World Cup Ready: Managing the Triple Threat of Heat, Alcohol, and Other Drugs

By Colleen Cowdery, MD

As the World Cup arrives in the U.S., we’re preparing for influx of fans and festivities all across the state. With a record-breaking heat wave forecasted for the upcoming week, and NOAA anticipating hotter-than-average temperatures throughout the summer, the potential for heat-related injury is significant.

When you combine high-energy crowds, rising temperatures, and increased social substance use, you may encounter a “triple threat”: the convergence of heat injury, alcohol intoxication, and drug exposure. We are here to support you with these complex cases.

Heat + Drugs

When managing patients, it’s critical to recognize how alcohol and other drugs compound heat-related stress:

  • Alcohol consumption significantly increases susceptibility to heat injury. Mechanisms include accelerated dehydration, impaired internal temperature regulation, and impaired judgment, which may prevent patients from utilizing safe cooling behaviors like seeking shade or drinking water.
  • Acute toxicity from recreational drugs—particularly stimulants like cocaine and methamphetamine—is significantly worse during hot weather.
  • Beyond recreational drugs, many prescribed medications interfere with thermoregulation. Common classes include:
    • Anticholinergics: Including many allergy medications like diphenhydramine (Benadryl), which decrease sweating.
    • Psychiatric Medications: SSRIs, SNRIs, TCAs, and both typical and atypical antipsychotics can interfere with internal temperature regulation.
    • Diuretics: lead to greater dehydration risk and decreased thirst sensation.
    • Sedating Medications: Opiates, benzodiazepines, and anticonvulsants are associated with a higher fall risk and reduced thirst sensation.
  • Multi-Drug Risk: Using multiple drugs at once is associated with the highest risk of death during hot weather.

Symptoms

Intoxication can mask the early, subtle signs of heat injury. Conversely, the cognitive impairment from heat can be indistinguishable from substance-related impairment, complicating your assessment.

Symptoms of heat injury:
  • Heat stress (mild): muscle cramps, heat rash
  • Heat exhaustion (moderate): Fatigue/weakness, nausea, headache, heavy sweating
  • Heat stroke (extreme): Confusion, slurred speech, tachycardia, tachypnea, hypotension, lack of sweating, seizure, coma
Symptoms of stimulant toxicity:
  • Tachycardia
  • Hyperthermia
  • Hypertension
  • Anxiety/agitation
  • Hallucinations
  • Seizures
Symptoms of Serotonin Syndrome:
  • Altered mental status
  • Muscle rigidity
  • Myoclonus
  • Hyperthermia
  • Rhabdomyolysis

Treatment

When treating patients with heat injury complicated by drug/alcohol toxicity, prioritize aggressive control of hyperthermia and rhabdomyolysis, as these are the greatest sources of morbidity and mortality.

Assessment & Monitoring:
  • Patients with significantly altered mental status or seizures require a core temperature measurement, either esophageal (if intubated) or rectal.
  • Labs and monitoring should include ABCs, IVF, EKG, core temperature, CMP, Phos, Mag, CPK, urine drug screen, and blood alcohol.
Active Cooling:
  • Remove extra clothing and place ice packs on the patient en route to the hospital.
  • Relay notification of hyperthermia to the medical facility so they can set up cooling measures prior to arrival.
  • Any patient with a core temperature greater than 105°F (41°C) requires aggressive cooling, including ice baths and chilled saline IV fluids.
Pharmacological Interventions:
  • Benzodiazepines are indicated for agitation, seizures, and as a treatment for sympathomimetic and serotonin toxicity. These patients may require higher doses than normal to achieve control.
  • If CNS depression is present, consider co-exposure to opiates like fentanyl, and administer naloxone and cardiopulmonary support as needed.

We’re on your team

Washington Poison Center is staffed by board-certified medical toxicologists, specially trained pharmacists, and nurses who are available 24/7/365 to support your clinical decision-making. Call us at 1-800-222-1222 for:

  • Complex Presentations: When a patient’s altered mental status is multifactorial and you need help untangling substance-induced vs. heat-induced symptoms.
  • Dosing & Management: Assistance with sedation protocols for agitated, hyperthermic patients.
  • Rare Exposures: Guidance on managing unique or unknown substances encountered in the crowd.