It was a Sunday night in the ER and it did not sound like the usual Sunday night.
The noises emanating from the emergency department the minute I walked through the door for my night shift were like nothing I had ever heard outside of a horror movie. There were three patients all in 4-point restraints, who were alternating between yelling, moaning, and muttering in a nightmarish version of a Gregorian chant. A nurse walked up to me with a coy smile and said, “turn around.”
As I started to sit down at my computer station in order to log in, I turned to the outgoing doctor and asked him what that sound was. He said, “That, my friend, is DOC.”
“What the hell is DOC?”
15 years working in Level 1 trauma centers and busy emergency departments and I have seen thousands of intoxicated patients who were high on everything from alcohol, crank, crack, Coricidin, PCP, LSD, marijuana, Benadryl, horny goat weed… you get the point.
But DOC is different.
2,5-Dimethoxy-4-chloroamphetamine is similar to methamphetamine with a few changes. These alterations are what make DOC so powerful. By making a couple of small changes in the chemical composition, the user will experience intense visual hallucinations. The inventor of DOC, Alexander Shulgin, called it an archetypal psychedelic; its presumed full-range visual, audio, physical, and mental effects show exhilarating clarity, and some overwhelming, humbling, and “composting/interweaving effects.” Translated into a language that the non-drug using bystander witnesses, this patient is going through a hell of a trip where, literally, all sensory inputs will be overloaded. Because the peak activity for DOC is 4-8 hours with lingering stimulating effects for the next 8 hours, we had to restrain, sedate and watch these patients go through what can only be categorized as hell. The response that the visual hallucinations had on them was profound. They pleaded for relief even though they were being treated aggressively with both antipsychotics and benzodiazepines.
Now I imagine that most of the trips that the average user is going through are not what occurred in the ER that night. What we as medical providers experience is a patient with who has severe psychomotor agitation with erratic, aggressive, behavior. All of this taking place in the confined space of a novel ER room. This is a volatile situation and nurses as well as the rest of the medical team should take great care when approaching and dealing with these patients as their perception of reality is horrifically skewed (based on observing these patients and reading the drug-user blogs).
You can bet that almost all ER providers know of a colleague who has been injured by an aggressive/drug affected patient while trying to provide care to a patient. In this era of increased violence towards nurses, we have to be increasingly diligent and aware of what our patients are experiencing. In this case, a true empathy of what the patient is experiencing might lead to an understanding of what might decrease their agitation and protect all staff. A team approach might be helpful here, calling for security backup and using restraints until the anti-psychotics and anxiolytics take effect.
Not much is known about DOC but we have seen increased use in our ED and there are increasing case reports in the medical literature. It appears that many of the patients had intended to take “regular meth” instead. A couple of our ER patients had choice words for their dealers while in the throes of their painful hallucinations.
People who use regular methamphetamine usually take it for its feeling of euphoria, increased libido, and energy. Meth is popular in the homosexual male date rave culture where it is revered for its ability to enhance and allow sexual intercourse for hours. The side effects of meth can include psychosis, especially in prolonged use cases. Other common side effects are horrific acne, rapid dental decay, and stereotyped psychomotor agitation. For the average user, DOC seems to provide much of the euphoria as meth but has a significantly greater hallucinogenic effect.
It is unclear if this is just the beginning of an onslaught of DOC use. There are reports that DOC is easier to manufacture or obtain than “regular meth” which is why it is being substituted or combined with methamphetamine. In either case, a heightened awareness of the drug's prevalence and effects will do much to make our hospitals a safer place for all of us who work there.