Drugs of Abuse (Macintyre)

Question 1

stats

Answer 1

144aDay(around 52,000/yr)the number of people that die everyday from all drug overdoses combined (CDC, updated 2017)US Surg Gen’l: substance abuse = major public health crisis: 1/7 Americans (c.21m people) will fall prey but only 10% will receive tx (# of people w/substance use disorder now exceeds # of people w/cancer!)

Question 2

DRUGS OF ABUSE: Some basics

Answer 2

Knowledge is power. Educate yourself. Know the lingo. www.Erowid.org is an excellent resource for information

Much as with sex, adopt a non-judgmental approach. A more evolved outlook treats substance disorders as medical conditions

Use common sense when prescribing medications in the presence of a hx of substance disorders (eg, don’t prescribe Methylphenidate to someone with an active/past hx of methamphetamine dependence). The use of controlled substances with any hx of a substance disorder is very problematic and should be avoided (risks recovery, activates the reward pathway, etc)

***Always ask about route of use

Become familiar with basic counseling techniques for substance use

We have a lot to learn about these substances, both good and bad. Some even hold the promise of beneficial use; others hold tremendous danger and the potential for extreme violence

Many are sympathomimetic

The following slides are only a sampling of the most common drugs of abuse; there are many more. There are usually multiple analogues for many of these drugs

Question 3

MOLECULAR MANIPULATION

Answer 3

New psychoactive drugs emerge at rate of appx one/week.

Question 4

Terms such as “abuse” and “dependence” were discarded in favor of:

Answer 4

Mild: 2-3 symptoms
Moderate: 4-5 symptoms
Severe: ≥ 6 symptoms

Question 5

Substance Use Disorder

symptoms

Answer 5

Tolerance
Withdrawal
More use than intended
Craving for the substance
Unsuccessful efforts to cut down
Excessive time spent in acquisition
Activities given up due to use
Use despite negative effects
Failure to fulfill major role obligations
Recurrent use in hazardous situations
Continued use in spite of consistent social/interpersonal problems

Question 6

Methamphetamine

Answer 6

aka meth, ice, crystal, Tina, T, speed, crank
Can be swallowed, snorted, injected or smoked

Highly addictive & toxic to dopamine nerve terminals → brain damage, esp in frontal cortex (teens > adults). Chronic use can lead to perm cognitive &/or motor disorders

Can cause ↑BP/HR/temperature, dilated pupils, irregular heartbeat, muscle twitching (“tweaking”), mood disturbances, wt loss, psychosis, dental problems, teeth grinding, insomnia, violence and extreme agitation

ED visits jumped dramatically (approx 68,000 in 2007 to approx 103,000 in 2011)

Question 7

Rx stimulants

Answer 7

Can be swallowed, snorted, or injected
16% rise in ADHD dx since 2007
Overdiagnosis? Overprescribing?
Concurrent use of benzos…???
Gaining use among parents as “designer drug” for kids…???
Abuse or overuse can cause anxiety, ↑ BP/HR, irritability, psychosis (esp paranoia), weight loss, insomnia, cardiovascular effects, teeth grinding
Abuse is clearly on the rise: ED visits related to stimulant use was 13,379 in 2005 and 31,244 in 2010 (SAMHSA). Biggest increase among 18-25yo. Rampant abuse in high schools & colleges (est 20% abuse rate in colleges). More than 19,000 reports of complications from ADHD meds since 2013 according to the FDA

Question 8

rx stimulants - stats

Answer 8

the number of adults in the United States taking AD/HD medications…rose 53 percent from 2008 to 2012…” “Women are using AD/HD medication at notably higher rates than girls, with those in the 26-to-34 age range posting a staggering 85 percent jump in the use of such drugs in just five years.”
-Huffington Post, 12/18/14

Sales of prescription stimulants have more than quintupled since 2002 (approx $2 billion in 2002 to nearly $9 billion in 2012)”

Question 9

Bath salts

Answer 9

Newer arrival on drug scene (eg, Flakka, 2015)
Routes: po, inhale, IV, vape
Contain amphetamine-like chemicals: methylenedioxypyrovalerone (MDPV), mephedrone and pyrovalerone
Surge in serotonin, norepinephrine, and dopamine (10x more dopamine than cocaine?) (↑risk Serotonin Syndrome)
Can cause: chest pains, ↑BP/pulse, agitation, hallucinations, suicidality, extreme paranoia, delusions, and extreme violence
Nearly 23,000 ED visits in 2011

Question 10

Marijuana

Answer 10

Most commonly used (il)legal drug
Psychoactive ingredient is Δ-9-tetrahydrocannabinol (Δ-9-THC, or just THC for short)
aka pot, green, 420, reefer, joint, blunt, dope, bud, Mary Jane, etc
Smoked or eaten
Causes euphoria, ↑appetite, sense of relaxation; can also cause tachycardia, injected conjunctivae, dry mouth, paranoia, distorted perceptions, and difficulty with memory or complex tasks
May accelerate psychosis in those predisposed
Gateway drug?

Question 11

Synthetic Cannabinoids

Answer 11

aka Spice, K2, fake weed, etc
Marketed as “natural” or “herbal” but active ingredient is synthetic
Popular among young people
Smoked or used as herbal infusion in drink
Causes effects similar to marijuana; in some cases, can be more potent and cause anxiety &/or psychosis. Can also cause ↑ heart rate & BP, vomiting, pulmonary irritation
May contain heavy metal elements…and…?
Now on Schedule I

Question 12

Cocaine

Answer 12

aka blow, snow, coke. Used to be in Coca-Cola
Powder or crystal (“crack”) form
Can be smoked (“crack”), snorted or injected; Can be mixed w/heroin (“speedball”)
Causes psychomotor agitation (“crack dance”), dilated pupils, ↑BP/HR/energy/speech, euphoria, sinus problems; chest pain, risk of HIV or hepatitis transmission; can also cause MI thru vasoconstriction (24-fold increased risk!)
Surge of dopamine release (150x more powerful than orgasm…?), uses a lot of available dopamine –> depletion –> depression, usu temporary but can be profound (“crash”) & accompanied by hypersomnia

Question 13

Psychedelics are being tested

Answer 13

as potential remedies for a host of tough-to-treat maladies.” Pilot studies and clinical trials of psilocybin, ketamine, lysergic acid diethylamide (LSD), and methylene-dioxy-meth-amphetamine (MDMA) “have shown that the drugs, often in combination with talk therapy, can be given safely under medical supervision and may help people dealing with opiate and tobacco addiction, alcoholism, anxiety, depression and post-traumatic stress disorder, or PTSD.”

Question 14

Psilocybin

Answer 14

aka magic mushrooms, shrooms, shroomies
Swallowed or used in tea
Causes distorted perceptions, dilated pupils, hallucinations, cholinergic excess, ↑BP/HR/temperature, anxiety, nausea
LSD frequently in play
Several studies have indicated a possible/quicker antidepressant effect & possible use in tx addictions

Question 15

LSD (Lysergic acid diethylamide)

Answer 15

aka acid
Tablets, capsules, liquid, or absorbent paper. Lasts 8-12 hrs
Produces vivid hallucinations and distorts reality; can also cause ↑BP/HR/temp and insomnia
Can produce “bad trips” and “flashbacks”

Question 16

Ecstasy (3,4-methylenedioxymethamphetamine)

Answer 16

aka MDMA, X, XTC, love drug, Molly, Adam, rave drug
Taken orally –> ↑serotonin release (↑ risk Serotonin Syndrome)
Causes intense feelings of mental stimulation, emotional warmth, connection to others, energy; can also disrupt temperature homeostasis (↓thirst signal), cause nausea, chills, muscle cramps, teeth clenching, ↑HR/BP, pupillary dilation. Death can occur thru dehydration
Neurotoxic: Use can lead to destruction of serotonergic neurons. Long-term use theorized to –> depression
Use on the rise: ED visits in 2005 = 4,460; 2011 = 10,176

Question 17

Inhalants

Answer 17

aka whippets, snappers; usually involves common household products incl gasoline & glue
Popular among younger children
Route: “huffing,” “bagging,” or direct inhalation
Causes rapid high; can resemble EtOH intoxication. Inhaling greater quantities can result in feelings of sensation loss and/or unconsciousness
Extremely dangerous and/or deadly: many contain heavy metals; can cause kidney failure, suffocation (inhalants displace O2), hearing loss, limb spasms, bone marrow damage, organ damage, or death
Some products can cause severe CNS damage incl white matter lesions, demyelination, atrophy and degeneration

Question 18

PCP

Answer 18

aka angel dust, wet, embalming fluid, sherms, ozone, wack. Original name/use: Sernyl
>30 known analogues
Usually smoked; can be swallowed or snorted
Mimics schizophrenia-like psychosis (NMDA antagonist); causes dissociation, detachment, ↑BP/HR, nystagmus, sensation of heat, unusual strength, anesthetic efx, volatility and unpredictability; pts can be highly agitated
Go read about Big Lurch on Wikipedia. Not after eating. And not right this second, pls 
“Sss…”
“Everything must go”

Question 19

Ketamine

Answer 19

aka Special K, vitamin K, jet, cat tranquilizer
Ironically, discovered while searching for an alternative to Sernyl…
Snorted, ingested, IM

Pet anesthetic; ltd human use for short-term medical procedures (↓ resp depression than w/other anesthetics)

Sx incl dreaminess, ataxia, ↓sensations, emotional warmth, epiphanies, hallucinations, near-death experiences, blackouts, etc.

Holds promising, possibly even revolutionary, possibilities in depression tx. Currently under intense study

Question 20

Benzodiazepines

Answer 20

aka benzos, bennies, Xannies, “anxiety pills”; very common Rx drug
Abuse can cause sedation, lethargy, memory problems, ataxia, slurred speech & sent 123,000 people to the ED in 2011
Wide therapeutic window; however, **be very careful if/when prescribing benzos to someone on other sedatives or opiates **(risk of respiratory depression, delirium) incl FDA Black Box Warning. Should not be given to those abusing alcohol, period.
Chronic benzo use, much like alcohol use, leads to ↑regulation of NMDA receptors, and ↓regulation of GABA receptors  CNS hyperactivity in withdrawal. Risk of seizure from benzo withdrawal just like EtOH withdrawal. Withdrawal can present as a delirium. These pts need detox
Careful w/Flumazenil: can precipitate acute, severe withdrawal

Question 21

Barbiturates

Answer 21

Not really such fun, actually. Narrower therapeutic window than benzos; hence, much easier to OD/die. Use is rarer as these were eclipsed by benzos (think of barbiturates as the dotard old grandfather and benzos as the young, hip, cool, sunglasses-wearing jock dude)
aka barbs, barbies, downers, Nembies, Seccies
Abuse –> tolerance. If drug is stopped abruptly, withdrawals and seizure can occur.
Intoxication similar to benzo picture and carries same risk of seizures
These pts also need detox

Question 22

DRUGS OF ABUSE: Others

Answer 22

Dextromethorphan (aka “Robotripping” and “DXM”)

• Popular among younger set
• Dissociative
• Dangerous w/serotonin agents, other anticholinergics, risk of Olney’s Lesions?

Anabolic steroids

Energy drinks, caffeine

Quetiapine (“Susie Qs”), Mescaline, morning glory seeds, nitrous, DMT…..!!!!!!

In short, just about anything can be abused if not taken as prescribed or used to get high. Remember: people will try just about anything to get high

Question 23

Treatment of Acute Agitation

Answer 23

Always find out if/what other substances are on board (ask!, UDS, Breathalyzer, etc)

“Talking down” can be effective for mild-moderate intoxication. Calm, quiet room w/proper lighting is appropriate

Medicate when appropriate: choose the right combination

• Antipsychotics (if appropriate & watch out for ↓ sz threshold) &/or
• Benzodiazepines, when appropriate (if pt is intoxicated on alcohol &/or benzos, would you want to give a benzo to ↓ agitation if they’re getting out of control? Why or why not?)
• Anticonvulsants when indicated

Most intoxications will clear within 24 hrs. Some substances may have symptoms that can persist for days or even weeks

Question 24

DRUGS OF ABUSE: Ongoing Treatment

Answer 24

Detox when appropriate (benzos, barbs, EtOH, opiates)

Rehab is the next step. Options are inpatient, outpatient, IOP, etc

Bupropion for cocaine? Naltrexone? Vaccines?

Ongoing psychosocial support: peer groups (NA, AA, etc), volunteer work, etc. Group tx important

Lapses are a typical part of recovery, should be minimized, and the pt encouraged to immediately continue recovery

Incarceration or rehab? Punish or treat? What’s your thoughts? What effect will health care changes have?

Question 25

Sheryl is 22yo and already looks much older than that. She admits that she has been abusing many substances recently. She has prominent track marks on both arms and is clenching and unclenching her teeth nearly every other second. She says her boyfriend injects her with his “special recipe” daily that makes her feel “both energetic and relaxed, it’s weird.” She says it always makes her heart pound and then feel like somebody cushioned it. She complains that he’s been gone for 2 days and she’s feeling nauseated, craving the “special recipe,” and she’s having bouts of nausea and diarrhea today. She says she’s exhausted but she can’t sleep. Her boyfriend’s “special recipe” is likely:

A)  Methamphetamine
B)  Speedball
C)  Cocaine
D)  Heroin
E)  Ketamine

Answer 25

Speedball– cocaine and heroin