Amphetamine-Related

Presentations to EDColleen Taylor CME 15th May 2014

What we will cover

A little bit of history

A little bit of epidemiology

Case study

Acute and chronic complications of amphetamine

use

What are Amphetamines?

Synthetic psychoactive drug

Phenylethylamine derivative

Stimulates the release of catacholamines and

inhibits reuptake of monoamines. Increase in

central + peripheral NA, DA and 5HT

Prescription formulations e.g. dexamphetamines,

methylphenidate (Ritalin)

Or illegal formulations: Ice, speed, tablets

History of Amphetamines

First synthesised in Germany in 1887 (1)

Used medically in 1930’s as stimulant for nasal

decongestion, which progressed to treatment for

narcolepsy, hyperemesis and hyperactivity in

children (2)

Widely used in WWII to improve concentration

and endurance

Rendered an illicit drug 1970’s (3)

How Common is

Amphetamine use?Multiple sources state that amphetamines are the second most common drug of abuse in Australia after cannabis (1, 3, 4)

Lifetime use 7.7% in men vs 4.9% in women (1)

Study at RPH in 2005 showed 1.2% of all attendances related to amphetamines, with high acuity (66% triage 1-3) and 1/3 of all needing psychiatric assessment (4)

Between 2006 and 2010, there were 2062 persons with a primary diagnosis of amphetamine-related psychosis in outpatient and inpatient services of metropolitan hospitals in WA (5)

Case Study

34 year old man

PMH: Cluster B personality disorder, ? Bipolar

affective disorder

Long history of polysubstance abuse mainly

alcohol and methamphetamines

Abstained from amphetamine use for past 3

months, but took several amphetamine tables

orally the night before presenting to Charlies ED

Case Study

Complaining of sudden onset of severe left sided chest pain, both dull and sharp. Radiated to the left of the chest and through to the back

Associated with shortness of breath, sweating and nausea

No cough, fever, haemoptysis

Had some numbness in all 4 limbs, which may have been slightly worse in the left arm and leg than the right

No weakness, no slurred speech or facial droop. No headache

Recent flu-like illness 5/7 ago

Case Study

O/e:

- A = Patent

- B = RR 18 sats 89% RA, Clear chest, no chest wall tenderness

- C = CRT <2, pulse 140, BP 141/60 (L), 147/85 (R), CV I+II+O

- D = GCS 15, normal neuro examination with no reduced sensation to light touch or pinprick

- E = Temp 37.6, Soft abdomen, no obvious track marks

Case Study

Bloods:

- WCC 13.5, otherwise normal

- U+E normal

- LFT normal

- Troponin 34/23

CXR: normal

ECG: Sinus tachy with no ST changes

CT Aortogram: Normal

Case Study

Treatment:

- IV diazepam

- IV opiates

- Anti emetics

- Fluids

After period of observation, chest pain settled, tachcardia settled, blood pressure reduced.

Diagnosis of acute amphetamine toxicity

Acute complications - CVS

Tachycardia

HTN

Dysrhythmias

Acute coronary syndrome

Acute cardiomyopathy

Acute pulmonary oedema

Acute Complications - CVS

Tachycardia and HTN

- Use titrated doses (2.5 -5mg) of IV benzodiazepines

- If unresponsive, consider use of nitrites

- Beta-blockers are contra-indicated

Dysrhythmia's:

- Treat with benzodiazepines and conventional measures

- Correct hypoxia, acidosis, electrolyte disturbances

Acute Complications - CVS

Acute Coronary Syndrome

- Mechanism may be increased myocardial oxygen demand, coronary artery spasm, platelet aggregation, and thrombus formation secondary to elevated catacholamine levels (9)

- ACS diagnosed in 25% of patients presenting to the ED with chest pain after methamphetamine use (6)

- The population attributable risk suggests that amphetamine abuse is responsible for 0.2% of acute myocardial infarction (6)

- Manage ACS conventionally but consider CT brain should be performed prior to anticoagulation or angiography if headache is a feature

Acute complications - CVS

Aortic dissection

- Amphetamine abuse is significantly associated

with aortic dissection. In one study odds ratio =

3.33, 95% CI = 2.37-4.69, P < .0001 (7)

- Another study suggests 20% of all patients with

aortic dissection under the age of 50 years are

due to amphetamine misuse (8)

Acute Complications -

NeurologicalAgitation/Aggressive behaviour

Psychosis

Movement disorders

Seizures

Intra-cerebral haemorrhage

Acute Complications -

NeurologicalAgitation/behavioral disturbance

- Mild: PO diazepam 10-20mg +/-olanzapine

wafer. Consider review of benzodiazepines after

more than 60mg required

- Moderate/severe/refusing PO meds: IV

benzodiazepines +/- droperidol. If failing to

respond, consider IM olanzapine

Acute Complications -

NeurologicalMovement disorders

- Increased muscle tone or repetitive movements e.g. bruxism/choreoathetoid movement

- Treat with PO/VIV benzodiazepines

Seizures

- Treat with PO/VIV benzodiazepines

- Consider barbituates as a second line agent

- Correct reversible causes as per normal seizures

Acute Complications -

NeurologicalIntra-cerebral haemorrhage

- Headache should be considered as a red flag in

amphetamine users; early CT is a priority

- Many factors could be involved including

vasospasm, cerebral vasculitis, enhanced

platelet aggregation, cardioembolism, and

hypertensive surges. Around 40% of patients

have pre-existing lesions (10)

Acute Complications -

OtherHyperthermia

- Temperature >38.5°C: continuous core-temperature monitoring, IV benzodiazepines and passive cooling with tepid sponging/cool spray/fluids

- Temperature >39.5°C: Consider intubation and ventilation for rapid active cooling. Paralysis if intubated.

Hyponatraemia

- If >120mmol, no seizures/change in GCS, manage conservatively with fluid restriction. If any of above, consider 3% hypertonic saline

- Think about glucose and K+ abnormalities

Acute Complications -

OthersRhabdomyolysis

Dirty hit

Foreign body embolus

Chronic complications

Increased risk of septic emboli e.g. endocarditis,

lung/brain abscesses

Increased risk of stroke

Increased risk of cardiovascular disease

including cardiomyopathy

Increased mental health issues

Poor socioeconomic outcomes

Conclusions

Amphetamine use is common

Look for features of amphetamine toxicity

including tachycardia, HTN, sweating and

agitation

Headache, chest pain and hyperthermia are all

red flags and should be thoroughly assessed and

managed

If in doubt, give benzodiazepines!

References

1. Greene, SL, Kerr F and Braitberg, G. Review article: Amphetamines and related drugs of abuse. EMA 2008; 20: 391-402

2. http://www.cesar.umd.edu/cesar/drugs/amphetamines.pd. Accessed 14/05/2014.

3. Ellatt EC, Montgomery S, Nemiki T, Noguchi T. Misrepresention of stimulant street drugs: a decade of experience in an analysis program. J. Toxicol. Clin. Toxicol1986; 24: 441–50.

4. Gray SD, Fatovich, DM, McCoubrie DL and Daly, FF. Amphetamine-related presentations to an inner-city tertiary emergency department: a prospective evaluation. Med J Aust2007; 186 (7): 336-339

5. http://drugaware.com.au/Drug-Information/Amphetamines/Amphets-And-The-Ed.aspx. Accessed 14/05/2014.

6. Turnipseed SD, Richards JR, Kirk JD,Diercks DB, Amsterdam EA. Frequency of acute coronary syndrome in patients presenting to the emergency department with chest pain after methamphetamine use. J Emerg Med. 2003;24(4):369-373.

7. Westover AN and Nakonezny PA. Aortic dissection in young adults who abuse amphetamines. Am Heart J. 2010 Aug; 160(2):315-21. doi: 10.1016/j.ahj.2010.05.021.

8. Wako, E., LeDoux, D., Mitsumori, L. and Aldea, G. S. (2007), The Emerging Epidemic of Methamphetamine-Induced Aortic Dissections. Journal of Cardiac Surgery, 22: 390–393. doi: 10.1111/j.1540-8191.2007.00432.x

9. Nolan J and Ghuran A. The cardiac complications of recreational drug use. West J Med. Dec 2000; 173(6): 412–415.

10. Pozzi M, Roccataglitan D and Sterzi R. Drug abuse and intracranial haemorrhage, Neurol Sc. 2008; 29 (issue 2): 269-270