Best practices in treating “club drug” toxicity
Written by Paul Cole, PharmD, CSPI at the Washington Poison Center
For fast, accurate assistance managing drug exposures, call the Washington Poison Center at 1–800–222–1222.
With more venues returning to pre-COVID-style EDM (electronic dance music) events, it’s time to brush up on best practices for treating common drug exposures in this setting.
EDM events, especially multi-day festivals, can be a perfect storm of factors leading to adverse drug events:
- Inexperienced or new users: some event attendees may seek out a novel experience with substance use and do not have drug tolerance. These individuals may not be well-informed on drug effects or harm reduction strategies.
- Poly-substance use: many attendees will use multiple substances, including alcohol.
- Environmental factors: events are often held outdoors and/or in crowded settings, where attendees dance in extreme heat conditions without consuming sufficient amounts of water (by choice or due to limited access). Dehydration may be exacerbated by alcohol and/or drug use — this is especially concerning with drugs that affect body temperature and hydration status, such as MDMA.
- Fear of repercussions: individuals who are overdosing may not seek medical help in a timely manner due to fear of legal repercussions or being dismissed from the venue.
In Washington, the most common synthetic drugs encountered at or around past EDM events include:
- MDMA (3, 4-methylenedioxymethamphetamine; also known as Ecstasy or Molly)
- GHB (gamma-hydroxybutyrate)
- Ketamine (also known as Special K)
- LSD
- Bath salts/other hallucinogenic amphetamines (cathinones)
- Other hallucinogens
Drugs used at events are rarely pure and are often adulterated with other drugs such as amphetamines, synthetic hallucinogens, cathinones, and fentanyl. These drugs may be taken orally, snorted, injected, or inserted rectally or vaginally.
When treating toxicity from stimulant drugs of abuse, the main goal is to prevent death from hyperthermia:
1. Any patient with significantly altered mental status or seizures requires a core temperature measurement, either esophageal (if intubated) or rectal.
2. Remove extra clothing and place ice packs on the patient while transporting to the hospital.
3. Relay notification of hyperthermia to the medical facility so they can set up cooling measures prior to arrival of patient to the ED.
4. Any patient with a core temperature greater than 105°F (41°C) should be cooled aggressively, including ice baths/bags, chilled saline IV fluids, and consideration for cooling catheter placement. Use benzodiazepines for agitation, seizures. Higher doses than normal may be required to control agitation and sympathomimetic toxicity.
5. Benzodiazepine therapy is indicated for sympathomimetic and serotonin toxicity.
6. Refractory cases with significant neuromuscular component may benefit from intubation and neuromuscular blockade.
When treating toxicity from sedative drugs of abuse, the main goal is to support the patient while the drug metabolizes:
1. Care is primarily supportive, monitoring mental status, respiratory status, and vitals.
2. Ensure the patient is protecting their airway and breathing. Intubate the patient, if necessary.
3. People with CNS depression should receive naloxone and cardiopulmonary support.
For fast, accurate assistance managing drug exposures, call the Washington Poison Center at 1–800–222–1222.
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