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THE ALCOHOL AND DRUG PRIMER

THE ALCOHOL AND DRUG PRIMER. DRUG CLASSES. ALCOHOL SEDATIVE/HYPNOTICS OPIATES STIMULANTS HALLUCINOGENS CANNABINOIDS DISSOCIATIVE ANESTHETICS INHALANTS/SOLVENTS ANABOLIC STEROIDS MUSHROOMS JIMSON WEED. DRUG CLASSES. ALCOHOL SEDATIVE/HYPNOTICS OPIATES STIMULANTS HALLUCINOGENS

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THE ALCOHOL AND DRUG PRIMER

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  1. THE ALCOHOL AND DRUG PRIMER

  2. DRUG CLASSES ALCOHOL SEDATIVE/HYPNOTICS OPIATES STIMULANTS HALLUCINOGENS CANNABINOIDS DISSOCIATIVE ANESTHETICS INHALANTS/SOLVENTS ANABOLIC STEROIDS MUSHROOMS JIMSON WEED

  3. DRUG CLASSES ALCOHOL SEDATIVE/HYPNOTICS OPIATES STIMULANTS HALLUCINOGENS CANNABINOIDS DISSOCIATIVE ANESTHETICS INHALANTS/SOLVENTS ANABOLIC STEROIDS MUSHROOMS JIMSON WEED

  4. ALCOHOL DESIRED EFFECTS • EUPHORIA • DECREASE SOCIAL ANXIETY • DECREASE SEXUAL INHIBITION • SEDATION

  5. ALCOHOL INTOXICATION BLOOD ALCOHOL CONCENTRATION (BAC) 20 - 99 mg%: LOSS OF MUSCULAR COORDINATION 100 - 199 mg%: NEUROLOGIC IMPAIRMENT,ATAXIA, PROLONGED REACTION, MENTAL IMPAIRMENT, INCOORDINATION 200 - 299 mg%: NAUSEA, VOMITING, ATAXIA 300 - 399 mg%: HYPOTHERMIA, DYSARTHRIA, AMNESIA, STUPOR 400 - > mg%: COMA * BAC GREATER THAN 150 IF NOT SHOWING SIGNS OF INTOXICATION OR ANY TIME BAC IS > 300 EQUALS A DIAGNOSIS OF ALCOHOL DEPENDENCE

  6. ALCOHOL METABOLISM 1/3 OUNCE PER HOUR 3 BEERS = BAC OF .05 .015 /HOUR DECREASE 15-20 mg/dl/hr *ZERO ORDER METABOLISM ** URINE IS 1.3 X’S CONCENTRATION OF THE BLOOD ALCOHOL CONCENTRATION

  7. MINOR WITHDRAWAL TIME • 6 - 60 HOURS SYMPTOMS • TREMULOUS • INSOMNIA • NAUSEA • ANOREXIA • ANXIETY • WEAKNESS

  8. MINOR WITHDRAWAL SIGNS • ACTION TREMOR • INATTENTION • EASY STARTLE • PLETHORA • CONJUNCTIVAL INJECTION • INCREASED REFLEXES TREATMENT • PHARMACOLOGIC SUBSTITUTE PROGNOSIS • EXCELLENT

  9. EARLY WITHDRAWAL ILLUSIONS AND HALLUCINATIONS • ILLUSIONS ARE MISINTERPRETATIONS • MOST COMMON (25% OF PATIENTS) • VISUAL AND AUDITORY HALLUCINATIONS • LESS COMMON IS TACTILE AND OLFACTORY HALLUCINATIONS • SENSORIUM IS RELATIVELY CLEAR

  10. EARLY WITHDRAWAL SEIZURES ( “RUM FITS” ) • USUALLY GENERALIZED MAJOR MOTOR • 25% ARE MULTIPLE • 2 - 3% GO ONTO STATUS EPILEPTICUS • HEIGHTENED SENSITIVITY TO PHOTIC STIMULATION DURING PERIOD OF SEIZURE VULNERABILITY • 30% OF PATIENTS HAVING WITHDRAWAL SEIZURES GO ONTO DT’S • MUST RULE OUT OTHER CAUSES

  11. EARLY WITHDRAWAL TREATMENT • WATCH FOR DT’S • EVALUATE FOR OTHER ILLNESSES AND INJURIES • LIGHT SEDATION WITH BENZODIAZEPINES • THIAMINE • ELECTROLYTE BALANCE • PATIENTS MUST UNDERSTAND THAT THEY NEED TO GO ONTO FURTHER TREATMENT

  12. LATE WITHDRAWAL DELIRIUM TREMENS • HIGH RISK FOR DT’S IF BLOOD ALCOHOL LEVEL GREATER THAN 300 mg% OR WITHDRAWAL SEIZURES • PROFOUND CONFUSION AND MISPERCEPTIONS • DISORIENTATION • HALLUCINATIONS • PARANOID DELUSIONS • MOTOR HYPERACTIVITY • TREMOR, RESTLESS, AGITATED, INCREASED REFLEXES • AUTONOMIC HYPERACTIVITY • TACHYCARDIA, PROFUSE SWEATING, DILATED PUPILS • MORTALITY IS 10 - 15% IF UNTREATED, 1 -2% IF TREATED

  13. PERSISTENT MILD WITHDRAWAL LASTS FOR WEEKS TO MONTHS SLEEP DISTURBANCES ARE COMMON MILD ACTION TREMOR ANXIETY DEPRESSION

  14. MISCELLANEOUS METHANOL OVERDOSE • TOXICITY DUE TO CONVERSION INTO FORMALDEHYDE AND FORMIC ACID • LETHARGY, CONFUSION,VISUAL SYMPTOMS INCLUDING BLINDNESS, SIGNIFICANT INCREASE IN RESPIRATORY RATE • TREATMENT • ETHANOL .6 gm/kg IN 5% D/W OVER 30 - 45 MINUTES THEN 110mg/kg/hr TO MAINTAIN ALCOHOL LEVEL AT 110 - 150 mg/dl

  15. DRUG CLASSES ALCOHOL SEDATIVE/HYPNOTICS • BENZODIAZEPINES, BARBITURATES, GHB OPIATES STIMULANTS HALLUCINOGENS CANNABINOIDS DISSOCIATIVE ANESTHETICS INHALANTS/SOLVENTS ANABOLIC STEROIDS MUSHROOMS JIMSON WEED

  16. SEDATIVE/HYPNOTICS DESIRED EFFECTS • DECREASE ANXIETY • INDUCE SLEEP • OFFSET EFFECTS OF OTHER DRUG CLASSES

  17. SEDATIVE/HYPNOTICS INTOXICATION • DECREASE IN ANXIETY • SEDATION • OCCASIONAL ELATION SECONDARY TO DEPRESSION OF INHIBITIONS AND JUDGMENT • PUPILS ARE MIDPOINT AND SLOWLY REACTIVE EXCEPT FOR GLUTETHIMIDE WHERE PUPILS ARE ENLARGED • HICCUPS IN LONGTERM BENZODIAZEPINE USE

  18. SEDATIVE/HYPNOTICS BENZODIAZEPINE OVERDOSE • SEDATION WITH DECREASE IN LEVEL OF CONSCIOUSNESS • DECREASE IN RESPIRATORY RATE • HYPOTENSION • DECREASE IN TEMPERATURE • GASTRIC PARALYSIS • RESPIRATORY COMPROMISE • PULMONARY EDEMA

  19. SEDATIVE/HYPNOTICS CLASSIC SIGNS OF OVERDOSE IN OLDER SEDATIVES • METHAQUALONE • HYPERREFLEXIA, HYPERTONIA, SEIZURES, RHABDOMYOLYSIS • MEPROBAMATE • SEVERE HYPOTENSION, GI BEZOARS • GLUTETHIMIDE • CYCLIC COMA • BARBITURATES • SKIN BLISTERS IN 6% • CLORAL HYDRATE • GASTRITIS • ETHCHLORVYNOL • PROLONGED COMA ESPECIALLY IF LIVER DISEASE IS PRESENT

  20. SEDATIVE/HYPNOTICS BENZODIAZEPINE OVERDOSE TREATMENT • FOR SHORT ACTING BENZODIAZEPINES USE FLUMAZENIL .2MG UP TO 1 MG IV • BE AWARE OF COMPLICATIONS • SEIZURES • CARDIAC ARRYTHMIAS • PANIC ATTACKS • BE AWARE OF CONTRAINDICATIONS OF USE • TRICYCLIC ANTIDEPRESSANT OVERDOSE • BENZODIAZEPINE DEPENDENCE • SEIZURE HISTORY • ACTIVATED CHARCOAL • BE AWARE OF CONCRETIONS IN THE GUT DUE TO SLOWER GUT MOTILITY WITH SEDATIVE USE. PATIENT MUST HAVE A POSITIVE GAG REFLEX

  21. SEDATIVE/HYPNOTICS BENZODIAZEPINE WITHDRAWAL • CAN LAST 3 - 5 WEEKS • VERY MUCH LIKE ACUTE ALCOHOL WITHDRAWAL • TIME COURSE AND SEVERITY DEPEND ON • DOSE OF DRUG • DURATION OF USE (DOES NOT WORSEN AFTER ONE YEAR OF USE) • DURATION OF DRUG ACTION • PROLONGED IN THE ELDERLY

  22. SEDATIVE/HYPNOTICS BENZODIAZEPINE AND BARBITURATE WITHDRAWAL IS LIKELY • IF THERAPEUTIC DOSE IS GIVEN QD FOR 4 - 6 MONTHS • IF 2 - 3 TIMES THE THERAPEUTIC DOSE IS GIVEN QD FOR 2 - 3 MONTHS • IN BARBITURATE USE, 50% HAVE SEVERE WITHDRAWAL IF 600MG OF PHENOBARBITAL OR EQUIVALENT IS USED QD FOR 50 OR MORE DAYS • IN BARBITURATE USE, 100% HAVE SEVERE WITHDRAWAL IF 900 - 1200MG OF PHENOBARBITAL OR EQUIVALENT IS USED QD FOR 50 OR MORE DAYS

  23. SEDATIVE/HYPNOTICS BENZODIAZEPINE & BARBITURATE WITHDRAWAL • MORE LIKELY TO BE SEVERE IF • RAPIDLY ELIMINATED DRUG IS USED • HIGHLY POTENT DRUG (ATIVAN, XANAX) • ABRUPT DISCONTINUATION • HIGH DOSES USED • PRN SCHEDULE OF USE AND NOT FIXED • HISTORY OF DEPENDENCY • HISTORY OF CONCURRENT ALCOHOL USE • FEMALES • LOWER EDUCATION • HISTORY OF PANIC ATTACKS

  24. SEDATIVE/HYPNOTICS BENZODIAZEPINE WITHDRAWAL • MOOD CHANGES • NEGATIVE, DYSPHORIA, RUMINATIVE • SLEEP CHANGES • INSOMNIA, ALTERATIONS OF SLEEP - WAKE CYCLE • PHYSICAL CHANGES • INCREASE IN PULSE RATE AND IN BLOOD PRESSURE, INCREASE REFLEXES, TREMORS, RESTLESS, NAUSEA, ATAXIA, SEIZURES, POSTURAL HYPOTENSION, PUPILS ARE DILATED, EXAGGERATED BLINK REFLEX (ESPECIALLY BARBITUATES), METALLIC TASTE • PERCEPTION CHANGES • ILLUSIONS, HALLUCINATIONS, DEPERSONALIZATION, SENSORY HYPERACTIVITY ( LIGHTS BRIGHTER, NOISE LOUDER, ETC.)

  25. SEDATIVE/HYPNOTICS PROTRACTED WITHDRAWAL • CAN LAST FOR MONTHS • NO PATHOGNOMONIC SIGNS OR SYMPTOMS • WAXING AND WANING OF SYMPTOMS • DEPRESSION • ANXIETY • PANIC • TINNITUS • HEADACHES • DIZZINESS *INCREASE RISK IF FAMILY HISTORY OF ALCOHOLISM, DAILY USE OF ALCOHOL OR OTHER SEDATIVES

  26. SEDATIVE/HYPNOTICS TREATMENT OF WITHDRAWAL (OUTPATIENT) • 5 MG DIAZEPAM EQUIVALENT/WEEK DECREASE OR 10% OF STARTING DOSE DECREASE PER WEEK. FINAL 20%, DECREASE BY 1/2 OF THE INITIAL DOSES • EQUIVALENT DOSES • PHENOBARBITAL 30MG • SERAX,VALIUM 10MG • KLONOPIN,ATIVAN 2MG • XANAX 1MG • LIBRIUM 25MG • INDERAL FOR INCREASED BP AND TREMORS

  27. SEDATIVE/HYPNOTICS SPECIAL CASES GHB • GAMMA - HYDROXYBUTYRATE • CLEAR LIQUID, WHITE POWDER, OR TABLET • INITIALLY SOLD TO BODY BUILDERS TO RELEASE GROWTH HORMONE • FAST ACTING - 20 MINUTES FOR SEDATIVE EFFECT • LASTS ONLY 4 HOURS • “DATE RAPE” DRUG *GBL (GAMMA BUTYROLACTONE) MARKETED AS AN INDUSTRIAL SOLVENT USED TO CLEAN CIRCUIT BOARDS AND DEGREASE ENGINES IS METABOLIZED TO GHB

  28. SEDATIVE/HYPNOTICS SPECIAL CASES ROHYPNOL • ONE OF THE FIRST “DATE RAPE” DRUGS • BENZODIAZEPINE CLASS • DISSOLVES EASILY IN CARBONATED DRINKS • SIGNIFICANT AMNESIA FOR UP TO 12 HOURS WHEN USED

  29. DRUG CLASSES ALCOHOL SEDATIVE/HYPNOTICS OPIATES • HEROIN, DEMEROL STIMULANTS HALLUCINOGENS CANNABINOIDS DISSOCIATIVE ANESTHETICS INHALANTS/SOLVENTS ANABOLIC STEROIDS MUSHROOMS JIMSON WEED

  30. OPIATES DESIRED EFFECTS • “THE RUSH” • SEDATION • EUPHORIA • ANALGESIA

  31. OPIATES • OPIUM COMES FROM THE POPPY PLANT PAPAVER SOMNIFERUM • An erect herbaccous annual or bi-annual • 50 - 150 cm tall • Stems are slightly branched • Leaves are large, erect, and oblong • Petals are 4 - 8 cm in length • Petal colors are white, pink, purple and violet

  32. Papaver somniferum • After flowering, the petals drop in a few days leaving bulbous green capsules atop the stalks. These are the pods.

  33. Papaver somniferum • Incisions are made in the pods and the milky fluid that oozes out is air dried. This must be done before the seeds are discharged.

  34. CONTENTS OF THE POPPY POD FLUID • Morphine 4 - 21 % • Codeine 1 - 25% *There are at least 20 other alkaloids in the fluid

  35. OPIATES • HEROIN • Heroin does not occur naturally, but is a semi - synthetic opiate(ACETYLATION OF MORPHINE)

  36. OPIATES HEROIN METABOLISM

  37. OPIATES • HEROIN USE - URINE DRUG SCREEN SHOWS • Free morphine • Morphine Glucuronide • Free codeine • 6 - Monoacetylmorphine* • Only seen with heroin use • POPPY SEEDS IF EATEN IN QUANTITY CAN SHOW UP AS A POSITIVE URINE DRUG SCREEN FOR MORPHINE AND CODEINE

  38. METHADONE • Synthetic narcotic • Developed in Germany - WWII • 1963 : Drs. Dole and Nyswander treated the addict so as to control craving • 1972 : FDA approved use for treatment of narcotic addiction Despite research validating the efficacy of methadone, it continues to be controversial.

  39. HEROIN INTOXICATION • MOST COMMON • MIOSIS (EXCEPT DEMEROL WHICH CAUSES PARALYSIS OF THE CILIARY BODY AND PUPILS DILATE) • NODDING • HYPOTENSION • DEPRESSED RESPIRATION • BRADYCARDIA • EUPHORIA • FLOATING FEELING

  40. OPIATE OVERDOSE • CLASSIC TRIAD SEEN IN OVERDOSE • MIOSIS • COMA • RESPIRATORY DEPRESSION • PULMONARY EDEMA • SEIZURES • DEMEROL, DARVON, TALWIN

  41. HEROIN WITHDRAWAL - EARLY • LACRIMATION • YAWNING • RHINORRHEA • SWEATING

  42. HEROIN WITHDRAWAL - MIDDLE PHASE • RESTLESS SLEEP • DILATED PUPILS • ANOREXIA • GOOSEFLESH • IRRITABILITY • TREMOR

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