Prescription for Danger

This CE activity is approved by EMS World Magazine, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS) for 1 CEU. To take the CE test that accompanies this article, go to www.rapidce.com to take the test and immediately receive your CE credit. Questions? E-mail editor@EMSWorld.com.

OBJECTIVES

• Review the incidences of teenage prescription drug abuse
• Discuss risk factors for drug abuse
• Review prehospital assessment and management of teenage prescription drug abusers
• Discuss drug isolation and long-term management of these patients.

Case Study

   Squad 22 arrived on scene at Longfellow High School for a 16-year-old male who was reportedly lethargic. When the crew walked into the nurse's office, they were directed into the side exam room, where their patient was curled up under a blanket. They noticed the nurse had placed the patient on a nasal cannula. She explained that, at the end of study hall, which was 50 minutes long, the monitor noticed that "Joshua" did not get up with the bell. The nurse was summoned to his side and Joshua responded to verbal stimuli. He was then placed in a wheelchair and brought to the nurse's office.

   While the nurse gave her report, the two EMTs performed an examination and obtained vital signs. The crew noted that the patient was slow to open his eyes and roll over with verbal command. He would not obey any other commands and kept rolling back into a fetal position. His pupils were equal, round and sluggish to light, airway was patent, lungs were clear, abdomen was soft and nontender, and there were no signs of trauma. Vital signs were: pulse 94, respirations 10 and shallow, blood pressure 108/62, skin warm, moist and pink.

   The crew lifted Joshua to their cot and, as they checked his blood sugar to rule out hypoglycemia, they began reviewing the list of potential causes for Joshua's condition:

• Postictal following a seizure
• Toxin exposure
• Drug overdose
• Cerebral hypoxia
• Increased intracranial pressure
• Alcohol intoxication.

Epidemiology

   Prescription drug misuse and abuse is on the rise. More than 15 million Americans are currently abusing prescription drugs; 4.7 million admit to abusing pain relievers, the most commonly abused prescription drug in the United States.¹ Opioid analgesics are the leading cause of prescription drug overdose-related deaths.² Other commonly abused prescription drugs include central nervous system (CNS) depressants, such as barbiturates and benzodiazepines, and stimulants. In 2004, more than 48 million Americans ages 12 and older admitted to abusing prescription drugs at some point in their life.³

   Prescription drug abuse is a rampant problem among today's adolescents. In 2004, more than 1.5 million teens met the diagnostic criteria for substance dependence and abuse.³ In 2009, the number increased to 1.9 million teenagers aged 12-17.⁴ A 2007 study showed that more teenagers recreationally used opioids than marijuana.² Two opioids, oxycodone and hydrocodone, top the list of prescription drugs abused by today's teenagers, followed by analgesics, tranquilizers and stimulants.³ Somewhat surprisingly, girls abuse more prescription drugs than boys between the ages of 12 and 17.⁵ These numbers raise the questions of what drugs are being abused and why. It's important to answer these questions and solve this problem, because every day a new group of 2,000 teenagers take a prescription drug without a doctor's order.⁴

Drug Types and Frequencies

   A variety of reasons help trigger the high abuse rate in teenagers. Among the most commonly cited are ease of access at home, ease of purchase via the Internet, prescription sharing at school, and the general mentality that the drugs are legal and thus safer than illegal drugs. Under the auspices of these beliefs, the majority of prescription drugs abused by teenagers fall into three main categories.

OPIOIDS

   Opioids, or opioid analgesics, are derived from opium seeds and are potent pain-relieving drugs. There are myriad opioid analgesics available, but the most commonly abused is the pill version of methadone. The low cost of this pill is cited as the main reason for its abuse prevalence.² Other opioids include oxycodone, propoxyphene, hydrocodone, hydromorphone, meperidine, and the most well known, morphine.⁵ An untold number of people across the country are given prescriptions for opioids following surgery, injury or disease diagnosis because our country rightfully believes that no person deserves to live in pain. Between 1990 and 2002, there was a fourfold increase in the number of prescriptions for opioid analgesics. Interestingly, this also corresponds with an 18.1% increase in unintentional drug poisonings during the same time frame.⁶ While researchers have found these numbers very similar and believe there is a link, this link is purely theoretical and cannot currently be proven. There was also a 91% increase in "opioid analgesic poisoning" deaths between 1999 and 2002.⁶

SEDATIVES

   Different central nervous system depressants work to slow normal or hyperactive brain function for disorders including anxiety, insomnia and seizures. Sedatives can include barbiturates like phenobarbital; benzodiazepines like Valium, Xanax, midazolam and Ativan; and tranquilizers.⁵ The most common sedative category is benzodiazepines; 15 are available in the United States and an additional 20 are available in other countries. Benzodiazepines work by potentiating the activity of gamma-aminobutyric acid (GABA), the brain's major inhibitory neurotransmitter. By potentiating GABA's neurotransmissions, there is striated muscle relaxation and neurological transmissions slow down, causing sedation.⁷ More than 100 million prescriptions for benzodiazepines are filled across the country annually. In 2008 alone, over 78,000 benzodiazepine overdoses were reported.⁷

STIMULANTS

   Narcolepsy, attention-deficit disorders (ADD and ADHD), obesity and depression are examples of conditions that can be treated with stimulants which increase alertness, attention and energy. Every stimulant enhances the brain's activity, but has a slightly different action on the brain itself. These actions are beyond the scope of this article. Nearly all stimulants also increase heart rate, respirations, blood pressure and metabolism. Different stimulants include amphetamines, methamphetamine, methylphenidate, Adderall, Dexedrine, Ritalin and Concerta. The National Institute on Drug Abuse reported that up to 6.6% of all high school-aged students abused stimulants.⁸

Risk Factors for Misuse

   Prescription drug abuse and addiction is a disease. Like most disease, there are several risk factors that increase the chances an individual may begin misusing a prescription drug.

PAIN

   Opioids are commonly used for managing acute and cancer-related pain; however, their use remains controversial because they do have a relatively high addiction potential. Nearly all patients with chronic pain eventually develop a physiologic tolerance and the risk of withdrawal symptoms when their treatment regime ends. Single doses of an opioid, or any medication, cannot cause dependence or tolerance. It is long-term use that leads to a dysregulation of neurochemical transmissions in the brain that affect the motivational systems for drug intake. This means the body thinks it needs more to reach the same pain threshold.³ Patients who receive an opioid prescription risk dependence, and, as they become dependent, they have a higher risk of self-managing their drug doses. Generally, this self-management is to increase drug doses. Besides cancer, other reasons for opioid prescriptions include: acute injury and recovery, post-surgical pain, nervous system disease and migraines.

ATTENTION DEFICIT DISORDERS

   Up to 10% of children suffer from attention deficit disorder and attention deficit hyperactivity disorder (ADD & ADHD). However, among those with the disorders, more than 85% struggle to control it before they enter adolescence. As age increases with this population, the risk of substance abuse rises disproportionately compared to the average population. Thirty percent of adolescents who receive treatment for drug abuse have diagnostic criteria for ADHD. Further, as diagnosis rises, so does the frequency of stimulant prescriptions. Additionally, 22% of adolescents with ADHD admit they have misused their prescribed medications; 11% admit selling their medication to others.³

ACCESSIBILITY

   Nearly half of all teens (47%) who abuse prescription drugs report that they can get them for free from friends and relatives. More than 65% of teenagers admit that pain relievers can be taken from their parent's medicine cabinets without their knowledge. There is a common conception that these drugs are more easily and more safely obtained than illegal drugs.⁵

Assessment

   A thorough and accurate patient assessment should be performed on any patient. It can be divided into two parts: a history and a physical exam. When managing a patient who is suspected of having misused or overdosed on prescription medication, the importance of an accurate history rises astronomically. It is essential to establish a rapport with a patient and anyone surrounding them as, without trust, the information gathered during the history is essentially useless. As part of the patient history, try to determine the following:

• Drugs ingested; single drug or poly drug abuse
• Amount of ingestion
• Time of ingestion
• Cause and/or reason for ingestion
• Whether ingestion is acute or chronic
• Past medical history and history of drug abuse
• Circumstances surrounding the overdose
• Has the patient vomited; if so, how much?

   These questions drive both the immediate care of the patient's symptoms and acute condition, and also will determine their long-term care. For example, if the cause of ingestion was attempted suicide or intentional abuse, then the patient may be admitted for psychological counseling or into a drug rehab program. The time since any ingestion determines how much of the drug may have been absorbed by the intestinal tract.

   When a patient does not admit to drug misuse but presents with symptoms of abuse, look for clues that he may be misusing drugs. Signs and symptoms of prescription drug misuse include:^3,9

• Diversion behaviors
• Past or current abuse of other substances
• Nonadherent behaviors including escalation
• Prescriptions from multiple clinicians
• Signs of declining social functioning
• Stealing, forging or selling prescriptions
• Taking higher than recommended doses
• Mood swings
• Change in sleep patterns.

   Table 2 lists the signs and symptoms of the different drug groups commonly misused by teenagers. When evaluating a patient, always assess and stabilize the circulatory, respiratory and nervous systems before trying to determine what drug is affecting the patient. Once the critical systems are stabilized, try to determine, when possible, what drug the patient has taken. If you can identify the drug, determine if the patient is experiencing chronic/subacute symptoms, acute (toxic) symptoms, or if he/she is in withdrawal. Determining the category of the drug effect the patient is in drastically changes patient management.

Associated Problems

   Once patients begin either intentional or unintentional prescription drug abuse, they are at risk for several other problems. This patient group experiences an increased rate of hospital admissions, need for detoxification and suicide rate compared to the general population. Teenagers between 12-17 who misuse prescription drugs are responsible for over 5,000 suicide attempts each year.³ Amphetamine misuse provides a unique constellation of complications, including renal failure, chronic dehydration, metabolic hyperthermia, cerebral hemorrhage,¹⁰ and vasospasm-induced stroke.¹¹

Treatment

   As stated previously, determining the type of drug, timing of misuse and exposure influences patient management. While determining if the patient is experiencing symptoms of chronic abuse, toxicity/overdose or withdrawal, begin to stabilize the critical systems. Patient care for overdose patients can be divided into three parts: symptom relief, drug reversal and elimination, and long-term care.

   One symptom that cannot be underappreciated is the development of physically aggressive behavior when patients are under the influence of drugs, particularly stimulants. Amphetamine toxicity often results in very aggressive behavior.¹¹ These patients may need physical or chemical restraints so they do not harm themselves, bystanders or EMS providers. Utilize established local protocols for restraining patients, as acceptable techniques vary by region. Any patient who is restrained requires careful monitoring. Do not put yourself or other rescuers at risk by not restraining a patient who has displayed aggressive or violent characteristics.

   Airway management is extremely important in all stages of patient care, particularly when a patient has overdosed. Ensure a patent airway and protect the patient from aspiration. Insert a nasal or oral airway as indicated. Patients who cannot protect their own airway, whose symptoms cannot be reversed with other medications, may need advanced airway management such as intubation. At toxic levels, many drugs can cause central nervous system depression and impair the respiratory drive. Should these patients vomit, they are at risk for aspiration.

   Support the patient's breathing with supplemental oxygen to maintain oxygen saturations at normal levels. If necessary, provide ventilations. When patients experience respiratory depression from drugs that can be reversed, it is often better for them to be ventilated via bag-valve mask until the drug is reversed, rather than providing advanced airway management like intubation.

   The circulatory system also requires careful monitoring. Patients can experience a variety of related problems ranging from palpitations and chest pain to lethal dysrhythmias. Check the patient's pulse rate and blood pressure often. EKG monitoring is indicated; ALS providers should watch for both bradycardias and tachycardias. Patients also need IV access and often require fluid therapy. Dehydration is a common side effect of drug misuse, and adequate rehydration helps to eliminate drugs and maintain end organ function.

   Hypertension is a common problem, and management depends on the drug that induced it. When it is induced by stimulants, and if they are authorized by medical direction, ALS providers can manage hypertension with IV benzodiazepines, with a goal systolic blood pressure below 180 mmHg. The benzodiazepine helps to counter the CNS excitation of stimulants, which helps the patient relax and slows the triggers causing hypertension. When benzodiazepines fail to provide adequate blood pressure control, consider infusions of nitroglycerin or nitroprusside.¹¹ Nitroglycerin is a primary venous dilator with some arterial effects, while nitroprusside is primarily an arterial dilator with some venous effects. Sublingual nitroglycerin is a poor choice for hypertension, as absorption is irregular, making it nearly impossible to maintain a regular therapeutic level in the bloodstream. Intravenous nitroglycerin, which is becoming more common on paramedic-staffed ambulances, has therapeutic effects at doses ranging between 5-100 mcg/min. Always stay within established protocol guidelines, but consider contacting medical control if higher doses are required to obtain blood pressure control. Nitroprusside is a very sensitive arterial dilator often used in air medical and critical care transport, but is probably not the drug of choice during prehospital care. Don't be surprised, though, to see this drug if your service provides interfacility transport.

   Never administer a beta-blocker to a patient experiencing hypertension from a stimulant overdose. Beta-blockers selectively block the beta receptors in the body, and doing so in the case of stimulant overdose will leave the alpha adrenergic system stimulation unopposed. This would lead to worsening hypertension, decreased coronary blood flow, and could precipitously drop cardiac output.

   Check a core body temperature on all overdose patients with mental status changes. A core body temperature is best obtained rectally or via esophageal probe. A rectal temperature is probably the most reasonable in the prehospital setting, and is obtained by inserting a covered and lubricated temperature probe about 1 inch into the rectum. A rectal thermometer is preferred over other methods, such as oral, axillary and temporal thermometers, as current research has shown it to be the most accurate way to determine core body temperature. Patients who have overdosed on stimulants risk developing hyperthermia with a core body temperature above 104°F and require immediate rapid cooling.¹¹ Rapid cooling is best performed on scene by placing the patient in water that's as cold as possible, preferably an ice bath, for 15-20 minutes.¹¹ This is one instance where transport must be delayed, as delaying cooling even 15 minutes can drastically increase morbidity. Another option for cooling is to cover the patient with cold, wet towels and fan him with cool air. Simply placing ice packs in the groin, axilla and on the neck does not provide effective rapid cooling. Figure 1 shows the cooling rates for a variety of established and currently taught cooling methods. It clearly shows that immersing patients in ice water provides the most rapid cooling, while commonly used methods such as placing ice packs on major arteries and fanning cold air provide little to no cooling.

Drug Isolation and Elimination

   Patients who have toxic effects from opioid overdoses and are experiencing respiratory depression may benefit from naloxone administration. Naloxone is a pure competitive antagonist for opiate receptor sites throughout the body. When administered, it blocks the opiate from causing symptoms but does not affect the opiate itself. Typically administered in doses ranging from 0.4 mg-2 mg, naloxone is best given in small, titrating doses and can be administered intravenously, intramuscularly, intranasally or via an endotracheal tube. Intranasal administration is roughly similar in timing to intramuscular administration. Use caution, though, as administering too much naloxone too quickly can trigger withdrawal symptoms in chronic opioid users. A good rule to follow is to administer just enough naloxone to reverse the respiratory depression opioids can cause.

   Flumazenil is the drug of choice for pure benzodiazepine overdoses, but it can be very risky to administer. When patients are known to have overdosed on a benzodiazepine and are in respiratory arrest or respiratory failure, flumazenil can be administered IV 0.2 mg at a time to help increase the patient's respiratory drive by competing with the benzodiazepine at GABA receptor sites and blocking it. This is where the risk comes. If a patient takes a benzodiazepine for seizures, blocking the GABA site can cause seizures that can not be controlled by benzodiazepine administration.⁷

   Consider the digestive tract from the mouth to the anus as a hollow tube. Technically, things inside this tube have not entered the inside of the body. Anything that can be isolated inside the intestines and kept from being absorbed by the bloodstream will not harm the body. This is the goal of limiting drug absorption. A few options are available to EMS providers. Activated charcoal is an excellent option up to about an hour after drug ingestion. Beyond an hour, drugs have often already entered the bloodstream and thus the charcoal's benefits become very limited. One exception to this is with sedatives, especially those that are time-released. Activated charcoal has been shown to be beneficial up to four hours after sedative ingestion.⁷ The activated charcoal works by binding with drugs and other chemicals in the body and preventing the body from absorbing the drug out of the bloodstream. Another option available to ALS providers is placing a nasal or oral gastric tube and then performing gastric lavage. Placing a NG/OG tube has the added benefit of allowing administration of activated charcoal directly into the stomach so the patient does not have to swallow it.

Long-Term Care

   Upon hospital admission, a variety of treatment options are available, depending on what exactly the patient has ingested. Buprenorphine is a drug that is given to manage and ease opioid withdrawal symptoms, and paramedics working in emergency departments may utilize this medication. However, due to strict FDA regulations governing its administration, it is unlikely to be usable in the prehospital setting.⁹ Hypertension experienced during opioid withdrawal can be adequately managed with clonidine. When stimulants are identified, and the patient has symptoms of toxicity, many emergency departments administer chlorpromazine,³ which can help alleviate the symptoms

   Activated charcoal, hypertension management and chlorpromazine can be used to manage the psychotic symptoms of stimulants³ by affecting different central nervous system receptors and producing a calming effect.

Case Study Conclusion

   Based on Joshua's history, the EMTs felt that a seizure was unlikely, and they did not observe any signs of incontinence, which is common during seizures. A postictal patient's mental status also progressively improves and Joshua's did not. There was no odor of alcohol on Joshua's breath or clothing, so alcohol seemed unlikely, although it could not be completely ruled out.

   Joshua's pattern of symptoms-- mental status changes, respiratory depression, and sluggish and dilated pupils--didn't fit the presentation of increasing intracranial pressure or cerebral hypoxia, especially when no reason for either was identifiable. The crew felt that a toxin exposure was likely, and, based on the symptoms, suspected an opioid-based drug. Joshua was in the age group where drug misuse is common, and his symptoms fit the pattern.

   The crew transported Joshua to the nearby children's hospital, where he was evaluated and tested positive for opioids. He was admitted for observation and then admission into a drug-treatment program.

Conclusion

   When treating a patient who is suspected of misusing a prescription medication, take time to establish a good rapport, or the information obtained in the patient's history may be inaccurate. Only after accurately identifying what drugs the patient ingested can complete symptom relief be obtained by blocking the drug's effect in the body and limiting its absorption.

REFERENCES

1. National Institute on Drug Abuse, Prescription Drug Abuse Chart. www.nida.nih.gov/DrugPages/PrescripDrugsChart.html.

2. Association of State and Territorial Health Officials. Prescription Drug Overdose: State Health Agencies Respond, Arlington, VA.

3. Hertz JA., Knight JR. Prescription drug misuse: A growing national problem. Adolescent Medicine Clinics 17(3):751, October 2006.

4. National Institute on Drug Abuse for Teens, Prescription Drug Abuse. https://teens.drugabuse.gov/facts/facts_rx1.php.

5. Office of National Drug Control Policy Executive, Office of the President. Teens and Prescription Drugs, https://www.theantidrug.com/pdfs/TEENS_AND_PRESCRIPTION_DRUGS.pdf.

6. Meehan WJ. Opioid abuse. https://emedicine.medscape.com/article/287790-overview.

7. Mantooth Robin. Benzodiazepine toxicity. https://emedicine.medscape.com/article/813255-overview.

8. National Institute on Drug Abuse for Teens. Stimulants. https://teens.drugabuse.gov/facts/facts_stim1.php.

9. Mayo Clinic. Prescription Drug Abuse Symptoms. https://www.mayoclinic.com/health/prescription-drug-abuse/DS01079/DSECTION=symptoms.

10. Larson MF. Amphetamine-related psychiatric disorders. https://emedicine.medscape.com/article/289973-overview.

11. Handly N. Amphetamine toxicity, https://emedicine.medscape.com/article/812518-overview.

12. Casa DJ, Armstrong LE, Ganio MS, Yeargin SW. Exertional heat stroke in competitive athletes. Competitive Sports and Pain Management, 4(6): 309-317, 2005.

Table 1: Percentage of High School Students Misusing Prescription Drugs by Type, 2005³

Table 2: Signs and Symptoms of Abuse of Different Prescription Drugs^3,10,11

FAST FACT

   Research shows 26% of Native American teens, 11.1% of Caucasian teens, 10.2% of Hispanic teens, 9.3% of African American teens, and 6% of Asian teens abuse prescription drugs.³

DANGER!

   Administration of syrup of ipecac is contraindicated, as it produces violent vomiting and increases the risk of aspiration.

DANGER!

   Never give beta blockers to a patient who overdosed on stimulants.

   Kevin T. Collopy, BA, CCEMT-P, NREMT-P, WEMT, is an educator, e-learning content developer and author of numerous articles and textbook chapters. He is also a flight paramedic for Spirit Ministry Medical Transportation in central Wisconsin and a lead instructor for Wilderness Medical Associates. Contact him at kcollopy@colgatealumni.org.

    Greg Friese, MS, NREMT-P, is the director of education for CentreLearn Solutions, LLC. He specializes in the development, production and distribution of online education for emergency responders. Greg is a leading advocate for the use of social media by EMS agencies and training organizations. Greg is a regular conference presenter, the co-host of the EMSEduCast, the founder of the EverydayEMSTips.com blog, marathon runner, and participant in many online EMS communities.