SUBSTANCE ABUSE PHARMACOLOGY

1. SUBSTANCE ABUSE PHARMACOLOGY David R. Turpin MA, LCAS, CCS,

2. SLANG TERMS • Lovers Speed Blunt • Smack Rock • Sinse Zig-Zag • 8-Ball O.C. • Roach Uppers • Shrooms Oz. Roofies Downers

3. Addiction is a “BIO-PSYCHO-SOCIAL” process. • BIOLOGICAL – Alcohol and other drugs alter the chemistry of the brain and body functioning. Continued use can cause damage or injury to vital organs. (?) • PSYCHOLOGICAL – Altered brain chemistry affects the brain’s ability to think, alters feeling states, and impacts the personality of the user. (?) • SOCIOLOGICAL – Behavioral interactions with family and social contacts are altered and/or misinterpreted by the user and those observing the behavior. (?) • There has been some “debate” re: “which type of addiction is worse” Whatcha think?

4. BIOCHEMICAL • Biologically Alcohol & other Drugs (interfere with/alter neurotransmitters), transmitters that allow neurons to communicate with each other, tell us/body what to do, how to react, what to experience etc. These things all happen in the “primitive brain (survival section) • The four major neurons addressed in addictions/abuse are: • 1. DOPAMINE (governs- reward; stimulation) (Cocaine, Methamphetamines) • 2. SEROTONIN (governs- mood; sleep, appetite, perceptions etc. (THC, Hallucinogens) • 3. GABA ( governs- sedative; anti-anxiety) (Benzodiazepines) • 4. ENDORPHINS (governs pain) (Opiates/Opioids) When most addictive drugs enter they brain they give corresponding messages (more of this less of that)

5. Defining Terminology “Psychoactive” – substances that can pass the Blood Brain Barrier and become active in the brain & central nervous system, with effects on mood, cognition, psychomotor movement, and personality. “Drug” – any chemical entity or mixture of entities that alters biological (body & brain) function or structure when administered. (We often say “alcohol & drugs” which suggests a difference. It is more correct to say “alcohol and other drugs” as alcohol is also a “drug”.)

6. Four Principles of Psychoactive Drug Use • Drugs, per se, are not good or bad. It is the resulting behavior associated with the use /abuse that causes judgment by the observer about the user. “Good & Bad” • Every drug has multiple effects. Not just the subjective effect but effects on the brain/body functions. • Both the extent and the quality of a drug’s effects depend on the amount taken (dosage), and potency. examples: • The effect of any psychoactive drug depends on the user’s history and expectations. examples: (Ray & Kiser, 2002)

7. How Drugs Enter the Body Orally /Sublingual (drinking, swallowing , etc.) When someone swallows a drug, it passes through the esophagus and stomach to the small intestine where it is absorbed into the tiny blood vessels lining the walls. It usually takes approx. 20-30 minutes for full reaction time. Snorting(sniffing) When drugs are taken this way they are absorbed by the tiny blood vessels in the mucous membranes lining the nasal passages. It takes approx. 3-5 minutes for full reaction

8. How Drugs Enter The Body • Inhaling(smoking, huffing) Smokes a “joint” or inhales “ heroin/crack”, the vaporized drug enters the lungs and is “rapidly” absorbed thru tiny blood vessels lining the air sacs of the bronchi. From the lungs, the “drug laden” blood is pumped back to the heart and then directly to the body and brain thus acting more quickly than any other methods of use. (7-10 seconds for full reaction time). • Injection(IV or IM- mainlining or skin popping) Injecting with needles, either into the bloodstream, or under the skin. IV takes approx. 15-30 seconds, where IM takes approx. 3-5 minutes for full reaction time. Anally (suppositories)

10. How Long Drug Use/Abuse 100 yrs ? 500 yrs ? 1000 yrs? 2000 yrs ? Ever since the beginning of written history: Cave Walls, Hieroglyphics, Bible, Torah, Koran, Dead Sea Scrolls: All indicated the use/abuse of mind altering mood altering substances

11. CATEGORIES OF DRUGS OF ABUSE STIMULANTS Depressants Hallucinogens Narcotics

12. NARCOTICS OPIUM OPIATESOPIOIDS MORPHINE HEROIN CODEINE DILAUDID VICODIN METHADONE OXYCODONE (oxycontin) Primarily Physically Addicting

13. NARCOTICS/OPIUM • Has been around since the beginning of time, the first written account of it’s use dates back to approx. 4,000 B.C. • Homer wrote in the Odyssey: When Helen said; “Into the bowl in which their wine was mixed, she slipped a drug that had the power of robbing grief and anger of their sting and banishing all painful memories. No one who swallowed this in their wine could shed a single tear that day even for the death of their mother or father, or if they put his own son to the sword…”

14. NARCOTICS/OPIUM • The ancient “Arabs” both used and organized the trade of Opium, (Why ?) “The Holy Prophet had forbidden the use of Alcohol; not Hashish or Opium.” Some “ancient” descriptions of Opium include: The Hand of GOD, The Destroyer of Grief, Fruit of the Gods, The Milk of Paradise!

15. NARCOTICS/OPIUM • It is easy to see why such a “potentially” deadly drug was sought after. The ancient Greek physicians said of OPIUM; • “it resists poison and venomous bites, cures chronic headache, vertigo, deafness, epilepsy, apoplexy, dimness of sight, loss of voice, asthma, coughs of all kinds, spitting of blood, tightness of breath, colic, jaundice, urinary complications, fever, dropsies , leprosies, and the trouble to which women are subject, melancholy and all pestilences”. • OPIUM is the “Granddaddy” of all Narcotics. All Narcotics come from or are chemically altered to mimic the properties of Opium. • How big do you think the “Opium” problem is today? (Why)

16. NARCOTICS • Used “commonly” to control moderate-severe acute pain. • Can cause physiological tolerance(more to get same effect). • Can cause physical dependence (discomfort if abruptly stopped)

17. QUIZ 1st popularized in the US, not as a devastating/disgusting or dangerous drug we have come to know, but a legitimate, “researched "and widely dispensed medication which had the following attributes: more powerful then any commonly used pain drug, cheaper to manufacture, will last “forever” and causes no lingering cravings. Introduced When, by Who and Drug Name 1888 The Bayer Pharmaceutical Company The name of this “new” miracle medicine was “Heroin”

18. HEROIN HEROINas well as various prescription analgesics, all function by binding with naturally occurring opiate receptors in the CNS. HEROIN, known primarily as a “street drug” is typically snorted or injected, (IV or IM ? Where and how ?). The duration of “sensation” is usually 2-4 hours, this causes users to have to dose multiple times per day. It can also be smoked (which we see increasing due to potency). This is called (?) All Narcotics are “cross tolerant ” which means ? (examples)

19. NARCOTICS Pain Pills A number of “recent” patients/consumers/clients present addicted to or for use/abuse of prescription Narcotics. All symptoms, cautions and treatments previously mentioned for the “street” narcotics remain. However, patients may present somewhat “differently” (examples). Popular types of “prescribed” pain meds: codeine, dilaudid, fentanyl, demerol, methadone, oxycontin, ultram, percocet, vicodin, darvon, darvocet, lortab, etc., etc

20. NARCOTICS • With narcotic and opioid medications, there is a potential for the development of tolerance and dependence as well as a great potential for abuse and “severe” withdrawal reactions (why). • Are there any “considerations” that should be taken when a “prescription abuser” request/enters treatment?? • Because Narcotics are so powerful, withdrawal will cause DEATH (True/False)

21. NARCOTICS/METHADONE Methadone Is it “villain or savior” What is it (?) Discovered in 1937, by German Scientist as an “alternative” pain reliever (Dolophine). “Rediscovered” in 1960 by Drs. Doyle & Nyswynder as a “possible cure” for Narcotic Addiction. Their research was supported both nationally and locally to address the “Dreaded Scourge of America” HEROIN Addiction”. Realizing (already knowing), no “cure” for addictions they began to investigate the potential “craving blockage” aspects of this drug. They introduced the drug (Methadone) as a “medication” to assist in the tx. of narcotic addiction.

22. Narcotics/Methadone • Methadone “quickly” became the demon drug, “treating addiction to one drug with another”, “it’s worst than heroin,” “they stay addicts for life” “it gets into the bones etc, etc”. (True or False) • Methadone can be and is an effective “Medication Assisted Treatment” in conjunction with other therapies. (?) • Methadone patients can/do live productive “healthy” lives.. However, it can and is abused like all “psychoactive” drugs and has a potential to be lethal, particularly when “mixed” with other drugs.

23. OXYCONTIN Oxy is a prescription painkiller used for mild to moderatepain control, chronic pain, and the treatment of cancer pain. The active ingredient is oxycodone.(effects similar to that of Heroin) Is time-released and contains much larger amounts of oxycodone than other painkillers (vicodin, percocet, percodan). Tablet form last for approx 12 hours. Used by swallowing tablets, crushing and snorting or injection. When snorted or injected effects sooner. Abusers are attracted because effects are very similar to HEROIN,and much cheaper (40 milligram tablet cost about $4, but often sells on the streets for $20-$40) also obtained by prescription for pain.

24. HALLUCINOGENS • LSD (acid, window pane) • PSILOCYBIN (shrooms) • MDMA (ecstasy) • MESCALINE (mesc, buttons) • PCP (angel dust, blast) • PEYOTE • STP, MDA (love drugs) • MARIJUANA ( grass, pot, weed, chronic, herb,) Primarily Psychologically Addicting

25. Marijuana

26. CLUB DRUGS • Ecstasy (methylenedioxymethamphetamine) • GHB(Gamma-hydroxybutyrate) • Rohypnol (Flunitrazepam – related to Valium, Xanax) • Ketamine ( anesthetic for humans and animals, injected, smoked) • Methamphetamine • LSD (Lysergic Acid Diethylamide 25)

27. CLUB DRUGS EcstasyDeve. In 1900 as appetite suppressant. Has effects of Stimulant and Hallucinogen, effects last approx 3-6hrs. Usual side effects (confusion, depression, sleep problems, anxiety, paranoia, dehydration, hypertension and heart or kidney failure) can last up to 1 mo. Significant increase in BP, heart rate, increased sense of alertness and energy. GHBSometimes used as Muscle Builder, and to enhance sexual performance. GHB is a central nervous system depressant that can relax or sedate the body. At higher doses it can slow breathing and heart rate to dangerous levels. Its intoxicating effects begin 10 to 20 minutes after the drug is taken. GHB is cleared from the body relatively quickly, so it is sometimes difficult to detect in emergency rooms and other tx. facilities.

28. CLUB DRUGS Rohypnol In the benzodiazepine family (valium, xanax). Is tasteless and odorless, dissolves easily in carbonated beverages. Effects are aggravated by concurrent use of alcohol. “Even without alcohol, a dose of Rohypnol can impair a victim for 8 to 12 hours.”. The drug causes profound “anterograde amnesia”;, individuals may not remember events experienced while under the influence. One of the “street names” is the “forget-me-pill”, and has/is used in many reported/unreported sexual assaults. Ketamine Actually classified as an anesthetic (animal). Popularized in the 1980’s. High doses produced effects similar to PCP (dream-like states and hallucinations. (smoked-usually in marijuana, snorted, injected)

29. STIMULANTS DEXEDRINE CAFFEINE METHEDRINE AMPHETAMINE COCAINE (CRACK) Both Physically & Psychologically Addicting

30. CLUB DRUGS Methamphetamines A toxic, addictive stimulant that affects many areas of the central nervous system. Smoked, snorted, injected or orally ingested. Easily dissolves in beverages. Serious health consequences, (memory loss, aggression, violence, psychotic behaviors, and potential cardiac and neurological damage. Side effects: Signs of agitation, excited speech, decreased appetite, and increased physical activity levels. LSD LSD is classified as an Hallucinogen, it induces abnormal sensory perceptions. It’s effects are unpredictable depending on the amount and purity, as well as the users personality, mood and expectations. Effects begin approx. 30-90 minutes. Physical effects include dilated pupils, higher body temp., increased heart and blood rates, sweating, loss of appetite, sleeplessness, dry mouth nausea. FLASHBACKS! 1 week to 1 year reported

31. COCAINE FACTS • 1855-1860 Cocaine isolated from other chemicals in the coca leaf = “COCAINE HYDROCHLORIDE” • 1884 Used as a local anesthetic • 1885 Rbt. Louis Stevenson wrote “Dr. Jekyll and Mr. Hyde” in 3 days under the influence of cocaine • 1886 Dr. Sigmund Freud prescribed and used cocaine daily gave to patients for a number of ailments, “cure for the disease of alcoholism and morphine addiction” • 1887 Arthur Cannon Doyle-(Sherlock Holmes), used cocaine continuously to combat “fatigue & depression”. He also included the use of cocaine by his major character. In plays like “The Seven % Solution”. The actor playing Holmes actually injected cocaine on stage.

32. COCAINE FACTS One famous line from the play was “Quick Watson the Needle”. Remember Watson was a Medical Doctor. • 1888 A new “medicine” called a “brain tonic”, was intro- duced in the southern USA- (?). The drink became very, very, very popular because it tasted good and gave you a definite “rush” due to it’s cocaine content. • 1914 Classified as a “Dangerous Narcotic”, cocaine largely went “underground “ used by affluent people. • 1960-70,80 With the big “Crack Down” on the use of amphetamines cocaine began to re-emerge as a stimulant of choice.

33. COCAINE FACTS Cocaine was used mainly by the “AFFLUENT”, it enjoyed a kind of acceptance by the in-crowd. The drug was seen/used/abused at all the ‘fashionable’ places and glorified in novels, movies and other media. • Late 70s & 80s The Debut of a “new” phenomena called FREE BASING- The smoking of Cocaine, made infamous by the likes of Richard Pryor. It’s used spread like “wild fire” further and faster than any drug before, and went on to change the face of not only the USA but the world. How and why did this happen – CHEAP, A FASTER HIGH, NO NEEDLES AND YES TOUTED AS NON- ADDICTING!!!!!!!! DANGERS ?????

34. DEPRESSANTS BARBITURATES • SECONAL • TUNIAL • PHENOBARBITUAL TRANQUILIZERS • Valium • Librium • Xanax • Ativan Primarily Physically Addicting

35. INHALANTS • SOLVENTS (polish & paint removers, lighter fluid, gas) • AEROSOLS (paint sprays, hair sprays) • ADHESIVES (airplane glue, rubber cement) • CLEANING AGENTS (spot removers, dry cleaning fluid) • ROOM DEODORIZERS (glade, etc) • NITROUS OXIDE (whipped cream, laughing gas) Primarily Psychologically addicting “One of the most dangerous”

36. Detection of Drugs in Urine Samples • Amphet/Meth 2 days (1 use) • Barbiturates 2 Days • Benzodiazepines 2 Days (1 use) • Marijuana 2 Days (1use) 7-28 Days (prolonged) • Cocaine/Metabolite 2 Days (1 use) 4 Days (daily) • Methadone 2-3 Days • Narcotics 2 Days • PCP 7 days (1 use) “Hair Test can detect presence for up to 90 Days “

37. ALCOHOL A Central Nervous System Depressant, alcohol can truly be called, “The Great Masquerader”. It can do what most other drugs cannot “It can MIMIC the actions of most psychoactive drugs” • Beer • Wine • Whiskey or Distilled Liquor

38. ALCOHOL FACTS The body’s ability to tolerate alcohol depends on the LIVER. Thus as we drink over a period of time the liver adapts and changes. It creates more enzymes to handle thePOISONthat is attacking the system. Unfortunately, since alcohol destroys liver cells, the liver eventually becomes less able to handle it. A condition called Reverse Tolerance occurs. So a person who could handle 2 fifths of alcohol at age 30 will/can get drunk from a half pint of wine at age 50. Alcohol is actually chemically classified as a Protoplasmic Poison. It can kill liver, brain, kidney and other tissue on contact. It affects all systems of the body. Another danger of Alcohol is it’s involvement in SYNERGISM. What is Synergism?

39. ALCOHOL FACTS Alcohol in it’s various forms has been around since the earliest of times. The “oldest psychoactive drug” known to man (probably fermented fruit) Later discovered that the starch in potatoes, rice, corn etc. could be “fermented”, first to sugar then alcohol. The concentration of alcohol in each type of beverage depends on the time fermented. Aside from being an enjoyable drink, alcoholic beverages were credited with reducing tension, lowering risk of heart attacks, and aiding people to “cope” etc. Alcohol ranks third behind heart disease and cancer as greatest health threats in USA. Alcohol is metabolized at defined, continuous rate based on a persons weight, amount, amount of time passed etc. We can usually determine how much alcohol is circulating in the system (BAC)