Substance Misuse, Violence & Aggression

Week 4

Addiction Statistics

• 15-24 yr olds experience more substance abuse disorders

• Men have higher rates of substance abuse than women

• People with mental illness are 2x more likely to have substance abuse

• People with substance abuse disorders are 3x more likely to have mental illness

• 67 000 deaths per year in Canada

Addiction

Any behaviour that is ‘out of control’ in some way. It becomes a problem when there is harmful consequences or a loss of control.

4 C’s

Craving, Loss of Control (amount or frequency), Compulsion (to do or use), Continued use despite Consequences

Why do people become addicted?

• Genetic Vulnerability (predisposition - addictive personality)

• Drug-brain Interactions (dopamine, pain relief)

• Environment (exposure to substance abuse in home, peer pressure)

• Coping Mechanisms (abuse to trauma, stress, MH issues)

Controlled Drugs and Substances Act

1. Schedule I (Opioids, Cocaine, Amphetamines, PCP, MDMA)

2. Schedule II (Cannabis, Cannabinoid, Hashish)

3. Schedule III (LSD, Psilocybin)

4. Schedule IV (Barbiturates, Benzodiazepines, Anabolic Steroids, Date Rape)

Health Canada: National Drug Schedules

1. Schedule I: Prescription-only drugs

2. Schedule II: No prescription required, sold by pharmacist, kept in inaccessible area to public

3. Schedule III: No prescription required, sold from self-selection section of pharmacy

4. Unscheduled: No prescription required, sold without professional supervision

Alcohol Factsheet

Class: Depressant

Forms: Wine, beer, mouthwash (yellow listerine)

Alcohol Overdose (S/S Acute)

• Lowered GCS and LOC

• Slow, irregular breathing and HR

• Low temp, pale, clammy

• Dulled responses, loss of protective reflexes

• Vomiting and seizures

Alcohol Use: Chronic

• HTN, stroke, heart attack, liver disease, ascites

• Wernicke-Korsakoff Syndrome (B1 deficiency, memory loss, acute encephalopathy)

• Alcohol-induced hypoglycaemia (inhibits gluconeogenesis)

Alcohol Withdrawal

• Begin within 6 hours of stopping drinking

• Mild/Moderate: HTN, tremors, anxiety, palpitations

• Delirium tremens (DTs): Hallucinations, body spasms, diaphoresis, tachycardia, seizures 

Alcohol Use Disorder (AUD)

A person has a hard time controlling how much they drink, even when it's causing problems in their life. Has two or more traits in a 12-month period

AUD Management

Antabuse: Makes them uncomfortable when drinking (psychological deterrent)

Naltrexone and Topiramate: Makes drinking less rewarding (anti-craving medications)

Caffeine Factsheet

Class: Stimulant (people with ADHD)

Caffeine Overdose

• Tachycardia and tachycardic dysrhythmias (VT/SVT)

• Headache

• Nausea/vomiting

• Dizziness

• Dilated pupils

Caffeine Withdrawal

• Begin within 12-24 hours after stopping caffeine intake

• Reduced LOC, fatigue, mood

• Headache, ‘foggy’ feeling, difficulty concentrating

Nicotine Factsheet

Class: Stimulant

Difficult to overdose on (besides children and teenagers)

Nicotine Overdose

• Early/Mild: Nausea, HTN, Tachycardia, Tachypnea, Salivation, Dizziness

• Severe: Respiratory failure, Bradycardia, Seizures, loss of reflexes

Cannabis Factsheet

Class: Difficult to classify (depressant, stimulant, hallucinogen effects)CA

Cannabis Overdose

• Anxiety/panic attacks

• Psychotic reactions (paranoia, hallucinations, delusion)

• Loss of judgement and perception, Low LOC

• Tachycardia, HTN

• Seizures

Cannabinoid Hyperemesis Syndrome

• Excessive vomiting (years of use, pattern of hyperemesis, resolution confirmed after negative urine sample)

• Symptoms relieved by hot baths or showers

Medical Marijuana

Prescribed to ease or control symptoms of various diseases or disorders. (Alzheimer’s, ALS, HIV/AIDS, Crohn’s, Epilepsy, etc)

Opioid Factsheet

Class: Depressant

Usually white but can be different colours

Presentations: Rocks, powder, tablets

Often mixed

Opioid Overdose

• Intoxication: Miosis, Bradypnea, Altered LOC, drowsiness, confusion

• Overdose: Unconscious, Miosis, Apnea, Bradycardia, Cardiac arrest

Opioid Withdrawal (Dope Sick)

• Mild/Moderate: Aches, anxiety, runny nose, sweating, inability to sleep

• Severe: Abdominal pain, nausea, dilated pupils, tachycardia, HTN, diaphoresis

Clinical Opioid Withdrawal Scale

• S - sweating

• T - tremors

• O - pupil size

• P - piloerection (goosebumps)

• T - tachycardia

• R - restlessness

• Y - yawning

• I - Irritability or anxiety

• N - nose running or eyes tearing

• G - GI upset

• Joints - joint/bone pain

• Req. > 8 score to be treated with suboxone by paramedic

Opioid Addiction Mangement

• Naloxone: Used in acute overdose, blocks opioid receptors temporarily

• Methadone: Safer, long acting opioid, reduces cravings

• Naltrexone: After stopped using opioids to remain opioid-free

• Suboxone: Mixture of buprenorphine and naloxone, reduces cravings without sedative/depressive effects

Naloxone Use by PCPs

• Indications: Opioid toxicity

• Age: > 24 hours

• LOA: Altered

• HR: N/A

• RR: < 10 breaths/min

• SBP: N/A

• Other: Inability to adequately ventilate or persistent need to assist ventilations

• Contradictions: Allergy or sensistivity to naloxone

Suboxone Use by PCPs

• Indications: Opioid toxicity

• Age: > 16

• LOA: Unaltered

• HR: N/A

• RR: N/A

• SBP: N/A

• Other: Received naloxone for current opioid episode and patient is > 8 on COWS

• Contradictions: Allergy or sensitivity to buprenorphine or taken methadone in past 72 hours

Stimulant Factsheet

Class: Stimulant

Forms: Amphetamines, methylphenidate, methamphetamine, cocaine/crack, cathinones

Meth Overdose

• Dilated pupils

• Twitching, facial ticks

• Skin sores

• Aggressive

• Hyperactivity, tachycardia

• Rotting teeth (meth mouth)

Cocaine Overdose

• Anxiety, panic, fear

• Restlessness

• Talkative, high energy

• Dilated pupils

• Tachycardia and tachydysrhythmias (VT/SVT)

• Heart attack

• Psychosis

Excited Delirium

• From stimulant drug use

• Extreme agitation, aggression and violent behaviour

• Altered mental status

• Hyperthermia and diaphoresis

• Tachycardia and hypertension

• Increased pain tolerance

• Superhuman strength (Sudden passive tranquility after frenzied activity often indicates pre-arrest state)

• Often require restraint and/or sedation

Excited Delirium Statistics

1 in 10 cases result in cardiac arrest

• Excessive dopamine - strain on heart

• Electrolytes imbalances and rhabdomyolysis

• Asphyxiation during restraint

Sedatives, Hypnotics & Anxiolytics Factsheet

Class: Depressant

Forms: Benzodiazepines, Ketamine, GHB, PCP, Nitrous Oxide

Sedatives, Hypnotics & Anxiolytics Overdose

• Reduced LOC, drowsiness, dissociation

• Slurred speech

• Confused 

• Shallow, slow or absent breathing

Hallucinogens Factsheet

Class: Hallucinogens

Forms: LSD (visual patterns and changes perception), Psilocybin (magic mushrooms, alters senses), Ketamine, (‘out of body’ experiences, hypersalivation), Ecstasy (MDMA, enhanced mood)

Hallucinogens Overdose

• Unpleasant experiences known as a ‘bad trip’

• Feeling like time is standing still

• Extreme paranoia

• Fear and intense emotional distress

• Frightening hallucinations/delusions

• Agitation/violence

• Negative thought spirals

• Emotional mood swings

Assault vs Battery

Verbal vs physical abuse

Aggressive vs Assertive

Abusing power vs mom voice

Your needs vs others’ needs (in between)

Violence & Aggression

1. Triggering Event 

2. Escalation

3. Crisis

4. Plateau/Recovery

5. Post-crisis Depression

Treating/transporting WITHOUT consent

1. The patient does not have the capacity

2. The patient is at severe risk of sustaining bodily harm if not treated

3. The delay to obtain consent/refusal will prolong the suffering which can lead to sustaining bodily harm is not treated.

Physical Restraint

• Restrain only when: directed by physician/police, pt becomes violent en route, required to provide treatment and pt is non-compliant

• Supine, with one arm above head and one at waist level

• Side-lying (facing you!) with both hands secured to one side

• Raise head for airway protection and monitor closely

• Less invasive restraint for elderly (blanket burrito)

Chemical Restraint

• Request ACP assistance

• Midazolam and Ketamine

Electrical Restraint

• Only by police (taser)

• Remove probe by holding skin taught and pull upwards quickly

• Police may required probes to be left in place for investigation/evidence

• Avoid removing probes from: above clavicles, close to nipples, genitals