Beyond the Basics: Street Drugs

CEU Review Form Street Drugs (PDF)Valid until July 6, 2007

     There is a wide variety of street drugs that makes street identification challenging. Due to the enormous number of abused drugs, it's not possible to cover all of them here. This article focuses on many traditional street drugs, including heroin, cocaine, methamphetamine, LSD, ecstasy and GHB, and includes methods of street use and packaging to help providers identify and understand how drugs may be found on the street. We also touch briefly on the illicit use of prescription drugs. A subsequent article will discuss additional substances and trends (e.g., dextromethorphan in cough medicine).

     Traditional drug classifications include narcotics, stimulants, hallucinogens, etc. This article uses a more street-based approach to classification: uppers, downers and all-arounders. Not only does this simple classification represent the actions of the medications covered, it generally matches the presentation of patients taking each type of substance.

Uppers
     The wide classification of "uppers" actually includes stimulants, amphetamines and other substances. Ecstasy also has stimulant properties and is discussed later in this article.

Cocaine
     Cocaine is a stimulant derived from the coca plant, which is grown primarily in the Andes mountains in Bolivia and Peru. Inhabitants of the region chew coca leaves for their stimulant properties. Using a seven-step process involving kerosene or gasoline, cocaine is extracted from the leaf of the coca plant and eventually converted into cocaine hydrochloride (powder) or cocaine base (crack).

     In the 1980s, cocaine was primarily used in the powder form, which was snorted. When snorted, cocaine enters the body through the nasal mucosa, travels through the capillaries into the venous circulation, the right side of the heart, lungs, left side of the heart and then to the brain, where the effect is felt. This route of administration takes about 2-3 minutes to take effect.

     Later in the 1980s, crack cocaine became more prevalent for a number of reasons: It was less expensive, sold in individual doses and provided a potent high in a fraction of the time. Prior to the "invention" of crack cocaine, the dangerous process of "freebasing" using volatile chemicals was the only choice when smoking cocaine was preferred.

     From the standpoint of a drug user, crack cocaine is physiologically more efficient. Smoked cocaine enters the lungs, goes to the left side of the heart and to the brain in 2-10 seconds. It creates a remarkably quick and powerful sensation of euphoria, which adds to the chemical reasons this form of cocaine is so profoundly addictive.

     After being mixed into a liquid solution, cocaine powder can also be injected. Although injection provides quicker action (about 30 seconds), this method is least popular, due to the limited availability and risks associated with needle use and sharing.

Methamphetamine
     As the name implies, methamphetamine is an amphetamine. Methamphetamine had some medical uses in the 1960s, but the addiction potential quickly caused methamphetamine to be placed as a schedule II controlled substance.

     The thing about methamphetamine that introduced it into the illegal drug market and has caused dramatic increases in its use is that it can be manufactured or "cooked" in a clandestine drug laboratory. Anyone who has recently tried to purchase an over-the-counter drug remedy knows that those medications are commonly placed behind the pharmacy counter. This is because the nasal decongestant pseudoephedrine is a chemical that can be used in the manufacture of methamphetamine. Recipes for cooking methamphetamine using a variety of materials may be easily found on the Internet.

     The Drug Enforcement Administration, in its publication Drugs of Abuse, reports that methamphetamine abuse has outpaced the traditional leaders cocaine and heroin in Western states and is rising dramatically throughout the country.

     Methamphetamine, called speed, meth, crystal meth, ice and crank, is crystalline in appearance and may range from clear to off-white to brownish, depending on the method and ingredients used in cooking. Methamphetamine is commonly smoked, but can be injected, snorted or taken orally.

     Signs and symptoms of methamphetamine abuse range from mild euphoria to excitation, insomnia, loss of appetite, aggression and, in severe cases, increased body temperature, tachycardia and hypertension, seizure and death.

     "Meth mouth" is often seen in methamphetamine abusers. This condition involves a cycle of poor oral hygiene, dry mouth caused by the drug, ingestion of large quantities of sweets and sugar-containing beverages, and possibly by a corrosive effect of the drug itself. As a second wave of social impact, many municipalities' entire healthcare budget for jail inmates is expended early in the budget year on emergent dental care for those incarcerated for methamphetamine possession or sale.

     There is a range of other abused stimulants (e.g., Ritalin), which will be discussed in a subsequent article.

Pathophysiology and Treatment: Cocaine and Methamphetamine
     Cocaine is a local anesthetic with a potent effect on the central nervous system. Effects are believed to be caused by action on dopaminergic neurotransmitters (e.g., serotonin) by slowing reuptake and leaving more available neurotransmitters in the synapse. Common problems with cocaine- and stimulant-related overdose and emergencies include hyperthermia, seizure, hypertension, severe agitation and cardiac dysrhythmias.

     There is no known antidote to these substances, so treatment is directed toward reversing the signs and symptoms like severe hypertension, seizure and dysrhythmia as they appear.

     Vigilant airway care and attention to potential concurrent problems (e.g., hypoglycemia from reduced oral intake) are also vital.

     The signs and symptoms, and the amount of stimulant required to cause them, vary widely from person to person.

Drug Facts: Cocaine

• Cocaine is most commonly used in its base (crack) form and smoked.
• Crack cocaine may be smoked in glass pipes or an endless variety of makeshift devices.
• A heat source is required to turn the solid crack into a vapor. This often causes discoloration of the fingers.
• Cocaine, as described by users, causes a powerful feeling often referred to as "euphoria."
• Cocaine is a powerful stimulant which can cause rapid and dramatic increases in pulse and blood pressure.
• Cocaine is often packaged in small zip-seal bags or in tied-off balloons or sandwich bag corners.

Drug Facts: Methamphetamine

• Methamphetamine is a stimulant that is most commonly smoked, but may also be injected or snorted.
• Methamphetamine users report feeling euphoria after consuming the drug.
• Street names for methamphetamine include crank, speed, meth, ice, crystal meth.
• Meth users may go on what is called a "run" in which they will use meth frequently and for days at a time until they are physically unable to function.
• Methamphetamine can cause significant emergent conditions such as seizure, elevated body temperature and death. Chronically, wasting, malnourishment, "meth mouth" and nervous system damage may occur.

Vitamin Abusers Ending Up in the ED
     People who mistakenly believe that large amounts of niacin will help conceal their illicit drug use can end up in the emergency department with toxic reactions. An article appearing online in the Annals of Emergency Medicine examined four case studies of niacin overdose associated with misguided attempts to pass required drug screening (Toxicity From the Use of Niacin to Beat Urine Drug Screening).

     "A widely circulating urban legend on the Internet promotes the use of high doses of niacin, or Vitamin B3, to clear drugs out of your system before a drug test," says Manoj K. Mittal, MD, of The Children's Hospital of Philadelphia. "In addition to the fact that this does not work, overdoses of niacin can lead to vomiting, dizziness and heart palpitations. It can cause liver injury, and, in extreme cases, even liver failure leading to a need for liver transplant."

     Niacin is available by prescription, as well as an over-the-counter food supplement. Under a doctor's care, it is used legitimately for preventing and treating niacin deficiency, high cholesterol and high triglycerides.

     "Niacin can sometimes cause flushing of the skin, itching and rash," says Mittal. "If an emergency physician does not know the patient has ingested large amounts of niacin, he or she would likely conclude these symptoms indicate anaphylaxis, a life-threatening condition brought on by an allergic reaction. Treating a person for anaphylaxis could be very dangerous for a person who is actually suffering from niacin overdose."
-www.acep.org

Downers
     Downers, like uppers, can come from a wide range of drug classes. Many downers, or more accurately those with a depressant effect on the central nervous system, fall into the class of narcotic (e.g., heroin, methadone). This depressant effect can be achieved through illegal substances (heroin) or prescription drug diversion or theft (methadone, Vicodin, oxycodone). Benzodiazepines (e.g., Valium, Xanax) also depress the central nervous system.

Heroin
     Heroin, sometimes called H or smack, was a popular injected drug in the 1970s. The fact that needle use was required and the influence of HIV caused a temporary reduction in heroin use over a decade; however, it has rebounded significantly in recent years with a new generation of users. Heroin is still most frequently injected, but heroin with higher purity may also be snorted.

     Because most heroin is injected, users will have a tourniquet and syringe, commonly called their "works," available. The needles may be reused; it is common to see an eyedropper with a needle on the end used as a syringe. A spoon and a heat source for mixing the heroin powder into a liquid solution for injection will usually be found.

     The "works" are often kept in an eyeglass case, wrapped in cheese- cloth or similar material to keep the items together and protected. Depending on where the heroin is injected, a tourniquet may or may not be necessary. Heroin may be injected into the arm, but this leaves visible "track marks." It can also be injected into any vein in the foot, legs and even the neck.

     Use caution when performing a patient assessment on any drug user to avoid accidental needlestick. In most cases, using a straightforward approach to ask a known heroin user where his "works" is helps reduce that chance.

     Heroin users describe a "rush" immediately after injecting the medication, sometimes followed by a period of somnolence referred to as going "on the nod." This will vary depending on the amount of heroin used, the purity of the drug and tolerance of the individual.

     It should be noted that the purity of heroin varies widely--even within the same city. This is why heroin is often packaged with a street "brand name" stamped on it. If a user who is used to 10% pure heroin injects heroin with 80% purity, respiratory arrest and death are likely to occur.

     Narcotics, also called opioids, fit into three categories: true narcotics (direct derivatives of the poppy plant: thebaine, codeine and morphine); semi-synthetic narcotics which modify a narcotic (e.g. heroin, Vicodin); and synthetic narcotics that are created chemically to resemble narcotics (e.g., Demerol, methadone, fentanyl).

Methadone, OxyContin and Prescription Narcotics
Drug seekers are seen frequently in hospitals and doctors' offices, and sometimes in EMS. Illicit use of legal narcotic medications is widespread. A few of these medications deserve specific mention.

     Methadone is an addictive substitute for heroin that is used in treatment of heroin addiction and dispensed through methadone clinics. Methadone is longer acting than heroin, and heroin addicts will visit a clinic two or three times per week to get methadone. Methadone--in liquid form--is often ingested in front of a clinic employee. After a client tests negative for heroin for a period of time, methadone tablets may be dispensed. It is common for the liquid (by spitting it back out) or take-home tablets to be diverted for illegal sale.

     Not all persons on methadone are being treated for heroin addiction. As a narcotic, methadone is a potent analgesic and is prescribed with increasing frequency for chronic pain and some cancer patients. Its sustained action and reasonable cost make methadone attractive for chronic pain treatment.

     OxyContin, a long-acting form of oxycodone (Percocet is oxycodone with acetaminophen), has had wide media coverage over the past several years. It is commonly taken twice daily by patients with moderate to severe pain that is present most or all of the time.

     The abuse potential of OxyContin increases when the tablet is crushed or chewed, which releases a large quantity of narcotic all at once. Illegal demand for this drug has been so strong that many pharmacies have stopped carrying it to prevent armed robberies and burglaries.

Narcotic Pathophysiology and Treatment
     Narcotic medications are used primarily as analgesics, although they also reduce coughing (by depressing the cough reflex) and anxiety. Analgesia is created when the drug binds to receptors in the central nervous system, which prevents pain impulses from reaching the brain. The actual drugs that act as agonists for various suspected opioid receptors in the central nervous system (e.g. mu, kappa, delta) have not been definitively identified.

     Unlike stimulant overdose, the narcotic antagonist naloxone (Narcan) is available for narcotic overdose. Narcan is typically administered intravenously at a dose of 0.4 mg to 2.0 mg titrated to reverse respiratory depression and hemodynamic instability. Narcan can be administered subcutaneously and intramuscularly, and can be administered intranasally using a nasal atomizer device to ensure the appropriate micron-sized drug particle is delivered for maximal absorption across the nasal mucosa. This method provides a direct route to the blood-brain barrier. Repeat doses may be administered at 10-minute intervals as needed.

Withdrawal
     Many of the drugs discussed have significant withdrawal syndromes. The syndromes for cocaine and heroin are different and worthy of contrasting here.

     Heroin addicts will begin withdrawal about 12-24 hours after the last dose. Simply stated, withdrawal creates a severe physical illness, beginning with mild flu-like signs and symptoms that include sweating, chills and nausea, which progress to severe flu-like signs and symptoms with profound aches, chills, nausea and vomiting. Taking heroin eliminates the withdrawal signs and symptoms rapidly.

     Cocaine withdrawal is described by addicts as a craving or "gnawing at the soul." Since cocaine use is believed to prevent reuptake of neurotransmitters in the brain, withdrawal significantly reduces the neurotransmitters, causing the craving sensation.

All-arounders

LSD
     LSD (lysergic acid diethylamide) has been a commonly used hallucinogen for decades. Its relatively low cost, availability and ease of use keep this substance high on the list of popular hallucinogenic substances. A "hit" of LSD usually costs $2-$5.

     LSD is most commonly found on blotter paper. The clear liquid LSD is dropped onto small perforated sheets of paper, which the abuser places in his or her mouth, where their saliva liberates the LSD from the paper. Uncooked pasta and small paper dots and stars are used in the same fashion to house and abuse LSD.

     Depending on the amount of LSD ingested, the effects can last anywhere from 4 to 12 hours. These effects include hallucinations and sensory distortion. Taking LSD sends the user on what is commonly referred to as a "trip." While most take the drug for pleasurable sensations, it is possible to have a "bad trip" with unpleasant, dangerous or paranoid sensations.

Ecstasy
     Known as "X," "E," XTC or MDMA, ecstasy combines stimulant properties with those of a mild hallucinogen. The drug, originally brought into the spotlight at rave and techno parties, is now used by younger populations on high school and college campuses.

     The combination of a stimulant (ecstasy is actually 3,4-methylenedioxymethamphetamine) and hallucinogen provides an energizing effect, as well as euphoria and reduced inhibitions, and reportedly increases the intensity of feelings and sensations.

     Since ecstasy is created in a drug lab, other substances are commonly found in the tablet, including methamphetamine, caffeine and dextromethorphan. A patient or bystander may admit to taking ecstasy, but may have unknowingly ingested another substance. Further complicating ecstasy overdose is the frequent concurrent ingestion of alcohol, marijuana and other substances.

     Ecstasy is found in tablet form in varied colors, often with a symbol pressed into the tablet (e.g., a peace sign or extended middle finger). This makes ecstasy easily discernable from tablets produced by pharmaceutical companies.

GHB
     GHB, short for gamma hydroxybutyrate, is also called "G", goop, liquid E and liquid X. (GHB has no chemical relation to ecstasy.) GHB is most commonly found as a liquid and is consumed in drinks like alcoholic beverages.

     GHB is a depressant, which also causes a feeling of euphoria. Depending on the dose, the euphoria may be followed by a period of significantly altered mental status, including unresponsiveness, agitation or a combination of both. Its liquid format and depressant effect make this a potential date rape drug.

Pathophysiology and treatment
     All substances described in this article achieve their effect through the central nervous system. LSD and ecstasy are believed to cause their predominant effects through serotonin receptors in the central nervous system: LSD by inhibition and ecstasy by slowing reuptake. GHB has a wide range of effects on several different receptors in the brain.

     In this group of drugs, it is challenging to get an accurate history of the substance ingested. This is because patients and their friends are hesitant to disclose this information, and because what has been passed off as a particular substance may not actually be that substance. Yet, it is crucial for the EMS provider to gather as much information as possible from the patient, bystanders and law enforcement at the scene. This may be the only valid information on which the hospital will base its care decisions.

     While each substance has different actions, without an antidote, treatment is directed at urgent signs and symptoms that arise, including airway care in unresponsive patients, temperature derangement, and treating significant hypertension, tachycardia and seizure. Be alert to the possibility of sexual assault when patients are suspected of ingesting these substances. The ingestion may be intentional or unintentional if it was placed in a drink.

CEU Review Form Street Drugs (PDF)Valid until July 6, 2007

Daniel D. Limmer, AS, EMT-P, is a paramedic with Kennebunk Fire-Rescue in Kennebunk, ME, and EMS Program Coordinator at York County Community College in Wells, ME. He is the author of several EMS textbooks and a nationally recognized lecturer.

Joseph J. Mistovich, Med, NREMT-P, is a professor and chair of the Department of Health Professions at Youngstown (OH) State University, author of several EMS textbooks and a nationally recognized lecturer.

William S. Krost, BSAS, NREMT-P, is an operations manager and flight paramedic with the St. Vincent/Medical University of Ohio/St. Rita's Critical Care Transport Network (Life Flight) in Toledo, OH, and a nationally recognized lecturer.