Methods for Identifying Street & Prescription Drug Abuse
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1 Methods for Identifying Street & Prescription Drug Abuse presented by Sharon S. Kelley, MS, PhD Chief Executive Officer Associates In Emergency Medical Education, Inc. Alliance for Global Narcotics Training, Inc. Identifying Drug Abuse Local epidemiologic / online resources History and Physical Examination Street terms and paraphernalia associated with specific drugs Laboratory testing options and utilization for evidence of abuse/diversion Epidemiologic Tools Literature, local and internet updates Local law enforcement Prescription Drug Monitoring Program (PDMP) Populations at risk Local drug testing agencies 1
2 Internet Resources Medical PubMed Drug Community Erowid.com Opiophile.org Bluelight.ru Government Usdoj.gov.ndic Streetdrugs.org DEA.gov Mctft.com Drugfree.org Whitehousedrugpolicy.com 2014 Interim Report by Florida Medical Examiners 2
3 Populations At Risk Populations At Risk High stress workplace Medicine Neonatal Elderly Teens / College Military / Law Enforcement 3
4 Drug Testing SAHMSA (formerly NIDA) 5 Cocaine (COC) Marijuana / Tetrahydrocannabinol (THC) Opiates (OPI) Amphetamines (AMP) Phencyclidine (PCP) Field Testing Advantages and Disadvantages Collection techniques Sample characteristics False Positives / False Negatives Metabolism considerations Comparison to laboratory analysis History - Age / Sex - History of drug and alcohol abuse - Previous hospital admissions - Criminal history - Baker Act - Current medications / drugs of abuse - Socioeconomic 4
5 CNS Stimulants General Presentations Tachycardia Tachynpea Diaphoresis Midriasis Electrolyte abnormalities Serotonin syndrome Psychological Tachycardia / Potential Ischemia CNS Stimulants General Presentations Tachycardia Tachynpea Diaphoresis Midriasis Electrolyte abnormalities Serotonin syndrome Cardiac / cerebral ischemia Psychological 5
6 Midriasis Dilated Pupils Powder Cocaine Specific Presentations Loss of nasal hair / septum Epistaxis (nosebleeds) Sniffing Selective gingivitis Long fingernail on one finger 6
7 Specific Presentations Toxic Epidermal Necrolysis Syndrome Crack Cocaine Cookies 7
8 Crack Cocaine Pipes Specific Presentations - Crack Crack thumb / fingers Callouses on lips Weight loss Pulmonary infections Analysis Cocaine/Amphetamines Cocaine high sensitivity on screening tests GC/MS, TLC Amphetamines difficult due to number of variances and cold medication false positives L-methamphetamine versus D-methamphetamine 8
9 MDMA - Ecstasy Euros Specific Presentations Ecstasy Hyperthermia Electrolyte imbalances Hallucinations Paranoia 9
10 Viagra + Ecstasy = VE Complex Viagra use is associated with men's substance abuse behaviors rather than their sexual risk behaviors. Sex Transm Infect Dec;80(6): Crosby R, Diclemente RJ. College of Public Health, 121 Washington Avenue, Room 111C, Lexington, KY , USA Methamphetamine CNS stimulation - Dental Erosion 10
11 % of Basal DA Output % Basal Release % of Basal Release DA Concentration (% Baseline) % of Basal Release % of Basal Release 8/12/2015 Natural Rewards Elevate Dopamine Levels 200 FOOD NAc shell 200 SEX Empty Box Feeding Time (min) Source: Di Chiara et al. 100 ScrScr BasFemale 1 Present Scr Scr Female 2 Present Sample Number Mounts Intromissions Ejaculations Source: Fiorino and Phillips Copulation Frequency 1500 Accumbens METHAMPHETAMINE 400 Accumbens COCAINE DA DOPAC HVA hr Time After Methamphetamine NICOTINE 250 Accumbens Time After Cocaine ETHANOL Accumbens Caudate Dose (g/kg ip) hr 0 Time After Nicotine hr Time After Ethanol Source: Shoblock and Sullivan; Di Chiara and Imperato 11
12 12
13 Analysis Cannabinoids & Cathinones Time-of-flight mass spectrometry (TOF- MS) may be effective Schedule I drug Modifications are problematic 3,4-methylenedioxypyrovalerone (MDPV) and 4-methylmethcathinone (mephedrone) are schedule I drugs as of June 2012 CNS Depressants Presentation Syndromes Bradycardia Bradypnea / Apnea Miosis Pulmonary edema Bradycardia & Bradypnea 13
14 Gamma-Hydroxybutyric Acid (GHB) 14
15 Analysis - GHB Important to total GHB and GBL due to in vitro conversion ph, temperature, time are relative factors to conversion GC/MS, liquid GC/MS, capillary electrophoresis H E R O I N 15
16 Top 20 Drugs of Abuse Oxycodone (Percodan, Percocet, OxyContin) Alprazolam (Xanax) Diazepam (Valium) Rivotril, Clonazepam (Klonopins) Carisoprodol (Soma) Oxymorphone (Opana) Propoxyphene (Darvon, Darvocet) Hydromorphone (Dilaudid) Hydrocodone (Vicodin) Triazolam (Halcion) Analysis - Benzodiazepines Difficulties due to the number of drugs and functional groups Immunoassays may be limited due to minimal cross-reactivity GC/MS best overall method, LC/MS, UV detection 16
17 Specific Presentations Endocarditis related septic pulmonary emboli Specific Presentations Decreased gastric motility Spinal abscesses Valvular disease 17
18 Fentanyl Patches (Duragesic Patches, Sublimaze) 18
19 Analysis - Opioids Sample pre-treatment often necessary Extractions through liquid-liquid or solidphase Immunoassays are not specific High-performance liquid chromatography (HPLC), GC or GC/MS most commonly used Presumptive Testing - True Positive Presumptive testing device METH AMPHETAMINE Methamphetamine POSITIVE Presumptive Testing False Positive Presumptive testing device METHAMPHE TAMINE Phentermine POSITIVE 19
20 20
21 Lethal level = >200 ng/ml Lethal level >200 ng/ml 21
22 Lethal above 3 ng/ml Sudden death smoking fentanyl patch Transdermal patches contain mg 22
23 Sharon Kelley, MS, PhD CEO Alliance for Global Narcotics Training, Inc. Associates In Emergency Medical Education, Inc office 23
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