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Chemicals of Abuse

Chemicals of Abuse. Sean Koon, MD California Academy of Family Physicians California Society of Addiction Medicine April 14, 2005. Substances. Stimulants Cannabis Hallucinogens Opiates “Club” Drugs. Stimulants. Used for: “High” Energy, increase job performance, driving, studying

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Chemicals of Abuse

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  1. Chemicals of Abuse Sean Koon, MD California Academy of Family Physicians California Society of Addiction Medicine April 14, 2005

  2. Substances • Stimulants • Cannabis • Hallucinogens • Opiates • “Club” Drugs

  3. Stimulants • Used for: • “High” • Energy, increase job performance, driving, studying • Sexual enhancement • Weight loss

  4. Cocaine • Made from coca plant/leaf “chewed” in the Andes mountains of South America • Original Coca-cola contained cocaine and kola beans • Proposed by Freud for treatment of mental illness. He also used this habitually, finally conceding its detrimental effects in his last paper on the subject

  5. Forms of Use • Cocaine HCL: snorted, not potent when smoked • Freebase cocaine: converted to a base by removal of HCL with ether or NH4OH. Can be smoked or vaporized. More pure than reg. cocaine. • Crack Cocaine: a form of freebase. Many impurities. Cheaper

  6. Cocaine Intoxication • Effects: euphoria, confidence, decreased inhibitions • 1. Rush (1-5 minutes) • 2. High (10-20 minutes) • 3. Crash • 4. (Binge / cycle)

  7. Clinical Presenting Symptoms • Chest pain • Insomnia, fatigue • Weight loss • Paranoia • Nasal infections • Headaches • Sexual Dysfunction • Magnon’s Syndrome (coke bugs) More Common

  8. “Coke bugs”

  9. Medical Sequelae: Cocaine • Can cause vasoconstriction or ischemia in various organs • Cardiac • Cocaine is the leading cause of drug related ER visits, excluding alcohol • Risk of heart attack is increased 2x in the first 60 minutes of ingestion • The amount of cocaine causing heart failure or dysfunction can vary widely • Tachyarrythmias (v-tach/v-fib) • LVH, abnormal segmental wall motion

  10. Medical Sequelae, cont’d • ENT: Chronic rhinitis, perf. septum • Neurologic: • Seizures with acuteintoxication (not withdrawal) • CVA, TIA, SAH • Pulmonary (rare): infarction, alveolar hemorrhage, pneumothorax • GI: ischemia, ulcers (most in greater curvature or near pylorus)

  11. Cocaine and ETOH • Cocaine + alcohol = cocaethylene • Enhances the cardiac side effects (MI, arrythmias, cardiomyopathy) • Combination increases the risk of sudden death 25X

  12. Amphetamines • Originally marketed for asthma in 1932 as “benzedrine” • used during WWII by Japan, US, Germany, Great Britain (200 million tablets supplied to American troops) • Taken in pill form, snorted, smoked, injected

  13. Amphetamines • Similar effect to cocaine, but longer lasting and cheaper • Made from industrial reagents, over 150 methods of “cooking” • Environmental impact: lots of toxic waste in the production

  14. Amphetamine Intoxication • Alertness, energy, decreased inhibition, euphoria, increased confidence, increased sexual activity • Confusion, dry mouth, anxiety, HTN, sensitivity to light and sound, bruxism • Cardiac and neurological sequelae are similar to cocaine • Does not work synergistically with alcohol like cocaine

  15. Amphetamine Intoxication • 1. Rush (5-30 min) • 2. High (4-16 hours) • 3. Binge (3-15 days) • 4.“Tweaking”(24 hours) • End of high dose binge: depression, irritability, w/paranoia aggression • 5. Crash (1-3 days of extreme fatigue/sleep) • Compare with cocaine • 1. Rush (1-5 minutes) • 2. High (10-20 minutes)

  16. Medical Sequelae • Psychosis, delusions, hallucinations, violence, formication “speed bugs, crank bugs”, stereotypy • Decay and discoloration of teeth • Seizures (with intoxication only) • Withdrawal usually requires no medical management (symptomatic)

  17. Marijuana • Used throughout history for rope, clothing, food and oil (from seeds) • Earliest written reference: Chinese Emperor Shen Nung in 2737 recommended for gout, constipation and rheumatism

  18. Marijuana, cont’d • Found to work on CB1 (in the brain) and CB2 (in the spleen, on macrophages) receptors • “anandamide” is endogenous ligand that binds to these receptors. • Affects memory consolidation d/t effect on hippocampus • Via the amygdala, MJ interacts with: novelty, appetite regulation, pain threshold regulation, anxiety and fear regulation

  19. Marijuana Intoxication • Peak high 15-45 minutes • Acceleration of HR for 10-30 minutes (by 30-50%), moderate increase in BP • Poor judgment and motor coordination (for 4-8 hours even after the “high” is gone • Very significant risk in driving • Redding of the eyes • Slight drop in body temp. • Dryness of mouth and throat, possible blistering

  20. MJ Intoxication • Desired effects • Euphoria • Relaxation, reduced physical activity • Rapid mood changes, heightening of humor • Intensifies ordinary experiences • Other effects • Anxiety or panic • Impaired memory, esp. short term • Reduced concentration

  21. MJ: Consequences • Over the years many medical consequences were suggested but only the lung consequences are consistently found in the research: • Bronchitis • Emphysema • Lung Cancer • Many biopsychosocial issues: relationships, education, anhedonia and mood problems, legal • Can serve as a “gateway drug” (3x more likely to lead to dependency if smoked before 18 years old)

  22. MJ: Medical Applications • Medical applications: • Antiemetic • Pain management (esp. neuropathic and inflammatory pain in cancer patients) • Asthma • Glaucoma • Appetite stimulant

  23. Hallucinogens:LSD • POTENT: One ounce=567,000 hits • Taken on blotter paper, gels, or sugar cubes • Effect in 30-60 minutes. May last for up to 12 hours It’s believed that as few as 10 people make all of the LSD used in the US!

  24. LSD cont’d • Perceptual distortion, impaired judgement • Synesthesia: “crossing of senses” • Dilated pupils, increased saliva, increase HR, BP, RR • Sometimes extreme fear, anxiety and paranoia with high risk of physical injury: “talk down” • Flashbacks can be weeks months, or years after last use • No evidence of physical addiction

  25. PCP • “Dissociative anaesthetic” • Introduced by Parke-davis (1967) for anesthetizing large animals • Usually smoked (“sherms”), sometimes snorted or swallowed • Highly variable concentrations

  26. PCP Intoxication • Onset 2-5 minutes • Peak 15-30 minutes • Lasts 4-6 hours • Fat soluble: sporadic concentrations • Three levels of intoxication • Low dose: “drunken state” • Mod. dose: agitation, hallucinations, muscle rigidity, poor coordination, marked nystagmus • Big dose: convulsions, respiratory depression, cardiac instability, coma • Possible agitation in withdrawal, 11-15 hrs after last dose • “Flashbacks” (true chemical)

  27. PCP: Medical Sequelae • Rhabdomyolysis • Renal failure • Intractable seizures • Hyperthermia • HTN, CVA • Psychosis

  28. Opiates: Heroin • Desired effect: euphoria • Respiratory depression – • Sometimes a purchase has greater purity than expected • Nearly all heroin OD’s secondary to this • Often combined with cocaine to make “speedballs” • Most medical complications are due to injection use • Heavy risks of the “Heroin lifestyle”

  29. Heroin Withdrawal • Usually peaks in 24-72 hours, gone by 7-10 days, usual detox is 3-7 days • Dilated pupils • Goosebumps • Nausea, Vomiting, Diarrhea • Increased BP, HR • Muscle pain/spasms • Rhinorrhea, watery eyes • Yawning • (More on withdrawal in Dr. Ey’s lecture)

  30. Medical Concerns with Injection Drug Users • Hepatitis, especially Hepatitis C • Transmitted by blood: needles, syringes, cottons, cookers, rinsewater • Studies claim 70+% Heroin users are Hep C+ • Infective endocarditis, typically right sided, 50% staph, 15% strep • Pneumonia • concomitant cigarettes, malnutrition, depressed gag reflex • More often H. flu, S. aureus, Ps. aeruginosa relative to non-IDUs • IDU’s have increased risk of TB activation, unknown why • Cellulitis, abscesses (mostly staph, often strep) • HIV

  31. Medical Issues with Injected Drugs, cont’d • Necrotizing fasciitis • Pain way out of proportion to findings • Medical emergency • Renal: • Nephrotic syndrome • Glomerulonephritis (usually from to bacterial endocarditis)

  32. Notable RX opiates: • Meperidine, Propoxyphene, and Pentazocine (and tramadol the partial agonist) • Can all cause seizures in OD as well as with higher therapeutic doses • May cause agitation, confusion, and frank delirium when given around the clock • Long acting opiates • Oxycontin attractive to addicts for its high amount of oxycodone. Crushed form can be injected or snorted (ms contin abused as well, but apparently not as easy to crush/snort/inject) • Duragesic patches can be chewed or squeezed and contents injected

  33. Club Drugs • Used typically by teens/youth • GHB (Gamma Hydroxybutyric acid) • Liquid, dosed in “capfuls” • Rapid onset, ½ life 20 minutes • Side effects • Dizzines, nausea, emesis, dec. resp, coma • Overdose similar to sedatives, consciousness returns within 5 hours after ingestion

  34. Club Drugs • Ketamine • Similar to PCP • SE’s confusion, delirium, psychosis, coma,seizures • DMX (dextromethorphan): euphoria, dissociation, hallucinosis • May last 3-6 hours • Doses up to 100x therapeutic dose (esp. “Coricidin HBP”)

  35. Club Drugs: Ecstasy/MDMA • Desired effects: • Stimulant/psychedelic • Altered time perception • Decreased aggression/sexual activity • Empathy, Enhanced touch • Light trailers

  36. MDMA Intoxication • Intox. 30-45 minutes after ingestion • Intense effects 60-90 minutes after ingestion • Most effects wear off by 4-6 hours • Some effects may persist for days to longer

  37. MDMA: Adverse effects • Causes large amounts of serotonin to be released, and prevents re-uptake • Serotonin syndrome (elevated body temp., sweating, spasm, coma, CV collapse, etc.) • Heat stroke • Fluid & electrolyte imbalances • Anxiety, confusion, sleep disturbance, paranoia • Muscle tension, bruxism • Depression, perhaps even chronic depression after few doses (after w/d of drug)

  38. Sedatives • Interact with GABA Receptor • Cross-tolerant with alcohol, thus useful for withdrawal • Benzodiazepines • Barbiturates • SOMA : metabolizes to meprobamate, a barbiturate-like compound • Withdrawal may mimic the indication (e.g. anxiety or insomnia) • Seizures and delirium are possible in withdrawal from sedatives

  39. Questions… Primary Care Workshop California Academy of Family Physicians and California Society of Addiction Medicine April 14, 2005

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