Drug_Abuse

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Drug Abuse:

Drug Abuse Self administration of drug or drugs in manner not in accord with accepted medical or social patterns

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:

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

Drug Abuse:

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

Drug Abuse:

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

Drug Abuse:

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!

Narcotics:

Narcotics Opium Opium derivatives Synthetic opium substitutes

Narcotics:

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

Narcotics:

Narcotics Effects Analgesia CNS depression Euphoria Drowsiness Apathy Antidiarrheal action Antitussitive action

Narcotics:

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)

Narcotics:

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

Narcotics:

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

Narcotics:

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

Narcotics:

Narcotics Withdrawal Lasts 7 to 10 days NOT life threatening

Sedative-Hypnotic Drugs:

Sedative-Hypnotic Drugs

Categories:

Categories Barbiturates Benzodiazepine Barbiturate-like non-barbiturates Chloral hydrate

Mechanism of Action:

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

Sedative-Hypnotics :

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

Sedative-Hypnotics:

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

Chloral hydrate:

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

Barbiturates:

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

Barbiturates:

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

Barbiturates :

Barbiturates Initial overdose presentation Slurred speech Ataxia Lethargy Nystagmus Headache Confusion

Barbiturates:

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

Barbiturates:

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

Barbiturates:

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)

Barbiturates:

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

Barbiturate-like, non-barbiturates:

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.

Placidyl (ethchlorvynol):

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

Doriden (gluthethimide):

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

Benzodiazepines:

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

Benzodiazepines:

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

Benzodiazepines :

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

Benzodiazepines:

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

Benzodiazepines:

Benzodiazepines Produce withdrawal syndrome similar to barbiturate withdrawal

Benzodiazepine-like non-benzos:

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

Neuroleptics:

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

Neuroleptics:

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

Neuroleptics:

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

Neuroleptics:

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

Neuroleptics:

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

Neuroleptics:

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

Stimulants:

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

Stimulants:

Stimulants Produce euphoria hyperactivity alertness sense of enhanced energy anorexia

Stimulants:

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

Stimulants:

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

Stimulants:

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

Stimulants:

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

Stimulants:

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

Hallucinogens:

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

Hallucinogens:

Hallucinogens Produce altered/enhanced sensation Effects highly variable depending on patient Increased dose does not intensify effect Toxic overdose virtually impossible

Hallucinogens:

Hallucinogens Some patients may experience “bad trips” Depends on surroundings, emotional state Signs and symptoms Paranoia, fearfulness, combativeness Anxiety, excitement Nausea, vomiting Tachycardia, tachypnea Tearfulness Bizarre Reasoning

Hallucinogens:

Hallucinogens Moderate Intoxication Tachycardia Mydriasis Diaphoresis Short attention span Tremor Hypertension Hyperreflexia Fever

Hallucinogens:

Hallucinogens Life-threatening toxicity (rare) Seizures Severe hyperthermia Hypertension, arrhythmias Obtunded, agitated, or thrashing about Diaphoretic, hyperreflexic Untreated hyperthermia can lead to hypotension, coagulopathy, rhabdomyolysis and multiple organ failure

Hallucinogens:

Hallucinogens Management of “bad trip” Rule out other causes of hallucinations Hypoglycemia Alcohol, drug withdrawal Infection Quiet, supportive environment Benzodiazepines, haldol for agitation, anxiety

Phencyclidine (PCP):

Phencyclidine (PCP) Street names Angel dust Peace Pill Hog Krystal Animal tranquilizer Used as veterinary anesthetic

Phencyclidine (PCP):

Phencyclidine (PCP) Actions Dissociative anesthesia Generalized loss of pain perception Little or no depression of airway reflexes or ventilation CNS-stimulant, anticholinergic, opiate, and alpha-adrenergic effects

Phencyclidine (PCP):

Phencyclidine (PCP) Low Doses Lethargy, euphoria, hallucinations Slurred speech Blank stare Insensitivity to pain Midposition to dilated pupils Vertical and horizontal nystagmus Occasionally bizarre or violent behavior

Phencyclidine (PCP):

Phencyclidine (PCP) High Doses Diaphoresis Salivation Hypertension Tachycardia Hyperthermia Localized dystonic reactions Wide-eyed coma Rigidity Seizures

Phencyclidine (PCP):

Phencyclidine (PCP) Treatment Maintain airway Assist ventilations, as needed Treat coma, seizures, hypertension, hypothermia as needed Quiet environment Sedation if needed to control agitation Haldol Benzodiazepines

Inhalants:

Inhalants Examples Hydrocarbons (solvents, paints, aerosols) Gases (freon, halon fire extinguishing agent) Metallic paints (“huffing”)

Inhalants:

Inhalants Effects Dysrhythmias including VF CNS depression Seizures Respiratory irritation Epinephrine may increase risk of dysrhythmias Treatment Oxygen Treat symptomatically

“Date rape” drugs:

“Date rape” drugs Flunitrazepam (Rhohypnol) Gamma hydroxybutyrate

Flunitrazepam (Rhohypnol):

Flunitrazepam (Rhohypnol) Street names Rophies Roofies R2 Roofenol Roche Roachies La rocha Rope Rib

Flunitrazepam (Rhohypnol):

Flunitrazepam (Rhohypnol) Benzodiazepine Similar to Valium but 10x more potent Produced, sold legally in Europe, South America Uses Short-term treatment of insomnia Sedative hypnotic Preanesthetic medication

Flunitrazepam (Rhohypnol):

Flunitrazepam (Rhohypnol) Effects Disinhibition and amnesia Onset within 30 minutes, peak within 2 hours, may persist 8 hours or more Frequently abused with alcohol or other drugs Enhances high produced by heroin

Flunitrazepam (Rhohypnol):

Flunitrazepam (Rhohypnol) Adverse Effects Drowsiness Dizziness Confusion Decreased BP Memory impairment GI disturbances Excitability, aggressive behavior

Flunitrazepam (Rhohypnol):

Flunitrazepam (Rhohypnol) Management of overdose Lethal overdose very unlikely Oxygenate, ventilate Intubate if necessary to control airway Vascular access ECG Fluid for hypotension Dextrostick (rule out hypoglycemia) Treat trauma resulting from assault

Flunitrazepam (Rhohypnol):

Flunitrazepam (Rhohypnol) Withdrawal Headache Anxiety, tension Numbness, tingling of extremities Restlessness, confusion Loss of identity Hallucinations Delirium Seizures (up to a week after cessation) Shock Cardiovascular collapse

Flunitrazepam (Rhohypnol):

Flunitrazepam (Rhohypnol) Management of withdrawal Oxygen/ventilation Intubate if necessary EKG Vascular access Fluid for hypotension Dextrostick Diazepam for seizures

Gamma hydroxybutyrate:

Gamma hydroxybutyrate Street names Cherry meth Liquid X Liquid ecstacy Originally developed as anesthetic Banned in 1991 because of side effects Promoted as aphrodisiac

Gamma hydroxybutyrate:

Gamma hydroxybutyrate Effects Odorless, nearly tasteless Tremors Seizures Death

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