Drugs of Abuse (Macintyre) Flashcards
stats
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!)
DRUGS OF ABUSE: Some basics
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
MOLECULAR MANIPULATION
New psychoactive drugs emerge at rate of appx one/week.
Terms such as “abuse” and “dependence” were discarded in favor of:
Mild: 2-3 symptoms
Moderate: 4-5 symptoms
Severe: ≥ 6 symptoms
Substance Use Disorder
symptoms
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
Methamphetamine
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)
Rx stimulants
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
rx stimulants - stats
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)”
Bath salts
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
Marijuana
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?
Synthetic Cannabinoids
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
Cocaine
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
Psychedelics are being tested
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.”
Psilocybin
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
LSD (Lysergic acid diethylamide)
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”
Ecstasy (3,4-methylenedioxymethamphetamine)
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
Inhalants
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
PCP
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”
Ketamine
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
Benzodiazepines
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
Barbiturates
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
DRUGS OF ABUSE: Others
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
Treatment of Acute Agitation
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
DRUGS OF ABUSE: Ongoing Treatment
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?
