By Alexander Glaros, MD, and Ahmar U. Zaidi, MD

In 1971, then-President Richard Nixon declared drug abuse to be “public enemy number one,” and The War on Drugs was born. It has now been nearly 50 years since the dawn of what proved to be a seismic shift in the focus of domestic as well as international law enforcement. Yet the health consequences of drug abuse seem only to become more complex with each passing year. In the past half-century, we have seen drugs become more varied, more potent, and more likely to result in overdose. We’ve witnessed the intertwining of the AIDS epidemic with the abuse of heroin, and more recently, crystal meth. We’ve seen the pharmacist in the corner store become just as dangerous as the “pharmacist” on the street corner, as opioid prescriptions spiraled out of control and brought us to the current state of crisis. We’ve seen those who would profit from the mental illness of others grow more creative, inventing designer drugs with higher highs, longer half-lives, and lower profiles on routine testing.

The problem for the modern physician is that the more creative these amateur (or not so amateur) chemists get, the more our day-to-day practice seems to turn into an episode of “House,” where the diagnostic dilemmas are even more impressive than the doctors’ ability to operate an IV pump without pressing the call button. But don’t worry, you don’t have to go full Gregory House and become a drug addict in order to recognize the secret recipes of the underground chemistry labs. You just have to come to the Education Program session presented by Thomas Ortel, MD, PhD, of Duke University Medical Center, and Daniel Federman, MD, of Yale University School of Medicine, titled, Street Drugs: Emerging Hematologic Complications of Illicit Drug Use.

As it has become increasingly trendy to include pharmacologically active adulterants in preparations of recreational drugs, unexpected toxicities have also become more common. From a hematologic perspective, these effects can seemingly be unrelated to the other presenting symptoms of a patient if the physician only considers the classic syndromes, diseases, and toxicities taught in medical school. It is the hematologist’s job to remain current with trendy drug recipes and to share new presentations of drug overdose, since as we all know, it is a rare medication that doesn’t have a hematologic side effect listed on the package insert.

In part one of this session, Dr. Ortel will discuss the problem of synthetic cannabinoids and the recent cluster of cases reported to have had hemorrhagic complications secondary to coagulopathies, attributed to the effects of the rat poison cousin of Coumadin, brodifacoum. The inclusion of rat poi- son in a product reveals the unscrupulous lengths to which a street drug designer will go to achieve the all-consuming goal of creating the best high money can buy. Dr. Ortel will discuss the thought process required to recognize such toxicity, as well as the appropriate management of an unfortunate victim of this careless chemistry.

In part two, Dr. Federman will discuss another dangerous additive, this time to cocaine, which can be just as dangerous but also much more common. Levamisole is an antihelminth used in veterinary medicine that is present in an astonishing proportion of cocaine samples tested globally. Given cocaine’s resurgence in recent years, it behooves any hematologist to be able to recognize not only the adverse effects of the drug learned in medical school, but also those of the levamisole that more likely than not has also been ingested by any cocaine abuser to come through the clinic. To be a modern physician, becoming the next Dr. House is not necessary, but understanding the modern world most certainly is. Attend this session to get up to speed.

Dr. Glaros and Dr. Zaidi indicated no relevant conflicts of interest.

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