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Drug Abuse

Drug Abuse. Drug Abuse. Psychological Dependency (Habituation) Drug necessary to maintain user’s sense of well-being Physical Dependency Physical symptoms if intake reduced. Drug Abuse. Compulsive Drug Use Preoccupation with obtaining drug

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Drug Abuse

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  1. Drug Abuse

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

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

  4. Drug Abuse • Addiction • Includes • Psychological dependence • Physical dependence • Compulsive use • Tolerance • Plus, complete absorption with obtaining, using drug to exclusion of all else

  5. Drug Abuse • Suspect drug-related problem in patients with: • Altered LOC • Bizarre behavior • Seizures

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

  7. Narcotics • Opium • Opium derivatives • Synthetic opium substitutes

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

  9. Narcotics • Effects • Analgesia • CNS depression • Euphoria • Drowsiness • Apathy • Antidiarrheal action • Antitussitive action

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

  11. Narcotics • Overdose • Management • Support oxygenation/ventilation • Vascular access • D50W 50cc • Narcan 0.4 to 2.0 mg • Improve respirations • Do NOT awaken completely • Restrain before giving

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

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

  14. Narcotics • Withdrawal • Lasts 7 to 10 days • NOT life threatening

  15. Sedative-Hypnotic Drugs

  16. Categories • Barbiturates • Benzodiazepine • Barbiturate-like non-barbiturates • Chloral hydrate

  17. Mechanism of Action • Most overdoses of sedative-hypnotics are from benzodiazepines, barbiturates • Both enhance effects of gamma-aminobutyric acid (GABA) • GABA enhancement results in down-regulation of CNS activity

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

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

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

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

  22. Barbiturates • Short-acting • Amytal • Pentathiol • Intermediate-acting • Nembutal • Seconal • Tuinal • Long-acting • Phenobarbital

  23. Barbiturates • Initial overdose presentation • Slurred speech • Ataxia • Lethargy • Nystagmus • Headache • Confusion

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

  25. Barbiturates • Early deaths • Respiratory arrest • Cardiovascular collapse • Delayed deaths • Acute renal failure • Pneumonia • Pulmonary edema • Cerebral edema

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

  27. Barbiturates • Withdrawal signs/symptoms • Apprehensiveness • Anxiety • Tremulousness • Diarrhea • Nausea • Vomiting • Seizures Life-threatening

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

  29. Placidyl (ethchlorvynol) • “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

  30. Doriden (gluthethimide) • 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

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

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

  33. Benzodiazepines • Adverse Effects • Weakness • Headache • Blurred vision • Vertigo • Nausea • Diarrhea • Chest pain

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

  35. Benzodiazepines • Produce withdrawal syndrome similar to barbiturate withdrawal

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

  37. Neuroleptics • Antipsychotics, major tranquilizers • Used in treatment of schizophrenia, other psychoses • Examples • Haldol • Mellaril • Thorazine • Stellazine • Compazine

  38. Neuroleptics • Extrapyramidal muscle contractions (dystonias) • Bizarre, acute, involuntary movements, spasms of skeletal muscles • Reversible with Benadryl

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

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

  41. Neuroleptics • Neuroleptic malignant syndrome • Life-threatening reaction • Signs, symptoms • Hyperthermia • Muscular rigidity • Altered LOC • Tachycardia, hypotension

  42. Neuroleptics • Neuroleptic malignant syndrome • Management • ABCs • Oxygen • Assist ventilation, as needed • Benzodiazepines • Rapid cooling • Volume for hypotension

  43. Stimulants • Examples • Cocaine • Amphetamines • Benzedrine (bennies) • Dexedrine (dexies, copilots) • Methamphetamine (ice, black beauties) • Ephedrine • Caffeine • Ritalin

  44. Stimulants • Produce • euphoria • hyperactivity • alertness • sense of enhanced energy • anorexia

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

  46. Stimulants • Overdose complications • Hyperthermia, heat stroke • Hypertensive crisis • CVA • Acute MI • Intestinal infarctions • Rhabdomyolysis • Acute renal failure

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

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

  49. Stimulants • Withdrawal • Drowsiness • Profound depression (“cocaine blues”) • Increased appetite • Abdominal cramps, diarrhea, nausea • Headache

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

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