Transcript drug
Chapter Thirteen: Drugs of Abuse Other Than Alcohol points for consideration Legal drugs most common Drug use often accompanied by alcohol Pharmacological principles Major drug classes use patterns 2003 alcohol nicotine any illicit drug marijuana/hashish cocaine heroin * % past yr % past mo 65.0 50.1 35.1 29.8 14.7 8.2 10.6 6.2 2.5 1.0 0.1 0.1 * National Household Survey 2003 use patterns 2003 (cont.) % past yr % past mo. hallucinogens LSD PCP ecstasy inhalants prescription drugs pain medication tranquilizers stimulants methamphetamine sedatives 1.7 0.2 0.1 0.9 0.9 6.3 4.9 2.1 1.2 0.6 0.3 0.4 0.1 0.0 0.2 0.2 2.7 2.0 0.8 0.5 0.3 0.1 patterns of use Vary by — Type of drug Age Gender Education Employment Geographic Area social costs $$$ $160.7 billion (2000) 30% of property crimes, drug-related 15% of all arrests social costs (cont.) $$$ Many criminal charges due solely to illicit status 90% marijuana arrests for possession 80% federal budget for supply reduction example: border patrol Latin America “drug war” early control efforts First legislation 1908 creation of Food and Drug Agency 1914 Harrison Narcotics Act In response to — indiscriminate prescribing over-the-counter patent medicines current control policies Demand side approaches goal: decrease market for drugs treatment prevention Supply side approaches goal: reduce availability of drugs primarily criminal justice, military pharmacological concepts Route administration Site of action Solubility fat and water Metabolism Abuse potential Organization by drug classes routes of administration Routes by mouth inhalation injection absorption through skin Route influences — speed of action, potential complications solubility of drug Substances soluble in water or fat tissue Influences distribution in the body Basis for drug testing abuse potential Abuse potential is related to — Speed of action influenced by drug type how administered Duration of action Intensity of effects Experience of effects highest abuse potential Characteristics intense action rapid onset short duration Prime examples nicotine cocaine opiates assessing abuse potential Animal laboratory studies Human laboratory studies comparing choice to known drug comparing drugs to one another ratings of “attractive-ness” Surveys of use in population use patterns as index of abuse potential Comparison of last year use to past month use Limitations of index Non-pharmacological factors important social acceptance legal status access relative abuse potential 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Heroin Crack Nicotine Stimulants Pain meds Methamphetamine Cocaine Sedatives Alcohol* (adjusted) Marijuan* (adjusted) LSD past year and past month PCP abuse potential: % past yr. users with diagnosis of abuse or dependent drug % Nicotine Heroin Cocaine Sedatives Marijuana Stimulants 85.0 57.4 25.6 19.0 16.6 13.7 drug % Pain Relievers 12.2 Alcohol 11.5 Tranquilizers 8.6 Hallucinogens 8.2 Inhalants 8.2 classification schemas Legal status Federal drug schedule class influenced by abuse potential and medical use Pharmacological effects schema used by American Psychiatric Association, Diagnostic and Statistical Manual Controlled Substance Act control schedule Schedule I high level of abuse no accepted medical use examples: heroin, LSD, marijuana Schedule II similar to Schedule I, but has accepted medical use prescriptions non-refillable examples: methadone, morphine, amphetamines, cocaine, oxycodone Control Schedule (cont.) Schedule III moderate risk of physical dependence high risk of psychological dependence established medical use examples: Vicodin, Tylenol #3 Schedule IV low risk of physical dependence moderate risk of psychological dependence established medical use examples: Ativan, Halcion, Darvon Schedule V low risk of dependence established medical use example: Lomotil DEA drug schedule Characteristics I Medical use Physical depend high Psychological depend High Medium Prescription required non-refillable Schedule II III IV V x x x x x x x x x x x x x x classes of abused drugs Nicotine Opiates Stimulants Hallucinogens and dissociatives Cannabinoids Steroids nicotine Cigarettes, cigars, chewing tobacco Frequently accompanies other drug use High abuse potential Tolerance develops quickly Nicotine receptors throughout the brain nicotine Dangers largely due to smoking not the nicotine Substantial morbidity Major cause of mortality (cont.) nicotine: use patterns Current smokers 25% U.S. population Additional 5% use other nicotine products Virtually no difference by sex Initiation of use use increases markedly between age 12 &16 at age 21, 40% are smokers rate of decline much slower only in late 50s that % equals rate at age 16 nicotine: use patterns (cont.) racial/ethnic groups Racial/ethnic groups Percent regular smokers Native Americans Whites African Americans Hispanics Asians 42% 26% 23% 21% 17% nicotine: use patterns (cont.) other demographic factors Education Less smoking with more education Work status Unemployed, highest rate smoking Region South, highest rate of smokers West, lowest rate Type of community Highest rates in rural areas, lowest rates in metropolitan areas nicotine: absorption Absorption when smoked tar droplets inhaled nicotine moves from lungs to bloodstream reaches brain 10-19 sec. other routes less rapid Dose variable, depends on smoking patterns Wad of chew tobacco = 4 1/2 cigarettes nicotine: pharmacology Half-life of nicotine = 2 hours More than 1 cigarette per a two hour period build-up of nicotine during day Metabolized by liver Cotinine major metabolic product levels 15 that of nicotine marker of nicotine half-life 16 hours physical impact unclear nicotine: treatment Smoking cessation through hospitals, clinics Success rates between 15% - 20% Treatment = patient education group support counseling nicotine replacement opiates historical notes Opium known over 10,000 years ago A mainstay of medicine Laudanum developed 1500 (alcohol+opium) Use continued through 1800s Outlawed in US by Pure Food and Drug Act 1906 opiates historical notes Early 1800s opium poppies refined to morphine refinement increases potency morphine 10x more potent Syringe introduced 1853 route of administration IV use first extended medical use, Civil War addiction common, “army disease” Early 20th century, addiction largely iatrogenic opiates pharmacological notes Heroin synthesized from morphine, 1898 intended for persistent cough 20 times more potent than opium rapid onset and short half-life metabolites pharmacologically active use declined with passage of Pure Food & Drug and Harrison Acts opiates use patterns Popularity waxes and wanes related to supply impact of “generational” memories Recent emergence with new set of users lower price greater purity, so smoking street dealers began trading heroin Use peaked in 1996 opiates medical issues Compounds differ in length of action shorter the duration, more intense withdrawal Detoxification substitute methadone then taper off less medical risk than alcohol withdrawal New detox techniques rapid detoxification ultra-rapid detoxification under anesthesia, use of blocking agent Drug maintenance methadone or buprenorphine opiates Includes heroin fentanyl codeine Route of administration intravenous smoking patch Length of action: variable heroin: 3-4 hrs summary oxycodone methadone morphine smoking oral snorting methadone: 12 hrs -days opiates summary (cont.) Desired effects the “rush” or high feelings of intense pleasure Other acute effects sedation decreased pain constricted pupils Intoxication/Overdose decreased respiration decreased blood pressure possible stupor depressed respiration opiates Common problems rapid tolerance dependence HIV/AIDs Withdrawal symptoms craving perspiration cramps Interaction with alcohol potentiation summary (cont.) infection cellulitis (injection sites) hepatitis sleep difficulty fever nausea sedative-hypnotics Central nervous system depressants Patterns of use general population: under 2% Examples benzodiazepines barbiturates meprobamate sedative-hypnotics (cont.) GHB (gamma-hydroxybutyrate) synthesized in 1960 intended as relaxant, short anesthetic limited medical use 1980s touted as body builder banned as dietary supplement club drug attraction is its disinhibiting and relaxant effect source, not drug diversion, but illicit labs problem: dose causing euphoria close to dose for sedation sedative-hypnotics (cont.) Route of administration oral Length of action variable Desired effects anxiety reduction similar to alcohol Other acute effects sedation impaired driving repressed respiration with overdose sedative-hypnotics (cont.) Intoxication and overdose possible decreased respiration slurred speech stupor coma/death (unlikely with benzodiazepines) Withdrawal symptoms similar alcohol, but slower onset anxiety sweating and tremulousness sedative-hypnotics (cont.) Interaction with alcohol Potentiation especially breathing Cross-tolerance Basis for use in alcohol detoxification stimulants Name derives from action on CNS Includes legal and illicit drugs amphetamines methylphenidate (Ritalin®) cocaine illicitly manufactured amphetamines stimulants: amphetamines Once widely prescribed Prescriptions peaked late 1960s Available as pills, liquids, powders Route of administration: oral or intravenous Methamphetamine (a derivative) made in home labs stimulants: cocaine Cocaine use patterns Use peaked in 1985 Highest rate use, ages 18-34 More common in men Few racial/ethnic differences Use highest in metropolitan areas stimulants: cocaine route of administration Route of administration Free-basing unlimited quantity used Free-basing and smoking increases risks between 1975 and 1995, rate of use use down but 20 times more admissions to emergency departments stimulants: summary Route of administration drug route Cocaine: Amphetamine: Methylphenidate: snorted, smoked (free-base) orally, intravenously oral, crushed and injected stimulants: summary Length of action drug Cocaine Amphetamine Methamphetamine length action lasts 20-30 min 8-12 hours 8-24 hours (con’t.) stimulants: summary (con’t.) Desired effects Increased alertness, sense well-being, increased energy Other acute effects Anxiety, confusion Possible medical problems stimulants: summary (con’t.) Intoxication/overdose heart rate up elevated blood pressure cardiac arrhythmias Common problems dependence social withdrawal medical complications methamphetamine, long-term CNS damage stimulants: summary (con’t.) Withdrawal depression lack of pleasure craving Alcohol interactions decreases side effects Alcohol-cocaine special problems cocaethylene, psychoactive by-product cocaethylene, similar effects as cocaine cocaethylene, medical risks hallucinogens and dissociatives Hallucinogens earliest plants used religious rituals mescaline, psilocybin, LSD hallucinogens and dissociatives Dissociatives different chemically effects similar medical use abandoned, due to effects used at raves Include anesthetics ketamine phencyclidine (PCP) MDMA (ecstasy) hallucinogens and dissociatives PCP (phencyclidine) anesthetic easily manufactured inexpensive active as liquid, powder, or crystal common adulterant in street drugs hallucinogens and dissociatives MDMA (ecstasy ) designer drug analog of methamphetamine classified here, hallucinogenic properties used at raves, “club drug” hallucinogens and dissociatives Use patterns Largest group, 18-20 year olds rate of use, 7.8% drops significantly by age 25 More common among — whites higher household incomes hallucinogens and dissociatives summary Route of Administration LSD-like MDMA-like PCP Ketamine smoked oral or smoked smoked, oral, snorted liquid form easily converted to powder, then smoked hallucinogens and dissociatives summary Length of action varies Desired effects blurred sense of self hallucinations more vivid senses Other acute effects variable ketamine (k-hole) panic attacks hallucinogens and dissociatives summary varies common increased blood pressure increased heart rate elevated temperature Common problems flashbacks after-images jaw- teeth-clenching Intoxication hallucinogens and dissociatives summary Alcohol interaction increased risk dehydration Withdrawal none (LSD and MDMA) unclear (ketamine) Dependence possible ketamine cannabinoids Marijuana, hashish, hash oil Active ingredient THC Derived from hemp plant Historical colonists imported from Europe for hemp psychoactive properties known also a medicine into 1800s cannabinoids: use Use for psychoactive properties last century “bohemians” 1920s and 1930s “counter-culture” of the 1960s Currently, use not uncommon higher strengths than before cultivated as cash crop cannabinoids: use patterns Most widely used illicit drug 7% total population, over age 11 24% ages 18-25 Use more common among men in metropolitan areas racial/ethnic groups, little difference cannabinoids: societal perspectives Many distinguish marijuana from other illicit drugs less social disapproval considered private matter dependence risk lower medical consequence less than alcohol decriminalization being promoted cannabinoids: medical use Efforts to legalize medical use Occurring through state referendum Federal opposition Mixed medical opinions Dronabinol® (THC) already available Proposed medical uses pain relief, glaucoma, post-chemotherapy cannabinoids: clinical issues Clients with marijuana-related problems By definition use not discrete, not private nor non-problematic Initiate self-examination to identify problems assess relationship cannabinoids: summary Desired effects relaxation euphoria altered perceptions Other acute effects slowed reaction time dizziness difficulty expressing thoughts Intoxication/ overdose increased respiration increased heart beat paranoia not lethal depression vital centers cannabinoids: summary Withdrawal/Dependence in some regular heavy users Symptoms irritability agitation depression anxiety Long-term physical effects respiratory smoking-related (cont.) Inhalants Fumes of products inhaled for psychoactive effects Three different chemical classes Hydro-carbons: common household products Nitrates: name from chemical formula Nitrates form of anesthesia, laughing gas inhalants: use patterns Age most popular adolescents easily available inexpensive commonly group activity no college expectations Geography highest in west Racial/ethnic highest among Hispanics inhalants: effects Examples paints, aerosols, gasoline, glue, vasodilators Route “huffing” (inhalation) Desired effects rush, euphoria, disinhibition enhance intercourse Other acute effects cardiac depression increased blood pressure “sudden sniffing death” inhalants: effects Withdrawal craving little research Alcohol interactions potentiation with hydro-carbons club drugs Not a single drug class Associated with raves all-night dancing, electronic music, laser light shows and drug use Major club drugs ecstasy PCP rohypnol (benzodiazepine) GHB (classed with sedatives) Often taken with along with alcohol steroids Not used for psychoactive properties male hormones used to enhance athletic performance used to enhance physical appearance Use patterns starting at younger age little data high school seniors, 2.9% steroids: summary (cont.) Route of administration tablet injected into muscle Pattern of administration cycle intended to enhance performance on-off cycles, different steroid Intoxication/Overdose rare steroids: summary (cont.) Common problems Physical changes — virilizing effects Differ by gender Men: male-pattern baldness, acne Women: menstrual irregularities Longer term: liver disorder, liver cancer Psychiatric problems aggressive behavior hypomania depression treatment issues Treatment goals Role of harm reduction Pharmacological therapy Prenatal drug exposure pharmacological therapy Drug Replacement prescription of same or similar drugs nicotine patch methadone Anti-craving agents reduce craving Zyban® smoking cessation Blocking agents prevent effects of a drug naltrexone an opiate agonist prenatal drug exposure Drug use in pregnancy major concern passes to fetus disrupts fetal development difficulties in pregnancy Illicit drug use during pregnancy African Americans 11.3 % Hispanics, 4.5 % whites, 4.4% in absolute numbers, majority are white prenatal drug exposure Rates of drug use during pregnancy Nicotine Alcohol Any illicit use Marijuana Cocaine Other illicit 20.0 % 18.8 % 5.5 % 2.9 % 1.1 % 1.1 % (cont.) prenatal drug exposure: cocaine Easily transferred to fetus soluble, both water and fat smoking or injecting transfer Effects constriction of blood vessels premature labor increased still births “crack babies” (delayed development) little research support prenatal drug exposure: opiates Problems from drug effect and circumstances Poor injection practice High-risk environment No prenatal care Major complications Low birth weight Premature birth Respiratory problems Neonatal withdrawal neonatal opiate withdrawal Occurs in 60-90% infants Symptoms Irritability Tremors Startle easily GI problems High-pitched cry Respiratory distress Nursing difficult, frequent regurgitation neonatal opiate withdrawal (cont.) Factors influencing Level of maternal use Use close to delivery, delays withdrawal Maturity of baby’s own system, related to ability to metabolize Duration can last several days to weeks Drug therapy may be used for detox neonatal methadone exposure No complications for neonate Proper maternal dose important Methadone use provides benefits of contact with health care setting drug use - pregnancy social and legal issues Approaches to drug-dependent women: both therapeutic and punitive special treatment programs coercive treatment importance of post-pregnancy support arrests for child endangerment