Opiates, PEDs + Alcohol

Question 1

How is opium extracted from the poppy seed plant?

Answer 1

Seedpod is incised with a blade
Milky fluid seeps from cuts in the unripe poppy seed pod
Scraped off and air-dried to produce opium
Dried in open wooden boxes
Resin is placed in bags or rolled into balls for sale

Question 2

How is opium transformed for illicit use?

Answer 2

1. Raw opium + hot water/Ca2+ oxide (lime) - Alkali pH dissolves morphine
2. Ammonium chloride added after filtration to precipitate morphine
3. Crude morphine powder ~50%
4. Crude morphine + acetic anhydride/boiling to acetylate
5. Brown heroin precipitation
6. Hydrochloric acid purification - 75% diacetyl morphine = 6% yield

Question 3

Which receptors do opioids work on and what reactions do they elicit?

Answer 3

Mu and Delta opioid receptors = reinforcement, reward and euphoria

Kappa (k) receptors = aversion, hallucinations, dysphoria (state of unease0

Question 4

Describe how the euphoric effects of opiates arise

Answer 4

Euphoric effects of opiates arise from activation of opioid receptors on GABAergic neurons that inhibit dopaminergic neurons in the ventral tegmental area causing disinhibition and greater dopamine release from VTA presynapses terminating in the nucleus accumbens

Question 5

What are the side effects of opioids?

Answer 5

Respiratory depression:
reduces sensitivity of respiratory centre; most common cause of death from overdose with street use of opioids

Euphoria:
action on reward pathway in the brain to increase dopamine release

Cough suppression (anti-tussive)

Nausea:
activate the chemoreceptor trigger zone (which in turn activates the vomiting centre)
Aspiration of vomit when unconscious common

Constipation:
due to maintained contraction of smooth muscle

Small pupils
Nausea, vomiting
Confusion or poor judgment

Question 6

What are the long term effects of opioid use?

Answer 6

Addiction and tolerance leads to:
Ignore pain
Social withdrawal/job loss
Overdose

Question 7

Describe some of the withdrawal symptoms?

Answer 7

Anxiety
Irritability
Craving for the drug
Rapid breathing
Yawning
Runny nose 
Salivation
Goosebumps
Nasal stuffiness
Muscle aches
Vomiting
Abdominal cramping
Diarrhoea 
Sweating 
Confusion
Enlarged pupils
Tremors
Loss of appetite

Question 8

What are signs of an acute opioid overdose?

Answer 8

Sleepiness
Loss of consciousness
Widening of pupils
Coldness, Clamminess, blue skin 
Slowed, shallow breathing 
Seizures

Question 9

What is the procedure to deal with an overdose?

Answer 9

Assess patient to clear airway.

Provide support ventilation, if needed.

Assess and support cardiac function.

Provide IV fluids.

Frequently monitor the vital signs and cardiopulmonary status until the patient has cleared opioids from the system.

Give IV naloxone if necessary (opioid antagonist)
Administered intravenously or subcutaneously
Rapidly reverses the respiratory depression and sedation caused by heroin intoxication.

Naloxone (Evzio) as an autoinjector dosage form for home
Since 01/10/2015 any worker in a commissioned drug service can provide naloxone without a prescription

Question 10

What is given as an opioid antagonist in a case of overdose?

Answer 10

Naloxone

Question 11

What can be used as opioid drug replacement for therapy?

Answer 11

Opioid maintenance

Methadone maintenance (longer lasting effects, can be overdosed)

Buprenorphine/naloxone maintenance: 4/1 ratio (naloxone gives withdrawal symptom if used i.v.

Alpha-2 adrenoceptor agonists, such as clonidine and lofexidine

Diacetyl morphine:
Recent trials show better outcome
Societal resistance (see also approval of foil in kits)

Cognitive behavioural, supportive, or analytical-oriented psychotherapies

Question 12

What are PEDs? Regulated by who?

Answer 12

Performance enhancing drugs

Regulated by WADA - World Anti-Doping Association

Question 13

Give examples of groups of drugs that are PED types

Answer 13

Stimulants (such as amphetamines)
Anabolic steroids (such as nandrolone)
Diuretics (to help lower body weight)
Blood doping agents (such as EPO)

Question 14

How would they boost oxygen in blood?

Answer 14

Homologous transfusion
Autologous transfusion
EPO treatment - hormone produced by kidney enhance oxygen during hypoxia 0 to 19mU/ml
Artificial blood substitutes

Question 15

What are the side effects and risks of increasing oxygen levels in the blood?

Answer 15

Misuse can lead to thickening the blood

Heart disease, stroke, and cerebral or pulmonary embolism

May also lead to autoimmune diseases

Question 16

When can using EPO be beneficial?

Answer 16

Proper use of EPO has an enormous therapeutic benefit in the treatment of anaemia related to kidney disease

Question 17

What percentage of total deaths in the age group 20-39 are attributed to alcohol?

Answer 17

25%

Question 18

How many units does a 
Standard glass of wine
Large glass of wine
Bottle of wine (750ml)
contain?

Answer 18

Standard glass of wine: 2
Large glass of wine: 3
Bottle of wine (750ml): 9

Question 19

How many units does a 
Pint of strong beer/lager
Pint of normal strength beer/lager
Can of normal strength beer/lager
contain?

Answer 19

Pint of strong beer/lager: 3
Pint of normal strength beer/lager: 2
Can of normal strength beer/lager: 2

Question 20

How many units does a 
Spirits double
Alcopop bottle (250ml)
Spirits single
contain?

Answer 20

Spirits double: 2
Alcopop bottle (250ml): 1.4
Spirits single: 1

Question 21

At the following % of alcohol in blood what effects are seen?
0.05
>0.1
0.3
0.4

Answer 21

0.05 = Stimulant, social relaxation
>0.1 = Incoordination
0.3 = Unconsciousness
0.4 = Possible lethal level

Question 22

What are 12 health risks of chronic heavy drinking?

Answer 22

Anemia
Cancer
Cardiovascular disease
Cirrhosis
Dementia
Depression
Seizures
Gout
Hypertension
Infectious disease
Nerve damage
Pancreatitis

Question 23

What are the scales of dependence in terms of detoxification?

Answer 23

Mild dependence (<20 units): home with no drugs
Heavy dependence (>20 units): home with tranquilizers, chlordiaxepoxide
Extreme cases: hospitalisation and drug administration

Question 24

What are detoxification symptoms?

Answer 24

Withdrawal symptoms will be at their worst for the first 48 hours
This usually takes 3-7 days from the time of your last drink
Sleep is disturbed. Sleep patterns should return to normal within a month.
During detox, drink plenty of fluids (about three litres a day). Water, squash or fruit juice arebetter choices.
Risk of seizures during detox

Question 25

What therapies are available for abstinence maintenance and preventing relapses?

Answer 25

Drug support
Acamprosate (MoA not fully understood; may be NMDAR related)
Disulfiram (aldehyde dehydrogenase inhibitor)
Naltrexone (opioid antagonist; prevents capacity to experience rewarding effects of alcohol)

Counselling support
Self help groups
Twelve steps facilitation therapy
CBT

Question 26

what are the coping strategies?

Answer 26

Social situation: maintain distance people and situations that may impair recovery.

Develop healthy habits: e.g. good sleep, regular physical activity and eating well.

Activities that don’t involve alcohol: e.g. replace destructive habits with hobbies or pastimes that are not centred around alcohol