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Ascertaining Drug Consumption: A Practical Guide for First Responders

Updated: Jan 8

This article will tell you everything you need to know as a first responder (Police Officer, paramedic, nurse or fireman) in a situation in which recreational narcotics may have been consumed by one of the relevant patients or other parties. This guide contains everything they never taught you at Police School.

The author of this article is a paramedic, and it has been written at the suggestion of two Police Officers in a European jurisdiction. The question often arises whether someone has consumed a recreational narcotic still in their bloodstream; whether they are experiencing an overdose so serious that it requires prompt intervention; and which narcotic(s) they are likely to have taken. With a blood testing kit at the scene and a prone patient, the problem is best resolved by administering an immediate blood test. Relying upon physical symptoms is much more prone to error, not least because the behavioural effects of so many narcotics often manifest themselves in extremely similar ways. Moreover people may have mixed drugs, in particular alcohol and some other substance, which can render it difficult to parse out the effects of each one or to establish what else may be underlying the subject's drunkenness.


There are many myths in this pseudo-science, such as that users of MDMA can't stop dancing or that users of cocaine have dribbling nostrils. The problem with these platitudes - and they are often adopted even (or particularly) by senior categories of first responder - is that they are neither necessary nor sufficient to establish intoxication using the narcotic imagined. That is because each of these so-called giveaway indications holds true of more than one narcotic; each of them can likewise be symptoms of illness rather than intoxication; each of them may be down to a particular physical or psychological characteristic of an individual; and some of them can be quite misleading because the effects of narcotics upon different individuals varies from one person to the next, often very substantially.


To give just one rather obvious example for the time being, the assumption that people at a "rave" (slang for an underground party with music people dance to) are taking any particular narcotic, or even are drunk, is quite misconceived. Nobody has undertaken any reliable studies, because most recreational narcotics are illegal and therefore people consuming them do not want to volunteer for scientific observation.


While some people at a rave might well have taken what for years was considered as the classic rave drug, "Ecstasy" (a tablet containing slow-release MDMA, a euphoric), others may have taken a wide variety of other substances; some may be drunk; and some may not have taken any narcotics or alcohol at all. People in this latter category tend to be extremely fit, and have come to the rave because they like the feeling of constant exercise over a period of several hours while dancing to the music. Many other narcotics have primary effects virtually indistinguishable from the propensity for dancing with which Ecstasy is imagined to imbue its consumer. Some people who take Ecstasy do not dance at all. Some people react differently to MDMA crystals (without the slow release component). And so on and so forth.


The following point may sound rather obvious, but this is a subject worth brushing away casual illusions. MDMA does not "re-wire" your brain so as to make you start liking music with repetitive beats that you did not previously like. MDMA is an anti-depressant; it affects things such as serotonin uptake in the brain. Serotonin does not cause you to like certain types of music. It's the other way round: certain types of music that you like cause serotonin release, which is associated with pleasure. Contemporary music styles have always been reviled by the elder generation. But recreational narcotics do not cause young people to like certain sorts of repetitive music. Hence a room full of people listening to music you don't like is not a reliable indicator alone that people are taking drugs.


With these overarching thoughts in mind about the practical limitations of establishing the substance by which a suspected drug user has become intoxicated, we can now study some general principles.


Look in the person's pockets


The most reliable way of establishing what drug a person has been taking is to find more of it on them. This is more effective with drugs that come in powder form, because the drug user is likely to be taking several hits of the powder in the course of the event being attended. That is straightforwardly because snorting powder causes the intoxicant to enter the blood stream more quickly than ingesting a tablet; and hence the narcotic's half life will tend to be shorter. That may entail that should the powder user wish to remain high throughout the event, he may have extra powder in his pockets. Other places to look include in a lady's shoulder bag, where most drugs are barely disguised.


One problem with this approach is that once you have found a narcotic substance, how will you identify which one it is? Cocaine, amphetamine and ketamine all look almost identical. Do not be distracted by gasbags who tell you that they know when something is cocaine because it is crystalline or reeks of paraffin (the solvent in which mass transport of cocaine is used). Those qualities apply only to near-pure cocaine; and very little cocaine sold is near-pure because near-pure cocaine is so strong that it can cause an overdose very easily if the user of the narcotic is not familiar with its strength or effect upon his or her body. In other words, cocaine is "cut" (diluted) by dealers for reasons of safety as much as anything else, and you cannot reliably tell what is cocaine by examining the crystalline structure of a powder. The nature of cocaine powder can vary widely, and is typically the product of the agent with which it is mixed rather than of the underlying cocaine itself.


Some eyesight identifications of narcotics are very easy. Crystalline MDMA has a specific brown colour and translucent jagged crystals. But others are more difficult. What appears to be an Ecstasy pill might have something else in it (or something else as well as MDMA). No drugs smell except marijuana and cigarettes. To tell whether someone has been smoking, just smell their breath; there is nothing can do to hide it except brushing their teeth. Marijuana can come in a variety of fairly identifiable forms: dark green bushes or a dark brown crumbly substance are the most common.


In many cases the only way you can make the inference from discovery of a narcotic on the person being responded to is to try it yourself. Do not waste time with a tongue test; you can tell nothing from this (except perhaps the mixer with which what might be cocaine has been cut). Any drug can be snorted; to establish whether an Ecstasy pill is really MDMA, crush it up and snort a bit. This is also the way to establish the difference between cocaine, ecstasy and ketamine. The difference is immediately obvious when you consume a little bit, in a way that goes straight into your bloodstream. Don't take so much that you get high yourself, of course. Your job is to assist in a situation in which a person may have placed themselves or others in danger through over-consumption of narcotics. Always remember the first rule of dealing with ill people, irrespective of your profession: first do no harm, not least to yourself.


Ask people in the vicinity


This method is often forgotten. It should never be neglected, irrespective of whatever other acts of observation are undertaken. The worst thing is that the people in proximity may say nothing or may lie. If they do lie, then it will usually be obvious. A person who genuinely wants to help in a crisis is obvious, and it is obvious when they will be telling the truth. A person who is concerned for their own legal wellbeing may lie, particular if you as the First Responder are a Police Officer but not always. If you are a Police Officer in a First Responder situation, don't start trying to stop-search everybody. You will only create a sense of crisis. If you are a paramedic or ambulance worker, be aware of the sense of crisis you may instil if you immediately call the Police. There may be other unwell people in the environs. If you cause them to panic and run off, you may be abrogating your duties to assist those who need care and you may create a situation of confrontation between the public and yourselves. You want to avoid this at all costs, as such commotion can lead to unpredictable results.


If you have good relations with the bar staff, security guards or owners, ask them what this person is likely to have taken. The people with the best skills at identifying self-intoxication are people who work around intoxicated people all the time, namely bar staff and security guards in nightclubs. They are a hive of valuable information. They may know the intoxicated person. If you have built relationships with them, they may quietly tell you what has happened.


In all events stay calm. If a person has fallen ill, and particularly if violence has accompanied the incident, then there may be all sorts of people screaming. You must stay calm irrespective of how many high people are screaming or crying. Look for the close friends, the boyfriend or the girlfriend in particular, calm them down with soothing language and ask them what happened. They are bound to know, and just a few minutes of reassuring conversation may save a lot of time later. They just have to trust you. If you are a Police Officer, find the right friends or partners of the ill person in a non-confrontational way; and reassure them quietly that you are not going to arrest them. Do not make a drama out of a crisis. I have seen this happen far too many times.


If you are lucky, a member of the security team, or even a member of the public, may be a paramedic and may already have intervened before the first responders have arrived. Do not shove these people away or act aggressively towards them. They may know exactly what happened and they may be prepared to tell you truthfully. Pull such a person into your team, always reassuring them that there is no risk of arrest; they may be an asset, and they may become a prime witness in a subsequent coroner's investigation or criminal prosecution.


With those comments, we will now briefly run through the most common drugs that people consume and that cause incidents requiring primary response.


Ketamine


This is one of the easiest narcotics to identify. Although superficially the effects of ketamine may appear to be like those of other euphoric (MDMA and amphetamine, for example), it has a very distinctive subjective effect upon the user that can be ascertained with the right line of questioning.


Ketamine creates in the user a mental state of being outside events, as though the world is in a different place from the consumer. People dancing using ketamine often look to the ceiling or off into the distance. They tend to be very unaggressive. Conversation with them tends to involve discussions of which dimension we might be in, or other metaphysical hallucinations. But the easiest way of confirming a ketamine user, who is often very susceptible to suggestions, is to invite them to go and sit down, talk with them for a bit, and then stand up and walk away. They will continue sitting there, thinking about whatever point of ontology you directed their minds towards.


It is relatively difficult to overdose dangerously on ketamine. In the case of suspected overdose, sit the user down and wait a few hours.


MDMA


MDMA should be classified distinctly from Ecstasy, because although they are one and the same pharmacological substance, the difference in their preparation and administration leads to dramatically different half-lives and behaviour patterns.


MDMA crystals are typically ground and snorted. They are so unappealing to the nose that the nostril will typically stream liquid for up to 20 minutes afterwards, accompanied by a stinging sensation that substantially discomforts the user. Flowing liquids out of noses is more often an indicator of MDMA usage than of cocaine usage.


The other way of consuming MDMA crystals is to swallow them (perhaps dissolved in water); but this often leads to immediate vomiting. MDMA is highly antagonistic to the digestive system.


In terms of effects, MDMA causes near-immediate but short lived extreme euphoria, to the extent that all communications may become impossible. MDMA is one of the few narcotics that prevent people from speaking entirely. It also prevents sleeping; those high on MDMA will not able to rest until the effects of the drug wear off.


The good news is that MDMA, like Ecstasy, is mostly harmless and very rarely fatal. The damage that snorting it may cause to the internal membrane of the nostril will seldom last more than 24 hours. If someone is high on MDMA, let them keep on being high. if someone overdoses, they will probably lie down and vomit. Place them in the recovery position and they will very quickly recover.


Ecstasy


Ecstasy is an oral form of MDMA typically mixed with an acrylic to ensure slow-release. It is less intense a euphoric than MDMA, for this reason. On the other hand, a person who overdoses (and this is quite difficult - you need to take several Ecstasy pills at once to overdose) will feel ill for a considerable period of time until the slow-release MDMA wears off. Dancing is not always associated with Ecstasy; many people sit down and just smile. As with a number of euphorics, capacity for conversation or complex thought is substantially inhibited even with relatively small amounts. Conversations rarely progress beyond themes such as "I have nice trousers". "Yes, they're nice." "Great!" If anyone is speaking coherently about a complex subject, they are not high on MDMA.


Repeated use of the lavatory is a good indicator of Ecstasy intoxication, because the narcotic causes irritable bowel syndrome upon its consumption. This means that people keep repeatedly going to the toilet, either to urinate or to defecate, but often there is nothing to come out (the sensation of desire to use the lavatory is stimulated without their necessarily being a need to go); and sometimes they forget why they even went. If you find someone sitting on the lavatory wondering what they are doing there, they are probably high on Ecstasy. This is in contradistinction to MDMA, that has far less of such an effect by reason of its shorter half-life.


Another way of checking for Ecstasy intoxication is to place yourself in the doorway to the lavatory when the person wants to go to the bathroom. Typically they will fall into you, because one of the principal side-effects of Ecstasy is the failure of motor skills. It is this that makes Ecstasy potentially dangerous. People drop their drinks; glasses break; people fall into one-another or fall over onto the floor that is covered in glass, and the like.


Some people panic after taking euphorics, particularly such as Ecstasy, by reason of its relatively long half-life for a few hours. Such people realise that they cannot "come down" at a time down they want to, and this may cause a sensation of panic. In such circumstances, remind them that they are safe (Ecstasy is a very harmless drug), and then sit them down in the company of others with a fizzy non-alcoholic sweet drink such as Coca Cola or lemonade. After a couple of hours, they will be just fine.


Alcohol


Recall that a substantial proportion of people at a music party (or "rave") may be using alcohol as a stimulant. Although generally categorised as a depressant, the drug has stimulant effects for many people as long as one keeps drinking it, particularly in high concentrations (i.e. hard liquor or spirits). It can cause aggression or it can cause sedation; or one and then the other. Alcohol is uniformly diagnosed by First Responders as one of the most dangerous recreational narcotics, both by reason of its high availability (bar owners will not stop serving a consumer absent extraordinary circumstances); the propensity for violence that consumption of high levels of alcohol can generate; and the possibility of collapse and choking upon one's own vomit, in which scenario the narcotic can become fatal.


There cannot be a stronger case for regulating a narcotic than there is for regulating the consumption of alcohol. It is extremely dangerous, and its use is engrained in many societies as culturally acceptable notwithstanding its dangerous effects.


The aggression and violence alcohol causes requires constant monitoring in party and rave environments, generally by trained security guards who can spot a violent alcoholic quickly through experience and expel them from the venue. Nightclub security guards tend to care little about the use of any drug except alcohol, which causes them the most problems.


A person who has overdosed upon alcohol may fall unconscious or become very close to it. They should be placed in the recovery position so that they will not choke on their own vomit. In extreme cases they should be transferred to hospital; in less extreme cases they should simply be left until the half-life of the alcoholic drink has expired and they will wake up with a dreadful headache, whereupon they can make their own way home.


Alcohol is highly physically and psychologically addictive; possibly the most addictive of any narcotic when combined physical and psychological factors are taken together. Escaping the physical addiction of alcohol (what is known as "drying out") always takes 10 days, irrespective of the physical features of the patient. The process, which can be very painful for a person with a heavy physical addiction to alcohol, can be rendered more easy by the use of benzodiazepines as cross-tapers.


Cocaine


Cocaine use is one of the most difficult narcotics to recognise, because its symptoms share those of other euphorics to a great extent. Conversation becomes meaningless, but that is true with many drugs. Cocaine users may dance, sit, speak or be quiet. Here are a few myths to be busted. Cocaine users' noses do not dribble more than most people's. They do not go to the lavatory on average more than most people. They do not lose weight. There is no such thing as a "cocaine diet". People who lose weight in a drug-related context might do so as a result of their high levels of routine exercise in dancing, and that may not entail that they are taking any drugs at all. Nor is increased consumption of alcohol associated with taking cocaine. That all depends upon the individual.


One thing that can be said about cocaine is that it is a rich man's drug. You may be able to exclude cocaine intoxication if a person does not look particularly wealthy.


Cocaine is often "cut" (i.e. "mixed") with amphetamines, which have specific and more unpleasant effects. When considering cocaine usage, always also consider the possibility of amphetamine intoxication. Cocaine does not make people paranoid; that is the amphetamine that is consumed at the same time. Cocaine is virtually always cut for the consumer, because of the risk of overdose. This in fact is cocaine's major danger: overdose leading to cardiac arrest, with the consequent mixing with other substances that may cause distinctive types of harm that the user does not anticipate because it is not known at the point of purchase what substance the cocaine is cut with.


Any genuine test for cocaine usage derives from its short half-life. A high can be observed almost immediately upon consumption (a rarity amongst many narcotics or even pharmaceuticals; perhaps only lorazepam, the very short-acting benzodiazepine given to people with acute anxiety conditions can compare), and then it wears off within say half an hour. Cocaine is not physically addictive. But if a person's mood is changing very quickly - within ay half-an-hour cycles, then that is a fairly reliable indicator of cocaine usage. They take some cocaine; they starting acting in a particular way; 30 minutes passes; and then they revert to the prior way they were acting. Cocaine users often overstate traditional personality traits amidst a high. So an aggressive person may become even more aggressive. But one must be careful here; some people are simply aggressive by nature, or volatile by nature. It does not mean they are all cocaine addicts.


For as long as it is used in repeat cycles, cocaine typically excludes sleep - but not always. It is usually the amphetamine with which cocaine is often mixed that causes longer-term sleep deprivation.


Cocaine overdose is a quick and sharp exercise. If a cocaine user overdoses, he or she may enter cardiac arrest very quickly; unless a First Responder is present to provide resuscitation the overdosed person will probably die. Because drug dealers do not want to kill their buyers, they cut the cocaine. On the other hand, if (as is far more common) a person has taken more cocaine than they are comfortable with, and starts worrying, then sit them down with an alcoholic drink, and a benzodiazepine if available, and simply wait with them. They will be fine within 15 minutes. With a cocaine overdose, you either die or you recover very quickly: usually the latter.


Heroin


Heroin is one of the most commonly used narcotics that causes substantial physical addiction. Its effect is as a depressant-euphoric. Its user is easy to identify; they become sedated, sitting or lying down, and they do not speak nor are they responsive to stimuli. The person lying on the sofa in a nightclub not moving despite the fact that the music is incredibly loud, is likely taking heroin. It has a substantially longer half-life than cocaine, and therefore despite its relatively high price (heroin prices in Europe are typically EUR60 per gramme), it can be afforded by less wealthy people. Heroin can be snorted, but usually it is not because its effects are lesser. More commonly it is injected or smoked. Because of its physically addictive qualities, it can cause petty crime amongst its users who seek to steal in order to fund their habits. The film "Trainspotting" is an archetypical account of heroin addicts.


Physically addictive narcotics may cause the skin to age or for blotches to appear, as lack of exposure to the drug causes essential chemicals to be transferred away from the skin.


Recovery from heroin addiction is a process that typically takes one to two weeks, involving a tapering process using methadone and then subotex, another substitute. So the tapering regime is down-up-down-up-down. It requires substantial expertise to supervise a patient undergoing heroin withdrawal. The withdrawal process has been described to this author as like having "bad 'flu". It is not particularly difficult to do; but it requires supervision so that the patient does not take the opportunity to escape his environs and procure more of the substance.


In higher doses, heroin is fatal as it causes the heart and nervous system to stop functioning. Absent immediate application of an antidote, the person will die, even with cardiac resuscitation. Call an ambulance immediately and say "serious heroin overdose".


Amphetamine


Amphetamine is also physically addictive. Its elation effects are similar to MDMA or Ecstasy, at least on the "high". Meaningless conversation is one of the first symptoms. The principal difference between amphetamine and MDMA drugs however is that the user is incapable of staying calm or quiet. They will not sit still. They also tend to adopt a unique sort of thousand-yard stare, that has to be experienced to be understood. People intoxicated with amphetamines will generally be more aggressive than those intoxicated with MDMA.


A good test for a person high on amphetamines is therefore to ask them to sit down. They won't do it for very long. They can appear to have limitless amounts of energy, for extended periods because amphetamines typically have a long half-life. Once they do start to come down, they may become motionless and intense, sitting down and staring at their mobile telephones for example and not being much responsive to the rest of the world.


Persons who frequently take amphetamine can appear unnaturally thin, because amphetamine is a long-term appetite suppressant. (Cocaine by contrast suppresses the appetite, but only for about 20 minutes.) So spindly, unnaturally thin physiques are corroborative of long-term amphetamine addiction. Because amphetamines are physically addictive, a change in the skin is possible just as with heroin use; important chemicals are drawn from the skin to service the rest of the body.


If a person has overdosed with amphetamine, because of its long half-life benzodiazepine treatment may be important to stabilise the patient. This should not be attempted by unqualified personnel, as the levels of benzodiazepine that may be necessary might be fatal or might cause extreme complications in a person who is not in fact suffering from an amphetamine overdose. On the other hand, alcohol is a reasonable short-term sedative while awaiting more sophisticated medical attention than a First Responder may be able to provide.


Psilocybin (Magic Mushrooms)


Psilocybin is virtually harmless, save from the fact that the mushrooms containing it taste revolting. It is lawful in several jurisdictions including the Netherlands. It is a euphoric and mild hallucinogenic, although the hallucinogenic effects increase at higher dosage rates. One of this narcotic's most curious features is that it attracts its consumers towards bright lights and vivid colours: hence why all the food stalls in De Waal, the Red Light District in the centre of Amsterdam, are full of brightly coloured snacks. Psilocybin, as with many euphoric, will reduce a person's judgment, often substantially, so they can get lost walking and the like. The period of onset is about 45 minutes and the half-life is about four hours. Sometimes people panic when they realise that they cannot "come down" from the high straight away. This may cause a "bad trip". In such circumstances put the person in a darkened room with something bright in the corner, e.g. a television show with TV programmes. In the case of overdose the consumer will just vomit.


Psiloycbin is not really addictive or habit-forming. If a person takes psilocybin too frequently, it will simply stop working until it has dried out of their system.


Lysergic acid dyethilamide (LSD or "Acid")


The effects of LSD are almost identical to those of Psiloycbin, save that the euphoria and hallucinations can be more intense depending upon the individual. LSD's principal distinguishing feature and disadvantage, namely its long half-life of 12-13 hours. As with psilocybin, a bad trip may derive from the user's experience of an inability to come down such cases, a dark room with a bright light in the corner is again the best solution; and one has to wait. Because LSD is very strong, people may do very silly things while it has effect upon their minds. Their conversations may become extremely strange; and they may acquire fertile imaginations or paranoia. To bring a person down quickly from LSD, use either zoplicone (the sleeping pill) or a strong benzodiazepine (such as lorazepam) and monitor.


All that having been said, LSD is mostly harmless. The harm that LSD causes people derives not from the drug itself but from the silly things they may do while under its influence. Do not carry valuables or baggage; stay away from main roads or bodies of water; carry enough money for the taxi, and one's door key, in the sock of one's foot so that when you come down, if you have indeed lost everything in your pockets and bag you at least have those basic items still with you that permit you to get home safely where hopefully you will have left your valuables.


Conclusions


When faced with a situation of narcotic over-intoxication, stay calm. Do not be judgmental or you will scare people away who might be able to provide you with valuable information. In the modern world there are very few people under the age of 35 who have not overdosed on various narcotics at various times. The phenomenon may be at least as typical as drunkenness. Treat these incidents as social health problems; use forensic methods to establish exactly what the intoxicated person has consumed; and calmly apply an appropriate remedy accordingly.









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