LECT Drugs of abuse/opiates - MacIntyre Flashcards
methamphetamine effects
this is an amphetamine
Highly addictive & toxic to dopamine nerve terminals → brain damage, esp in frontal cortex (teens > adults)
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
Prescription stimulants
type of amphetamine
Abuse or overuse can cause anxiety, ↑ BP/HR, irritability, psychosis (esp paranoia), weight loss, insomnia, cardiovascular effects, teeth grinding
abuse is on the rise, especially college age
don’t give benzo’s for patients who are agitated and having side effects. lower the dose
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
bath salts effects
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***
effects of marijuana
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?
substance in bath salts
Contain amphetamine-like chemicals:
methylenedioxypyrovalerone (MDPV),
mephedrone
pyrovalerone
Spice , K2
fake weed
synthetic cannabinoids
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…really whatever else you could think of
schedule 1 drug
effects of cocaine
“Blow, snow, coke”
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
Name 3 hallucinogens
Psilocybin (shrooms)
LSD
Ecstasy (MDMA, X, XTC, love drug, molly, adam, rave drug)
Psilocybin
Shrooms
cholinergic rush…
Causes distorted perceptions, dilated pupils, hallucinations, cholinergic excess, ↑BP/HR/temperature, anxiety, nausea
LSD frequently in play
effects of LSD
Produces vivid hallucinations and distorts reality;
can also cause ↑BP/HR/temp and insomnia
Can produce “bad trips-” and “flashbacks”
lasts 8-12 hrs
ecstasy (3,4-methylenedioxymethamphetamine)
aka MDMA, X, XTC, love drug, Molly, Adam, rave drug
↑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
what can happen with long term use of ecstasy
Use can lead to destruction of serotonergic neurons. Long-term use theorized to –> depression
inhalants?
high effects
Causes rapid high; can resemble EtOH intoxication. Inhaling greater quantities can result in feelings of sensation loss and/or unconsciousness
what are the adverse outcomes of inhalants
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
PCP
aka angel dust, wet, embalming fluid, sherms, ozone, wack. Original name/use: Sernyl
Mimics schizophrenia-like ***(psychosis (NMDA antagonist)
Dissociation detachment increased BP/HR nystagmus sensation of heat unusual strength anesthetic effects volatility and unpredictability pt's can be highly agitated
making “ssssss’ noise
“Everything must go”
Ketamine effects
aka Special K, vitamin K, jet, cat tranquilizer
Sx incl dreaminess, ataxia, ↓sensations, emotional warmth, epiphanies**, hallucinations, near-death experiences, blackouts, etc.
“arms are 40 feet long”
could eventually be used for depression !! under intense study
30-60 min duration of effects
chronic benzodiazepine 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
benzo’s and alcohol? benzo’s and other sedatives?
Wide therapeutic window; however, be very careful if/when prescribing benzos to someone on other sedatives or opiates (risk of respiratory depression, delirium). Should not be given to those abusing alcohol. Period.
abuse of benzos looks like what in a pt?
Abuse can cause sedation, lethargy, memory problems, ataxia, slurred speech & sent 123,000 people to the ED in 2011
barbituates
low therapeutic window
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
dextromethorphan
Dextromethorphan (aka “Robotripping” and “DXM”)
Popular among younger set
Dissociative
Dangerous w/serotonin agents, other anticholinergics, risk of Olney’s Lesions?
why don’t you give a benzo to someone with acute agitation from alcohol (substance abuse)
b/c its making them more drunk/toxic
which pt’s (substance abuse) require detox
benzo’s
barbs
etoh
opiates
what is speedball
cocaine mixed with heroin
energy and relaxed combo
heart pounding
sympathomimetic response
heroin is an opiate and causes the relaxing part
methamphetamine route of admin
Can be swallowed, snorted, injected or smoked
Rx stimulants route of admin
Can be swallowed, snorted, or injected
bath salts route of admin
po, inhale, IV, vape
synthetic cannabinoids route of admin
Smoked or used as herbal infusion in drink
route of admin of cocaine
Can be smoked (“crack”), snorted or injected; Can be mixed w/heroin (“speedball”)
route of admin of psilocybin
Swallowed or used in tea
route of admin of LSD
Tablets, capsules, liquid, or absorbent paper. Lasts 8-12 hrs
route of admin of ecstasy
Taken orally
PCP route of admin
Usually smoked; can be swallowed or snorted
ketamine route of admint
snorted, ingested or IM
how many people die per day from opioid OD
44
that’s b/c these are so addictive
Physiologic dependence is pure misery for most people. It robs them of life and livelihood and can lead to incarceration due to criminal acts pursued to obtain the drug (prostitution, theft, etc)
people who die of drug OD often have combo of what in their bodies
benzos and opioids
what percent of pt’s prescribed opiates for 30 days are taking them 3 years later
1/2 !
MC opiates and routes of admin
Oxycontin
Vicodin (acetominophen/hydrocodone)
Percocet (Oxycodone/Acetaminophen)
Swallowed or crushed and snorted, sometimes injected as well
effects of opiate “high”
Leads to feelings of euphoria and sedation.
Causes constricted pupils, slurred speech, impaired coordination.
Can cause ↓BP/HR and respiratory depression***
Consider drug-drug interactions and CYP-450 system (most of these are metabolized thru liver) possible ↑ risk of respiratory depression
if you are taking a 3A4 inhibitor then the level of opiates will go up
aka H, horse, dope, junk, smack
Heroin
full opiate agonist
IV, IM, snorted (sometimes smoked but not efficient, $$), “skin popping”
effects of heroin “high”
Euphoria, sedation, constricted pupils, impaired coordination, can cause ↓BP/HR, respiratory depression (dangerous when combined w/other substances)
IV use shared/dirty needles risk of HIV, HCV, HBV, cellulitis, sepsis, bacterial endocarditis, etc
Street heroin can be “cut” w/adulterants; some can be harmful/deadly (Fentanyl, barbiturates, household powders, etc)
Intoxication symptoms of opiates **
Intoxication symptoms Pupillary constriction Flushing Sedation Slurred speech Bradycardia Hypotension Respiratory depression Hypothermia Constipation (nausea/vomiting are rarer)
Intoxication rapid if IV, delayed if po. Duration of effect depends on the drug (wide variety available)
Typically, users always yearn for that first high that can never be recreated (“chasing the dragon”)
Withdrawal symptoms of opiates
Withdrawal symptoms Pupillary dilation Piloerection Nausea Vomiting Diarrhea Lacrimation Rhinorrhea Joint/muscle pain Abdominal cramps Yawning
Withdrawal peaks in 3-4 days (for short-acting opiates, longer for others), but symptoms can continue for weeks, even months
Won’t kill you…but it’s very unpleasant
how do you prevent opioid-related death
Watch for co-morbid respiratory conditions (asthma, PNA, flu, OSA). Reduce opiate dose 20-30% in the presence of these
Do not use extended-release opioids for acute pain. Period.
Avoid benzos! If they must be used, consider reduction of opioid dose. Benzos enhance opioid toxicity and runs risk of resp depression
Rx Naloxone when/where appropriate
Naloxone (Narcan)
Now available for patients, friends, family (check your State law).
In CO, anyone who is an interested party in someone’s care can obtain a Rx for it
If a patient is using ≥100mg morphine equivalents/day, this is recommended
The same drug that the ED uses to reverse opiate OD (opiate antagonist)
Available as shown, in “Epi-Pen”-like format, or intranasal as well
what are detox treatment options (detox is the first step in opiate treatment)
“Cold turkey”
Methadone: start w/approx 20-25mg/day and decrease by 5mg/day
Buprenorphine: start w/4mg upon 1st signs of withdrawal and, if sx persist in 1 hr, give another 2-4mg dose. For the next couple of days, give 8-12mg daily and then begin to taper
Supportive medications: Trimethobenzamide (for nausea/vomiting), Dicyclomine (stomach cramps), Loperamide (diarrhea), Ibuprofen (muscle/joint pain) all used during withdrawal period
Clonidine is very useful both as monotherapy for mild withdrawal or as adjunct tx for “supportive medication” option above. Good at treating tremor, diaphoresis, and agitation
why is maintenance required after detox
Detox does absolutely nothing to address cravings (physiological and psychological)
Other agents are usually required after the detox period to assist the patient in remaining sober.
Many patients are simultaneously both detoxed and transitioned to new treatment (methadone, etc.)
Patients who do not transition to maintenance treatment have an extremely high likelihood of returning to drug use
pros of using methadone
long ½ life –> once daily dosing
Safety
Safe in pregnancy (fetal withdrawal can be fatal)
Intoxicating effects are less euphoric and less sedating than heroin
Pts may eventually be allowed to utilize daily tablets from home
cons of using methadone
Usu have to go to clinic daily
Can’t leave clinic vicinity > 1 day (“the methadone chain”)
Prolongs QT
Multiple drug-drug interactions
Use is restricted only to certain facilities
Patient is still opioid-dependent
LAAM Levo-α-acetylmethadol
Very similar to Methadone treatment except that the dosing is less (2-3x/week vs. daily)
Many of the same problems with Methadone exist
buprenorphine
High affinity for opioid receptors mu (as partial agonist) and kappa (as antagonist)
prevents binding of other opiates
Can cause nausea/vomiting
Lower potential for abuse because partial activation produces much less effect (↓euphoria) and ↓risk of resp depression as partial agonist
don’t need to go to the clinic every day to get the drug, you can take it at home
route of admin of buprenorphine
Sublingual d/t poor oral bioavailability
Still can be abused, esp if taken IV. Can still be fatal
Suboxone
Combo of Buprenorphine/Naloxone
Buprenorphine: partial agonist, quick onset, prevents binding of other opiates–> sublingual so works very quick
Naloxone: opiate antagonist w/poor sublingual bioavailability
Can still be abused
In combination:
Poor oral bioavailability, needs sublingual release
When taken sublingually, only the buprenorphine is absorbed (not naloxone)
If crushed and injected, pt goes into withdrawal
Office-based, portable
allows outpatient treatment of opioid dependence
Naltrexone
MOA
uses
Synthetic opiate antagonist
Begin 7-10 days after last opiate use to avoid precipitation of withdrawal
Comes in IM depot form
Also effective for EtOH and possibly cocaine
Naltrexone ADR’s
Hepatotoxic: baseline liver fxn tests & monitor LFTs
Requires that the patient carry an alert card notifying medical personnel that they are on an opiate antagonist and add’l higher doses of opiates may be needed in an emergency to overcome blockade
