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Drug Abuse

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

Drug Abuse

Psychological Dependency (Habituation)


Drug

necessary to maintain users sense of well-being symptoms if intake reduced

Physical Dependency
Physical

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

Addiction
Includes
Psychological

dependence Physical dependence Compulsive use Tolerance


Plus,

complete absorption with obtaining, using drug to exclusion of all else

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

(Percodan) Meperidine (Demerol) Propoxyphene (Darvon) Talwin Fentanyl

Narcotics

Effects
Analgesia
CNS

depression

Euphoria

Drowsiness
Apathy

Antidiarrheal

action Antitussitive action

Narcotics

Overdose
Mild

to Moderate

Severe
Respiratory Coma

Lethargy Pinpoint

depression

pupils Bradycardia Hypotension Decreased bowel sounds Flaccid muscles

Aspiration
Seizures

with certain compounds (meperidine, propoxyphene, tramadol)

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

abscesses Phlebitis Sepsis Hepatitis HIV Endocarditis

Adulterant

toxicity Cotton fever Malnutrition Tetanus Malaria

Narcotics

Withdrawal
Insomnia Watery

Restlessness
Irritability Anorexia

Tremors
Back,

extremity pain

eyes Yawning Rhinorrhea Sneezing Diarrhea Diaphoresis

Resembles Severe Influenza

Narcotics

Withdrawal
Lasts

7 to 10 days NOT life threatening

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

Initial overdose presentation


Slurred Ataxia

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

depression occurs Peripheral vasodilation occurs


Hypotension,

shock

Hypothermia

Blisters

(bullae) form on skin

Barbiturates

Early deaths
Respiratory

arrest Cardiovascular collapse

Delayed deaths
Acute

renal failure Pneumonia Pulmonary edema Cerebral edema

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

(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)

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

Produce withdrawal syndrome similar to barbiturate withdrawal

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
Antipsychotics, major tranquilizers Used in treatment of schizophrenia, other psychoses Examples

Haldol Mellaril Thorazine Stellazine Compazine

Neuroleptics

Extrapyramidal muscle contractions (dystonias)


Bizarre,

acute, involuntary movements, spasms of skeletal muscles Reversible with Benadryl

Neuroleptics

Acute Overdose Presentation


CNS

depression Hypotension Anticholinergic symptoms: flushing, dry mouth, hyperthermia, tachycardia, urinary retention Ventricular arrhythmias, including Torsades Seizures

Neuroleptics

Acute Overdose Management


ABCs Fluid,

vasopressors for hypotension Lidocaine, phenytoin for ventricular arrhythmia Magnesium, isoproterenol for Torsades Benzodiazepines, phenobarbital for seizures

Neuroleptics

Neuroleptic malignant syndrome


Life-threatening

reaction Signs, symptoms


Hyperthermia Muscular

rigidity Altered LOC Tachycardia, hypotension

Neuroleptics

Neuroleptic malignant syndrome


Management
ABCs Oxygen Assist

ventilation, as needed Benzodiazepines Rapid cooling Volume for hypotension

Stimulants

Examples
Cocaine Amphetamines
Benzedrine

(bennies) Dexedrine (dexies, copilots) Methamphetamine (ice, black beauties)


Ephedrine Caffeine Ritalin

Stimulants

Produce
euphoria hyperactivity alertness sense

of enhanced energy anorexia

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

beta-blockers, including labetolol (Why?)

Body

temperature reduction

Stimulants

Withdrawal
Drowsiness Profound

depression (cocaine blues) Increased appetite Abdominal cramps, diarrhea, nausea Headache

Hallucinogens

Examples
Indole

hallucinogens LSD (acid) Morning-glory seeds Psilocybin DMT

Amphetamine-like

hallucinogens Peyote Mescaline DOM MDA MDMA (ecstasy)

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

attention span Tremor Hypertension Hyperreflexia Fever

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

Management of bad trip


Rule

out other causes of hallucinations


drug withdrawal

Hypoglycemia Alcohol, Infection

Quiet,

supportive environment Benzodiazepines, haldol for agitation, anxiety

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

Localized dystonic reactions Wide-eyed coma Rigidity Seizures

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

Date rape drugs


Flunitrazepam (Rhohypnol) Gamma hydroxybutyrate

Flunitrazepam (Rhohypnol)

Street names
Rophies
Roofies R2 Roche Roachies

La

Roofenol

rocha Rope Rib

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)

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

BP Memory impairment GI disturbances Excitability, aggressive behavior

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

tension Numbness, tingling of extremities Restlessness, confusion Loss of identity

(up to a week after cessation) Shock Cardiovascular collapse

Flunitrazepam (Rhohypnol)

Management of withdrawal
Oxygen/ventilation Intubate EKG

if necessary

Vascular

access Fluid for hypotension Dextrostick Diazepam for seizures

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

Effects
Odorless, Tremors Seizures Death

nearly tasteless

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