Drug Abuse Flashcards
What are the main effects (uses) of cocaine?
- Anti-dysarrhythmic
- Local anaesthetic
- Sympathomimetic
Symptoms: Feel on top of the world, confident, wide awake, short acting, ↓ hunger
Who is most likely to take cocaine?
Youths
Socially marginalised groups
Opiate dependent patients
How does physiological tolerance to cocaine occur?
Brain notices dopamine flood so down regulates dopamine receptors so no longer active and post-synaptic neurone not stimulated, therefore more cocaine is needed for an effect
How does dependence to cocaine occur?
Cocaine causes HR, BP & wakefulness increase so body pre-emptively decreases these reactions for next time cocaine is used to make things ‘normal’. If cocaine use is stopped the body feels abnormal as these factors are lower than normal. If meds needed to make the person feel normal
What are the signs of mild & severe cocaine withdrawal?
MILD: Depression & anxiety, fatigue, reduced conc, cravings, tiredness, inc appetite, excessive vivid dreaming (inc REM)
SEVERE: Cocaine Crash, Suicidal ideation, N&V, sensation of insects on the skin Usually leads to relapse & negative reinforcement
What are the complications of cocaine abuse?
Excited delirium Overdose Crack keratitis Mood disorders (anxiety, paranoia, panic, depression) Renal failure Psychosis (Magnun syndrome) IV blood borne viruses MI, Heart failure Seizure
What is the management in cocaine abuse?
ACUTE: Anxiolytic & treatment of urgent complications (Lorazepam)
Drug counselling/mental health referral
ONGOING: Drug counselling/ mental health referral
Define amphetamine abuse
Involves the recreational use of a class of non-catecholamine sympathomimetic amines.
What are the demographics for amphetamine abuse?
18-25
What does tachyphylaxis mean?
User requires a higher dose to get the same effect due to down-regulation of the postsynaptic receptors & depletion of presynaptic stores of neurotransmitters
How do amphetamines work?
Monoamine agonist/antagonist
Stimulate the release of norepinephrine from central adrenergic receptors.
Higher doses: Release dopamine from mesocorticolimbic system and nigrostriatal dopamine systems.
Acts as a direct agonist on 5-HT receptors & inhibits monoamine oxidase.
Periphery: Release norA by acting on the adrenergic nerve terminals and alpha & beta receptors.
What are the signs of amphetamine use?
Hallucinations & Paranoia HypoN Reduced hunger/appetite Trismus, Bruxism Hyper-vigilance/ wide awake Talkative & Hyper-arousal Increased energy Reduced need for sleep Comedown: Lethargy, anergia, anxiety, irritable, restless, Unable to sleep, exhaustion
How is amphetamine abuse investigated?
Urine toxicology testing Gas chromatography/ mass spectrometry of urine/blood ECG: ST changes, SVT/arrhythmia Serum sodium: <130mmol/L Serum creatine phosphokinase: Elevated
How is amphetamine abuse managed?
ACUTE:
Activated charcoal 1g/kg <1hour
Sedative/antipsychotic (Olanzapine/Lorazepam)
ONGOING:
Psychosocial &behavioural treatment (Matrix Model, CBT)
Pharmacotherapy (Modafinil/Risperidone/Naltrexone)
Depression: Antidepressant (20-60mg/daily Fluoxetine)
How does cannabis work?
Bind to cannabinoid receptors found in NS & immune cells
Type 1: CNS- cerebellum, hypothalamus,SC, hippocampus, cerebral cortex binding slows activity in these areas & releases dopamine ADDICITIVE PATHWAY
Type 2: Immune system &peripheral nerve terminals, analgesic & anti-inflammatory effects
What are the long-term effects of cannabis use?
Airway & lung damage (hyperinflated lungs, chronic bronchitis)
What are withdrawal symptoms of cannabis?
Not lethal as few receptors in the brainstem Loss of appetite Mood changes Irritability Anxiety Difficulty sleeping
What are signs of cannabis misuse?
Acute chest pain in a young person
Acute psychosis +/- precipitate schizophrenia
Mood/sleep disorders (anxiety & paranoia)
Poor concentration & memory
How is cannabis abuse managed?
Anti-anxiety: Buspirone
Psychotherapy: CBT, Self-help, Motivational counselling
Brief interventions
Contingency management
What receptors do the following drugs act on:
- LSD
- Mephedrone
- Mushrooms
- Ketamine
- Benzos
- GBL
- Heroin
- Amphetamines
- Alcohol
- LSD: Dopamine & 5HT agonist
- Mephedrone: Monoamine (ant)agonist
- Mushrooms: 5HT partial agonist
- Ketamine: NMDA antagonist
- Benzos: Gaba agonist
- GBL: GABA agonist
- Heroin: Opioid agonist
- Amphetamines: Monoamine (ant)agonist
- Alcohol: GABA agonist & depressant
How can amphetamines be taken?
Sniff
Smoke
Swallow
Inject (Class A)
What are the negative risks associated with amphetamines?
Panic attacks, depression, aggressiveness, paranoia, hallucinations, psychosis, dependency, chronic sleep deprivation, weight loss, tremors, seizures, immune system suppression, poor concentration, cardiac problems
Severe: Skin picking, excoriations, skin lesions
Dental decay, gum disease
What is the stronger form of amphetamine known as? What are its affect?
Methamphetamine (Crystal meth)
Reaches brain more easily; effects longer
Addictive, ↑MI risk, damages cognition
What is the toxidrome for sympathomimetics?
E.g: Cocaine, Epinephrine, Amphetamine ↑ HR & BP & RR & Temp Dilated pupils ↑ Bowel sounds ↑ Diaphoresis
What is the toxidrome for sedatives/hypnotics?
E.g: Benzos, barbituates, antihistamines ↓ HR & BP & RR & Temp Normal pupils ↓ Bowel sounds ↓Diaphoresis
What is the toxidrome for opioids?
E.g: Morphine, Heroin ↓ HR & BP & RR & Temp Constricted pupils ↓ Bowel sounds ↓ Diaphoresis
What are the class A drugs?
Heroin Ecstasy PCP LSD MDMA Cocaine (incl. crack) Methamphetamine Psilocybin mushrooms Any class B drug made for injection
What are the class B drugs?
Cannabis Synthetic cannabinoids Ketamine Mephedrone Amphetamine Codeine Methoxetamine Methylphenidate
What are class C drugs?
Khat GHB/GBL Benzodiazepines Tramadol Anabolic steroids
What are the criminal convictions for possession & supply of illegal drugs?
Possession- A: 7yrs/ unlimited fine B: 5yrs/ unlimited fine C: 2yrs/ unlimited fine Psychoactive Substances: NOT an offence
Supply-
A: Life/ unlimited fine
B & C: 14yrs/ unlimited fine
What are the exemptions of the Psychoactive Substances Act 2016?
Nicotine
Alcohol
Caffeine
What are the symptoms of opioid withdrawal?
Tremors Anxiety & irritability Yawning Sweating & runny nose & watery eyes Sleep disturbance, insomnia, restlessness nausea & diarrhoea Goose-bumps Abdominal cramps and muscle spasms Tachycardia, hypertension. Dilated pupils.
Tx: Loperamide (diarrhoea), Metoclopramide, NSAIDs, Diazepam (insomnia)
Feeling hot and cold.
Increased bowel sounds.
Coughing
What is the criteria for dependence?
> 3 in last 12months:
- Tolerance
- Withdrawal
- Using more/ for longer than intended
- Unsuccessful attempt to reduce
- Large amount of time spent seeking, using and recovering from use
- Drug use taking priority over social, work and recreational activities
- Persistent use despite harm
How is a patient managed who wants to come off opioids?
28days as in-patient, 12weeks in community
Maintenance: Heroin substitute at stable dose (Methadone, Buprenorphine)
Detox: Switch to heroin substitute and gradually taper down over time
ALL: CBT, stopping OH, support groups, incentives
Naltrexone:
• Long acting opiate antagonist
• Oral, depot, implant
• Blocks euphoric effects, little effect on cravings
• Also used in Alcohol dependency (better evidence base)
How is opioid dependency diagnosed?
A strong desire or sense of compulsion to take the substance.
Difficulty in controlling use.
A physiological withdrawal state.
Tolerance.
Neglect of alternative pleasures and interests.
Persistence of use despite harm to oneself and others.
How is cocaine detox managed?
Psychotherapy: CBT, motivational interviewing
Beta blockers: Symptoms of withdrawal
Benzos: <2weeks, ‘come down’ & insomnia
Disulfiram (secondary care only)
What is the mechanism of action of cocaine?
Cocaine binds to dopamine, serotonin, and norepinephrine transport proteins
Directly prevents the re-uptake into pre-synaptic neurons. Dopamine effect is most responsible for the addiction
What is the mechanism of action of opioids?
Mu-opioid agonist
How do benzodiazepines work?
GABA agonists
What are the signs of benzo withdrawal?
Mild: Decreased concentration, Tremors, N&V, Headache, Mood changes: Anxiety, panic attacks, depression, nightmares, insomnia, sweating, tachy, mild HTN
Serious symptoms: seizures, delirium, confusion. Usually due to abrupt withdrawal.
Other: anorexia, nausea, tinnitus, photo/phonosensitivity, depersonalisation & derealisation.
What are the negative consequences of benzos?
Respiratory depression Falls Hangover Memory loss Sedation Death with injection
How is a benzo detox managed?
Gradual dose reduction- withdrawal 3m-1yr
?Switch to longer acting benzo (Diazepam)
Psychotherapies: CBT, relaxation techniques
Anxiety: Propanolol
Severe: Short-term flumazenil infusions, ?Carbamezepine
How is a benzo overdose treated?
Supportive
Flumazenil
