Objectives Recognizing Persons

Under the Influence  Define the term “drug”  Define the term “impairment” “People on Drugs”  Name the seven categories of drugs  Identify common methods of drug administration  Describe the symptoms, observable signs, and other effects for each drug category as it applies to EMS Alan M. Bell, EMT-P  Explain the “polydrug” effect as it applies to Drug Recognition Expert EMS  Drugs vs. Medical Conditions

1 What is a drug? Impairment

Any substance that, when taken into When the effects of a drug, or a the human body, alters the effects of combination of drugs, visibly alters a body system normal functioning of the body to – Thousands of variations perform a function or task. – Widely different interpretations – Many non-traditional substances used illicitly which may or may not be considered a drug

Law Enforcement Definition of Workplace Definition of Drug Drug

Any substance, which when taken into the Any substance, which when taken into the human body can impair the ability of the of human body can impair the ability of a the person to perform their job both safely person to operate a vehicle safely and efficiently

2 EMS Definition of Drug Impairing Drug Categories

• You tell me • Broken down into seven categories: – CNS Depressants – CNS – – Anesthetics – Narcotic Analgesics – Inhalants – Marijuana

CNS Depressants CNS Depressants

Barbiturates Sedate the function of the CNS Non-Barbiturates – Tranquilizers Anti-Anxiety Tranquilizers Taken orally or injected Anti-Depressants Onset and duration are varied, Anti-Psychotic Tranquilizers depending on the drug Many are abused prescription medications

3 Common Depressants Alcohol is a CNS Depressant

• Non- • Most common used and abused • Barbiturates barbiturates – Seconal • We run into this at all different stages – Nembutal – Noctec or – Tuinal Felsule – Amytal – Doriden • Anti-anxiety – Noludar – Valium – Quaalude – Librium – Placidyl – Xanax – Equanil or – Serax Miltown – Soma

Alcohol CNS Depressant Effects Effects of Intoxication • Smell • Depressed • Reduced • Lack of • Slurred Speech internal clock inhibitions coordination • Uncoordinated • Inability to • Divided attention • Slurred mumbled • Unsteady Gait concentrate impairment or incoherent • Glassy gaze • Emotion • Slowed reflexes speech amplification • Droopy eyes • Impaired • Emotional instability • Watery, judgment and reddened eyes concentration • Impaired vision

4 Central Nervous System Stimulants Stimulants  Enhance the body’s “fight or flight” Methamphetamine chemical response • Ice, crank Speed metabolism, alertness Ephedrine Heightens sensory response Caffeine Suppresses appetite Creates a euphoric effect Decreases pain response

Effects of Cocaine Influence of CNS Stimulants

Onset is almost immediate Effects can last hours • Anxiety • Eyelid and Leg tremors Inability to concentrate • Body tremors • Irritability Decreased perception of time, • Bruxism • Redness to nasal area distance • Dry mouth • Restlessness • Running nose Restless, overtalkative • Euphoria • Exaggerated • Talkative reflexes

5 Hallucinogens Indicators of Causes a distortion of reality Impairment – Illusions  Dazed appearance – Delusions  Body tremors – Synesthesia  Perspiring Many naturally occurring agents  Paranoia – Peyote  Disoriented – Psilocybin  Nausea A chemical, LSD  Difficulty with speech  Piloerection A chemical, MDMA  Statements suggesting hallucinations

Dissociative Anesthetics PCP

Drugs that inhibit pain by cutting Phencyclidine off or dissociating the brain’s Patented in the 50’s as an IV perception of pain anesthetic and in treatment of Induce a state of sedation, psychological disorders immobility, amnesia and Discontinued in 1967 due to analgesia undesirable side effects

6 Indicators of Dissociative Dextromethorphan Anesthetic Impairment A drug used in OTC cough  Blank stare medicines that inhibits the cough  Loss of memory  Perspiring heavily reflex in the brain  Warm to touch In high doses (the whole bottle) it  Incomplete, slurred verbal responses produces effects similar to PCP  Cyclic behavior  Agitated  Rigid muscle tone  Disoriented  Non-responsive  Chemical odor

Narcotic Analgesics Indicators of Narcotic Analgesic Impairment Refers to any natural or synthetic derivative of the opium poppy  “Track marks”  “On the nod” Painkillers (analgesics)  Slowed reflexes Rx drugs widely used  Low, slow, raspy speech Morphine, Codeine, Demerol,etc.  Facial itching  Dry mouth Rx drugs widely abused  Euphoria Heroin the most common illicit  visibly and obviously narcotic constricted  Flaccid or normal muscle tone

7 Inhalants Indicators of Inhalant Impairment

Typically, powerful solvents that Odor of the inhaled substance create a short duration dissociative Dizziness, numbness effect Possible traces of the substance around – Buzz, head rush the face and nose Bloodshot, watery eyes Anesthetic gasses (NO ) 2 Distorted perception of time and distance – “Whipits” Confused, disoriented appearance Glues, spray paint

More Indicators of Inhalant Cannabis Impairment • Marijuana Light headedness Flushed face, possible sweating • Hashish Intense headaches • Hashish Oil Slow, thick, slurred speech Nausea Non communicative Floating sensation

8 Marijuana Marijuana Effects

 Active Ingredient: THC • Body tremors • Increased appetite – Tetrahydracannabinol • Disoriented • Marked reddening  How Administered: • Debris in mouth of conjunctiva – Smoked (possible) • Odor of marijuana – Can be ingested • Eyelid tremors • Possible paranoia  Onset • Impaired • Relaxed – If smoked, immediate onset of effects which perception of inhibitions last 1-3 hours… If ingested, onset of effects within 1 hour and lasts up to 12 to 24 hours time and distance

The Problem The Studies

 Estimates vary widely, however we do Over 90% of alcohol abusers and know that: 74% of drug users are employed . Marijuana is the most used illegal drug with about 14.6 million users . In 2004, 19.1 million Americans CDC An average of 15 to 17% of aged 12 years or older were current illicit drug users CDC employees in every US company are A 2009, Center for Disease Control showed substance abusers More than one-third (36.8 percent) had ever smoked marijuana, including 20.8 percent • US Department of Labor statistics in the past month. – Approximately 6 million people were users of psychotherapeutic drugs taken non- medically

9 More Studies Recognizing Impairment

• 2009 National Youth Risk Behavior Survey A multi-sensory perception task – One high school student in five has taken a – The “look test” prescription drug without a doctor's order – Smells • Unintentional overdose deaths involving – Alertness levels, attentiveness prescription increased 114 percent – Changes in behavior from 2001 (3,994) to 2005 (8,541)Center for – Changes in patterns Disease Control • Absenteeism, tardiness • Chronic illnesses, issues

Divided Attention How Cops do it….

 The ability for a person to perform two or more tasks simultaneously  The ability to follow a series of directions  The ability to question direction prior to performance Almost all substance impairment has an effect on divided attention

10 How Cops do it… Roadside Standardization

 For decades, officers had various informal NHTSA standardized the DWI Field tests in their battery: Sobriety testing. – Alphabet recital Tasks were given scientific – Finger to nose justification, and unified probability – Walk and Turn – Finger Count Three tasks, one physiologic and – Time estimation (Romberg Test) two divided attention, are standard – Eye Tests (Horizontal Gaze Nystagmus) nationwide – Their observations & experience

Our Divided Attention Tasks Our Divided Attention Tasks

The “walk and turn” The “one leg stand” – 9 heel-to-toe steps out and back in a – Keep a foot elevated for 30 seconds straight line – 6” off the ground – A specifically prescribed turn – Can’t put it down – Arms not to be used for balancing – Don’t use arms to balance

11 The Physiologic Divided Attention Tests

One Leg Stand: Horizontal gaze nystagmus Right Left Balance Eyes Closed Draw lines to spots touched – The involuntary jerking of the eyes due 2 1 L R to sedation 4 3 Sways while balancing. Uses arms to balance. Hopping. 5 6 Internal Clock: Puts foot down. – Check for smooth tracking ______Estimated as 30 sec. Type of Footwear – Angle of onset Cannot keep balance______Walk And Turn Test Starts too soon ______– Nystagmus at maximum deviation 1st Nine 2nd Nine Stops Walking Misses Heel-Toe Steps Off Line Raises Arms Actual Steps Taken Describe Turn Cannot Do Test (explain)

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HGN Walk and Turn

http://www.youtube.com/watch?v=9fQ2Zaiay2U&feature=related

12 One Leg Stand The eyes never lie…

Eye and pupillary response is involuntary, and a great indicator – HGN for alcohol, Dissociative Anesthetics, and many inhalants – Marked Dilation for stimulants, cannabis, and hallucinogens – Pinpoint constriction for narcotics

Other Tests We Use Putting It All Together

Depressant Hallucinogen Dissociative Narcotic Inhalant Cannabis Romberg Test Anesthetic Analgesic Horizontal Present None None Present None Present None Finger to Nose Nystagmus Vertical Present None None Present None Present None Pulse Rate Nystagmus Lack of Present None None Present None Present Present Blood Pressure Convergence Body Temperature Size Normal Dilated Dilated Normal Constricted Normal Dilated Pupil Slow Slow Normal Normal Little or Slow Normal Muscle Tone Reaction None Pulse Rate Down Up Up Up Down Up Up

Blood Down Up Up Up Down Up/Down Up Pressure

Body Temp. Normal Up Up Up Down Any Normal

13 Driving While Intoxicated Observations SUSPECT’S BREATH PHYSICAL ACTIONS ____Odor of alcohol ____Facial itching ____Chemical odor ATTITUDE ____Dry mouth Driving a car is the most common ____Cannabis odor ____Anxious ____Nodding ____Restless ____Droopy eyelids OBSERVATION OF FACE divided attention task ____Agitated ____Low, raspy voice ____Normal ____Flushed ____Excited ____Body tremors ____Other (describe) ____Pale ____Combative ____Muscle tone - rigid .08% BAC is the recognized level of ____Disinterested ____Muscle tone - flaccid GENERAL APPEARANCE ____Uninhibited impairment for driving ____Disoriented ____Muscle tone - normal ____Clean ____Orderly ____Drowsy ____Grinding of teeth ____Disarranged ____Bloody ____Confused OTHER There is no lab results with drugs ____Vomit____Urine ____Hallucinating ____Nasal redness ____Loss of memory ____Runny nose that show impairment EYES ____Cyclic mood swings ____Normal ____Watery ____Track marks ____Polite ____Perspiring ____Bloodshot ____Pink/Red ____Antagonistic ____Warm to touch ____Stuporous ____Intense headaches SPEECH ____Cooperative/indifferent ____Residue of paint on person ____Talkative ____Thick, slurred ____Laughing ____Debris ____Incoherent ____Rapid ____Insulting ____Pills ____Slow ____Repetitive ____Argumentative ____Vials ____Fumbling ____Non-communicative ____Syringes ____Drug paraphernalia II-1

EMS CASE REVIEW WHAT MIGHT TRICK US • Hypoglycemia • Hypoxia • Stroke Discussion and Questions • Traumatic Head Injuries • Hypo/Hyperthermia • Seizure Disorders

14 My Contact Information

Detective Alan Bell, EMT-P, MPA Niskayuna Police Department One Niskayuna Circle Niskayuna, New York 12309 (518) 374-3159 [email protected]

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