Key Facts

Recreational drug intoxication presents an evolving challenge with the emergence of novel psychoactive substances and changing patterns of drug use. Management is predominantly supportive with treatment of specific complications.

Epidemiology

Drug-related deaths in the UK exceed 4,500 per year and are increasing. Opioids remain the leading cause of drug death. Cocaine-related deaths have tripled over the past decade. NPS-related deaths are increasing. Scotland has the highest drug death rate in Europe.

Aetiology

• Stimulants: Cocaine, amphetamines, MDMA, methamphetamine, mephedrone
• Depressants: GHB/GBL, benzodiazepines (recreational), ketamine
• Cannabis and synthetic cannabinoids: 'Spice', K2
• Hallucinogens: LSD, psilocybin, DMT
• Dissociatives: Ketamine, PCP, nitrous oxide
• Novel psychoactive substances: Evolving range of synthetic drugs

Pathophysiology

Different drugs act on different neurotransmitter systems:

• Stimulants: Increase catecholamines (dopamine, noradrenaline) → sympathomimetic toxidrome
• MDMA: Serotonin and noradrenaline release → serotonergic syndrome, hyperthermia, SIADH
• GHB/GBL: GABA-B agonism → rapid-onset sedation
• Synthetic cannabinoids: Full CB1 agonism (unlike THC partial agonism) → unpredictable severe effects

Stimulant Toxidrome (Cocaine, Amphetamines, MDMA)

• Agitation, psychosis, paranoia
• Tachycardia, hypertension, hyperthermia
• Dilated pupils (mydriasis)
• Seizures, arrhythmias, MI (cocaine), rhabdomyolysis

MDMA-Specific

• Hyponatraemia (dilutional — excess water drinking)
• Serotonin syndrome (clonus, hyperreflexia, hyperthermia)
• Hepatotoxicity

GHB/GBL

• Rapid deep sedation → coma (onset 15-30 min, duration 2-4h)
• Bradycardia, respiratory depression
• Agitated emergence from coma

Synthetic Cannabinoids

• Agitation, psychosis, seizures (unlike natural cannabis)
• Tachycardia, AKI, rhabdomyolysis

Red Flags

• Hyperthermia >40°C — actively cool (MDMA, cocaine, serotonin syndrome)
• Chest pain in cocaine user — ACS; treat with benzodiazepines, GTN, avoid beta-blockers
• Seizures — benzodiazepines first-line
• Hyponatraemia (Na⁺ <120) — hypertonic saline if symptomatic
• Body-packing — risk of massive drug release

Bedside

• ABCDE assessment: Priority
• Temperature: Hyperthermia is a medical emergency
• Blood glucose: Exclude hypoglycaemia
• ECG: Arrhythmias, QTc prolongation, Brugada-like (cocaine)
• GCS: Serial monitoring

Bloods

• U&Es: Sodium (MDMA — hyponatraemia), potassium, creatinine (AKI)
• CK: Rhabdomyolysis (stimulants, prolonged seizures, hyperthermia)
• Troponin: If chest pain (cocaine-associated MI)
• LFTs: Hepatotoxicity (MDMA, cocaine)
• ABG/VBG: pH, lactate
• Coagulation: DIC in severe hyperthermia
• Paracetamol level: Always check for co-ingestion

Imaging

• CXR: If respiratory symptoms
• CT head: If seizures, focal neurology, prolonged altered consciousness
• Abdominal X-ray/CT: If body-packing suspected

Special Tests

• Urine drug screen: Confirmatory but rarely changes acute management
• TOXBASE/NPIS: For NPS identification and management guidance

Non-pharmacological

• Supportive care: ABCDE, calm environment, reassurance (for mild stimulant intoxication)
• Active cooling: For hyperthermia >39°C — remove clothing, cold IV fluids, ice packs, evaporative cooling; consider dantrolene if >41°C
• Fluid restriction: For MDMA-induced hyponatraemia (NOT IV fluids)

Pharmacological

Stimulant toxicity (cocaine/amphetamines):

• Benzodiazepines (diazepam 10-20mg IV) for agitation, hypertension, tachycardia
• GTN for cocaine-associated chest pain
• Avoid beta-blockers in cocaine toxicity (risk of unopposed alpha stimulation)
• Sodium bicarbonate if wide QRS on ECG

MDMA toxicity:

• Cooling measures
• Benzodiazepines for seizures/agitation
• Cyproheptadine 12mg PO for serotonin syndrome (then 4mg every 2h)
• Hypertonic saline 3% (100mL over 10 min) if Na⁺ <120 with seizures/severe symptoms

GHB/GBL:

• Supportive — airway protection; usually self-limiting
• Atropine if symptomatic bradycardia
• Do NOT use flumazenil (not effective)

Ketamine:

• Benzodiazepines for emergence reactions/agitation
• Monitoring of cardiovascular parameters

Surgical/Interventional

• Body-packer: Whole bowel irrigation; surgical retrieval if package rupture with clinical toxicity

Referral Criteria

• ICU: Hyperthermia >40°C, cardiovascular instability, refractory seizures, severe hyponatraemia
• Drug and alcohol services: All patients with recreational drug use
• Psychiatric: If self-harm or suicidal ideation
• Safeguarding: If children exposed to drug use in the home

• Cocaine-associated MI: 5-10% mortality if not recognised; excellent outcome with appropriate management
• MDMA fatalities: Primarily from hyperthermia, hyponatraemia, or serotonin syndrome
• GHB/GBL: Narrow therapeutic window; death from respiratory depression; usually recover fully if airway managed
• Synthetic cannabinoids: Increasing mortality and morbidity; unpredictable pharmacology
• Nitrous oxide: Prolonged use → B12 deficiency → subacute combined degeneration of the cord (irreversible if severe)

Drug-Specific Emergency Management Summary

Serotonin Syndrome Diagnostic Criteria (Hunter)