Keeping Pace with a Rapidly Changing Drug Market

Stay ahead of emerging challenges with this episode on trends in the illicit drug market and their impact on emergency care. Commander Christine De Forest shares first-hand clinical experience managing patients with substance use disorders, with a focus on potent synthetics like fentanyl and xylazine (“tranq”), withdrawal protocols, pharmacologic strategies, and practical considerations for ED clinicians. Equip yourself with current approaches to improve outcomes for patients struggling with addiction in your emergency department.

Keywords: substance use disorder, emergency department, opioids, synthetic drugs, fentanyl, xylazine, withdrawal management, pharmacologic treatment, harm reduction, emergency medicine, clinical practice

Transcript

Unknown: 0:00

Announcer,

Narrator: 0:07

welcome to the government services Chapter of the American College of Emergency Physicians. Podcast gsapp represents emergency physicians who work in the federal government, including active duty military National Guard and military reserves, as well as the Veterans Administration, Indian Health Service and other federal agencies, our mission is advancing emergency care for America's heroes. In this podcast, we bring you lectures and conversations with leaders in federal emergency medicine to help you better care for your patients and lead your departments. The views expressed on this podcast are personal views and do not represent the views of the Department of Defense, any branch of the military or the federal government, and they do not constitute endorsement of any product by any of these entities. The

Matthew Turner: 1:17

Matt, hello everyone and welcome back to the government services ASAP Podcast. I'm Captain Matthew Turner, a current PGY three resident, and today I'd like to introduce our guest speaker. Commander Christine De Forest is an active duty em physician for the US Navy. She graduated from the Philadelphia College of Osteopathic Medicine with the HPSP program. She completed an Operational Medicine Torree as a flight surgeon, before completing her training as an EM physician through the residency training program at Navy medicine Readiness Training Command San Diego, she currently works at the University of Pennsylvania Presbyterian Medical Center through a civilian and military partnership, today, she will address the challenges of evaluating patients In the ED who have substance use disorder and discuss treatment considerations to improve their care.

Christine DeForest: 2:06

Now this is a really pivot on topic, but this is a lesson that I really had to become smart on when I joined the team at Penn and I graduated from medical school in Philadelphia, College of Osteopathic Medicine, and I thought I had some reference and exposure, having done my emergency medicine rotation in the inner city, understanding a little bit as to what that looks like, and most certainly in residency, we had exposure where we rotated through urban and underserved communities that have a higher proportion of patients that present with undiagnosed medical conditions complicated by drug use. And that is not to say that this is a problem that's unique to those subsets in emergency departments, but when I returned to Philadelphia just last summer, this is an area that I really had to become smart on, and this is an area where I was really impressed by the work of the colleagues who have addressed the needs of our patients in that city. And so I share that with you, and one of my focuses will be to look at the resources that can help you to become more equipped to helping these patients when you're doing off duty employment, or if you're transitioning to civilian, er, if you're come to the end of your military career. Now this is a presentation of the thoughts of my own. It does not represent the DOD, and I have no personal or financial disclosures. My objectives are going to be to review some of the trends the illicit drug market, as well as discussing pharmacologic options in addressing the substance use disorder while you're helping patients also concurrently treat their medical conditions. And I will close with some discussion points regarding dexmedetomidine, which is something that has come into more frequent use within our own emergency department as we address a lot of the cross contaminants in drugs. So the NIH National Drug early warning system is a program that has staffed and looks at the trend of drugs throughout the United States and the drug use within key cities, which helps in guiding some of the recommendations, not just in addressing public health, but also in addressing what has evolved or trend, and how do we need to advance in medical care to treat the needs of our patients. And so this is a great resource if you are working in any of these regions and even in distant proximity, it may give you an understanding as to what's predominantly in circulation in your own region. We have seen a progressive rise in opioid overdose. We have seen this since 2014 19, we have seen this with synthetic substances, and the predominant use of synthetic substances has made it even more challenging for us to help our patients. And I can't really address the treatment unless we give one big step back and remind ourselves as to the some of the effects of medications. So brief overview on a few drugs, and I'll reference you to the DEA that has site that does have overall information and a variety of substances, if you need a quick refresher yourself. So cocaine is actually a high volume use in Philadelphia. This is a long time drug of use, and it's primarily abused because of the for you associated with it. And you probably remember from medical school that there is a lot of cardiac concern with patients because the dysrhythmia or ischemia associated with use. This does have variety of methods, route for use, ultimately, snorting or inhaling medication may have the least secondary effects, as with most of these drugs, and that it does have a lower risk rate of concurrent infections, wounds, complications as such, heroin, still primarily of opiate extract abuse, also with euphoria, does have some sedating alert peaks associated with it. One of the big challenges with heroin use is because of how it is cut with other substances. This varies the strength, which can have a high risk rate for patients, because it's hard for them to have a reliable understanding as they try to dose themselves, changing suppliers, changing how they procure the substance, can have high risk that they'll overdose On a subsequent use. Overdose will result in respiratory depression, seizure, coma. So let's segue into synthetics, because this is really where we've seen that huge spike in evolution. And as we all know, we use fentanyl and an analgesic effect for our patients, but this is also something that has gone into high potency and use within patients for recreational use, once again, huge euphoria associated with this. Now reminder here the concentration effect. We know that in our dosing, but it's important to frame this as we start to then discuss in the future as to how we control withdrawal symptoms, so 100 times the potency of morphine, 50 times the potency of heroin. So patients that transition through different drugs of use may gradually have some dose effect or benefit out of the drug that they are using, but this also influences their dependence and their physiologic effect in the body and what they are then most used to overdose results in a lot of depression, so your respiratory depression, your blood pressure drop. These are the patients that are coming in with pinpoint pupils. Now, fentanyl is a challenge, one because of the potency of what's circulating in use. Secondly, is the adulterants that are being used. And so there's been a real transition into pushing for test trips and education to test not just whether or not there's contaminant within the substance, but also looking at if this is a true sample of what they have purchased or procured, so the adulterants that I have referenced. So this is a map of looking at xylazine use. And as you'll see in that purple area, which is of which spans from Philadelphia down through dc into kind of Virginia region has really a hotbed in high concentration, though, we have seen xylazine extend into other areas across the United States. This is an area, something that really you don't see significantly over on California and I PCs from California back to the East Coast when I moved to Philadelphia. So this is something that I rapidly had to become smart on and understanding. And a lot of my colleagues were used to a day to day practice of addressing some of the the needs that our patients had secondary to their use. So what is xylazine? So xylene is xylazine, is otherwise known as tranq, and it is important for us to become understanding of the common terms and references and names for our patients. But I am very humble in that encounter. Tell me what you're using. If I don't know what it is, then I will really try and look at. What else? What else does it go by in understanding it's important, if we don't know what our patient's using, then we really can't help in addressing withdrawal symptoms. So it's Veterinary and there are some articles out there and looking at kind of overdose options, particularly with accidental occupational exposures by our veterinarian colleagues. But there's no reversal on the market. And so it's not opiate. It's an analog to quantity, and that's important as I'll segue into some treatment on withdrawal symptoms. And it's alpha two adrenergic. And so these patients come in with variable sedating effect, and the sedative associated with it, and the analgesia associated is what makes it attractive for use. Now there's variable sedating effect timelines. This might be an hour. It might be a little bit more prolonged when patients come in, and because it's not an opioid, Narcan doesn't work. And so it's important to understand what's in circulation. As our patients present us and we start to get after how are we best going to treat respiratory distress, failure, cardiopulmonary collapse. On the flip side, withdrawal will cause a lot of agitation, tachycardia, elevated blood pressure. That's really helpful as well, because we may have a patient that presents with medical conditions, we start initiating treatment. We aren't able to get a full or reliable history, and their variable vital signs can help us in kind of process of elimination, what's going to work best in supporting them? Now metatomy, see the Health Alert up here on this slide, and this is the public health alert that was released in Philadelphia. And I encourage you to seek information through the public health alerts for your city. As you're looking at what is in circulation, and are we seeing a shift in the market that may affect our patients coming in, once again, veterinarian use sedative, non opioid, and this is where we look at and helpful for us to know, dexmedetomidine is your active enantiomer for human sedation. So that's our closest comparison to this, and something that's currently in pharmacological use in our hospitals, 200 times the potency of xylazine. So there's a real graduated effect. With that, we dealt with huge respiratory depression, prolonged sedation with xylazine. And now that we are a couple years from introduction of xylazine into the Philadelphia region, we're starting to see metatomidine. And with that, we're having these huge kind of almost recurrence of what we're seeing in the ED with a prolonged sedation. All right, so reversible challenges, as I address, Narcan, may not work on the concentration that people are using. There is a higher rate of flash pulmonary edema with a higher dosing on Narcan. So it's not something to ignore, but expect that your first dose may not work, and we're needing to go with higher doses up front. Also look at that other medications may have been used which will just fail to respond to Narcan, so it still leaves a drug overdose on the table for your differential All right, I am going to breeze through sedative hypnotics, but I want to include that because, once again, sedating effect on patients whole different receptor group with the GABA receptors. And with this, we're seeing withdrawal that further compounds agitation and autonomic hyperactivity. So a lot of concurrent use is important to recognize barbiturates have gone into circulation a little bit more as we look at additional states that are looking at assisted suicide. And so if that's applicable to where you work, become smart on those two methadone both a treatment as well as a drug of abuse. And so important to understand that. So let's get into treatment in the last few minutes that I have with you. Picture that you see on the screen is a patient that has used xylazine is chronic use. What we see is a lot of osteomyelitis. We see a lot of lymphedema. We see patients that have significant amount of vascular collapse with that, a lot of scarring with that. That's not unusual. For IV drug abuse, some patients may be injecting into the wound. It's important to create that quick physician patient relationship so that we can get to how best can I help and treat you? This 32 year old male patient presented with chills, rigor, and he was hypotensive, as you'll see, his heart rate, not so bad. There so key questions that I want to know, what do you use? Are using benzos with it? How about alcohol? It helps me in understanding, do we need a bimodal approach to withdraw symptoms? Where are you using and then why? And for this, it's why are you here in. Emergency Department, are you looking for detox? And that may be a patient that doesn't need a medical admission, but I really want to meet you with where you're at and give you support and resources. If I'm admitting you into the hospital, it helps us in understanding some of the medication plan for them. And if you're fortunate enough to be somewhere with addiction medicine, then that's going to guide some of their care. But in the ED, I want to understand, are you going to stick around for treatment, or do I have a very short window before you go into withdrawal? Want to be discharged? And I'm discharging a hypotensive patient with osteomyelitis, it certainly changes my antibiotic selection. We can't forget the current medical conditions, and of which includes with this HIV. So with withdrawal management for inpatients, primarily focusing on titrating to effect for medications and getting them on a long acting medication to assist. So let me go into that for this patient. This is a screenshot as the medications order to help and assist this patient. What you don't see in this screenshot is the methadone that I'll also discuss in ordering for him. You'll notice perhaps that the oxycodone is also of a high dose extender release 80 milligram every eight hours. This patient required extremely high doses to get as close as we could to matching what they were using before they presented, but it was important for us to address those needs so they were willing to stay and receive the medical care that they needed. This is higher than the entry dose for oxycodone for most of my patients. If you have a hard time in looking at what matches across to dose specific treatments, then consider using a calculator, and several states have that available. This is one that's through Washington State. Become familiar with cows. This helps in understanding and I will simultaneously put them on Siwa if they're using benzos and Ativan. It gives our nursing a framework to titrate the medications as well as to address the needs of our patient, it gives a concrete number to look at if we're catching up or if we're making ground on their symptoms. So let's go into what I will introduce to you for treatment, methadone. Our patients are coming in the emergency department. I get them on methadone. I start them at 30 milligrams, and in their first dose day, I will increase them to a total of 40 milligrams through an additional 10 milligrams added at four hours, depending on their cows, we do have benefit of a titrated effect. And with boarding, we'll see patients in the emergency department needing that day two, day three treatment. I order that a protocol up front that helps in supporting continue care, and that also helps our nursing colleagues. These are challenging patients. These can be frustrating. It is hard to help them because they are so agitated, anxious and just physically feeling sick and unwell. This helps me and our nursing to be on the same aim as we're working to help this patient. Now, a reminder get to that EKG, a lot of our patients may have electrolyte abnormalities, malnutrition, and it's important to correct those because methadone is a Qt prolonging medication, as is Zofran, which is one thing that helps with a lot of the vomiting that they experience. But I don't order if they have a prolonged QT also get them on short acting opioid agonists. I reference our patient presenting with a higher dose of opioid because he needed to be titrated up to that. But I start at 40 milligrams every eight hours, and I do that up front with then IV medication. Now Dilaudid wool has a very short half life. We're actually experiencing Dilaudid shortage. It makes it a challenge. Some people will say, I don't want to give a patient Dilaudid. It just adds in to their addiction when they leave. But this patient is going to leave if I don't address their medical and their addiction needs. And so to me, I'm treating this as a comprehensive problem, quantity. This is important because of the alpha two effect. This is now you'll be limited at starting at point one milligram, but reassess and increase that, and they can get to point two or point three Po. Po route has longer efficacy for our patients and greater benefit. But if they're having a lot of vomiting, I'll get a transdermal patch on while I'm trying to get control of their symptoms, and then reconsider transitioning them back to po tasanadine doesn't have the same concerns on hypotension or with the Qt prolongation, so become familiar with that as well. And then for severe withdrawal, like I said, we also look at addressing them with additional analgesia options. So osteomyelitis is painful for these patients as well. We may need to look at ketamine as a PO option and try to help in controlling that pain in addition to the withdrawal. Symptoms that can cause hypersensitivity and hyper alert to that. So this treatment adjunct list also addresses the GI side effects, as well as some of the temperature regulatory effects for patients who are coming in experiencing concurrent withdrawal. Now dexmedetomidine, we are held within the same parameters and looking at the sedation effect and protocol for us with ICU patients, this does buy them into an ICU bed. This is not the first thing that I start out the door, but if they're having hypertension and tachycardia, that's hard to control, particularly knowing that they're using medications within our city that has a high rate of metatomy adjutant, then I will reach for dexmedetomidine. This helps in gaining control of the symptoms and gets them on a treatment pathway that is closest to treating with what they're otherwise used to and dependent to when they're out of our doors. Our closest reference to that is ICU and controlling alcohol use disorder. And I remind you that if there are using alcohol or benzos, it is important that you also treat them, then with Ativan, benzos separate, but your facility may be pretty concerned on the sedating effect, respiratory effect, so talk this through before you just put this on a patient and land them in the ICU. All right. Dosing, as I referenced for us, we're point two, 2.4 micrograms per kg per hour. We titrate up. We look by Rasc score, just like we would for a sedating. And goal for us is still to have that pleasant alert, but we are at the minus two to two range. We have them on cardiopulmonary monitoring. It does buy them into an ICU admission and caution not to bolus this medication because of the concerns on hypotension and bradycardia. So this patient ultimately had treatment. He was continued on HIV meds, aside from methadone, oxycodone, he had his IV antibiotics and clonidine. So with that, I'll close. This is an overview as to medications to consider addressing our patient's needs with the dependence that they have prior to entering so they can best meet their medical needs while they're with in our care. Thank you.

Narrator: 22:35

Gsacep is proud to be the premier Continuing Medical Education Source for military and federal emergency physicians to purchase. Cme for the episode you just listened to, please click on the link in the show notes. The government services Chapter of the American College of Emergency Physicians promotes quality emergency care and enhances the development of Emergency Physicians who serve our nation from training through retirement. Learn more about our chapter at www. Dot GSAC ep.org, you.