Stump the Chump/medic: IV Opioids AND IV Alcohol

[croaker260]

OK, those who know me know I have an interest in street drugs and lecture a lot on them as well as try to keep abreast, etc. So its not often that I get stumped.

In a HIPAA SAFE, HYPOTHETICAL (wink wink) galaxy far far away....

EMS unit was requested to assist local LEO with a patient in opioid withdrawal The patient in question was being detained for a period in time while an investigation is going on. As this period of time progressed, the patient became dope sick (withdrawal) to the point LE were somewhat concerned and wanted to have the patient assessed.

The patient in question uses IV opioids 8-10 times per 24 hour period, typically crushing and desolving prescription opioids. he has been following this pattern of use in excess of 2 years. What the patient takes largely depends on what he can get, but typically Oxy or Dilaudid 8 mg. The patient will combine with meth as the mood strikes, and also will use Heroin as needed if he cant get his normal fix.

So, not that abnormal. Unfortunate, but not abnormal.

Here's where it takes a turn into left field.

The patient also reports that in addition to IV opioid use, the patient routinely uses Vodka and/or everclear instead of water to disolve the pill fragments in. he reports that he has also been doing this essentially uninturupted for the previous two years. The patient reports its a more complete desolution, as well as a more intense effect on injection.

My questions/discussion points are:

1- Knowing that this route would bypass 1st pass metabolism, what is the thoughts on tolorance, and/or toxicity?

2- Given #1 above, and the reported duration of use (2 plus years) what is the risk for alcohol withdrawal and DT over the next 12-48 hours?

3- what is the prevelance of this practice?

I've posted this to the Docs and other knowledgeable people and recived the same puzzeled looks.

Edited April 29, 2014 by croaker260

[chbare]

1) I would assume the area under the concentration/time curve would be larger as is the case for other substances that are given in a way that bypasses first pass. Ethanol already has a high bioavailability, but I would anticipate a bioavailability approaching 1.0 and a very rapid peak in plasma concentration. As far as metabolism and elimination, ethanol quickly reaches saturation kinetics and as such follows 0 order elimination kinetics even at low concentrations. I would not anticipate this to change. Ethanol is metabolised via three pathways: ADH enzyme, catalase enzymes and CYP2E1. Normally, catalase and CYP2E1 are minor pathways, but with chronic ethanol exposure, CYP2E1 is inducible. I'd expect that to occur with chronic ethanol exposure at sufficiently high enough concentrations regardless of the route.

2) Reasonably high with enough use.

3) Not sure, but I'm not surprised by the story.

[island emt]

what the LEO's and now unfortunately" you" have on your hands is a ticking time bomb.

He will be having severe withdrawal symptoms soon if he is shooting up with that frequency.

I'd be curious what his baseline ETOH level is? on top of all the narcotics he has been using with the ETOH chaser.

He is getting small dose , high level concentration of ETOH 8-10 x /day so toxicity levels must have "normalized in his system by now after 2 years +/- of abuse.

Does the extended release agent in the Oxy dissolve faster/ better in alcohol solvent compared to water / stomach fluids????

Anecdotally in a hipaa safe world: There is a gent we know that is beyond alcoholic status. He wakes up and starts his day with a 20 oz beer fresh from the tap in his fridge. His yard contains dozens of empty full size kegs. His normal everyday functioning baseline is in excess of a 250 BAC. he has been as high as a 685 BAC and still been conscious and walking. Beer is consumed on an all day basis as some might drink water or coffee, until it is dark and time to go unconscious. 7 Days a week that is the routine.

Recently he had to go to hospital for some internal organ malfunction[ imagine that ] without his almost continuous infusion of ETOH he went into withdrawal sequence within 8 hours. violent shakes , hallucinations, bugs crawling on him, NVD the whole drill.

Can't say it has been seen in this area, but then who really knows what the addicts are doing to get their fix.

We had a severe outbreak of opiod use/abuse a few years ago , that was scary. everyone & their mother had discovered oxy contin/codone by prescription, & the DR's were handing them out like breath mints at a church social.. we doubled the amount of Narcan we carried on the truck..

Now it is heroin that is strong as it is readily available and at low cost compared to prescription meds on the street.

[uglyEMT]

Don't think I have heard of IV alcohol use but I would assume it would be the same metabolism as "butt chugging". In that the toxicity spikes real quick and the crash seems harder. I say seems because of observation, nothing scientific. I have witnessed a patient start the withdrawal process within a short time span vs hours.

As for the opiod abuse my area has gotten so bad now that we have Narcan IN injectors given to LEOs and stock them on BLS rigs. It is a serious explosion around here and it is worrisome, especially seeing some of the ages of patients. Most of it stemmed from Rx abuse like island said. Then the addiction got to a point that they couldn't afford the Rx they turned to heroin. To add insult to injury this area has one of the purest kinds(according to LEOs) so the incidents of OD are climbing through the roof.

[island emt]

I've been told the street value of prescription narcs is $1.00 per milligram, while a 3 gram bag of heroin is less than $20.00 & as ugly has noted ,it is much purer content than in the past with a marked increase in OD deaths and near misses.

State of Maine legislature passed a new law today allowing family members of abusers and LEO's & FF's to carry Narcan IN as a means of saving OD deaths.

Edited April 29, 2014 by island emt

[croaker260]

Actually , bioavailability of rectal drugs (as a generalization ) tends to be about 0.8 where IV bioavailability approaches 1.0.. as a general rule. See CHBARES comments on 0 order elimination above.

[BAYAMedic]

Vodka would be good at a 50% water to 50% alcohol to get the best of both worlds. While I don't know about the solubility of narcotics in alcohol, I read in a druggie forum it takes about 1.8 mL of water per oxycontin tab to get the best cold water extraction. If they can achieve more with the alcohol and have a easier access to "sterility" vs what comes out of the tap, I can see how this would be an interesting logical move for your local IV Drug Users.

BayaMedic

[island emt]

there are druggie forums ?????

[Just Plain Ruff]

Vodka would be good at a 50% water to 50% alcohol to get the best of both worlds. While I don't know about the solubility of narcotics in alcohol, I read in a druggie forum it takes about 1.8 mL of water per oxycontin tab to get the best cold water extraction. If they can achieve more with the alcohol and have a easier access to "sterility" vs what comes out of the tap, I can see how this would be an interesting logical move for your local IV Drug Users.

BayaMedic

How is it that we both frequent the same forums?

Edited May 8, 2014 by Ruffmeister Paramedic

[island emt]

Share the wealth :-}