7. Outside (& Between)
the Lines

The point we just made — that
drug crises contain similar elements which can be assessed and
managed in similar ways — is valid and useful, as far as it
goes. But it’s still only part of the picture, and only a general
way of approaching drug emergency response. From here on out,
we’ll focus on specifics.

Because even though it may be helpful to see through the forest
of details that inevitably surrounds a discussion of drug effects
and emergency procedures, it can be absolutely vital to see a
tree when it jumps right in front of you.

Among other “jumping trees” we’ll be discussing in
this section are drugs that hop over both classification lines
and the response sets we proposed earlier. We will particularly
emphasize life-threatening emergencies, such as aspirin and acetaminophen
overdose and anticholinergic drug syndrome, which don’t fit well
into the CNS crisis model we proposed earlier.

That isn’t meant to contradict what we’ve said thus far about
the value of the CNS crisis continuum or the universal crisis
response. Both are important tools for viewing the context and
structure of crisis response.

If the earlier sections constituted the bare bones of drug crisis
response, this chapter represents the skin and teeth and bones
and hair.

Drug Overdose Syndrome

Of all the exceptions to the
CNS-arousal crisis model, perhaps the most distinctive is the
toxic reaction produced by anticholinergic drugs.

These drugs, which include a variety of prescription and non-prescription
medications based on the plant belladonna and its derivatives,
are used to treat problems as diverse (and far-flung) as sinus
congestion and irritable bowel syndrome. Other drugs having significant
anticholinergic properties are the antidepressants.

The term anticholinergic itself refers to inhibition of
the neurotransmitter acetylcholine, which is involved in the
regulation of a number of body processes in the central and parasympathetic
nervous system.

Why do anticholinergics figure so highly into drug emergencies?
One reason is the sheer volume and variety of drugs with anticholinergic

It’s possible, for example, for a person taking one product for
sniffles, say, and another for diarrhea and yet another for depression
to be completely unaware of the risk of drug synergism.

Another reason is that antidepressants are prescribed to depressed
people and depressed people sometimes try to kill themselves.

Any overdose involving drugs with anticholinergic properties
should be regarded as a serious medical emergency. Symptoms can
be tricky.

Both physiological and psychological effects can be determined
by a number of factors, including drug type and dosage, interactions
with other medications, route of administration, even user age
and personality.

Similarly, symptoms can run the gamut, incorporating features
that can be mistaken for both arousal-agitation and depressive-stupor

In addition, a severe psychological syndrome can develop, particularly
when the drugs are used with phenothiazine tranquilizers. Symptoms
include auditory and visual hallucinations and toxic delirium.

When responding to anticholinergic drug emergencies, it’s important
to remember that a specific antidote, physostigmine, does exist
for the syndrome. That’s only one more reason EMS back-up is
essential in resolving anticholinergic emergencies.

Drug Crisis

Emotional component: Agitation, anxiety, confusion, delusions
Physiological signs: Dilated pupils, rapid or irregular
heart beat, dry skin and mouth, flushed face, fever, abdominal
pain, urinary retention, ringing in the ears, muscle spasms,
Behavioral signs: Disorientation, incoordination, impaired
concentration, hallucinations.
Life-threatening complications: Convulsions, stroke, heart

Anticholinergic Drug OD Response

If the person is conscious:

Find out what drugs were taken
and when.
Monitor vital signs.
Reduce stimuli.
Induce vomiting, if drugs were taken in past hour.
Call EMS, if necessary.

If the person is unconscious:

Check ABC’s.
Call EMS.
If the victim is vomiting, place in recovery position.
Provide life-support and other emergency care.


Aspirin and acetaminophen are
main players in the drug crisis world, for reasons that might
surprise you.

Acetaminophen (which is sold generically and under the brand
names Tylenol™ and Datril™) was the fourth-most common
drug mentioned in U.S. emergency room admissions during 2000
(figuring into 33,613 emergencies), while good old-fashioned
aspirin was right behind, in the fifth spot, helping to land
15,657 folks in the hospital.


A main reason is that both drugs are often combined with other
more-potent analgesic and psychoactive drugs, like codeine (in
Empirin™ or Tylenol™ #1, 2, 3, and 4), oxycodone (Percodan™,
Percocet™), and even barbiturates (Fiorinal™).

One result for users can be dependence on the psychoactive component
and overdose on the acetaminophen or aspirin. And that can be
a real problem, particularly since each of the non-prescription
painkillers can trigger a life-threatening overdose syndrome.

A special danger of acetaminophen involves the mildness of symptoms
after an overdose. Symptoms may go unnoticed for up to two days
after an overdose, before serious problems emerge due to cumulative
toxic effects on the liver.

At high risk for both types of overdose are older people, who
can come to rely on either or both of the drugs for pain management:

Overdose can occur with as little as one or two tablets above
an ordinary tolerated dose, when a regular user crosses his or
her “metabolic threshold.”

A specific antidote, N-acetylcysteine, exists for acetaminophen
OD when administered in the first 10 hours of overdose, making
quick assessment and response — and quick action (and movement
in the direction of a hospital emergency room) — vital.


Emotional component: Confusion, fatigue, anxiety
Physiological signs: Headache, ringing in the ears, dim
vision, sweating, thirst, rapid breathing, nausea, vomiting,
abdominal pain, skin eruptions, convulsions, coma
Behavioral signs: Incoherent speech, delirium, hallucinations
Life-threatening complications: High body temperature,
dehydration, respiratory failure, heart attack

Aspirin OD Response

If the person is conscious:

  • Find out what drugs were taken
    and when.
  • Induce vomiting, if drugs were
    taken in past hour.
  • Monitor vital signs.
  • Reduce body heat, if excessive,
    by applying wet towels, etc.
  • Call EMS, if necessary. Crisis
    symptoms can develop quickly.

If the person is unconscious:

  • Check ABC’s.
  • Call EMS.
  • If the victim is vomiting, place
    in recovery position.
  • Reduce body heat, if excessive,
    by applying wet towels, etc.
  • Provide life-support and other
    emergency care.


Emotional component: Unease, anxiety, emotional distress
Physiological signs: Nausea, vomiting, pallor, profuse
sweating, skin rash, fever
Behavioral signs: Delirium, unconsciousness
Life-threatening complications: Liver and kidney damage,
hypoglycemic coma

Acetaminophen OD Response

If the person is conscious:

  • Find out what drugs were taken
    and when.
  • Monitor vital signs.
  • Induce vomiting, if drugs were
    taken in past hour.
  • Call EMS, if needed.

If the person is unconscious:

  • Check ABC’s.
  • Call EMS.
  • If the victim is vomiting, place
    in recovery position.
  • Monitor vital signs.
  • Provide life-support and other
    emergency care

Inhalant Overdose & ‘Sudden
Sniffing Death’

Of all the drugs that strain
the CNS-arousal emergency model, perhaps the group that’s most
immediately lethal is the inhalants, particularly volatile solvents
(“volatile” means they change from liquid to gas when
exposed to air) and aerosols.

Inhalants can get you in a couple of ways.

Probably the best-known way is the syndrome known as “sudden
sniffing death,” or SSD.

SSD typically follows a consistent pattern: After sniffing to
the point of intoxication, a user is suddenly surprised or abruptly
begins a strenuous activity — running at top speed, for example,
or lifting a heavy object.

Physical collapse and death frequently follow, usually due to
severe cardiac arrhythmia.

Besides SSD, inhalants can also cause a variety of other serious

  • Freon can cause suffocation in the form of “airway
    freezing,” as the refrigerant vaporizes in the throat.
  • Industrial solvents can cause a number of problems related
    to their toxicity, including irreversible organ damage.
  • Deaths can also result from
    the inhalation of various solvents (including naptha, benzene,
    acetones, and others) or when users pass out with solvent-soaked
    plastic bags still covering their nose and mouth.

Psychological effects of inhalants
can also be perplexing, with excited, agitated behavior sometimes
giving way rapidly to profound CNS depression.

Still, from a crisis perspective, the most distinctive element
of an inhalant OD is its speed of onset.

Rapid response is the only way to even the odds.


Emotional component: Excitement, euphoria, disorientation,
Physiological signs: Headache, ringing in the ears, double
vision, dilated pupils, increased heart rate, irregular heartbeat
Behavioral signs: Slurred speech, incoordination, increased
activity, slowed reflexes, unconsciousness, delusions, hallucinations
Life-threatening complications: Sudden sniffing death,
behavioral toxicity (sometimes brought on by impulsive, hazardous

Inhalant Overdose Response

If the person is conscious:

  • Find out what chemicals were
    inhaled and when.
  • Monitor vital signs.
  • Call EMS, if needed.

If the person is unconscious:

  • Check ABC’s.
  • Call EMS.
  • Remove rags, bags, or other
    sources of toxic fumes.
  • Monitor vital signs.
  • Provide life-support and other
    emergency care.

PCP/Ketamine Emergencies

The last drug group that we’ll
focus on that significantly deviates from our agitation-stupor
continuum is phencyclidine, or PCP, and its chemical cousin,
ketamine (commonly known as “K” or “Special K”).

Developed and used medically as animal tranquilizers and surgical
anesthetics, they deserve special consideration because each
combines wildly varying, even contradictory, effects in a single
pharmacological package.

Depending on dosage and personality characteristics of the user,
both PCP and ketamine can produce effects that mix — in the
same episode — stimulant, anesthetic, hallucinogenic, and depressant
properties. In addition, both drugs can trigger bizarre psychological
effects, including depersonalization, delusions, and visual and
auditory hallucinations.

Effects are dose-related, meaning that higher doses cause more
intense and more dangerous physical and psychological effects.
Still, since both drugs are depressants, it’s important to bear
in mind that both react synergistically with other CNS depressants
(including alcohol), which can lower overdose threshold and raise
overdose risk.

Effective crisis response must involve a careful reading of the
user’s behavioral and emotional state and physiological symptoms.

Paranoia and delusional thinking can so distort personality as
to pose a physical risk to the crisis helper. For this reason,
do not attempt to enter a user’s personal space without being

Stay calm and demonstrate relaxed self-control with a psychologically-distraught
user, but call for EMS back-up if obviously psychotic ideation
or dangerous behavior persists.

Overdose/Agitation Response

Emotional component: Excitement, agitation, anxiety, disorganized
thought, paranoia, terror
Physiological signs: Blank stare, flushing, vomiting,
convulsions, increased heart rate, rapid and shallow breathing,
involuntary rapid eye movements
Behavioral signs: Incoherence or inability to speak, incoordination,
fever, decreased reflexes and sensitivity to pain, hallucinations,
delusions, hostile or violent behavior
Life-threatening complications: Convulsions, stroke, respiratory
failure, behavioral toxicity

PCP/Ketamine Crisis Response

If the person is conscious:

  • Establish a friendly relationship.
  • Ask for permission to help.
  • Reduce stimuli.
  • Reassure person that he/she
    is experiencing the effects of a drug that will wear off soon.
  • Call EMS, if needed.

If the person is unconscious:

  • Check ABC’s.
  • Call EMS.
  • Monitor vital signs.
  • Provide life-support and other
    needed care.

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is one in a series of publications on drugs, behavior, and health
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