November 5, 2025 • 23 mins
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
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Episode Transcript
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Unknown (00:00):
Announcer,
Narrator (00:07):
welcome to the government services Chapter of
the American College ofEmergency Physicians. Podcast
gsapp represents emergencyphysicians who work in the
federal government, includingactive duty military National
Guard and military reserves, aswell as the Veterans
Administration, Indian HealthService and other federal
agencies, our mission isadvancing emergency care for
(00:31):
America's heroes. In thispodcast, we bring you lectures
and conversations with leadersin federal emergency medicine to
help you better care for yourpatients and lead your
departments. The views expressedon this podcast are personal
views and do not represent theviews of the Department of
Defense, any branch of themilitary or the federal
(00:52):
government, and they do notconstitute endorsement of any
product by any of theseentities. The
Matthew Turner (01:17):
Matt, hello everyone and welcome back to the
government services ASAPPodcast. I'm Captain Matthew
Turner, a current PGY threeresident, and today I'd like to
introduce our guest speaker.
Commander Christine De Forest isan active duty em physician for
the US Navy. She graduated fromthe Philadelphia College of
Osteopathic Medicine with theHPSP program. She completed an
Operational Medicine Torree as aflight surgeon, before
(01:40):
completing her training as an EMphysician through the residency
training program at Navymedicine Readiness Training
Command San Diego,she currently works at the
University of PennsylvaniaPresbyterian Medical Center
through a civilian and militarypartnership, today, she will
address the challenges ofevaluating patients In the ED
who have substance use disorderand discuss treatment
(02:02):
considerations to improve theircare.
Christine DeForest (02:06):
Now this is a really pivot on topic, but
this is a lesson that I reallyhad to become smart on when I
joined the team at Penn and Igraduated from medical school in
Philadelphia, College ofOsteopathic Medicine, and I
thought I had some reference andexposure, having done my
emergency medicine rotation inthe inner city, understanding a
(02:29):
little bit as to what that lookslike, and most certainly in
residency, we had exposure wherewe rotated through urban and
underserved communities thathave a higher proportion of
patients that present withundiagnosed medical conditions
complicated by drug use. Andthat is not to say that this is
(02:51):
a problem that's unique to thosesubsets in emergency
departments, but when I returnedto Philadelphia just last
summer, this is an area that Ireally had to become smart on,
and this is an area where I wasreally impressed by the work of
the colleagues who haveaddressed the needs of our
patients in that city. And so Ishare that with you, and one of
(03:12):
my focuses will be to look atthe resources that can help you
to become more equipped tohelping these patients when
you're doing off dutyemployment, or if you're
transitioning to civilian, er,if you're come to the end of
your military career.
Now this is a presentation ofthe thoughts of my own. It does
(03:32):
not represent the DOD, and Ihave no personal or financial
disclosures. My objectives aregoing to be to review some of
the trends the illicit drugmarket, as well as discussing
pharmacologic options inaddressing the substance use
disorder while you're helpingpatients also concurrently treat
their medical conditions. And Iwill close with some discussion
(03:54):
points regardingdexmedetomidine, which is
something that has come intomore frequent use within our own
emergency department as weaddress a lot of the cross
contaminants in drugs. So theNIH National Drug early warning
system is a program that hasstaffed and looks at the trend
(04:15):
of drugs throughout the UnitedStates and the drug use within
key cities, which helps inguiding some of the
recommendations, not just inaddressing public health, but
also in addressing what hasevolved or trend, and how do we
need to advance in medical careto treat the needs of our
patients. And so this is a greatresource if you are working in
(04:40):
any of these regions and even indistant proximity, it may give
you an understanding as towhat's predominantly in
circulation in your own region.
We have seen a progressive risein opioid overdose. We have seen
this since 2014 19, we have seenthis with synthetic substances,
(05:01):
and the predominant use ofsynthetic substances has made it
even more challenging for us tohelp our patients. And I can't
really address the treatmentunless we give one big step back
and remind ourselves as to thesome of the effects of
medications. So brief overviewon a few drugs, and I'll
(05:23):
reference you to the DEA thathas site that does have overall
information and a variety ofsubstances, if you need a quick
refresher yourself. So cocaineis actually a high volume use in
Philadelphia. This is a longtime drug of use, and it's
(05:43):
primarily abused because of thefor you associated with it. And
you probably remember frommedical school that there is a
lot of cardiac concern withpatients because the dysrhythmia
or ischemia associated with use.
This does have variety ofmethods, route for use,
(06:03):
ultimately, snorting or inhalingmedication may have the least
secondary effects, as with mostof these drugs, and that it does
have a lower risk rate ofconcurrent infections, wounds,
complications as such, heroin,still primarily of opiate
(06:24):
extract abuse, also witheuphoria, does have some
sedating alert peaks associatedwith it. One of the big
challenges with heroin use isbecause of how it is cut with
other substances. This variesthe strength, which can have a
high risk rate for patients,because it's hard for them to
(06:44):
have a reliable understanding asthey try to dose themselves,
changing suppliers, changing howthey procure the substance, can
have high risk that they'lloverdose On a subsequent use.
Overdose will result inrespiratory depression, seizure,
coma. So let's segue intosynthetics, because this is
(07:09):
really where we've seen thathuge spike in evolution. And as
we all know, we use fentanyl andan analgesic effect for our
patients, but this is alsosomething that has gone into
high potency and use withinpatients for recreational use,
once again, huge euphoriaassociated with this. Now
(07:32):
reminder here the concentrationeffect. We know that in our
dosing, but it's important toframe this as we start to then
discuss in the future as to howwe control withdrawal symptoms,
so 100 times the potency ofmorphine, 50 times the potency
of heroin. So patients thattransition through different
drugs of use may gradually havesome dose effect or benefit out
(07:57):
of the drug that they are using,but this also influences their
dependence and their physiologiceffect in the body and what they
are then most used to overdoseresults in a lot of depression,
so your respiratory depression,your blood pressure drop. These
are the patients that are comingin with pinpoint pupils. Now,
(08:19):
fentanyl is a challenge, onebecause of the potency of what's
circulating in use. Secondly, isthe adulterants that are being
used. And so there's been a realtransition into pushing for test
trips and education to test notjust whether or not there's
contaminant within thesubstance, but also looking at
(08:39):
if this is a true sample of whatthey have purchased or procured,
so the adulterants that I havereferenced. So this is a map of
looking at xylazine use. And asyou'll see in that purple area,
which is of which spans fromPhiladelphia down through dc
(09:01):
into kind of Virginia region hasreally a hotbed in high
concentration, though, we haveseen xylazine extend into other
areas across the United States.
This is an area, something thatreally you don't see
significantly over on Californiaand I PCs from California back
to the East Coast when I movedto Philadelphia. So this is
(09:23):
something that I rapidly had tobecome smart on and
understanding. And a lot of mycolleagues were used to a day to
day practice of addressing someof the the needs that our
patients had secondary to theiruse. So what is xylazine? So
xylene is xylazine, is otherwiseknown as tranq, and it is
important for us to becomeunderstanding of the common
(09:47):
terms and references and namesfor our patients. But I am very
humble in that encounter. Tellme what you're using. If I don't
know what it is, then I willreally try and look at. What
else? What else does it go by inunderstanding it's important, if
we don't know what our patient'susing, then we really can't help
in addressing withdrawalsymptoms. So it's Veterinary and
(10:08):
there are some articles outthere and looking at kind of
overdose options, particularlywith accidental occupational
exposures by our veterinariancolleagues. But there's no
reversal on the market. And soit's not opiate. It's an analog
to quantity, and that'simportant as I'll segue into
some treatment on withdrawalsymptoms. And it's alpha two
(10:30):
adrenergic. And so thesepatients come in with variable
sedating effect, and thesedative associated with it, and
the analgesia associated is whatmakes it attractive for use. Now
there's variable sedating effecttimelines. This might be an
hour. It might be a little bitmore prolonged when patients
(10:51):
come in, and because it's not anopioid, Narcan doesn't work. And
so it's important to understandwhat's in circulation. As our
patients present us and we startto get after how are we best
going to treat respiratorydistress, failure,
cardiopulmonary collapse. On theflip side, withdrawal will cause
(11:11):
a lot of agitation, tachycardia,elevated blood pressure. That's
really helpful as well, becausewe may have a patient that
presents with medicalconditions, we start initiating
treatment. We aren't able to geta full or reliable history, and
their variable vital signs canhelp us in kind of process of
elimination, what's going towork best in supporting them?
(11:38):
Now metatomy, see the HealthAlert up here on this slide, and
this is the public health alertthat was released in
Philadelphia. And I encourageyou to seek information through
the public health alerts foryour city. As you're looking at
what is in circulation, and arewe seeing a shift in the market
(11:58):
that may affect our patientscoming in, once again,
veterinarian use sedative, nonopioid, and this is where we
look at and helpful for us toknow, dexmedetomidine is your
active enantiomer for humansedation. So that's our closest
comparison to this, andsomething that's currently in
(12:18):
pharmacological use in ourhospitals, 200 times the potency
of xylazine. So there's a realgraduated effect. With that, we
dealt with huge respiratorydepression, prolonged sedation
with xylazine. And now that weare a couple years from
introduction of xylazine intothe Philadelphia region, we're
starting to see metatomidine.
And with that, we're havingthese huge kind of almost
(12:40):
recurrence of what we're seeingin the ED with a prolonged
sedation. All right, soreversible challenges, as I
address, Narcan, may not work onthe concentration that people
are using. There is a higherrate of flash pulmonary edema
with a higher dosing on Narcan.
So it's not something to ignore,but expect that your first dose
(13:02):
may not work, and we're needingto go with higher doses up
front. Also look at that othermedications may have been used
which will just fail to respondto Narcan, so it still leaves a
drug overdose on the table foryour differential All right, I
am going to breeze throughsedative hypnotics, but I want
to include that because, onceagain, sedating effect on
(13:26):
patients whole differentreceptor group with the GABA
receptors. And with this, we'reseeing withdrawal that further
compounds agitation andautonomic hyperactivity. So a
lot of concurrent use isimportant to recognize
barbiturates have gone intocirculation a little bit more as
we look at additional statesthat are looking at assisted
(13:50):
suicide. And so if that'sapplicable to where you work,
become smart on those twomethadone both a treatment as
well as a drug of abuse. And soimportant to understand that. So
let's get into treatment in thelast few minutes that I have
with you. Picture that you seeon the screen is a patient that
has used xylazine is chronicuse. What we see is a lot of
(14:12):
osteomyelitis. We see a lot oflymphedema. We see patients that
have significant amount ofvascular collapse with that, a
lot of scarring with that.
That's not unusual. For IV drugabuse, some patients may be
injecting into the wound. It'simportant to create that quick
physician patient relationshipso that we can get to how best
can I help and treat you? This32 year old male patient
(14:35):
presented with chills, rigor,and he was hypotensive, as
you'll see, his heart rate, notso bad. There so key questions
that I want to know, what do youuse? Are using benzos with it?
How about alcohol? It helps mein understanding, do we need a
bimodal approach to withdrawsymptoms? Where are you using
and then why? And for this, it'swhy are you here in. Emergency
(14:59):
Department, are you looking fordetox? And that may be a patient
that doesn't need a medicaladmission, but I really want to
meet you with where you're atand give you support and
resources. If I'm admitting youinto the hospital, it helps us
in understanding some of themedication plan for them. And if
you're fortunate enough to besomewhere with addiction
medicine, then that's going toguide some of their care. But in
(15:20):
the ED, I want to understand,are you going to stick around
for treatment, or do I have avery short window before you go
into withdrawal? Want to bedischarged? And I'm discharging
a hypotensive patient withosteomyelitis, it certainly
changes my antibiotic selection.
We can't forget the currentmedical conditions, and of which
(15:42):
includes with this HIV. So withwithdrawal management for
inpatients, primarily focusingon titrating to effect for
medications and getting them ona long acting medication to
assist. So let me go into thatfor this patient. This is a
screenshot as the medicationsorder to help and assist this
(16:02):
patient. What you don't see inthis screenshot is the methadone
that I'll also discuss inordering for him. You'll notice
perhaps that the oxycodone isalso of a high dose extender
release 80 milligram every eighthours. This patient required
extremely high doses to get asclose as we could to matching
what they were using before theypresented, but it was important
(16:24):
for us to address those needs sothey were willing to stay and
receive the medical care thatthey needed. This is higher than
the entry dose for oxycodone formost of my patients. If you have
a hard time in looking at whatmatches across to dose specific
treatments, then consider usinga calculator, and several states
have that available. This is onethat's through Washington State.
(16:48):
Become familiar with cows. Thishelps in understanding and I
will simultaneously put them onSiwa if they're using benzos and
Ativan. It gives our nursing aframework to titrate the
medications as well as toaddress the needs of our
patient, it gives a concretenumber to look at if we're
catching up or if we're makingground on their symptoms. So
(17:11):
let's go into what I willintroduce to you for treatment,
methadone. Our patients arecoming in the emergency
department. I get them onmethadone. I start them at 30
milligrams, and in their firstdose day, I will increase them
to a total of 40 milligramsthrough an additional 10
milligrams added at four hours,depending on their cows, we do
(17:32):
have benefit of a titratedeffect. And with boarding, we'll
see patients in the emergencydepartment needing that day two,
day three treatment. I orderthat a protocol up front that
helps in supporting continuecare, and that also helps our
nursing colleagues. These arechallenging patients. These can
be frustrating. It is hard tohelp them because they are so
(17:53):
agitated, anxious and justphysically feeling sick and
unwell. This helps me and ournursing to be on the same aim as
we're working to help thispatient. Now, a reminder get to
that EKG, a lot of our patientsmay have electrolyte
abnormalities, malnutrition, andit's important to correct those
(18:13):
because methadone is a Qtprolonging medication, as is
Zofran, which is one thing thathelps with a lot of the vomiting
that they experience. But Idon't order if they have a
prolonged QT also get them onshort acting opioid agonists. I
reference our patient presentingwith a higher dose of opioid
because he needed to be titratedup to that. But I start at 40
(18:33):
milligrams every eight hours,and I do that up front with then
IV medication. Now Dilaudid woolhas a very short half life.
We're actually experiencingDilaudid shortage. It makes it a
challenge. Some people will say,I don't want to give a patient
Dilaudid. It just adds in totheir addiction when they leave.
But this patient is going toleave if I don't address their
(18:54):
medical and their addictionneeds. And so to me, I'm
treating this as a comprehensiveproblem, quantity. This is
important because of the alphatwo effect. This is now you'll
be limited at starting at pointone milligram, but reassess and
increase that, and they can getto point two or point three Po.
(19:17):
Po route has longer efficacy forour patients and greater
benefit. But if they're having alot of vomiting, I'll get a
transdermal patch on while I'mtrying to get control of their
symptoms, and then reconsidertransitioning them back to po
tasanadine doesn't have the sameconcerns on hypotension or with
the Qt prolongation, so becomefamiliar with that as well. And
(19:41):
then for severe withdrawal, likeI said, we also look at
addressing them with additionalanalgesia options. So
osteomyelitis is painful forthese patients as well. We may
need to look at ketamine as a POoption and try to help in
controlling that pain inaddition to the withdrawal.
Symptoms that can causehypersensitivity and hyper alert
(20:03):
to that. So this treatmentadjunct list also addresses the
GI side effects, as well as someof the temperature regulatory
effects for patients who arecoming in experiencing
concurrent withdrawal. Nowdexmedetomidine, we are held
within the same parameters andlooking at the sedation effect
(20:25):
and protocol for us with ICUpatients, this does buy them
into an ICU bed. This is not thefirst thing that I start out the
door, but if they're havinghypertension and tachycardia,
that's hard to control,particularly knowing that
they're using medications withinour city that has a high rate of
metatomy adjutant, then I willreach for dexmedetomidine. This
(20:50):
helps in gaining control of thesymptoms and gets them on a
treatment pathway that isclosest to treating with what
they're otherwise used to anddependent to when they're out of
our doors. Our closest referenceto that is ICU and controlling
alcohol use disorder. And Iremind you that if there are
(21:12):
using alcohol or benzos, it isimportant that you also treat
them, then with Ativan, benzosseparate, but your facility may
be pretty concerned on thesedating effect, respiratory
effect, so talk this throughbefore you just put this on a
patient and land them in theICU.
(21:33):
All right. Dosing, as Ireferenced for us, we're point
two, 2.4 micrograms per kg perhour. We titrate up. We look by
Rasc score, just like we wouldfor a sedating. And goal for us
is still to have that pleasantalert, but we are at the minus
two to two range. We have themon cardiopulmonary monitoring.
It does buy them into an ICUadmission and caution not to
(21:55):
bolus this medication because ofthe concerns on hypotension and
bradycardia. So this patientultimately had treatment. He was
continued on HIV meds, asidefrom methadone, oxycodone, he
had his IV antibiotics andclonidine. So with that, I'll
(22:15):
close. This is an overview as tomedications to consider
addressing our patient's needswith the dependence that they
have prior to entering so theycan best meet their medical
needs while they're with in ourcare. Thank you.
Narrator (22:35):
Gsacep is proud to be the premier Continuing Medical
Education Source for militaryand federal emergency physicians
to purchase. Cme for the episodeyou just listened to, please
click on the link in the shownotes. The government services
Chapter of the American Collegeof Emergency Physicians promotes
quality emergency care andenhances the development of
(22:57):
Emergency Physicians who serveour nation from training through
retirement. Learn more about ourchapter at www. Dot GSAC ep.org,
you.
Announcer,
Narrator (00:07):
welcome to the government services Chapter of
the American College ofEmergency Physicians. Podcast
gsapp represents emergencyphysicians who work in the
federal government, includingactive duty military National
Guard and military reserves, aswell as the Veterans
Administration, Indian HealthService and other federal
agencies, our mission isadvancing emergency care for
(00:31):
America's heroes. In thispodcast, we bring you lectures
and conversations with leadersin federal emergency medicine to
help you better care for yourpatients and lead your
departments. The views expressedon this podcast are personal
views and do not represent theviews of the Department of
Defense, any branch of themilitary or the federal
(00:52):
government, and they do notconstitute endorsement of any
product by any of theseentities. The
Matthew Turner (01:17):
Matt, hello everyone and welcome back to the
government services ASAPPodcast. I'm Captain Matthew
Turner, a current PGY threeresident, and today I'd like to
introduce our guest speaker.
Commander Christine De Forest isan active duty em physician for
the US Navy. She graduated fromthe Philadelphia College of
Osteopathic Medicine with theHPSP program. She completed an
Operational Medicine Torree as aflight surgeon, before
(01:40):
completing her training as an EMphysician through the residency
training program at Navymedicine Readiness Training
Command San Diego,she currently works at the
University of PennsylvaniaPresbyterian Medical Center
through a civilian and militarypartnership, today, she will
address the challenges ofevaluating patients In the ED
who have substance use disorderand discuss treatment
(02:02):
considerations to improve theircare.
Christine DeForest (02:06):
Now this is a really pivot on topic, but
this is a lesson that I reallyhad to become smart on when I
joined the team at Penn and Igraduated from medical school in
Philadelphia, College ofOsteopathic Medicine, and I
thought I had some reference andexposure, having done my
emergency medicine rotation inthe inner city, understanding a
(02:29):
little bit as to what that lookslike, and most certainly in
residency, we had exposure wherewe rotated through urban and
underserved communities thathave a higher proportion of
patients that present withundiagnosed medical conditions
complicated by drug use. Andthat is not to say that this is
(02:51):
a problem that's unique to thosesubsets in emergency
departments, but when I returnedto Philadelphia just last
summer, this is an area that Ireally had to become smart on,
and this is an area where I wasreally impressed by the work of
the colleagues who haveaddressed the needs of our
patients in that city. And so Ishare that with you, and one of
(03:12):
my focuses will be to look atthe resources that can help you
to become more equipped tohelping these patients when
you're doing off dutyemployment, or if you're
transitioning to civilian, er,if you're come to the end of
your military career.
Now this is a presentation ofthe thoughts of my own. It does
(03:32):
not represent the DOD, and Ihave no personal or financial
disclosures. My objectives aregoing to be to review some of
the trends the illicit drugmarket, as well as discussing
pharmacologic options inaddressing the substance use
disorder while you're helpingpatients also concurrently treat
their medical conditions. And Iwill close with some discussion
(03:54):
points regardingdexmedetomidine, which is
something that has come intomore frequent use within our own
emergency department as weaddress a lot of the cross
contaminants in drugs. So theNIH National Drug early warning
system is a program that hasstaffed and looks at the trend
(04:15):
of drugs throughout the UnitedStates and the drug use within
key cities, which helps inguiding some of the
recommendations, not just inaddressing public health, but
also in addressing what hasevolved or trend, and how do we
need to advance in medical careto treat the needs of our
patients. And so this is a greatresource if you are working in
(04:40):
any of these regions and even indistant proximity, it may give
you an understanding as towhat's predominantly in
circulation in your own region.
We have seen a progressive risein opioid overdose. We have seen
this since 2014 19, we have seenthis with synthetic substances,
(05:01):
and the predominant use ofsynthetic substances has made it
even more challenging for us tohelp our patients. And I can't
really address the treatmentunless we give one big step back
and remind ourselves as to thesome of the effects of
medications. So brief overviewon a few drugs, and I'll
(05:23):
reference you to the DEA thathas site that does have overall
information and a variety ofsubstances, if you need a quick
refresher yourself. So cocaineis actually a high volume use in
Philadelphia. This is a longtime drug of use, and it's
(05:43):
primarily abused because of thefor you associated with it. And
you probably remember frommedical school that there is a
lot of cardiac concern withpatients because the dysrhythmia
or ischemia associated with use.
This does have variety ofmethods, route for use,
(06:03):
ultimately, snorting or inhalingmedication may have the least
secondary effects, as with mostof these drugs, and that it does
have a lower risk rate ofconcurrent infections, wounds,
complications as such, heroin,still primarily of opiate
(06:24):
extract abuse, also witheuphoria, does have some
sedating alert peaks associatedwith it. One of the big
challenges with heroin use isbecause of how it is cut with
other substances. This variesthe strength, which can have a
high risk rate for patients,because it's hard for them to
(06:44):
have a reliable understanding asthey try to dose themselves,
changing suppliers, changing howthey procure the substance, can
have high risk that they'lloverdose On a subsequent use.
Overdose will result inrespiratory depression, seizure,
coma. So let's segue intosynthetics, because this is
(07:09):
really where we've seen thathuge spike in evolution. And as
we all know, we use fentanyl andan analgesic effect for our
patients, but this is alsosomething that has gone into
high potency and use withinpatients for recreational use,
once again, huge euphoriaassociated with this. Now
(07:32):
reminder here the concentrationeffect. We know that in our
dosing, but it's important toframe this as we start to then
discuss in the future as to howwe control withdrawal symptoms,
so 100 times the potency ofmorphine, 50 times the potency
of heroin. So patients thattransition through different
drugs of use may gradually havesome dose effect or benefit out
(07:57):
of the drug that they are using,but this also influences their
dependence and their physiologiceffect in the body and what they
are then most used to overdoseresults in a lot of depression,
so your respiratory depression,your blood pressure drop. These
are the patients that are comingin with pinpoint pupils. Now,
(08:19):
fentanyl is a challenge, onebecause of the potency of what's
circulating in use. Secondly, isthe adulterants that are being
used. And so there's been a realtransition into pushing for test
trips and education to test notjust whether or not there's
contaminant within thesubstance, but also looking at
(08:39):
if this is a true sample of whatthey have purchased or procured,
so the adulterants that I havereferenced. So this is a map of
looking at xylazine use. And asyou'll see in that purple area,
which is of which spans fromPhiladelphia down through dc
(09:01):
into kind of Virginia region hasreally a hotbed in high
concentration, though, we haveseen xylazine extend into other
areas across the United States.
This is an area, something thatreally you don't see
significantly over on Californiaand I PCs from California back
to the East Coast when I movedto Philadelphia. So this is
(09:23):
something that I rapidly had tobecome smart on and
understanding. And a lot of mycolleagues were used to a day to
day practice of addressing someof the the needs that our
patients had secondary to theiruse. So what is xylazine? So
xylene is xylazine, is otherwiseknown as tranq, and it is
important for us to becomeunderstanding of the common
(09:47):
terms and references and namesfor our patients. But I am very
humble in that encounter. Tellme what you're using. If I don't
know what it is, then I willreally try and look at. What
else? What else does it go by inunderstanding it's important, if
we don't know what our patient'susing, then we really can't help
in addressing withdrawalsymptoms. So it's Veterinary and
(10:08):
there are some articles outthere and looking at kind of
overdose options, particularlywith accidental occupational
exposures by our veterinariancolleagues. But there's no
reversal on the market. And soit's not opiate. It's an analog
to quantity, and that'simportant as I'll segue into
some treatment on withdrawalsymptoms. And it's alpha two
(10:30):
adrenergic. And so thesepatients come in with variable
sedating effect, and thesedative associated with it, and
the analgesia associated is whatmakes it attractive for use. Now
there's variable sedating effecttimelines. This might be an
hour. It might be a little bitmore prolonged when patients
(10:51):
come in, and because it's not anopioid, Narcan doesn't work. And
so it's important to understandwhat's in circulation. As our
patients present us and we startto get after how are we best
going to treat respiratorydistress, failure,
cardiopulmonary collapse. On theflip side, withdrawal will cause
(11:11):
a lot of agitation, tachycardia,elevated blood pressure. That's
really helpful as well, becausewe may have a patient that
presents with medicalconditions, we start initiating
treatment. We aren't able to geta full or reliable history, and
their variable vital signs canhelp us in kind of process of
elimination, what's going towork best in supporting them?
(11:38):
Now metatomy, see the HealthAlert up here on this slide, and
this is the public health alertthat was released in
Philadelphia. And I encourageyou to seek information through
the public health alerts foryour city. As you're looking at
what is in circulation, and arewe seeing a shift in the market
(11:58):
that may affect our patientscoming in, once again,
veterinarian use sedative, nonopioid, and this is where we
look at and helpful for us toknow, dexmedetomidine is your
active enantiomer for humansedation. So that's our closest
comparison to this, andsomething that's currently in
(12:18):
pharmacological use in ourhospitals, 200 times the potency
of xylazine. So there's a realgraduated effect. With that, we
dealt with huge respiratorydepression, prolonged sedation
with xylazine. And now that weare a couple years from
introduction of xylazine intothe Philadelphia region, we're
starting to see metatomidine.
And with that, we're havingthese huge kind of almost
(12:40):
recurrence of what we're seeingin the ED with a prolonged
sedation. All right, soreversible challenges, as I
address, Narcan, may not work onthe concentration that people
are using. There is a higherrate of flash pulmonary edema
with a higher dosing on Narcan.
So it's not something to ignore,but expect that your first dose
(13:02):
may not work, and we're needingto go with higher doses up
front. Also look at that othermedications may have been used
which will just fail to respondto Narcan, so it still leaves a
drug overdose on the table foryour differential All right, I
am going to breeze throughsedative hypnotics, but I want
to include that because, onceagain, sedating effect on
(13:26):
patients whole differentreceptor group with the GABA
receptors. And with this, we'reseeing withdrawal that further
compounds agitation andautonomic hyperactivity. So a
lot of concurrent use isimportant to recognize
barbiturates have gone intocirculation a little bit more as
we look at additional statesthat are looking at assisted
(13:50):
suicide. And so if that'sapplicable to where you work,
become smart on those twomethadone both a treatment as
well as a drug of abuse. And soimportant to understand that. So
let's get into treatment in thelast few minutes that I have
with you. Picture that you seeon the screen is a patient that
has used xylazine is chronicuse. What we see is a lot of
(14:12):
osteomyelitis. We see a lot oflymphedema. We see patients that
have significant amount ofvascular collapse with that, a
lot of scarring with that.
That's not unusual. For IV drugabuse, some patients may be
injecting into the wound. It'simportant to create that quick
physician patient relationshipso that we can get to how best
can I help and treat you? This32 year old male patient
(14:35):
presented with chills, rigor,and he was hypotensive, as
you'll see, his heart rate, notso bad. There so key questions
that I want to know, what do youuse? Are using benzos with it?
How about alcohol? It helps mein understanding, do we need a
bimodal approach to withdrawsymptoms? Where are you using
and then why? And for this, it'swhy are you here in. Emergency
(14:59):
Department, are you looking fordetox? And that may be a patient
that doesn't need a medicaladmission, but I really want to
meet you with where you're atand give you support and
resources. If I'm admitting youinto the hospital, it helps us
in understanding some of themedication plan for them. And if
you're fortunate enough to besomewhere with addiction
medicine, then that's going toguide some of their care. But in
(15:20):
the ED, I want to understand,are you going to stick around
for treatment, or do I have avery short window before you go
into withdrawal? Want to bedischarged? And I'm discharging
a hypotensive patient withosteomyelitis, it certainly
changes my antibiotic selection.
We can't forget the currentmedical conditions, and of which
(15:42):
includes with this HIV. So withwithdrawal management for
inpatients, primarily focusingon titrating to effect for
medications and getting them ona long acting medication to
assist. So let me go into thatfor this patient. This is a
screenshot as the medicationsorder to help and assist this
(16:02):
patient. What you don't see inthis screenshot is the methadone
that I'll also discuss inordering for him. You'll notice
perhaps that the oxycodone isalso of a high dose extender
release 80 milligram every eighthours. This patient required
extremely high doses to get asclose as we could to matching
what they were using before theypresented, but it was important
(16:24):
for us to address those needs sothey were willing to stay and
receive the medical care thatthey needed. This is higher than
the entry dose for oxycodone formost of my patients. If you have
a hard time in looking at whatmatches across to dose specific
treatments, then consider usinga calculator, and several states
have that available. This is onethat's through Washington State.
(16:48):
Become familiar with cows. Thishelps in understanding and I
will simultaneously put them onSiwa if they're using benzos and
Ativan. It gives our nursing aframework to titrate the
medications as well as toaddress the needs of our
patient, it gives a concretenumber to look at if we're
catching up or if we're makingground on their symptoms. So
(17:11):
let's go into what I willintroduce to you for treatment,
methadone. Our patients arecoming in the emergency
department. I get them onmethadone. I start them at 30
milligrams, and in their firstdose day, I will increase them
to a total of 40 milligramsthrough an additional 10
milligrams added at four hours,depending on their cows, we do
(17:32):
have benefit of a titratedeffect. And with boarding, we'll
see patients in the emergencydepartment needing that day two,
day three treatment. I orderthat a protocol up front that
helps in supporting continuecare, and that also helps our
nursing colleagues. These arechallenging patients. These can
be frustrating. It is hard tohelp them because they are so
(17:53):
agitated, anxious and justphysically feeling sick and
unwell. This helps me and ournursing to be on the same aim as
we're working to help thispatient. Now, a reminder get to
that EKG, a lot of our patientsmay have electrolyte
abnormalities, malnutrition, andit's important to correct those
(18:13):
because methadone is a Qtprolonging medication, as is
Zofran, which is one thing thathelps with a lot of the vomiting
that they experience. But Idon't order if they have a
prolonged QT also get them onshort acting opioid agonists. I
reference our patient presentingwith a higher dose of opioid
because he needed to be titratedup to that. But I start at 40
(18:33):
milligrams every eight hours,and I do that up front with then
IV medication. Now Dilaudid woolhas a very short half life.
We're actually experiencingDilaudid shortage. It makes it a
challenge. Some people will say,I don't want to give a patient
Dilaudid. It just adds in totheir addiction when they leave.
But this patient is going toleave if I don't address their
(18:54):
medical and their addictionneeds. And so to me, I'm
treating this as a comprehensiveproblem, quantity. This is
important because of the alphatwo effect. This is now you'll
be limited at starting at pointone milligram, but reassess and
increase that, and they can getto point two or point three Po.
(19:17):
Po route has longer efficacy forour patients and greater
benefit. But if they're having alot of vomiting, I'll get a
transdermal patch on while I'mtrying to get control of their
symptoms, and then reconsidertransitioning them back to po
tasanadine doesn't have the sameconcerns on hypotension or with
the Qt prolongation, so becomefamiliar with that as well. And
(19:41):
then for severe withdrawal, likeI said, we also look at
addressing them with additionalanalgesia options. So
osteomyelitis is painful forthese patients as well. We may
need to look at ketamine as a POoption and try to help in
controlling that pain inaddition to the withdrawal.
Symptoms that can causehypersensitivity and hyper alert
(20:03):
to that. So this treatmentadjunct list also addresses the
GI side effects, as well as someof the temperature regulatory
effects for patients who arecoming in experiencing
concurrent withdrawal. Nowdexmedetomidine, we are held
within the same parameters andlooking at the sedation effect
(20:25):
and protocol for us with ICUpatients, this does buy them
into an ICU bed. This is not thefirst thing that I start out the
door, but if they're havinghypertension and tachycardia,
that's hard to control,particularly knowing that
they're using medications withinour city that has a high rate of
metatomy adjutant, then I willreach for dexmedetomidine. This
(20:50):
helps in gaining control of thesymptoms and gets them on a
treatment pathway that isclosest to treating with what
they're otherwise used to anddependent to when they're out of
our doors. Our closest referenceto that is ICU and controlling
alcohol use disorder. And Iremind you that if there are
(21:12):
using alcohol or benzos, it isimportant that you also treat
them, then with Ativan, benzosseparate, but your facility may
be pretty concerned on thesedating effect, respiratory
effect, so talk this throughbefore you just put this on a
patient and land them in theICU.
(21:33):
All right. Dosing, as Ireferenced for us, we're point
two, 2.4 micrograms per kg perhour. We titrate up. We look by
Rasc score, just like we wouldfor a sedating. And goal for us
is still to have that pleasantalert, but we are at the minus
two to two range. We have themon cardiopulmonary monitoring.
It does buy them into an ICUadmission and caution not to
(21:55):
bolus this medication because ofthe concerns on hypotension and
bradycardia. So this patientultimately had treatment. He was
continued on HIV meds, asidefrom methadone, oxycodone, he
had his IV antibiotics andclonidine. So with that, I'll
(22:15):
close. This is an overview as tomedications to consider
addressing our patient's needswith the dependence that they
have prior to entering so theycan best meet their medical
needs while they're with in ourcare. Thank you.
Narrator (22:35):
Gsacep is proud to be the premier Continuing Medical
Education Source for militaryand federal emergency physicians
to purchase. Cme for the episodeyou just listened to, please
click on the link in the shownotes. The government services
Chapter of the American Collegeof Emergency Physicians promotes
quality emergency care andenhances the development of
(22:57):
Emergency Physicians who serveour nation from training through
retirement. Learn more about ourchapter at www. Dot GSAC ep.org,
you.
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