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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 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 • Sexual enhancement • Weight loss
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
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
Cocaine Intoxication • Effects: euphoria, confidence, decreased inhibitions • 1. Rush (1-5 minutes) • 2. High (10-20 minutes) • 3. Crash • 4. (Binge / cycle)
Clinical Presenting Symptoms • Chest pain • Insomnia, fatigue • Weight loss • Paranoia • Nasal infections • Headaches • Sexual Dysfunction • Magnon’s Syndrome (coke bugs) More Common
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
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)
Cocaine and ETOH • Cocaine + alcohol = cocaethylene • Enhances the cardiac side effects (MI, arrythmias, cardiomyopathy) • Combination increases the risk of sudden death 25X
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
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
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
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)
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)
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
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
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
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
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)
MJ: Medical Applications • Medical applications: • Antiemetic • Pain management (esp. neuropathic and inflammatory pain in cancer patients) • Asthma • Glaucoma • Appetite stimulant
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!
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
PCP • “Dissociative anaesthetic” • Introduced by Parke-davis (1967) for anesthetizing large animals • Usually smoked (“sherms”), sometimes snorted or swallowed • Highly variable concentrations
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)
PCP: Medical Sequelae • Rhabdomyolysis • Renal failure • Intractable seizures • Hyperthermia • HTN, CVA • Psychosis
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”
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)
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
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)
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
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
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”)
Club Drugs: Ecstasy/MDMA • Desired effects: • Stimulant/psychedelic • Altered time perception • Decreased aggression/sexual activity • Empathy, Enhanced touch • Light trailers
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
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)
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
Questions… Primary Care Workshop California Academy of Family Physicians and California Society of Addiction Medicine April 14, 2005