2025 – PAGE 207 – EMERGENCY MEDICINE & TOXICOLOGY

COCAINE

Cocaine may cause AGGRESSION, VIOLENCE, EUPHORIA, overconfidence, and HTN (which you should treat with nitroprusside). Death is not dose-dependent. IV benzodiazepines (diazepam or lorazepam) are the most commonly used medications for cocaine overdose. They reduce sympathetic outflow in patients who are anxious, agitated, hypertensive, or tachycardic.

HALLUCINOGENS

Hallucinogens include phencyclidine (PCP), lysergamide (LSD), peyote (mescaline), psilocybin mushrooms, and recreational nutmeg.

PHENCYCLIDINE (PCP)

Phencyclidine, AKA PCP, may cause vertical and/or horizontal nystagmus. It also causes ataxia, lid edema, muscle rigidity, RHABDOMYOLYSIS, paranoia, agitation, HTN, violence, and hallucinations (auditory or visual). There may be miosis, mydriasis, or normal pupils. Treat with a cooling blanket ± haloperidol. Do NOT use restraints.

LYSERGAMIDE (LSD)

LSD is a colorless, tasteless, and odorless powder from the fungus, Claviceps purpurea. It results in perceptual changes and hallucinations (auditory or visual). Sympathomimetic effects and dysphoria are common and result in unpredictable and aggressive behaviors. Overdose results in hyperthermia, coma, respiratory arrest, tachycardia, hypertensions and coagulopathy.

SEDATIVE HYPNOTICS

The sedative hypnotics class of drugs includes benzodiazepines, barbiturates, chloral hydrate (when mixed with ethanol, this is called a “Mickey Finn”), methaqualone (“Quaaludes”), baclofen, carisoprodol and meprobamate.

BENZODIAZEPINES

Benzodiazepines, such as midazolam, have common symptoms of abuse such as CNS depression, nystagmus, and ataxia. In cases of overdose, RESPIRATORY DEPRESSION and hypotension can occur. Reversal of acute benzodiazepine ingestion may be accomplished with flumazenil. Flumazenil should NOT be given to a patient on chronic benzodiazepines because it may induce seizures.

BARBITURATES

BARBITurates (e.g., phenobarbital) may cause RESPIRATORY DEPRESSION, hypotension, and psychosis.

OPIOIDS

Use of opioids may result in respiratory depression, miosis, euphoria, INDIFFERENCE to pain, hypotension, hypothermia, urinary/stool retention, and pulmonary edema.

MARIJUANA (MJ)

Look for poor interpersonal skills and inattentiveness (poor memory) when marijuana (MJ) use is suspected. The patient may have mydriasis or gynecomastia. Withdrawal is not common but may result in insomnia, nystagmus, or tremors. Drug testing can be positive for up to about ONE week (actually five days) for ONE use, about TWO weeks (or 10 days) for frequent use, and one month for daily use.

PEARL: Alcohol is the most common “substance of abuse,” but MJ is the most common “illicit” drug used. Tobacco has fallen out of favor in recent years.