Toxicology Today
Never underestimate the ingenuity of drug users
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. When EMS is called, the challenges are great. Neither patient nor caregiver 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. EMS providers are often caught unaware of what is going on in the drug-abuse community. Understanding the basics of pharmacology is mandatory, because if we understand the actions of the substances that people take, we will be better able to deal with them.
