ER nightmare: Users overdosing on toxic drug supply turn violent, putting doctors, patients at risk

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Tests of street drug samples are turning up fentanyl containing medetomidine and xylazine, tranquilizers and sedatives from the world of veterinary medicine that, in humans, decrease blood pressure and heart rate and slow breathing. Others contain Valium or other “benzos” (benzodiazepines). Some analyses show a mixture of fentanyl, medetomidine and benzos in the same sample.

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Naloxone only works for opioids. It doesn’t treat or reverse the effects of other contaminants.

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Overdoses have become more complex, Lang and other emergency physicians said. The toxicity of the contaminants can lead to significant changes in heart rhythms or heart rates, prolonged sedation and brain injuries. They also hang around in the bloodstream longer.

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Paramedics are finding people in deeper states of coma. “Unfortunately, sometimes the amount of oxygen deprivation that occurs during these prolonged ingestions is fatal,” Lang said.

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Unlike 30 years ago, when most cardiac arrest patients were people in their 60s and 70s who’d collapsed with chest pain, “many are now younger people whose hearts stopped because of opioid ingestion,” he said.

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The intensity of the care necessarily means more resources — more equipment, more staff, more medications, more space in emergency departments that are already overcrowded and out of beds, with people often lying on floors.

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“Previously these patients wouldn’t require high levels of critical care and are now requiring admission to hospital or admission to ICU for more intensive care for longer periods of time,” said Dr. Taryn Lloyd, an emergency and addictions medicine doctor at Toronto’s St. Michael’s Hospital.

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“There’s no question: When we use naloxone to reverse patients, they can become very agitated and violent,” says Dr. Eddy Lang. Photo by Supplied/File

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Some people come in already agitated from naloxone and in withdrawal, sweating profusely, their heart beating too fast and in acute pain.

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“It’s such a powerful addiction,” Lang said. Opioid users describe the high “as being so encompassing and so euphoric.

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“They’re in this warm cloud of happiness that is just so addictive. They have to go back and back, even if it means they’re homeless, they’re involved in crime, they’ve alienated their families,” Lang said.

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“So, imagine, you’re in this state of warm cloudiness and suddenly you are abruptly and violently woken up by naloxone. Any pain you may have been covering up with the opioid use is now heightened, and your whole body is aching.”

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The situation can move from someone barely breathing who can’t be roused “to now they’re thrashing, jumping up in bed and their arms flailing in a way that is really scary to see and can be very traumatizing to the staff,” Lang said.

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ERs sometimes have separate areas used for mental health and addiction cases, rooms that are locked and secured, without windows or any items people can use to hurt themselves. But there’s a limit to those spaces “and only a few places in North America have taken the whole idea of keeping mental health and addiction patients separate from the general population,” Lang said.

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Despite the concerns around opioid overdoses, Lang said alcohol and crystal meth are likely bigger sources of violence than opioid overdose withdrawal. “When people get intoxicated with alcohol, it’s just a recipe for very bad decisions.”

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The approach at St. Michael’s is to prevent agitation from opioid withdrawal as much as possible. “Five years ago, we would have gone with a different dosing strategy,” Lloyd said. “Now we go low and slow and take our time, anticipating that the patient may respond in a manner that’s unsafe.” Like the emergency medicine journal article, they’re now spreading the word to other emergency providers.