Toxicology Today: What Are They Using?

Authors’ note: In this article we will discuss some products which are legal and sold over the counter, and others which are illegal. We will comment upon their use by drug abusers, but in no way do we intend to imply that any of the legally sold products are bad, per se or as marketed.

In addition to the old standbys—heroin, marijuana, crack cocaine, meth, ecstasy and alcohol—today’s EMS responders are encountering a new set of drugs being abused, which can cause a variety of serious side effects.

An ER physician described one drug as having “potentially lethal side effects, which include extreme agitation, increased heart rate and blood pressure, hallucinations and paranoia,” and as being “tremendously addictive.”¹

Bath Salts

He was talking about “bath salts,” sometimes also called “plant food,” a substance which up until now has been sold legally in smoke shops, gas stations and other businesses. These substances can be smoked, snorted or swallowed, and produce similar effects to methamphetamine and cocaine.

These are not your mother’s bath salts at all. They are not soothing or relaxing, and if they have any pleasant fragrance at all it is secondary to their primary purpose—getting high.

Arizona and Louisiana have recently joined a number of other states in making the substances illegal to manufacture, possess or sell, but they are still readily available from multiple Internet sites, and not all states, nor the federal government, have yet made them illegal. However, on Sept. 11, 2011, the U.S. Drug Enforcement Administration (DEA) invoked its “emergency scheduling authority” to control mephedrone, merhylone and methylenedioypyrovalerone (MDPV), the three most common synthetic stimulants found in bath salts. However, chemists are always inventing new versions of the same chemicals and changing the ingredients, so there is no guarantee about what is actually in these substances. The buyer, in effect, has no idea what he is putting into his body, and responding EMS providers are just as clueless. This presents a nasty dilemma for rescuers—what measures to take to control the body’s responses to the substances. ²

 Bath salts are sold under a delightful variety of imaginative names, such as Blizzard, Snow Leopard, Bliss, Red Dove, Blue Silk, Cloud Nine, Scarface, White Lightning, Hurricane Charlie, Vanilla Sky and White Night, among many others which can be found by Googling “bath salts.”

Synthetic Marijuana

Bath salts are not the only drugs now popular with the party set. Synthetic marijuana is also finding a wide market. Sold under names like K2 and Spice, they are available at “head shops”³ and other places catering to drug users. They are also widely available through mail order Internet outlets.

These drugs seem to have first popped up around 2000 and were made of compounds which mimicked the effects of cannabis. Two of these compounds, JWH-018 and JWH-200, were both apparently invented by a scientist with the initials JWH, who worked at a major university. Others such as CP-47, 497, and cannabicyclohexanol were formulated by others. All have been placed in Schedule I of the Controlled Substances Act as of March 11, 2011.⁴

However, the chemists manufacturing these so-called “designer drugs” are always searching for ways to thwart the laws by producing isomers of the substances that will be chemically similar to the original substances but different enough to pass legal muster. In the race between regulation and intoxication, intoxication usually finds a way to stay ahead.

It is virtually impossible for law enforcement authorities and toxicologists to keep up with these changes, since none of them are available for testing until they hit the street.

K2 and Spice show up in some areas of the country but not others. Drug fads tend to follow regional patterns. EMS providers are often the first to see folks who are trying something new, and they are always at a disadvantage because neither the patient nor the EMS providers really know what has been ingested.

Herbal Teas

Since the beginning of time, people have experimented with plants and plant extracts to produce both medicines and recreational drugs. Digitalis, originally extracted from the Common Foxglove plant (digitalis purpurea), is one of the best examples of legitimate use of plants in medicine.

Society has divided plants into those that are acceptable for recreational use and those that are not. For example, tobacco is a dangerous and addictive substance containing nicotine, as almost everyone will agree, but it is legal to smoke and chew. Cannabis, on the other hand, is illegal.

In between are many substances that may be chewed, brewed and smoked, which can produce a variety of physiological and psychological changes in the user. Many substances are anticholinergics when consumed as tea, for example.

One example is Jimson weed, also known as Loco Weed, Devil’s Trumpet, Angel’s Trumpet and by other names. It contains, among other things, belladonna alkaloids which produce strong anticholinergic properties. These alkaloids include atropine and scopolamine. They are competitive antagonists with acetylcholine and bind to peripheral and central muscarinic receptors. The peripheral receptors are on exocrine glands which affect sweating, salivation, and smooth and cardiac muscle. Poisoning causes paralysis of organs innervated by the parasympathetic nervous system.  Jimson weed can produce hallucinations, hyperthermia, tachycardia, photophobia and other typical anticholinergic effects.⁵

Use of Jimson weed seems to occur in cycles. Plants can be bought from numerous sources online. With the explosion of social media, information about “highs” can explode and result in a surge of overdose cases popping up in various places all over the world.

Brugmansia is another genus of flowering plants sometimes called Angel’s Trumpet. Its properties are similar to Jimson weed.

A study published in 2002 reported an increase of intoxications in persons using alkaloid-containing plants for their hallucinogenic effects. The study found that adolescents were the principal users of these plants. The authors found a syndrome of toxic psychosis with hallucinations, disturbances of orientation, psychomotor agitation, aggression and anxiety resulting from use.⁶

For EMS responders, patients experiencing hallucinations are among the most dangerous, since they can become severely paranoid. These patients are also a threat to themselves as well, and they can get into situations that lead to excited delirium.

In 2009, the American College of Emergency Physicians issued a white paper recognizing excited delirium as a syndrome.⁷

Excited delirium is a condition characterized by a number of ingredients:  Males with a mean age of 36, who become hyperaggressive, combative, and exhibit bizarre behavior, insensitivity to pain, hyperthermia and tachycardia. There is typically a struggle with law enforcement involving physical combat, use of pepper spray or Taser, followed by a period of quiet, and then sudden death. The majority of cases involve ingestion of cocaine, but methamphetamine, PCP and LSD have also been implicated.

The syndrome is characterized by pain tolerance, tachypnea, sweating, agitation, tactile hyperthermia, noncompliance with police, lack of tiring and unusual strength.

EMS providers often arrive to find the patient subdued, handcuffed and possibly “hog-tied,” and lying on his chest. Prone positioning of the restrained patient can be lethal, so it is most important to place the patient in a position where he can breathe—which means, at a minimum, turning him onto his side.

It is beyond the scope of this article to explore all the aspects of excited delirium. But it is important to understand that it can be a part of the outcome of ingestion of recreational drugs.

Drug Cocktails

The ingenuity of drug users can never be underestimated. They will seek and discover new and more stimulating ways to abuse substances on a daily basis.

But some things remain relatively static. Drug users mix drugs. One of the most famous cases involving a mixture of drugs involved the death of John Belushi, who allegedly self-administered a combination of heroin and cocaine, commonly known as a “speed ball.” There are various versions of that cocktail, but they all involve a depressant plus stimulants. The idea is to produce a “mellow high.”

Currently, ethanol (ETOH) is one of the most commonly used depressants, and crack cocaine or methamphetamines, or other versions of them, are commonly used with it to produce that “mellow” high.

In the context that cocaine and meth are illegal, caffeine has become one of the drugs of choice to mix with ETOH. So-called “energy drinks” containing large amounts of caffeine are commonly used with ETOH to produce an “awake drunk.” Some also add in opioids. Vicodin (acetaminophen and hydrocodone) is one of the most often abused opioid combinations. According to users, it “smoothes out” the drug response to caffeine and ETOH. Typical drug cocktails would involve caffeine, ETOH and Vicodin.

Caffeine is available from many sources. Traditionally coffee and tea were the vehicles for caffeine ingestion, but common soft drinks such as colas were also sources. Then came the energy drinks, such as Red Bull and 5-Hour Energy.

They advertise that they contain about as much caffeine as one-half (5-hour Energy) to one (Red Bull) cup of coffee. Red Bull contains about 80 mg of caffeine.

Recently new ways to ingest caffeine have come on the market. One such product is

Sheets™ Brand Energy Strips. These are “paper-thin dissolvable strips” which dissolve on the tongue. Each “sheet” contains 100 mg of caffeine.⁸ These are sold at convenience stores, liquor stores and other venues. They are popular at parties and are mixed with ETOH—typically vodka—to produce a “balanced high.”

The latest version of caffeine products is AeroShot Energy, a caffeine inhalant. It comes in a canister filled with powder that “you draw into your mouth,” according to its website, which also discloses that it contains 100 mg of caffeine plus “B-vitamins.”⁹

There is nothing wrong with these caffeine products. They are legal, and we do not intend to cast any aspersions upon them. However, while these products appear to be marketed as legitimate energy enhancers, they are nonetheless popular choices among recreational drug users as new ways to get high.

The Skittles Party

Finally, the most disturbing trend in drug abuse is something called the “Skittles Party,” or Pharm parties.

Here, party-goers raid their parents’ medicine cabinets and bring all the prescription and non-prescription pills they can find to the party and toss them into a bowl. The pills and capsules are usually prescription drugs such as pain killers, muscle relaxants, tranquillizers or antibiotics, but could also be over-the-counter cold medicines and illicit drugs bought from dealers. The party is called a “Skittles Party” because of the varied colors of the pills.

While typically consuming ETOH and frequently marijuana, the partiers dip into the bowl of pills and take them, having no idea what they are taking. While polypharmacy is a common finding among recreational drug users, many of the overdose victims of Skittles Parties have toxicology results that can be summarized as “yes.”

When EMS is called, the challenges are great. Neither patient nor care-giver has the slightest idea what has been ingested. This is a recipe for disaster.

All the EMS providers can do is offer basic life support and, if necessary, advanced life support using the tools we have.

For patients showing signs of opioid overdose, naloxone is the indicated drug. For anticholinergic poisoning, there is little to do in the prehospital setting.

For the agitated patient, benzodiazepines probably are the first thought, but neuroleptic drugs such as haloperidol (Haldol) or ziprasidone (Geodon) may be useful.

For anticholinergic syndrome, physostigmine was once recommended, but it is not normally carried on ambulances and its use has been called into question for cardiac side-effects.

Overall, basic life support, IV fluids and, when necessary to protect the airway, advanced airway management may be indicated. Sometimes patients will be hyperthermic and cooling measures may be needed.

Bottom Line

Management of the agitated patient is challenging. There are often many signs and symptoms which must be dealt with, without a clear understanding of what has happened to the patient physiologically.

Histories are often difficult or impossible to obtain due to chaotic situations, uncooperative patients and witnesses, and the fact that the patient and witnesses may not know what has been consumed.

Keeping up with what drug abusers are doing is a never-ending process. Illicit drug suppliers are forever inventing new drugs and drug users are ingenious at finding new ways to get high. As EMS responders we are often caught unaware of what is going on in the drug-abuse community. Understanding the basics of pharmacology is mandatory for EMS responders. If we understand the actions of the substances that people take, we will be better able to deal with them.

Always remember, do the basics first.

References

1. Jamar Younger, Arizona Daily Star, March 7, 2012.

2. McMillen, “Bath Salts” Drug Trend: Expert Q&A, WebMd. https://www.webmd.com/mental-health/features/bath-salts-drug-dangers.

3. A “head shop” is a retail outlet that specializes in drug paraphernalia.

4. https://en.wikipedia.org/wiki/JWH-018.

5. Jimson Weed (Datura stramonium) Poisoning. Clinical Toxicology Review 18:3, Dec. 1995. https://www.erowid.org/plants/datura/datura_info5.shtml.

6. https://www.ncbi.nlm.nih.gov/pubmed/11869466#.

7. Excited Delirium Task Force, White Paper Report to the Council and Board of Directors, September 10, 2009, American College of Emergency Physicians. https://ccpicd.com/Documents/Excited%20Delirium%20Task%20Force.pdf.

8. https://www.sheetsbrand.com/faq.

9. https://www.aeroshots.com/.

Steven “Kelly” Grayson, NREMT-P, CCEMT-P, is a critical care paramedic for Acadian Ambulance in Louisiana. He has spent the past 14 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is a former president of the Louisiana EMS Instructor Society and board member of the Louisiana Association of Nationally Registered EMTs. He is a frequent EMS conference speaker and the author of the book En Route: A Paramedic’s Stories of Life, Death, and Everything In Between, and the popular blog A Day in the Life of An Ambulance Driver.

William E. (Gene) Gandy, JD, LP, has been a paramedic and EMS educator for over 30 years. He has implemented a two-year associate’s degree paramedic program for a community college, served as both a volunteer and paid paramedic, and practiced in both rural and urban settings and in the offshore oil industry. He has testified in court as an expert witness in a number of cases involving EMS providers and lectures on medical/legal aspects of EMS. He lives in Tucson, AZ.