Self administration of drug or drugs in manner not in accord with accepted medical or social patterns
Drug Abuse
Physical Dependency
Physical
Drug Abuse
with obtaining drug Rituals of preparing, using drug as important as drug effects
Tolerance
Increasing
Drug Abuse
Addiction
Includes
Psychological
Drug Abuse
Suspect drug-related problem in patients with: Altered LOC Bizarre behavior Seizures
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
Opium Opium derivatives Synthetic opium substitutes
Narcotics
Examples
Opium Morphine Heroin Codeine Dilaudid Oxycodone
Narcotics
Effects
Analgesia
CNS
depression
Euphoria
Drowsiness
Apathy
Antidiarrheal
Narcotics
Overdose
Mild
to Moderate
Severe
Respiratory Coma
Lethargy Pinpoint
depression
Aspiration
Seizures
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
Associated Dangers
Skin
Adulterant
Narcotics
Withdrawal
Insomnia Watery
Restlessness
Irritability Anorexia
Tremors
Back,
extremity pain
Narcotics
Withdrawal
Lasts
Sedative-Hypnotic Drugs
Categories
Barbiturates Benzodiazepine Barbiturate-like non-barbiturates Chloral hydrate
Mechanism of Action
Most overdoses of sedative-hypnotics are from benzodiazepines, barbiturates Both enhance effects of gammaaminobutyric acid (GABA) GABA enhancement results in downregulation of CNS activity
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
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
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
Introduced in 1903 Replaced older sedative-hypnotics Quickly became major health problem In 1950s-60s barbiturates were implicated in overdoses; were responsible for majority of drug-related suicides
Barbiturates
Short-acting
Amytal Pentathiol
Intermediate-acting
Nembutal Seconal Tuinal
Long-acting
Phenobarbital
Barbiturates
speech
Lethargy
Nystagmus Headache
Confusion
Barbiturates
As overdose progresses
Depth
of coma increases
Patient
anesthetized with loss of neurologic function EEG may mimic brain death
Respiratory
shock
Hypothermia
Blisters
Barbiturates
Early deaths
Respiratory
Delayed deaths
Acute
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
Withdrawal signs/symptoms
Apprehensiveness Anxiety
Tremulousness
Diarrhea Nausea
Vomiting
Seizures
Barbiturate-like, non-barbiturates
Examples
Doriden
Overdose produces sudden, prolonged apnea Highly addictive Withdrawal resembles barbiturate withdrawal Only Placidyl, Doriden remain available in U.S.
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)
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
Developed due to overdoses, deaths related to barbiturates, barbiturate-like nonbarbiturates Relatively few deaths In 1993, prescription rate for barbiturates dropped to one-sixth that of benzos
Benzodiazepines
Examples
Valium
(diazepam) Ativan (lorazepam) Versed (midazolam) Librium (chlorodiazepoxide) Tranxene (chlorazepate dipotassium) Dalmane (flurazepam) Halcion (triaxolam) Restoril (temazepam)
Benzodiazepines
Adverse Effects
Weakness Headache Blurred Vertigo Nausea Diarrhea Chest
vision
pain
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
Benzodiazepine-like non-benzos
BuSpar (buspirone)
Used
for generalized anxiety disorder Less sedating than diazepam Less potentiation by other CNS depressants
Neuroleptics
Antipsychotics, major tranquilizers Used in treatment of schizophrenia, other psychoses Examples
Neuroleptics
Neuroleptics
depression Hypotension Anticholinergic symptoms: flushing, dry mouth, hyperthermia, tachycardia, urinary retention Ventricular arrhythmias, including Torsades Seizures
Neuroleptics
vasopressors for hypotension Lidocaine, phenytoin for ventricular arrhythmia Magnesium, isoproterenol for Torsades Benzodiazepines, phenobarbital for seizures
Neuroleptics
Neuroleptics
Stimulants
Examples
Cocaine Amphetamines
Benzedrine
Stimulants
Produce
euphoria hyperactivity alertness sense
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
Overdose complications
Hyperthermia,
heat stroke Hypertensive crisis CVA Acute MI Intestinal infarctions Rhabdomyolysis Acute renal failure
Stimulants
Chronic effects
Weight
loss Cardiomyopathy Paranoia Psychosis Stereotypic behavior: picking at skin (cocaine bugs)
Stimulants
Overdose management
Oxygen,
monitor, IV Activated charcoal for decontamination in first hour Valium for sedation Hypertension control
Nipride
Phentolamine
Avoid
Body
temperature reduction
Stimulants
Withdrawal
Drowsiness Profound
depression (cocaine blues) Increased appetite Abdominal cramps, diarrhea, nausea Headache
Hallucinogens
Examples
Indole
Amphetamine-like
Hallucinogens
Produce altered/enhanced sensation Effects highly variable depending on patient Increased dose does not intensify effect Toxic overdose virtually impossible
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
Moderate Intoxication
Tachycardia Mydriasis Diaphoresis Short
Hallucinogens
hyperthermia Hypertension, arrhythmias Obtunded, agitated, or thrashing about Diaphoretic, hyperreflexic Untreated hyperthermia can lead to hypotension, coagulopathy, rhabdomyolysis and multiple organ failure
Hallucinogens
Quiet,
Phencyclidine (PCP)
Street names Angel dust Peace Pill Hog Krystal Animal tranquilizer Used as veterinary anesthetic
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)
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)
High Doses
Diaphoresis Salivation Hypertension
Tachycardia
Hyperthermia
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
Examples
Hydrocarbons
(solvents, paints, aerosols) Gases (freon, halon fire extinguishing agent) Metallic paints (huffing)
Inhalants
Effects
Dysrhythmias
including VF CNS depression Seizures Respiratory irritation Epinephrine may increase risk of dysrhythmias
Treatment
Oxygen Treat
symptomatically
Flunitrazepam (Rhohypnol)
Street names
Rophies
Roofies R2 Roche Roachies
La
Roofenol
Flunitrazepam (Rhohypnol)
Benzodiazepine Similar to Valium but 10x more potent Produced, sold legally in Europe, South America Uses
Short-term
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)
Adverse Effects
Drowsiness Dizziness Confusion
Decreased
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)
Withdrawal
Headache Anxiety, Hallucinations Delirium Seizures
Flunitrazepam (Rhohypnol)
Management of withdrawal
Oxygen/ventilation Intubate EKG
if necessary
Vascular
Gamma hydroxybutyrate
Street names
Cherry
Originally developed as anesthetic Banned in 1991 because of side effects Promoted as aphrodisiac
Gamma hydroxybutyrate
Effects
Odorless, Tremors Seizures Death
nearly tasteless