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© Borgis - Postępy Nauk Medycznych 7/2017, s. 371-375
*Beata Kudłacik1, Małgorzata Fraś1, Tomasz Ilczak1, Michał Ćwiertnia1, Arkadiusz Stasicki1, Anna Debudaj1, Halim Nammous2, Anna Walesiuk2, Grzegorz Łopieński2, Jerzy Robert Ładny2, Klaudiusz Nadolny3, 4, Łukasz Szarpak5, Rafał Bobiński1
Pre-hospital procedure in narcotic substance intoxication – case study
Postępowanie przedszpitalne w zatruciu środkami odurzającymi – studium przypadku
1Faculty of Health Sciences, Department of Nursing and Emergency Medicine, University of Bielsko-Biała
Head of Faculty: Associate Professor Rafał Bobiński, MD, PhD
2Department of Emergency Medicine and Disasters, Medical University of Białystok
Head of Department: Professor Jerzy Robert Ładny, MD, PhD
3Voivodeship Rescue Service in Katowice
Head of Service: Artur Borowicz
4College of Strategic Planning in Dąbrowa Górnicza
Head of College: Anna Rej-Kietla, MD, PhD, LLM
5Department of Emergency Medicine, Medical Univeristy of Warsaw
Head of Department: Zenon Truszewski, MD, PhD
Streszczenie
Według badań prowadzonych przez Światową Organizację Zdrowia (WHO) zatrucia należą do jednych z czołowych przyczyn zgonów na świecie.
Zespoły ratownictwa medycznego podejmujące działania u pacjentów z ostrymi zatruciami substancjami odurzającymi powinny działać według aktualnych wytycznych Europejskiej Rady Resuscytacji.
Każdy stan osoby potencjalnie zatrutej należy traktować jako stan zagrożenia życia. Objawy ostrego zatrucia środkiem odurzającym lub inną substancją chemiczną mogą występować natychmiast lub z kilkugodzinnym opóźnieniem, związanym z absorpcją z przewodu pokarmowego.
Summary
According to research conducted by the World Health Organization (WHO) intoxications are one of the main causes of deaths in the world.
Medical Rescue Teams undertaking rescue procedures in patients with acute intoxications caused by narcotic substances should act in accordance with the current guidelines of the European Resuscitation Council.
Every condition of a person who is potentially intoxicated should be treated as a life threatening condition. The symptoms of acute intoxication with a narcotic substance or a different chemical substance may occur immediately or with a few hours of delay related to the absorption from the digestive tract.
Introduction
Every year from 7000 to 8000 people die only in the European Union as a result of narcotic substance intoxications. In Poland there are from 100 000 to 120 000 people addicted to narcotics, however these data refer only to people who officially admit it. The Chief Sanitary Inspectorate presents quite disturbing data in which it is possible to notice that at the turn of 2014 and 2015 the number of designer drug intoxications increased from 6.29 per 100 000 inhabitants in 2014 to 18.92 cases per 100 000 persons in 2015 (1). This is nearly a threefold increase of such cases recorded by the Chief Sanitary Inspectorate. The WHO has considered acute intoxications the fourth leading cause of death in the world (2). The data demonstrate the great size of the problem which stimulants have become nowadays as people have started considering them a good escape from everyday stress related to work, school and family life.
Increased demand for various types of narcotic substances as well as the development of pharmaceutical technology make stimulants so popular.
One of the main routes of drug trafficking to western Europe is the “Balkan Trail” which starts in Afghanistan and the neighboring countries and goes to Poland through Turkey and the Balkan countries. This trail is mainly used for trafficking opioids which are responsible for 41% of all drug addictions in the countries of the European Union.
There is over a million registered people aged 15-64 who regularly take opioids and, what is interesting, ca. 4% of all the deaths of the inhabitants of Europe aged 15-39 are caused by the abuse of this drug (3).
According to the Polish law narcotic substances are substances of synthetic or natural origin affecting the central nervous system, the list of which has been published in annexes to the Act on counteracting drug addiction (4).
Despite of the constant extending of the list of narcotic substances every month new substances emerge; they are most often derivatives of the chemical substances present hitherto. The annexes to the act on counteracting drug addiction include several hundred psychoactive agents. Table 1 presents the latest changes to the list of narcotic substances included in the act on counteracting drug addiction dated 1st July 2015.
Tab. 1. The classification of narcotic and psychotropic substances based on the act on counteracting drug addiction (4)
GroupList of narcotic substances
I-NThe group I-N narcotic substances are strongly addictive gents which may be used for industrial, medical and scientific purposes. The group includes cannabis and poppy products, coca leaves, cocaine, ecgonine, synthetic cannabinoids – 183 substances in total.
II-NNarcotic substances from group II-N are moderately addictive substances which may be applied for industrial, medical and scientific purposes – in total 10 substances such as codeine, propiram, ethylmorphine and others.
III-NMedicinal substances of groups I-N and II-N subject to mitigated control. The narcotic substances of group III-N are more rarely addictive agents which are subject to mitigated control. Drugs containing agents from this group in specified doses and concentrations may be distributed in pharmacies without prescription, the group includes: nicodicodeine, ethylmorphine, dihydrocodeine, acetyldihydrocodeine – 8 substances in total.
IV-NSubset I-N subject to more restricted control. The narcotic substances of group IV-N are agents subject to more restricted control which may be applied only in the treatment of animals and for research purposes. This group includes: heroin, cannabis seeds other than fibrous, cannabis resins – 14 substances in total.
GroupList of psychotropic substances
I-PThe psychotropic agents of group I-P are substances of high possibilities of abuse which have been removed from the pharmaceutical market and are used only for research purposes. Group I-P includes 93 substances – i.a. agents obtained from hallucinogenic fungi such as psilocin and psilocybin.
II-PThe psychotropic agents of group II-P are substances of negligible medical application with high possibilities of abuse which may be used for industrial, medical and scientific purposes. This group includes: amphetamine, fenethylline, ketamine and 36 other substances.
III-PThe psychotropic agents of group III-P are substances of significant medical applications and moderate possibilities of abuse which may be applied for industrial, medical and scientific purposes. Group III-P includes a total of 8 substances, i.e. cathine, buprenorphine, flunitrazepam.
IV-PThe psychotropic agents of group IV-P are substances of significant medical applications and moderate possibilities of abuse which may be applied for industrial, medical and scientific purposes. This group includes: diazepam, clonazepam and 70 other substances.
Since 2010 a medical and social problem of growing significance are chemical substances called “designer drugs”. “Designer drugs” are products containing psychoactive substances which haven’t been included in the list of controlled substances annexed to the act on counteracting drug addiction. The sales of these substances has significantly increased in the last years thanks to distribution taking place via online shops. Changes to the above mentioned act have extended the list of controlled substances by another 114 substances which have previously been considered as “designer drugs” (4).
A very popular division of narcotic substances is the classification which has been presented by the WHO (5):
I. opium group,
II. alcohol and barbiturates, barbiturate-like substances group,
III. amphetamine, amphetamine-like stimulant drugs group,
IV. cocaine group,
V. cannabis group,
VI. hallucinogen group,
VII. khat group,
VIII. volatile solvents group.
The opium group includes ca. 20 substances which are divided into two types: phenanthrene alkaloids and isoquinoline alkaloids. The most popular substances in this group are: heroin, methadone, morphine, buprenorphine, tramadol, fentanyl as well as hydromorphone which is not available in Polish drug stores (6). The substance from this group most often applied by Medical Rescue Teams in Poland is morphine which is present in the following medications: Morphini sulfas WZF, MST Continus, Sevredol, Vendal, Doltard oraz M-Eslon (7). Morphine (MF) is a phenanthrene alkaloid constituting one tenth of opium. It is an agonist of opioid receptors, strongly acting on μ receptors, significantly less strongly on δ and κ. The primary effects of morphine are the analgesic, antitussive and anti-diarrheal effect. It is applied as a medicine of choice in patients with severe and very severe pain (8).
The next group are alcohols and barbiturates. The derivatives of barbituric acid have got a sedative, soporific, anxiolytic, anticonvulsant and amnestic effect. Their mechanism of action consists in activating the chlorine channel by binding to the GABAa receptor and blocking the conductance of the sodium and calcium channels. Due to the fact that these substances are strongly addictive, they exhibit high toxicity, they disrupt sleeping phases and they negatively affect the patients’ behavior, currently they’re applied only in anesthesiology and in the treatment of epilepsy. These medications include: phenobarbital, benzobarbital, methylphenobarbital (7-10).
The group of amphetamine and amphetamine-like stimulant drugs includes derivatives of phenylethylamine: amphetamine, methamphetamine, dexamphetamine, methylphenidate, dexmethylphenidate, ephedrine, fenfluramine, pheniprazine, phentermine, tranylcypromine. These are the so-called psychostimulants. Their mechanism of action is based on the intensification of dopaminergic and noradrenergic transmission and on weaker serotoninergic transmission. They cause increased releasing of catecholamines from presynaptic terminals and inhibit their neuronal re-uptake. Psychostimulants reduce the feeling of fatigue and sleepiness, they improve concentration and induce euphoria. Prolonged abuse leads to a serious mental addiction. Amphetamines are the cause of a number of side effects related to the stimulation of the sympathetic system such as arterial hypertension, coronary pain, arrhythmia or collapse. These substances proved to be effective in the treatment of obesity, however due to the risk of addiction and of the occurrence of side effects their usage is negligible. It should be added that the medications from this group, such as methylphenidate and dexmethylphenidate are used in the therapy of the attention deficit hyperactivity disorder in children (ADHD). In sport the derivatives of amphetamine are also illegally used as doping agents (7, 10).
Cocaine (benzoylmethylecgonine) which belongs to group IV according to the WHO classification, is produced mainly from the leaves of the cocaine bush (Erythroxylon coca). It is easily absorbed through the mucous membranes, it is considered a natural agent of local anesthesia and it strongly stimulates the sympathetic system and the central nervous system. The afflictions caused by this substance include tachycardia, hyperthermia, hypertensive crisis and myocardial ischemia with the symptom of angina pectoris. It belongs to strongly narcotic and addictive substances causing strong changes in the brain (7, 9, 10). Drug addicts abusing cocaine demonstrate atrophy of the nasal mucous membrane and mental changes: sexual and psychomotor agitation (characteristic symptoms are euphoria and the abolition of the feeling of fatigue) and visual and auditory hallucinations (7).
Cannabis (Cannabis sativa indica) is used for the production of hashish (a mixture of resin covering the tops of flowers), marijuana (dried leaves and inflorescences) and hashish oil. The most strongly acting substance is the hashish oil and the weakest one is marijuana. The derivatives of cannabis mainly contain cannabinols the most active of which is tetrahydrocannabinol. Cannabinols belong to psychodysleptic drugs and they have an analgesic, antiemetic and hallucinogenic effect. If they are taken for a long time they lead to a strong mental dependence causing mild symptoms of physical abstinence (7, 11).

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Piśmiennictwo
1. Dane z działalności Państwowej Inspekcji Sanitarnej w sprawie dopalaczy w latach 2011-2016; http://gis.gov.pl/zdrowie/dopalacze/dane-statystyczne (dostęp: 6.03.2017).
2. Zawadzki A (red.): Medycyna katastrof. Podręcznik dla studentów uczelni medycznych. Wyd. Lekarskie PZWL, Warszawa 2015: 272-289.
3. Europejski raport narkotykowy: Tendencje i osiągnięcia. Wyd. Europejskie Centrum Monitorowania Narkotyków i Narkomanii, Luksemburg 2015: 14-16.
4. Ustawa z dnia 24 kwietnia 1997 roku, o przeciwdziałaniu narkomanii (tekst jednolity: Dz. U. 1997, Nr 175, poz. 1462 z późn. zm.).
5. Jędrzejko M (red.): Narkomania – spojrzenie wielowymiarowe. Wyd. Akademia Humanistyczna im. A. Gieysztora, Pułtusk-Warszawa 2009: 33-34.
6. Wordliczek J, Dobrogowski J: Leczenie bólu. Wyd. Lekarskie PZWL, Warszawa 2012: 110-111.
7. Janiec W (red.): Kompendium farmakologii. Wyd. Lekarskie PZWL, Warszawa 2012: 38-131.
8. De Walden-Gałuszko K, Ciałkowska-Rysz A: Medycyna paliatywna. Wyd. Lekarskie PZWL, Warszawa 2015: 88-91.
9. Seńczuk W (red.): Toksykologia współczesna. Wyd. Lekarskie PZWL, Warszawa 2012: 302-310.
10. Truhlar A, Deakin CD, Soar J et al.: European Resuscitation Council Guidelines For Resuscitation 2015 Section 4. Cardiac arrest in special circum stances. Resuscitation 2015; 95: 148-201.
11. Atkinson P, Kendall R, Van Rensburg L: Emergency Medicine An illustrated colour text. Wyd. Elsevier, Toronto 2010: 152-157.
12. Nelle J, Stępka AJ: Dopalacze, czyli środki zastępcze w praktyce zespołów ratownictwa. Na Ratunek 2015; 4: 14-20.
13. Kózka M, Rumian B, Maślanka M: Pielęgniarstwo ratunkowe. Wyd. Lekarskie PZWL, Warszawa 2013: 280-300.
14. http://psychiatria.mp.pl/uzaleznienia/show.html?id=91680 (dostęp: 20.03.2016).
15. Cebula G, Jankowski M, Klimaszyk D: Resuscytacja krążeniowo-oddechowa według wytycznych European Resuscitation Council 2015. Część III: Postępowanie w zatruciach i urazach. Med Prakt 2016; 1: 36-41.
16. Rams P, Sosada K, WantułaT et al.: Ostre zatrucia – postępowanie w ratownictwie medycznym. Na Ratunek 2011; 2: 30-33.
17. Zając M, Waldman W: Postępowanie przedszpitalne w ostrych zatruciach. Na Ratunek 2015; 2: 25-31.
18. Janus T, Janus A, Piechocki J: Odtrutki zespołu podstawowego. Nalokson, flumazenil, atropina. Na Ratunek 2015; 6: 21-26.
otrzymano: 2017-06-02
zaakceptowano do druku: 2017-06-29

Adres do korespondencji:
*Beata Kudłacik
Zakład Ratownictwa Medycznego Katedra Pielęgniarstwa i Ratownictwa Medycznego Wydział Nauk o Zdrowiu Akademia Techniczno-Humanistyczna w Bielsku-Białej
ul. Konstytucji 3 Maja 66,
34-120 Andrychów
tel. +48 501-652-052
bkudlacik@ath.bielsko.pl

Postępy Nauk Medycznych 7/2017
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