Drug Abuse Drug Abuse n Psychological Dependency Habituation

Drug Abuse

Drug Abuse n Psychological Dependency (Habituation) u Drug necessary to maintain user’s sense of well -being n Physical Dependency u Physical symptoms if intake reduced

Drug Abuse n Compulsive Drug Use u Preoccupation with obtaining drug u Rituals of preparing, using drug as important as drug effects n Tolerance u Increasing doses needed to obtain drug effect

Drug Abuse n Addiction u Includes F Psychological dependence F Physical dependence F Compulsive use F Tolerance u Plus, complete absorption with obtaining, using drug to exclusion of all else

Drug Abuse n Suspect drug-related problem in patients with: u Altered LOC u Bizarre behavior u Seizures

Drug Abuse n n n Ask EVERY patient about recreational drugs. Be non-judgmental. Keep drug box/cabinet secured. Use discretion. If held up, give them what they want!

Narcotics Opium n Opium derivatives n Synthetic opium substitutes n

Narcotics n Examples u Opium u Morphine u Heroin u Codeine u Dilaudid u Oxycodone (Percodan) u Meperidine (Demerol) u Propoxyphene (Darvon) u Talwin u Fentanyl

Narcotics n Effects u Analgesia u CNS depression F Euphoria F Drowsiness F Apathy u Antidiarrheal action u Antitussitive action

Narcotics n Overdose u Mild to Moderate u Severe F Lethargy F Respiratory F Pinpoint F Coma pupils F Bradycardia F Hypotension F Decreased bowel sounds F Flaccid muscles depression F Aspiration F Seizures with certain compounds (meperidine, propoxyphene, tramadol)

Narcotics n Overdose u Management FSupport oxygenation/ventilation FVascular access FD 50 W 50 cc FNarcan 0. 4 to 2. 0 mg • Improve respirations • Do NOT awaken completely • Restrain before giving

Narcotics n Associated Dangers u Skin abscesses u Adulterant toxicity u Phlebitis u “Cotton fever” u Sepsis u Malnutrition u Hepatitis u Tetanus u HIV u Malaria u Endocarditis

Narcotics n Withdrawal u Insomnia u Watery eyes u Restlessness u Yawning u Irritability u Rhinorrhea u Anorexia u Sneezing u Tremors u Diarrhea u Back, extremity pain u Diaphoresis Resembles Severe Influenza

Narcotics n Withdrawal u Lasts 7 to 10 days u NOT life threatening

Sedative-Hypnotic Drugs

Categories Barbiturates n Benzodiazepine n Barbiturate-like non-barbiturates n Chloral hydrate n

Mechanism of Action Most overdoses of sedative-hypnotics are from benzodiazepines, barbiturates n Both enhance effects of gammaaminobutyric acid (GABA) n GABA enhancement results in downregulation of CNS activity n

Sedative-Hypnotics Use more then a week leads to tolerance to effects on sleep patterns n Withdrawal after long term results in “rebound” increase in frequency of occurrence, duration of REM sleep. n In high doses, sedative-hypnotics depress CNS to point of Stage III or general anesthesia n

Sedative-Hypnotics n Tolerance u Happens with all sedative-hypnotics u Appears very quickly even during short-term use. u Discontinuation will bring receptor response back to normal after drug has been metabolized u Withdrawal symptoms may take up to a week to see in some patients

Chloral hydrate “Micky Finn” when mixed with alcohol n Rapidly absorbed, acts quickly n Drowsiness, sleep n Alcohol, chloral hydrate compete for metabolism by same enzyme n Prolonged action for both when mixed n Not commonly abused n

Barbiturates Introduced in 1903 n Replaced older sedative-hypnotics n Quickly became major health problem n In 1950’s-60’s barbiturates were implicated in overdoses; were responsible for majority of drug-related suicides n

Barbiturates n Short-acting u Amytal u Pentathiol n Intermediate-acting u Nembutal u Seconal u Tuinal n Long-acting u Phenobarbital

Barbiturates n Initial overdose presentation u Slurred speech u Ataxia u Lethargy u Nystagmus u Headache u Confusion

Barbiturates n As overdose progresses u Depth of coma increases F Patient anesthetized with loss of neurologic function F EEG may mimic brain death u Respiratory depression occurs u Peripheral vasodilation occurs F Hypotension, shock F Hypothermia u Blisters (bullae) form on skin

Barbiturates n Early deaths u Respiratory arrest u Cardiovascular collapse n Delayed deaths u Acute renal failure u Pneumonia u Pulmonary edema u Cerebral edema

Barbiturates n Overdose management u Secure airway u Support oxygenation/ventilation u IV with LR or NS u Prevent heat loss secondary to vasodilation u Bicarbonate to alkalinize urine (long-acting only)

Barbiturates n Withdrawal signs/symptoms u Apprehensiveness u Anxiety u Tremulousness u Diarrhea u Nausea u Vomiting u Seizures

Barbiturate-like, non-barbiturates n Examples u Doriden (glutethimide) u Quaalude (methaqualone) u Placidyl (ethchlorvynol) u Noludar n n Overdose produces sudden, prolonged apnea Highly addictive Withdrawal resembles barbiturate withdrawal Only Placidyl, Doriden remain available in U. S.

Placidyl (ethchlorvynol) n n n n “Pickles”, “jelly beans”, “Mr. Green Jeans” Produces vinyl-like odor on breath Concentrates in CNS, slow hepatic metabolism Half-life >100 hrs Prolonged deep coma (100 to 300 hrs), hypothermia, respiratory depression, hypotension, bradycardia EEG is flatline Keep patient on life support for a few days; they wake up, are ok

Doriden (gluthethimide) n n n Abused in combination with codeine “sets”, “hits”, “loads”, “fours and doors” Prolonged coma (average 48 hours) Hypotension, shock common Anticholinergic signs: dilated pupils, tachycardia, dry mouth, ileus, urinary retention, hyperthermia

Benzodiazepines Developed due to overdoses, deaths related to barbiturates, barbiturate-like nonbarbiturates n Relatively few deaths n In 1993, prescription rate for barbiturates dropped to one-sixth that of benzos n

Benzodiazepines n Examples u Valium (diazepam) u Ativan (lorazepam) u Versed (midazolam) u Librium (chlorodiazepoxide) u Tranxene (chlorazepate dipotassium) u Dalmane (flurazepam) u Halcion (triaxolam) u Restoril (temazepam)

Benzodiazepines n Adverse Effects u Weakness u Headache u Blurred vision u Vertigo u Nausea u Diarrhea u Chest pain

Benzodiazepines n Overdoses u Relatively safe taken by themselves, even in overdose u Can be lethal with other CNS depressants especially alcohol u Look like other CNS depressant overdoses u Antidote is Romazicon ( flumazenil ) F Only recommended in known, controlled situations F Can lead to seizures that cannot be controlled

Benzodiazepines n Produce withdrawal syndrome similar to barbiturate withdrawal

Benzodiazepine-like non-benzos n Bu. Spar (buspirone) u Used for generalized anxiety disorder u Less sedating than diazepam u Less potentiation by other CNS depressants n Ambien, Stilnox (zolpidem) u Used for short-term insomnia treatment u Toxic effects similar to benzos

Neuroleptics Antipsychotics, major tranquilizers n Used in treatment of schizophrenia, other psychoses n Examples n u Haldol u Mellaril u Thorazine u Stellazine u Compazine

Neuroleptics n Extrapyramidal muscle contractions (dystonias) u Bizarre, acute, involuntary movements, spasms of skeletal muscles u Reversible with Benadryl

Neuroleptics n Acute Overdose Presentation u CNS depression u Hypotension u Anticholinergic symptoms: flushing, dry mouth, hyperthermia, tachycardia, urinary retention u Ventricular arrhythmias, including Torsades u Seizures

Neuroleptics n Acute Overdose Management u ABCs u Fluid, vasopressors for hypotension u Lidocaine, phenytoin for ventricular arrhythmia u Magnesium, isoproterenol for Torsades u Benzodiazepines, phenobarbital for seizures

Neuroleptics n Neuroleptic malignant syndrome u Life-threatening reaction u Signs, symptoms F Hyperthermia F Muscular rigidity F Altered LOC F Tachycardia, hypotension

Neuroleptics n Neuroleptic malignant syndrome u Management F ABCs F Oxygen F Assist ventilation, as needed F Benzodiazepines F Rapid cooling F Volume for hypotension

Stimulants n Examples u Cocaine u Amphetamines F Benzedrine (bennies) F Dexedrine (dexies, copilots) F Methamphetamine (ice, black beauties) u Ephedrine u Caffeine u Ritalin

Stimulants n Produce u euphoria u hyperactivity u alertness u sense of enhanced energy u anorexia

Stimulants n Overdose signs/symptoms u Euphoria, restlessness, agitation, anxiety u Paranoia, irritability, delirium, psychosis u Muscle tremors, rigidity u Seizures, coma u Nausea, vomiting, chills, sweating, headache u Elevated body temperature u Tachycardia, hypertension u Ventricular arrhythmias

Stimulants n Overdose complications u Hyperthermia, heat stroke u Hypertensive crisis u CVA u Acute MI u Intestinal infarctions u Rhabdomyolysis u Acute renal failure

Stimulants n Chronic effects u Weight loss u Cardiomyopathy u Paranoia u Psychosis u Stereotypic behavior: picking at skin (“cocaine bugs”)

Stimulants n Overdose management u Oxygen, monitor, IV u Activated charcoal for decontamination in first hour u Valium for sedation u Hypertension control F Nipride F Phentolamine F Avoid beta-blockers, including labetolol (Why? ) u Body temperature reduction

Stimulants n Withdrawal u Drowsiness u Profound depression (“cocaine blues”) u Increased appetite u Abdominal cramps, diarrhea, nausea u Headache

Hallucinogens n Examples u Indole hallucinogens F LSD (acid) F Morning-glory seeds F Psilocybin F DMT u Amphetamine-like hallucinogens F Peyote F Mescaline F DOM F MDA F MDMA (ecstasy)

Hallucinogens Produce altered/enhanced sensation n Effects highly variable depending on patient n Increased dose does not intensify effect n Toxic overdose virtually impossible n

Hallucinogens Some patients may experience “bad trips” n Depends on surroundings, emotional state n Signs and symptoms n u Paranoia, fearfulness, combativeness u Anxiety, excitement u Nausea, vomiting u Tachycardia, tachypnea u Tearfulness u Bizarre Reasoning

Hallucinogens n Moderate Intoxication u Tachycardia u Mydriasis u Diaphoresis u Short attention span u Tremor u Hypertension u Hyperreflexia u Fever

Hallucinogens n Life-threatening toxicity (rare) u Seizures u Severe hyperthermia u Hypertension, arrhythmias u Obtunded, agitated, or thrashing about u Diaphoretic, hyperreflexic u Untreated hyperthermia can lead to hypotension, coagulopathy, rhabdomyolysis and multiple organ failure

Hallucinogens n Management of “bad trip” u Rule out other causes of hallucinations F Hypoglycemia F Alcohol, drug withdrawal F Infection u Quiet, supportive environment u Benzodiazepines, haldol for agitation, anxiety

Phencyclidine (PCP) n n Street names u Angel dust u Peace Pill u Hog u Krystal u Animal tranquilizer Used as veterinary anesthetic

Phencyclidine (PCP) n Actions u Dissociative anesthesia u Generalized loss of pain perception u Little or no depression of airway reflexes or ventilation u CNS-stimulant, anticholinergic, opiate, and alpha-adrenergic effects

Phencyclidine (PCP) n Low Doses u Lethargy, euphoria, hallucinations u Slurred speech u Blank stare u Insensitivity to pain u Midposition to dilated pupils u Vertical and horizontal nystagmus u Occasionally bizarre or violent behavior

Phencyclidine (PCP) n High Doses u Diaphoresis n u Salivation n u Hypertension n u Tachycardia n u Hyperthermia Localized dystonic reactions Wide-eyed coma Rigidity Seizures

Phencyclidine (PCP) n Treatment u Maintain airway u Assist ventilations, as needed u Treat coma, seizures, hypertension, hypothermia as needed u Quiet environment u Sedation if needed to control agitation F Haldol F Benzodiazepines

Inhalants n Examples u Hydrocarbons (solvents, paints, aerosols) u Gases (freon, halon fire extinguishing agent) u Metallic paints (“huffing”)

Inhalants n Effects u Dysrhythmias including VF u CNS depression u Seizures u Respiratory irritation u Epinephrine may increase risk of dysrhythmias n Treatment u Oxygen u Treat symptomatically

“Date rape” drugs Flunitrazepam (Rhohypnol) n Gamma hydroxybutyrate n

Flunitrazepam (Rhohypnol) n Street names u Rophies u Roche u Roofies u Roachies u R 2 u La rocha u Roofenol u Rope u Rib

Flunitrazepam (Rhohypnol) Benzodiazepine n Similar to Valium but 10 x more potent n Produced, sold legally in Europe, South America n Uses n u Short-term treatment of insomnia u Sedative hypnotic u Preanesthetic medication

Flunitrazepam (Rhohypnol) n Effects u Disinhibition and amnesia u Onset within 30 minutes, peak within 2 hours, may persist 8 hours or more u Frequently abused with alcohol or other drugs u Enhances high produced by heroin

Flunitrazepam (Rhohypnol) n Adverse Effects u Drowsiness u Dizziness u Confusion u Decreased BP u Memory impairment u GI disturbances u Excitability, aggressive behavior

Flunitrazepam (Rhohypnol) n Management of overdose u Lethal overdose very unlikely u Oxygenate, ventilate u Intubate if necessary to control airway u Vascular access u ECG u Fluid for hypotension u Dextrostick (rule out hypoglycemia) u Treat trauma resulting from assault

Flunitrazepam (Rhohypnol) n Withdrawal u Headache u Hallucinations u Anxiety, tension u Delirium u Numbness, tingling of u Seizures (up to a week extremities u Restlessness, confusion u Loss of identity after cessation) u Shock u Cardiovascular collapse

Flunitrazepam (Rhohypnol) n Management of withdrawal u Oxygen/ventilation u Intubate if necessary u EKG u Vascular access u Fluid for hypotension u Dextrostick u Diazepam for seizures

Gamma hydroxybutyrate n Street names u Cherry meth u Liquid X u Liquid ecstacy Originally developed as anesthetic n Banned in 1991 because of side effects n Promoted as aphrodisiac n

Gamma hydroxybutyrate n Effects u Odorless, nearly tasteless u Tremors u Seizures u Death