Emergency Management of Drug Abuse in South Africa Drug Abuse Remains Both a Global Scourge and a Significant Social and Medical Problem in South Africa
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Emergency management of drug abuse in South Africa Drug abuse remains both a global scourge and a significant social and medical problem in South Africa. Charl J van Loggerenberg, MB BCh, FCEM (SA), MBA, Dip PEC (SA), Dip BM (DMS) Regional Medical Director, International SOS Charl van Loggerenberg is currently involved in medical management for the world’s largest medical assistance and security services company – managing global medical evacuations and assistance, delivering remote-site medical services and consulting in Africa and further afield. He has previously been extensively involved in aviation medicine, management of flight services, and EMS and pre-hospital training. He is a part-time consultant in emergency medicine at the Wits Emergency Medicine Department, ATLS Director, occasional media spokesman, travel fanatic (will have covered the globe before retirement) and family man. Correspondence to: Charl van Loggerenberg ([email protected]) Primary practice and emergency department adults of 2%, cocaine/crack (0.3%), Mand- • phenethylamine based – such as bromo- practitioners have the dual responsibility of rax or sedatives (0.3%), club drugs or am- dragonfly managing the acute medical complications phetamine-type stimulants (0.2%), opiates • methoxyketamine associated with illicit drug abuse and manag- (0.1%) and hallucinogens (0.1%). • piperazine based – such as trifluoro- ing the day-to-day problems associated with methylphenylpiperazine such abuse. The primary substances of abuse at • an entactogen such as 3,4-methylene- admission to South African drug treatment dioxy-N-methylcathinone Because many drugs of abuse are illegal, centres over the same period was cannabis • stimulants such as methadrone and also there are little accurate data on drug use in (16.9%), methamphetamine (tik) (12.8%), methylenedioxypyrovalerone South Africa. The simplest classification of crack cocaine (9.6%), cannabis and • sedatives such as gamma-butyrolactone, these drugs is into ‘uppers’ (such as cocaine Mandrax (3.4%), heroin/opiates (9.2%), both a precursor to and substitute for and methamphetamine), those taken for and prescription and OTC drugs (2.6%). GHB. sedation or narcosis, i.e. the ‘downers’ There has been an increase in admissions (besides alcohol, the opioid group including for the treatment of substance abuse. This review presents a system-based heroin) and the hallucinogens, i.e. the While the prevalence of illicit drug use in approach (as elucidated by Devlin and ‘round and rounders’ (such as lysergic acid South Africa is relatively low compared Henry3) highlighting suggestive histories diethylamide or LSD). This article does not with the USA (20% of American youths and certain acute system signs or deal with alcohol abuse. aged 16 - 23 having ever used one or more complications. club drugs) and Australia, the problem is Drugs are abused for their complex ef- steadily increasing.2 Clinical presentations and fects on mood, perceived enhancement of management pleasurable sensations, and physiological Respiratory complications3 endurance. These include 3,4 methylenedi- Because many drugs of Crack cocaine is the drug most commonly oxymethamphetamine (MDMA or ecstasy), associated with respiratory complications gamma-hydroxybutyrate (GHB) and keta- abuse are illegal, there that require hospital admission. Smoking mine. The US National Institute on Drug is little accurate data this drug can lead to severe thermal injury Abuse (NIDA) in its Community Alert on on drug use in South of the pharynx and airways. However, Club Drugs, defined ‘club drugs’ as ecstasy, cough, haemoptysis, pneumothorax, gamma-hydroxybutyrate (GHB), ketamine, Africa. pneumomediastinum, pneumopericardium flunitrazepam (Rohypnol), methampheta- and haemothorax are the main acute mine, and lysergic acid diethylamide (LSD).1 complications of inhaling crack cocaine Emergency present- ations are often compli- Designer drugs vapour and should be considered whenever cated by the fact that the drug is mixed with This remains a truly complex arena present without an obvious history of trauma. inert bulking agents (such as flour or chalk), – a multitude of illegally synthesised For enhanced absorption and effect, users toxic industrial agents and other drugs. compounds, often analogous to existing commonly inhale deeply and then perform Drug concentrations also vary widely. drugs, manufactured in efforts to find new a Valsalva manoeuvre. The rise in intra- markets, and to circumvent various countries’ alveolar pressure, in addition to barotrauma National surveys of cannabis use between drug laws. Some examples include: caused by vigorous coughing, can cause both 2000 and 2005 showed rates of use among • alpha methylfentanyl – or ‘china white’ alveolar rupture and air dissection in the adolescents from 2% to 9% and among on the heroin market peribronchiolar connective tissue. Cocaine 409 CME Nov/Dec 2012 Vol. 30 No. 11 Drug abuse and cannabis smoking as well as intravenous Respiratory depression caused by morphine alpha-adrenergic stimulation. Given methylphenidate abuse have been associated or heroin overdose is usually recognised the difficulty in definitively diagnosing with severe bullous emphysema, one by most clinicians. Management is cocaine-induced MI, thrombolysis is complication of which is pneumothorax. straightforward. Ensure a patent airway rarely used. The infarction is often due to Management of these complications follows and administer oxygen followed by coronary spasm rather than thrombosis conventional lines.4 naloxone (remembering its short half- and is associated with very low mortality.3,5 life) and continued respiratory support if necessary. Respiratory depression and Cocaine has also been associated with Cocaine is the most hypostatic pneumonia may occur in hypotension, cardiac arrhythmias and gamma GHB intoxication, for which there sudden death if taken in large quantities.6 common cause of is no effective antidote, so these patients Other substances associated with cardiac chest pain in young may require intubation and mechanical arrhythmias and sudden death include adults presenting ventilation.3 MDMA or ecstasy and amphetamines, thought to be linked to sympathetic to emergency Cardiovascular complications hyperstimulation. In many young victims departments. Cocaine is the most common cause of of sudden death, it is possible that death chest pain in young adults presenting to may be due to undiagnosed conduction emergency departments. In the USA it is defects precipitated by drug abuse. The main subacute pulmonary complica- the cause of 25% of myocardial infarctions MDMA can prolong the QT interval tions of cocaine use include pulmonary (MIs) in people under 45 years of age.5 while methadone, often sold on the illicit oedema, 'crack lung', interstitial pneumonitis Cocaine also promotes platelet aggregation market, or used in heroin rehabilitation and bronchiolitis obliterans with organising and thrombus formation, accelerates programmes, can cause long QT syndrome pneumonia. Cocaine-associated pulmonary atherosclerosis and produces left ventricular and torsades de pointes.3,7,8 oedema may not be recognised immediately hypertrophy.3 Widespread vasoconstriction in young patients. Treatment with diuretics, (coronary and peripheral) causes nitrates and oxygen followed by mechanical increased myocardial oxygen demand, The risk of immediate ventilation, if necessary, usually produces rapid and the sympathomimetic activity causes improvement. If the presentation is asthmatic, tachycardia and hypertension. Myocardial death is 18 - 25 times consider cocaine or heroin inhalation. ischaemia and infarction may occur in 6% greater for cocaine co- of cases. Always consider cocaine use in a ingested with alcohol young otherwise healthy patient presenting with an acute coronary syndrome. than for cocaine alone. Electrocardiogram (ECG) interpretation might be challenging.3 Neurological complications Management remains according to Illicit drug use (especially GHB and standard ACLS principles, with oxygen, opioids, often in combination with aspirin (unless at risk of subarachnoid benzodiazepines or alcohol) can cause haemorrhage), benzodiazepines and coma. Also consider the inhalation sublingual nitrates. The debate of of volatile substances in unconscious proactive co-administration of sublingual patients. Respiratory depression, nitrates and benzodiazepines remains aspiration, rhabdomyolysis and other active. The clinical reality is that these complications may follow, depending on patients remain prone to seizures due the depth and duration of central nervous to their cocaine usage, which provides system depression. Management is a rationale for the prophylactic use of supportive. Naloxone may be used if opioid benzodiazepines. Most clinicians would toxicity is apparent or suspected. Because agree that benzodiazepines should be of the risk of provoking convulsions, considered for all patients with cocaine- flumazenil is not recommended for induced chest pain who are anxious, reversal of benzodiazepine toxicity, tachycardic or hypertensive. In contrast, and physostigmine does not have a a clear consensus exists against the use of recommended role in reversing GHB beta-blockers, which potentiate cocaine- toxicity. Ketamine toxicity rarely causes induced chest pain via unopposed coma, and the ED doctor usually sees 410 CME Nov/Dec 2012 Vol. 30 No. 11 Drug abuse Table 1. Common toxidromes in illicit drug use Toxidrome Features Drugs implicated