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g h h n o e e e e e e y y y y y y s s s s t t r f l l , SUBSTANCE MISUSE FACT SHEETS CATEGORY II – SPECIALITIES & SETTINGS: DRUG MISUSE IN THE EMERGENCY DEPARTMENT

Depressants Attaining intravenous access may be difficult in intravenous l Opiates: Heroin or prescription opiates including drug users, due to venous damage from repeated puncture and morphine, fentanyl, methadone, oxycodone, codeine, injection. Naloxone may also be administered intramuscularly, dihydrocodeine and others although absorption is highly variable via this route, making it difficult to titrate to response. l Benzodiazepines: diazepam, temazepam, lorazepam, alprazolam and others The half-life of naloxone is approximately 1.5hrs. This is shorter than the half-life of most available opiates, thus there is a risk of l Gamma Hydroxybutyrate (GHB)/ Gamma butyrolactone relapse opiate toxicity. Patients who require naloxone (GBL)/ 1,4 butanediol (1,4BD) administration should be observed and patients who require 1. Opiates repeated doses of naloxone, may require a naloxone infusion. Opiates act on opiate receptors in the brain providing an 2. Benzodiazepines analgesic effect. Individuals may experience euphoric effects Benzodiazepines are sedative hypnotics that act on GABA due to dopamine release in the mesolimbic area of the brain. receptors in the brain. A variety of opiates (such as codeine, morphine, oxycodone, fentanyl) are used in medical practice due to their potent Common symptoms of acute toxicity include drowsiness, ataxia, analgesic effects (British National Formulary 2014). As a result of slurred speech, and reduced consciousness. Symptoms may be the euphoric and addictive properties of these medications they potentiated by the co-ingestion of alcohol or other CNS may be prone to misuse. Non-prescription opiate misuse depressants. Severe toxicity may result in hypotension and includes the use of heroin, which may be smoked or injected. bradycardia. Individuals may also ingest the long acting opiate methadone, Patients who have ingested supra-therapeutic doses of which is prescribed to counteract the severe withdrawal benzodiazepines, who present within one hour of ingestion symptoms that may be experienced by chronic heroin users. should be considered for administration of activated charcoal Excess opiate exposure may occur via oral ingestion, inhalation, (European Association of Poisons Centres and Clinical intravenous / intramuscular administration and trans-dermal Toxicologists Position Statement). routes (opiate patches). Emergency Department care focuses on supportive care with Targeted health initiatives and educational campaigns resulted close monitoring of respiratory rate, oxygenation, blood in the introduction of methadone prescribing and needle pressure and level of consciousness (Glasgow Coma Score). The exchange programmes, with the aim of reducing crime and majority of patients do not require any treatment. blood bourne virus (BBV) transmission associated with heroin Co-ingestion of alcohol or other CNS depressants may result in use and also to reduce the numbers of new users. It appears that vomiting or significant respiratory depression. Reduced GCS investment in these schemes, in combination with criminal may inhibit the patient’s ability to adequately protect justice effects on supply reduction, have been successful in themselves from aspiration. Consequently, intubation and reducing the number of new intravenous opiate and crack ventilation may be required. cocaine drug users. Data collected by the National Treatment Agency for Substance Misuse shows a significant reduction in Antidote the number of young people (18-24 years) seeking help for crack Flumazenil is benzodiazepine antagonist. Its use is generally cocaine and heroin addiction in 2011/12 when compared to confined to iatrogenic benzodiazepine overdose. Its use in pre- 2005/6 (NTA 2013). hospital overdose is not advised unless under the expert advice ED attendance following opiate misuse, most frequently occurs of the National Poisons Unit. Flumazenil administration in mixed as a result of acute toxicity (respiratory depression, coma and overdose may reduce the seizure threshold and result in collapse) but may also occur due to the physical consequences difficulty in controlling seizures should they occur. of intravenous use of heroin, including deep vein thrombosis, 3. Gamma Hydroxy-butyrate (GHB), Gamma Butyrolactone (BBV) related illness, accidental arterial puncture, or more rarely, (GBL), 1,4 Butanediol (1,4BD) as a result of a withdrawal syndrome. GHB and its analogues GBL and 1,4BD are ingested orally as a Failure to recognise and treat severe opiate toxicity may result liquid and act on GHB and GABA (B) receptors in the brain. There in respiratory arrest and subsequent death. is a significant risk of overdose due to the extremely low doses Antidote required for the intended effects, which include euphoria and relaxation. The difference in dose between intended effect and Naloxone is an opioid receptor antagonist that competitively acute overdose, resulting in collapse, respiratory depression and binds to opioid receptors in the brain. Indications for naloxone possible respiratory arrest, may be as little as 0.5mls. The risk of administration include respiratory depression, resulting in toxicity is increased if co-ingested with alcohol and other CNS respiratory acidosis on blood gas analysis, and/or hypotension, depressants. Severe toxicity may result in coma, respiratory in the context of suspected opiate ingestion. Naloxone should arrest, seizures or death if supportive care is not initiated be titrated to response as it may precipitate acute withdrawal promptly. Bradycardia and miosis are also common signs. in opiate dependent patients. Ideally, naloxone should be administered intravenously to facilitate accurate titration.

2 SUBSTANCE MISUSE FACT SHEETS CATEGORY II – SPECIALITIES & SETTINGS: DRUG MISUSE IN THE EMERGENCY DEPARTMENT

Antidote and psychosis. In severe cases, patients may require high doses No antidote exists. Supportive care is the mainstay of Emergency of benzodiazepines and/or intubation and ventilation to Department care in acute toxicity. In the majority of cases, manage withdrawal syndromes. patients may be monitored in the Resuscitation room and will wake up within 2hrs. In a minority, respiratory depression or Vignette One vomiting will require intubation and ventilation until the effects An unknown male, approximate age 20 is brought to the of the drug have worn off. Emergency Department. He has been found collapsed in a park. Aside from the risks of acute toxicity, users may develop physical On arrival in the ED, he is unresponsive to painful stimuli. His dependence with regular use. This may result in repeated dosing respiratory rate is 6 breaths per minute with oxygen saturations at 1-2hrly intervals, including waking overnight. Withdrawal of 92% on 15L/min of supplemental oxygen. His heart rate is symptoms include agitation, anxiety, tremor, seizures, and 64bpm and his blood pressure is 96/50mmHg. marked neuropsychiatric symptoms including hallucinations

Is the airway clear? Administer high flow oxygen as required. Consider added noises: Airway - snoring suggests partial airway obstruction. This may occur due to reduced conscious level. Always A (& Cervical consider alternative causes of reduced GCS (e.g. hypoglycaemia, head injury, sepsis). spine) - gurgling may occur due to blood from facial trauma or vomit. Patients with reduced GCS may require airway support. Patients with evidence of a head injury and reduced GCS should be assumed to have a cervical spine injury and appropriate immobilisation applied. What are the respiratory rate and oxygen saturations? Is there equal air entry bilaterally? Are there any added sounds in the lung fields? Patients who have vomited are at risk of aspiration. B Breathing Chest trauma may occur following collapse / falls. Look for bruising or deformity, reduced air entry or asymmetrical chest wall movement. Ingestion of depressants may result in reduced respiratory rate, low oxygen levels and hypoventilation leading to respiratory acidosis – these patients will require supported ventilation. Consider naloxone administration in suspected opiate overdose. What is the pulse rate and blood pressure? Depressant ingestion may result in hypotension but consider other causes including trauma and sepsis. Circulation Consider occult injury in patients who are acutely intoxicated. Falls may result in chest/abdominal/ pelvic C injuries or fractures. Patients may not always report pain. Patients with tachy/bradyarrhythmia will require a 12 lead ECG and cardiac monitoring. Treat as per ALS (Advanced Life Support) algorithms. Is the patient alert? (AVPU /Glasgow Coma Score (GCS) (alert, voice, pain, unresponsive) Pupil examination: Size, symmetry, reactivity – pinpoint pupils are suggestive of opiates but may also D Disability be seen with GHB/GBL. Does the patient have external evidence of a head injury? Patient with reduced GCS and evidence of head injury will require CT brain to exclude intracranial bleed as a cause for reduced GCS. Check the patient for other injuries. E Exposure Look for “track marks” evidence of multiple venous punctures. Temperature – risk of hypothermia following depressant ingestion. G Glucose Blood glucose – check as alternative cause of reduced GCS. Stimulants hallucinations or delusions, psychosis. Examination may identify – Amphetamines, ecstasy (MDMA), cocaine, mephedrone, tachycardia, hypertension, hyperpyrexia (increased benzylpiperazine, novel psychoactive substances such as temperature), neuromuscular excitability (bruxism [jaw- 4-MA & MPA grinding], clonus, increased tone), dilated pupils, seizures and altered GCS. Symptoms following stimulant use may include anxiety, palpitations, chest pain, sweating, disorientation, agitation,

3 SUBSTANCE MISUSE FACT SHEETS CATEGORY II – SPECIALITIES & SETTINGS: DRUG MISUSE IN THE EMERGENCY DEPARTMENT

Management hyperactivity with increased tone. Rhabdomyolysis may occur There is no antidote to stimulant toxicity. Supportive care should due to muscle hyperactivity. be initiated utilising an ABC approach. Ensure airway is clear and the patient has a normal respiratory rate and pattern. Patients Vignette 2 – Stimulant Use may have significant tachycardia and hypertension. Perform a A 20 year old female student (Amy) is brought to the Emergency 12 lead ECG. The first line treatment of tachycardia and Department from a local nightclub following a collapse. Amy’s hypertension is benzodiazepines, either orally or intravenous. friend (Sarah) has accompanied her to the hospital and states Benzodiazepines may also help with agitation. Patients may that she had bought what they had been told was a legal high report chest pain following stimulant use and benzodiazepines from a friend. She cannot remember the name. Sarah tells you are the first line treatment. Chest pain may occur for a variety of that they have both been drinking vodka and red bull, prior to reasons including coronary artery spasm, acute myocardial taking the tablet, approximately 1hr ago. Sarah said that she infarction and aortic dissection. Patients who insufflate (snort) feels fine, but Amy had become quite anxious after taking the stimulants may develop pneumothoraces from increased intra- tablet, complained of palpitations and chest pain, before thoracic pressures following vasalva manoeuvre. Patients who collapsing in the toilet. complain of chest pain should have a 12 lead ECG (serial ECG if On arrival, Amy is unresponsive to voice. Observations: pain continues) and a chest x-ray. Patients should have their Respiratory rate 20/minute, Oxygen Saturation 100% on temperature monitored and may require active cooling if 15L/min, pulse - 156 beats per minute, Blood pressure 160/100 temperature rises above 38 degrees. Patients are at risk of mmHg. Her temperature is 39.8°C. She is quickly transferred to developing serotonin syndrome, a triad of autonomic instability, the resuscitation room. including hyperpyrexia, tachycardia and neuromuscular

Is the airway clear? Administer high flow oxygen as required. Consider added noises: - snoring suggests partial airway obstruction. This may occur due to reduced conscious level. Always Airway consider alternative causes of reduced GCS (e.g. hypoglycaemia, head injury, sepsis). (& Cervical - Patients who have used stimulants may have seizures. This may occur due to hyponatraemia, cerebral A spine) oedema or intracranial bleeds secondary to rapid increases in blood pressure. - gurgling may occur due to blood from facial trauma or vomit. Patients with reduced GCS may require airway support. Patients with evidence of a head injury and reduced GCS should be assumed to have a cervical spine injury and have appropriate immobilisation applied. What are the respiratory rate and oxygen saturations? Is there equal air entry bilaterally? Are there any added sounds in the lung fields? Breathing B Patients who have vomited are at risk of aspiration. Chest trauma may occur following collapse / falls. Look for bruising or deformity, reduced air entry or asymmetrical chest wall movement. What is the pulse rate and blood pressure? Stimulant ingestion may cause marked tachycardia and hypertension. Circulation C 12 lead ECG should be performed and cardiac monitoring applied. First line treatment for tachycardia and hypertension is benzodiazepines. Is the patient alert? (AVPU/Glasgow Coma Score (GCS)) Reduced GCS following suspected stimulant use will normally result in CT brain being performed to exclude intracranial bleed or determine evidence of cerebral oedema. Pupil examination: Size, symmetry, reactivity - Dilated pupils are often present following stimulant use. Disability D Does the patient have external evidence of a head injury? Is the patient moving all 4 limbs equally? Assess tone and check for clonus. Patients may exhibit increased tone and clonus. If present, patients may be at risk of rhabdomyolysis - check serum creatine kinase, renal function and monitor urine output. Check patient for other injuries E Exposure Temperature: risk of hyperthermia. Patients with temperatures above 39 degrees should be actively cooled. Advice should be sought from National Poisons Information Service. G Glucose Blood glucose checked as alternative cause of reduced GCS. 4 SUBSTANCE MISUSE FACT SHEETS CATEGORY II – SPECIALITIES & SETTINGS: DRUG MISUSE IN THE EMERGENCY DEPARTMENT

Toxicological sample testing 4.0 References and useful resources Toxicological testing is of limited use in the Emergency Advisory Council on the Misuse of Drugs (2011). Consideration of the Novel Department. The majority of patients attending the Emergency Psychoactive Substances (‘Legal Highs’) https://www.gov.uk/government/publications/novel-psychoactive- Department may be managed symptomatically, with supportive substances-report-2011 care. Access to toxicological tests will vary between hospitals. American Academy of Clinical Toxicology; European Association of Poisons Routine toxicology test will identify only a limited number of Centre and Clinical Toxiciologists. Position statement and practice guidelines substances, e.g. amphetamine, MDMA, opiates and will not on the Use of Activated Charcoal in the treatment of acute poisoning. Clinical detect novel psychoactive substances unless analysed at a Toxicology 1999; 37(6): 731-751 https://www.eapcct.org/publicfile.php?folder=congress&file=PS_MultipleDos specialist laboratory. Frequently results will not be immediately eActivatedCharcoal.pdf available and thus will not influence emergency management. British National Formulary (2014) BNF 67, Opiod Analgesics pp275-286 In addition there is a risk of false positives, due to cross reactivity Brunt TM, van Amsterdam JG, van der Brink W.(2014) GHB,GBL and 1,4BD with prescribed drugs and/or drugs administered during Addiction. Curr Pharm Des; 20(25):4076-85 resuscitation. Buffin J, Roy A, Williams H, Winter A. Part of the Picture Lesbian Gay and Bisexual people’s alcohol and drug use in England (2012) http://www.lgf.org.uk Further things to consider: Dargan PI, Wood DM. (2013) Novel Psychoactive Substances: Classification, Pharmacology and Toxicology. London, Elsevier Press l Previous history: Has the patient had any other Department of Health (2011) A summary of the health harms of drugs Emergency Department attendances related to www.nta.nhs.uk/uploads/healthharmsfinal-v1.pdf recreational drug misuse or other substance misuse? European Association of Poisons Centres and Clinical Toxicologists http://www.eapcct.org/index.php?page=joint l Head injury: Patients who have a head injury should be assessed according to NICE Guideline 176 (2014) and a CT European Monitoring Centre for Drugs and Drug Addiction (2015) European drug report- trends and developments. brain performed as indicated. On discharge they should be http://www.emcdda.europa.eu/edr2015 given appropriate written advice. Ghodse H (2010) Ghodse’s Drugs and Addictive Behaviour A Guide to Treatment. 4TH edn. Cambridge & New York: Cambridge University Press l Self-harm: Always consider that a patient may have taken Glasgow Coma Score http://en.wikipedia.org/wiki/Glasgow_Coma_Scale a recreational substance as a method of self-harm. Enquire Health and Social Care Information Centre Statistics (2014) Drug Misuse – if the patient was taking the substance to have a good England 2014 Tables 3.6a & 3.15 time or intentionally cause self-harm and document the http://www.hscic.gov.uk/catalogue/PUB15943 response. Patients who admit to self-harm should have a Lucas A. Johnson, et al (2013) Current “Legal Highs”, The Journal of Emergency psychiatric assessment prior to discharge. Medicine, 44 (6), 1108-1115 http://dx.doi.org/10.1016/j.jemermed.2012.09.147. l Immunization: Patients who have sustained National Poisons Information Service: 08448920111 http://www.toxbase.org/ cuts/lacerations/ abrasions should have tetanus status National Treatment Agency (2013) Falling drug use: the Impact of treatment. documented and receive immunization as appropriate. www.nta.nhs.uk/falling-drug-use.aspx National Treatment Agency for Substance Misuse. Drug Treatment l Victimization: Whilst under the influence of drugs 2012:Progress made, challenges ahead. www.nta.nhs.uk/drug-treatment- patients may be at risk of sexual assault. Ask the patient if 2012.aspx this is a possibility and manage accordingly. Nelson LS, Lewin NA, Howland MA, Hoffman RS, Goldfrank LR, Flomenbaum NE.(2010) Goldfrank’s Toxicological Emergencies. 9th edn. McGraw-Hill Medical l Drug, alcohol and other substance history: Explore NICE (2014) Head injury: Triage, assessment, investigation and early management patterns of drug use with the patient and if they feel their of head injury in children, young people and adults drug use is problematic. Provide information about local http://www.nice.org.uk/guidance/cg176 drug services as required. ONS (2016) Statistical bulletin: Deaths related to drug poisoning in England and Wales, 2016 registrations http://www.ons.gov.uk/ons.gov.uk/peoplepopulationandcommunity/birthsde athsandmarriages/deaths/datasets/deathsrelatedtodrugpoisoningenglandan dwalesreferencetable Patient.co.uk( 2014)Recreational Drugs http://www.patient.co.uk/health/recreational-drugs Public Health England (2015) Young people’s statistics from the National Drug Treatment Monitoring System (NDTMS) 1 April 2014 to 31 March 2015 http://www.nta.nhs.uk/uploads/young-peoples-statistics-from-the-national- drug-treatment-monitoring-system-2014-2015.pdf Smith C D & Robert S (2014) ‘Designer drugs’: update on the management of novel psychoactive substance misuse in the acute care setting. Clinical Medicine 14 (4): 409–15 Takematsu, et al (2104) A case of acute cerebral ischemia following inhalation of a synthetic cannabinoid. Clinical Toxicology 52 (9):973-975 Wood DM, Brailsford AD, Dargan PI.(2011) Acute toxicity and withdrawal syndromes related to Gammahydroxybutyrate ( GHB) and its analogues gamma-butyrolactone (GBL) and 1,4 butanediol (1,4 BD). Drug Test Anal; 3(7- 8):417-25 Wyatt J, Illingworth R, Graham C, Hogg K. (2012) Oxford Handbook of Accident and Emergency Medicine. 4th edn. Oxford University Press

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