA, Cigarroa RG, Flores ED, et al. Ann Intern Med. 1990; 112:897-903. Source: http://thesource.com/2015/11/03/ireland-to-decriminalize-weed-cocaine-and-heroine/ Stimulants - Cocaine

• Cocaine Specific Effects – Rapid neurologic onset followed by a cocaine “crash” – Restlessness and panic attacks

Karch S. Drug Abuse Handbook. Boca Raton, Fla.: CRC Press; 1998. Source: www.pixabay.com/en/drugs-cocaine-user-addiction-908533/ Stimulants - Cocaine

• Drug-Drug or Drug-Disease Considerations – Cardiovascular disease • Endocarditis • Accelerated atherosclerosis • Acute Coronary Syndrome – Is it safe to use beta-blockers for ACS in patients who use cocaine?

Schurr JW, Gitman B, Belchikov Y. Pharmacotherapy. 2014; 34(12)1269-1281. McCord J, Jneid H, Hollander JE, et al. Circulation. 2008; 117:1987-1907. Lange RA, Cigarroa RG, Flores ED, et al. Ann Intern Med. 1990; 112:897-903 Source: http://www.medscape.com/viewarticle/859042 Stimulants - Cocaine

• Beta-blocker Controversy – Beta-blockers may potentiate cocaine-induced coronary vasoconstriction by blocking beta-receptors in the coronary vasculature leaving alpha-receptors unopposed – ACC/AHA 2008: Recommends against the use of beta-blockers due to the potential to provoke or exacerbate coronary vasospasm (Strength of Recommendation: Class IIIc) – ACC/AHA 2014 UA/NSTEMI: ACS in patients with cocaine use should be treated in the same matter as patients without cocaine use unless there is presence of acute cocaine intoxication (Level of Evidence: C)

Schurr JW, Gitman B, Belchikov Y. Pharmacotherapy. 2014; 34(12)1269-1281. Amsterdam EK, Wenger NK, Brindis RG, et al. JACC. 2014; 64(24):2645-2687. Lange RA, Cigarroa RG, Flores ED, et al. Ann Intern Med. 1990; 112:897-903. Amsterdam EA, et al. JACC. 2014; 64(24):2714-2715. Stimulants - Cocaine

Drug Receptor affinity Comments

Propranolol Β1, β2 Concerns of coronary artery vasospasm

Labetalol Β1, β2, α1 α-antagonism reduces potential unopposed α effects

Carvedilol Β1, β2, α1 Less potent at α compared to labetalol.

Cardioselective Metoprolol Β1 Less unopposed α due to lack of β2 antagonism

Esmolol Β1 Cardioselective

Schurr JW, Gitman B, Belchikov Y. Pharmacotherapy. 2014; 34(12)1269-1281. Stimulants - Cocaine

• Pulmonary disease: • Skin and soft tissue infections: – “crack lung” or lung thrombosis – cutaneous vasculitis from levimasole

Shah R, Patel A, Mousa O, Manocha D. QJM. 2015. Muirhead TT, Eide MJ. NEJM. 2011; 364:354. Source: www.qjmed.oxfordjournals.org/content/early/2015/04/13/qjmed.hcv064 Stimulants - Methamphetamine

• Routes of Administration: Oral, Injected, snorted, smoked • Street Names: Bennies, Black Beauties, Crank, Ice, Speed, Uppers

Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88. Stimulants - Methamphetamine

• Mechanism of Action: Noncatecholamine sympathomimetic amines promote release of dopamine and norepinephrine from presynaptic nerve terminals and block their reuptake by competitive inhibition

Karch S. Drug Abuse Handbook. Boca Raton, Fla.: CRC Press; 1998. Source: http://www.recovery.org/topics/methamphetamine-recovery/ Stimulants - Methamphetamine

• Drug-Drug or Drug-Disease Considerations – May exacerbate or precipitate movement disorders – Extensive tooth decay – Skin and soft tissue infections due to formication – Acute Coronary Syndrome – Endocarditis

Source: Powerpoint (Office 2010) [Computer Software]. Redmond, WA: Microsoft Stimulants – Dextromethorphan

• Routes of Administration: Oral • Street Names: Robo-tripping, Poor Man’s PCP, Dex, CCC, DXM, Skittles, Velvet, Robo

Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88. Source: Powerpoint (Office 2010) [Computer Software]. Redmond, WA: Microsoft Stimulants – Dextromethorphan

• Mechanism of Action: Dissociative anesthetic via nonselective serotonin reuptake inhibitors, sigma-1 receptor agonism, and NMDA receptor antagonism at high doses

Karch S. Drug Abuse Handbook. Boca Raton, Fla.: CRC Press; 1998. Source: Powerpoint (Office 2010) [Computer Software]. Redmond, WA: Microsoft Stimulants - Dextromethorphan

• Dextromethorphan Specific Effects: – 1st plateau: euphoria, auditory changes, change in perception of gravity – 2nd plateau: intense euphoria, vivid imagination, closed-eye hallucinations – 3rd/4th plateau: altered consciousness, out-of-body experiences, temporary psychosis

Karch S. Drug Abuse Handbook. Boca Raton, Fla.: CRC Press; 1998. Stimulants - Dextromethorphan

• Drug-Drug or Drug-Disease Considerations – Serotonin syndrome – Co-ingestant toxicity (antihistamines, alpha-1 adrenergic decongestants, or acetaminophen)

Karch S. Drug Abuse Handbook. Boca Raton, Fla.: CRC Press; 1998. Marijuana

• Routes of Administration: Oral, Inhaled • Street Names: Pot, Grass, Dope, MJ, Mary Jane, Doobie, Hooch, Weed, Hash, Reefers, Ganja, Dank

Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88. Source: www.pixabay.com/en/mortar-herbs-pistil-medicine-1031156/ Marijuana

• Mechanism of Action: Via cannabinoid receptor CB1 activation, THC causes release of acetylcholine, glutamate, GABA, NE, and dopamine

Karch S. Drug Abuse Handbook. Boca Raton, Fla.: CRC Press; 1998. Ashton CH. The British Journal of Pyschiatry. 2001; 178(2): 101-106. Marijuana

Physiologic Effects Neurologic Effects Tachycardia without effect on BP ↓ attention ↑ supraventricular and ventricular ↓ concentration ectopic activity ↓ testosterone in men ↓ short-term memory Corneal vasodilation ↓ anxiety Intraocular pressure reduction ↑ appetite Slurred speech Agitation Nystagmus Euphoria

Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88. Ashton CH. The British Journal of Pyschiatry. 2001; 178(2): 101-106 Marijuana

• Drug-Drug or Drug-Disease Considerations – Used for chronic severe pain, refractory nausea/vomiting, anorexia, cachexia, glaucoma, seizures – Pulmonary disease/cancer risk

Horn JR, Hansten PD. Pharmacy Times website. 2014. Ashton CH. The British Journal of Pyschiatry. 2001; 178(2): 101-106 Source: www.pixabay.com/en/seedling-cannabis-marijuana-1062908 Hallucinogens

• Ecstasy/MDMA, Synthetic cannabinoids, Ketamine, Lysergic acid diethylamide (LSD), Psilocybin

Physiologic Effects Neurologic Effects Pain relief ↓ tension Cough suppression ↓ anxiety Constipation ↓ aggression Miosis ↑ drowsiness Respiratory depression ↑ inability to concentrate Pruritis ↑ apathy

Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88. Hallucinogens – Ecstasy/MDMA

• Routes of Administration: Oral, snorted, injected • Street Names: Adam, Beans, Clarity, Disco Biscuit, E, Ecstasy, Eve, Go, Hug Drug, Lover’s Speed, MDMA, Peace, STP, X, XTC, Molly • Mechanism of Action: Indirect serotonin agonist (increases amount of serotonin released into the synapse), enhances release of dopamine, and may inhibit monoamine oxidase

Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88. Karch S. Drug Abuse Handbook. Boca Raton, Fla.: CRC Press; 1998. Source: Powerpoint (Office 2010) [Computer Software]. Redmond, WA: Microsoft Hallucinogens – Ecstasy/MDMA

• Ecstasy/MDMA Specific Effects – Both a stimulant and a psychedelic – Produces energizing effect and enhanced tactile experience enjoyment • Drug-Drug or Drug-Disease Considerations – Serotonin Syndrome – Hyperthermia – Hyponatremia

Karch S. Drug Abuse Handbook. Boca Raton, Fla.: CRC Press; 1998. Source: Powerpoint (Office 2010) [Computer Software]. Redmond, WA: Microsoft Drug Class Substance Examples Physiologic Effect Neurologic Effect

Pain relief Cough suppression ↓ tension, anxiety, aggression Miosis Narcotics Opioids ↑ drowsiness, apathy, inability to Respiratory depression concentrate Constipation Pruritis

Cocaine/Crack ↓ appetite Methamphetamines ↑ mental/physical performance, BP/HR, and ↑ self-esteem, wakefulness Dextromethorphan Stimulants insomnia Psychosis Synthetic cathinones Physical exhaustion Exhilaration (bath salts) Rhabdomyolysis Phencyclidine (PCP)

↓ testosterone in men ↓ attention, concentration, short ↑ supraventricular and ventricular ectopic term memory, and anxiety activity ↑ appetite Cannabinoids Marijuana Tachycardia without effect on BP Dysphoria Corneal vasodilation Agitation Slurred speech Euphoria Nystagmus Drug Class Substance Examples Physiologic Effect Neurologic Effect

MDMA (ecstasy) Synthetic cannabinoids Distortions of thought associated Ketamine ↑ HR/BP with time and space Hallucinogens Lysergic acid diethylamide Mydriasis Visual color changes (LSD) Flashbacks to time of abuse Psilocybin

↓ muscle spasms, BP, RR Slurred speech ↓ anxiety, reaction time, mental Loss of motor coordination function/judgement Barbiturates Weakness Sedative Depressants Gamma hydroxybutric Headache Seizure prophylaxis acid (GHB) Lightheadedness Amnesia Blurred vision Confusion Nausea/vomiting SIGNS AND SYMPTOMS OF AN OVERDOSE

What you can look for… Source: www.thesilverpen.com/inspired-living-celebrating-life/prescription-painkiller-overdose/ Opioid/Narcotics/Heroin

• Signs/Symptoms of an overdose: – Confusion – Convulsions – Unconsciousness – Slowed breathing – Cold, clammy skin – Extreme drowsiness – Constricted (pinpoint) pupils

Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88. Source: www. floridarecoverygroup.com/florida-suffering-from-a-surge-in-heroin-overdoses/ Stimulants

• Signs/Symptoms of an overdose: – Fever – Stroke – Seizures – Agitation – Convulsions – Cardiovascular collapse

Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88. Source: www.coub.com/view/37k1zrj Source: www.tvlistings.zap2it.com/tv/breaking-bad/EP01009396?aid=zap2it Marijuana/Cannabis

• Signs/Symptoms of an overdose: – No death from overdose has been reported

Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88. Source: www.hightimes.com/read/illinois-becomes-20th-state-legalize-medical-marijuana Source: www.blog.hrusa.com/blog/illinois-medical-cannabis-pilot-program/ Hallucinogens

• Signs/Symptoms of an overdose: – Coma – Seizures – Convulsions – Respiratory arrest – Respiratory depression • Overdose is rare – Death usually occurs from a suicide, accidents and dangerous behaviors

Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88. Source: www. drugs-forum.com/forum/showthread.php?t=115682 Narcan® (naloxone) Nasal Spray Evzio® (naloxone) Auto-injector OPIOID OVERDOSE TREATMENT KITS

Source: www.legacyfreedom.com/drug-overdose-statistics-facts/ Disclaimer!!!

• This presentation is NOT the same as the course offered by IPhA – Illinois State Opioid Antagonists Training Program • K. Gable, C. Herndon, J. Kerr and G. Reynolds • On-demand web-based program at IPhA.org • Benefits: – Gain certification, allowing for pharmacists to dispense naloxone without a prescription • First responders, school nurses, or any individual at risk of overdose • Requirements: – Licensed Illinois pharmacist – Complete certification course

– CPR certified IPhA.org. Program registration. 2016 Source: www.ipha.org/isoatp-registration Overdose Statistics

• National – Opioid and heroin overdose deaths • 2014 – 28,647 deaths – Quadrupled since 2000 • Illinois – Opioid and heroin overdose deaths • 2013 – 1579 • 2014 – 1705 – Percent increase: 8.3%* *statistically significant increased from 2013 to 2014

CDC. Drug overdose data. 2016. Antidote

• Naloxone – Antidote for opioid/heroin overdose – Competitive mu opioid receptor antagonist – Reverses all signs/symptoms of opioid intoxication – Parenteral, intranasal, pulmonary administration • No bioavailability after oral administration – Onset of action • < 2 minutes – Duration of action • 20 – 90 minutes

Boyer EW. NEJM. 2012;367:146-55. Thomas SA. US Pharm. 2015;40(3):HS2-HS6. Opioid Overdose Rescue Kits

• Evzio® (naloxone) Auto-injector – FDA approved in 2014 for opioid overdose reversal – Special training to use the device is not required – Automated • Once cap is removed, audible administration instructions are provided by the device – Rapidly delivers a single dose of naloxone (0.4mg) – Can be repeated if needed – Each prescription contained a training device – Injection site • Outer thigh muscle – Do not need to remove clothing Thomas SA. US Pharm. 2015;40(3):HS2-HS6. Source: www.evzio.com/hcp/ Opioid Overdose Rescue Kits

• Evzio® (naloxone) Auto-injector – Administration Trainer

Source: www.evzio.com/hcp/ Source: www.paindr.com/preventing-opioid-overdose-deaths-with-evzio-2/ Source: www..methadone.us/blog/evzio-for-reversal-of-opioid-overdose/ Opioid Overdose Rescue Kits

• Evzio® (naloxone) Auto-injector – Administration

PL Detail-Document. Pharmacist’s Letter/Prescriber’s Letter. 2016. Source: www.evzio.com/hcp/about-evzio/how-to-use-evzio.php Opioid Overdose Rescue Kits

• Narcan® (naloxone) Nasal Spray – FDA approved in 2015 for opioid overdose reversal – Special training to use the device is not required – Administer nasal spray in one nostril while patient is lying on their back – Rapidly delivers a single dose of naloxone (4mg) – Can be repeated if needed – No needle – Contains two blister packed, single-use nasal sprays – Narcan parenteral formulation is no longer available

Thomas SA. US Pharm. 2015;40(3):HS2-HS6. Source: www.narcannasalspray.com/ Opioid Overdose Rescue Kits

• Narcan® (naloxone) Nasal Spray – Administration

Source: www.nphotos.prnewswire.com/medias/switch.do PL Detail-Document. Pharmacist’s Letter/Prescriber’s Letter. 2016. Posttest Question #1

• Which of the following is true regarding the AHA/ACC 2014 statement on the use of cocaine and beta-blocker usage in patients presenting with non-ST-segment elevation acute coronary syndromes? A. ACS in patients with cocaine use should be treated in the same matter as patients without cocaine use unless there is presence of acute cocaine intoxication B. Beta-blockers use cannot be recommended due to the potential to provoke or exacerbate coronary vasospasm C. ACS in patients with acute cocaine intoxication should be treated with beta-blockers D. None of the above Posttest Question #2

A. Heat Stroke B. Serotonin Syndrome C. Neuroleptic Malignant Syndrome D. Meningitis Pretest Question #3

• Which is a sign/symptom of an overdose with opioids, stimulants and hallucinogens?

A. Fever B. Miosis C. Agitation D. Convulsions Pretest Question #4

• Which statement below does not accurately represent Evzio® (naloxone) auto-injector?

• National Institute on Drug Abuse (NIH). Trends & Statistics. Available at: https://www.drugabuse.gov/related-topics/trends-statistics. Accessed June 28, 2016. • Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Retrieved from http://www.samhsa.gov/ data/. Accessed June 28, 2016. • National Institute on Drug Abuse (NIH). Drug Facts: Nationwide Trends. Available at: https://www.drugabuse.gov/publications/drugfacts/nationwide-trends. Accessed June 28, 2016. • Substance Abuse and Mental Health Services Administration (SAMHSA). Reports by geography. Available at: http://www.samhsa.gov/data/reports-by-geography?tid=632&map=1. Accessed June 28, 2016. • Drugs Of Abuse 2015 Edition. 1st ed. Drug Enforcement Administration; 2015:1-88. Available at: http://www.dea.gov/pr/multimedialibrary/publications/drug_of_abuse.pdf. Accessed January 13, 2016. • Karch S. Drug Abuse Handbook. Boca Raton, Fla.: CRC Press; 1998. • Lange RA, Cigarroa RG, Flores ED, et al. Potentiation of cocaine-induced coronary vasoconstriction by beta- adrenergic blockade. Ann Intern Med. 1990; 112:897-903. • Schurr JW, Gitman B, Belchikov Y. Controversial therapeutics: the β-adrenergic antagonist and cocaine- associated cardiovascular complications dilemma. Pharmacotherapy. 2014; 34(12)1269-1281. References

• McCord J, Jneid H, Hollander JE, et al. Management of cocaine-associated chest pain and myocardial infarction. Circulation. 2008; 117:1987-1907. • Amsterdam EA, et al. 2014 ACA/AHA guideline for the management of patients with non-ST-elevation acute coronary syndromes. JACC. 2014; 64(24):2645-2687. • Shah R, Patel A, Mousa O, Manocha D. Crack lung: cocaine induced lung injury. QJM. 2015. , hcv064; DOI: 10.1093/qjmed/hcv064 • Muirhead TT, Eide MJ. Toxic effects of levamisole in a cocaine user. NEJM. 2011; 364:354. • Ashton CH. Pharmacology and effects of cannabic: a brief review. The British Journal of Psychiatry. 2001; 178(2): 101-106. • Horn JR, Hansten PD. Drug interactions with marijuana. Pharmacy & Healthcare Communications, LLC. Pharmacy Times website. 2014. Available at: http://www.pharmacytimes.com/publications/issue/2014/December2014/Drug-Interactions-with- Marijuana. Accessed June 26, 2016. • CDC. Injury prevention & control: opioid overdose. Available at: http://www.cdc.gov/drugoverdose/data/statedeaths.html. Accessed June 28, 2016. • Boyer EW. Management of opioid analgesic overdose. NEJM. 2012;367:146-55. • Thomas SA. Opioid overdose rescue kits. US Pharm. 2015;40(3):HS2-HS6. • PL Detail-Document, Naloxone for opioid overdose: FAQ. Pharmacist’s Letter/Prescriber’s Letter. January 2016. From the Street to the Pharmacy: Illicit Drugs and Reversal Agents