Drugs of Abuse Flashcards
Use disorder – DSM V
- Use more than planned- Worry about cutting back or unsuccessful - Lots of time using or recovering or getting- Craving- Life is affected - Continued to use even though life is affected - Risky behaviors - Tolerance- Withdrawal
Mild, moderate, severe substance disorder
- A mild substance use disorder is suggested by the presence of 2-3 symptoms- Moderate by 4-5 symptoms- Severe by 6 or more symptoms- No longer trying to sort out addiction (which is physical) from abuse, but defining much how it affects person’s life
Various drugs
- Stimulants- Benzodiazepines- Opioids- Hallucinogens- Dissociative drugs - Marijuana- Solvents/Inhalants- Alcohol
Stimulants
- Nicotine- Caffeine- Cocaine- Amphetamines
How stimulants work
- Release DA and NE
Stimulants route of administration
- Oral = Slow onset, low potency, no “rush”- Intranasal = Faster onset- Intravenous = Faster onset, “rush”- Smoking = Fastest onset, most addictive
Stimulant effects (low to moderate doses)
- Insomnia- Increased endurance- Increased activity- Euphoria and mood enhancing
Stimulant effects (high doses)
- Paranoia- Hallucinations- Suspiciousness- delusions- Picking- Pancreatitis/DM
Stimulant: Other negative effects
- Stroke- Seizures- MI- Psychotic Symptoms- Lung and Nasal problems
Cocaine
- Blow, coke, crack, rock, snow- Snort or rub on gums- Crack is heated and inhaled or injected
Biggest worry
- MI – 1% of all MIs – increases plaque formation and causes vasospasm- Don’t use Beta Blocker if concerned of cocaine use- Can cause issues with nose, lungs
Amphetamine (speed)
Methamphetamineo Added methyl to facilitate crossing the blood-brain barriero Ice or crystal meth is the crystalized formo Crank is made in home labsAmphetamineso Better oral absorption than cocaine and longer duration than cocaine
Snorting Adderall
- Pulmonary talcosis- Manufacturers use talc as a binder
Stimulants: Withdrawal and Dependence
3 stages of Abstinence:o 1-5 days: “crash” with intense craving, exhaustion, and intense depressiono 1-10 weeks: “withdrawal” depression, craving, hedonic state (relapse is strong)o Indefinite: occasional depression, moderate craving, loss of pleasureWithdrawal and dependence:o Depressiono Fatigueo Hungero Aches and paino Loss of pleasure
These help with stimulant withdrawal
- Benzos- SSRIs – need careful monitoring- Anti-psychotics
Smoking
- About 18% of the adult population now- Very fast acting (very addictive)- DA release- Also the physical habit
Why you don’t want your patient smoking?
- Increased risk of death- Increased risk of heart/lung issue- Anesthesia- Poor circulation means poor healing
Quitting smoking
- About ½ of smokers tried to quit for at least 1 day in previous year- 7 meds FDA approved to help (Chantix, Zyban, replacements)- Cold turkey about 4%- CBT- Trying 2 or more methods at once helpful
Benzodiazepines (benzos)
- Depressant effect on CNS by sitting on GABA receptor and stimulating GABA- Used to relieve anxiety, muscle relaxation and to treat seizures- Addictive- Will reset the “anxiety” level in the brain over time
BENZOS KNOW THIS
- Can be dangerous with ETOH- Fast withdrawal maybe fatal – weaning and close supervision if prolonged use and high doses.- Romazicon 0.2ml IV – use with caution and be prepared!!! Seizures possible
Opioid examples
Examples:- Heroin, morphine, codeine, oxycodone, hydromorphone, hydrocodone, fentanyl, oxymorphone, tramadol (yes tramadol), Dilaudid and others- Morphine-like effects by binding to brain opioid receptors
Opioid effects
- Change in mood- Mental clouding- Slow breathing- Sleepiness- Analgesia- Constipation- Urinary retention- Withdrawal not life threatening
Opioid withdrawal symptoms
- Irritable, agitated, anxious- Pain- Sweaty- Nausea
Help with opioid withdrawal
- Can get them on “safer” opioid – methadone- Wean- Benzos- Zofran- Clonidine- Suboxone (mix of narcotic and naltrexone)
Opioid reversal agent
- IV – Narcan (they may come up swinging)- Oral – naltrexone – many other uses
Prescribing opioids long term
- UDS, PMP- Have goals- Try to cut back, use non-opioid therapies, contracts
Hallucinogens
- Psychedelics- Alter consciousness- Abuse leads to cardiovascular and respiratory collapse- Synthetic Hallucinogens: LSD, peyote- Long term flash backs, paranoia
Dissociative anesthetics
- PCP and Ketamine - Sense of timelessness (being dead, not having limbs, floating in space), depersonalization- High doses DXM- Nitrous Oxide - NMDA/glutamate complex antagonized - Can cause depression leading to suicide, or self-inflicted wounds or violence- Profound anesthesia
Dissociative Desired Effects
- Dreamy and carefree state, altered perception, mood elevation- **Perceptual distortions, diminished pain sensitivity, depersonalization - **Ketamine being used in trauma
Dissociative undesired effects
- Mood swings, partial amnesia, and impaired judgement, disorientation, preoccupation with abnormal body sensations, amnesia, nystagmus, panic, motor impairment, and confusion, catatonia, delirium, psychotic behavior, hypertensive crisis, severe motor impairment…death
Dissociative PCP treatment if out of control
- Isolate patient with restraints- Haldol- Valium- Acidify urine
Marijuana
- Cannaboid receptors all over the body (not just brain)
Medical uses of marijuana
- Glaucoma- Muscle spasms- Seizures- Nausea/appetite- Insomnia- Pain
Marijuana: Starting Young and IQ
- Duke Study- Weekly use before age 18 – lose 8 IQ points- Potentially someone in 50th percentile now the 29th- Less likely to get educated after high school
Marijuana drug
- Active ingredient in cannabis is THC- Impairs motor coordination and perception- About 9-15% addictive (younger you start more addictive)- Mild withdrawal symptoms that last 1 to 2 weeks if big user
Solvents and inhalants
- Volatile intoxicants, anesthetics- Cheap- Accessible- Children and teenagers are the most frequent users
Inhalants
- 18% of high school seniors - 30% of those reported use before age 10- 20% of eighth graders
Solvents and inhalants
- Volatile intoxicants, anesthetics- Low income communities particularly affected- Affluent communities also affected- Toluene can cause permanent neurological damage
Four major groups of solvents and inhalants
- Volatile Solvents: Glue sniffing: lighter fluid, airplane glue, lacquer thinners, industrial solvents, ketones, propane and butane fuel, toluene, esters, and cleaning solutions2. Aerosols: Aerosol propellants such as fluorocarbons. Spray paint, products containing chlorofluorocarbons, ketones, organic metal and n-hexane are particularly dangerous—they can cause cardiotoxicity, neuropathies, and hepatotoxicity3. Anesthetic agents: Chloroform, methylchloride, nitrous oxide, trichloroethylene, and ethyl ether. Oil and grease dissolvers can contain some of this.4. Butyl, Isobutyl nitrite, and amyl: Isobutyl nitrite used as a room deodorizer, Amyl nitrite used for angina. Called “poppers”
Solvents and inhalants
- Alcohol increases the effect- No dependence- Onset is rapid and short duration- Low doses cause euphoria, dizziness, slurred speech, ataxia, perceptual distortions, and impaired judgement- High doses cause a generalized depressant effect
Overdose of solvents and inhalants
- Photophobia, diplopia, sneezing, nausea, chest pain, diarrhea, eye irritation, respiratory depression- Die of asphyxia
Alcohol
- 10 % raised by alcoholic- 43% have an alcoholic in life
CNS effects of alcohol
- Alcohol is a CNS depressant- Euphoria, decreased mechanical efficiency, and impaired thought processes- Stimulatory effects from depression of inhibitory control mechanisms
Alcohol withdrawal syndrome
- Can happen with abrupt stop or big decrease in use that is sudden- “Panic attack” – anxiety, palpitations, sweaty, nausea, shaking- More severe – MAY be fatal and needs medical managemento Seizureso Delirium tremens: auditory and visual hallucinations, disorientation
How to withdrawal someone from AUD?
- Benzos- +/- fluids- Nausea meds- Thiamine, Magnesium, Niacin “banana bag”
Alcohol
- Alcohol disorders involve about 17-18 million individuals- Alcohol abuse costs an estimated 184.6 billion dollars
Alcohol withdrawal syndrome
- Readjustment of the CNS to the neuroadaptation that occurs with prolonged intoxication- Decreased GABA activity- Increased Glutamate and NMDA activity
Alcohol and anxiety
- In an attempt to reduce anxiety, chronic alcohol use increases the brain chronic anxiety state- When alcoholics cut down or quit – will feel that higher set point of anxiety
Alcohol withdrawal
6-96 hours after hrs after drink (or big reduction)o Anxiety, tremulousness, HA, diaphoresis, palpitations, GI upseto Tachycardia, hypertension, fevero Generalized, tonic-clonic seizures, status epilepticus o Auditory and visual hallucinationsA rapid stopping or reduction in alcohol in someone who is chronic abuser can be fatal and needs to be medically managed
Physical exam findings in abuse
- Ascites- Caput Medusa (abdominal wall collaterals)- Jaundice- Malnutrition- Splenomegaly- Gynecomastia - Digital clubbing- Testicular atrophy- Dupuytren’s contractures- Tremors
Alcohol long term – Liver
- 50% Cirrhosis is caused by EtOH- Healthy liver Liver cirrhosis with EtOH
Alcohol and cancer
- The entire GI track (anything that is “touched” by elimination of EtOH) has an increased risk with heavy use
Alcohol and pancreatitis
- 50% of pancreatitis is EtOH related
Alcohol long term brain effects
- Causes brain atrophy – increases risk of brain bleed if fall- Dementia – alcohol abuse big risk for early dementia- Causes “scar tissue” between neurons
Alcohol treatment
Medical:o Topiramate, ondansetron, naltrexone, acamprosateCognitive/behavioral:o Controlled drinkingo Avoiding triggerso Understanding WHY drinkCommunity based treatment:o AA: well known
Study on alcoholism
- A 2007 study by the National Council on Alcoholism’s medical journal reported that people attending 12-step treatment programs had a 49.5% abstinence rate after a single year. Those who were in CBT programs were less successful, maintaining a 37% abstinence rate. - Some report AA success at 5-10% - all in how you define success- Where AA states you have no control, other programs try to teach how to have control
What we have learned about alcohol abuse
- A person’s use over time can be extremely variable- Harm reduction strategies can work in some people
NIH
- Only 25% with AUD get help (including AA)- Over time, 2/3 to ¾ of those with AUD will quit or reduce to moderate and stable
Study on alcoholism
- 100 alcohol dependent men – ½ got 3 week inpatient treatment and intense follow up versus 1 “brief advice” session followed by monthly telephone calls- One year later – same results; two years later better results in the brief intervention
Harm reduction model
- Person continues to drink but effort to reduce the risk and harm – concentrates on riskiest first (like drunk driving)- GOAL ORIENTED
Moderation
- Many programs out there to get people to cut back- Some people with AUD can do this and some people cannot
Things they don’t tell you in medical school
- People overcome addiction and use disorders (high school EtOH/Viet Nam and heroin) and MOST do it without treatment- They quit or cut down to achieve normalcy- Physicians can help- Shame doesn’t work (neither personally or professionally)- Developing coping mechanisms is huge
Children of alcoholics (or of hoarders or gamblers) may have these tendencies
- Feel that issues overshadowed your needs as a child- Had to be caretaker earlier- Independence- Resilience- Anxiety/anger/depression- Sometimes choose partners with use disorders- Duty to care for others- Comfort of chaos
NOTE
f you have a use issue – this is the time to work on that as use disorders can crash a medical career (counseling, lots of websites, change who you spend time with)- If you have someone important in your life with abuse disorder, get your own help
