Transcript Detoxification/Withdrawal

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Differences between adolescent and adult
patterns of use, effects on brain, concerns
with detoxification/withdrawal.
Understand top concerns with particular
substances
 Alcohol
 Opiates/opioids
 Cannabinoids
 Methamphetamine/cocaine/stimulants
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Continues to develop until 20s
Back to front
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Different patterns of use
 Alcohol: binge vs. daily
 Polypharmacy as a general rule
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Substances effect adolescent differently
The younger age at initiation the more risk
for abuse/dependence
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Pattern of Use
 Binge type
 Less likely to be daily drinkers
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Less sensitive to the sedating effects of
alcohol
 Higher BAC
 More blackouts
 More damage
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More likely to overdose than go through
medically significant withdrawal
What happens with alcohol overdose?
 Increasing BAC leads to increasing sedating
effects
 Loss of muscle control, stupor, coma, death
 Death from aspiration, choking, respiratory
depression
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Requires significant duration of daily drinking
with tolerance
 60% who meet criteria for dependence will
experience some symptoms of withdrawal (>90%
mild to moderate)
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6-24 hours from last drink
Changes to major neurotransmitters in brain
 Enchances GABA-major inhibitory neurotransmitter
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Homeostatic changes
Increase in blood pressure, heart rate, anxiety,
n/v, seizure, death
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Clinical Institute Withdrawal Assessment
Questionnaire /Assessment done by
clinician/nurse
Score 10 or more needs medical
treatment/evaluation
What to do if limited nursing?
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Nausea and Vomiting
Tremor
Paroxysmal sweats
Anxiety
Agitation
Tactile disturbances
Auditory disturbances
Visual disturbances
Headache, fullness in
head
 Disorientation
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J Clin Psychopharmacol 1991; 11:291-295
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Heroin
Prescription Drugs
 Hydrocodone (vicodin, norco)
 Oxycodone
 Morphine
 Methadone
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Sedation
Pupil Constriction
Slurred speech
Impaired attention/memory
Constipation/ urinary retention
Nausea
Confusion/delirium
Seizures
Slowed heart rate
Respiratory depression
 Depends on which opiate:
▪ Onset of action.
▪ Hydrocodone (peak .5hr, duration 3-4 hours)
▪ Methadone (peak: 2-4 hours, duration 24 hours)
▪ Tolerance of individual
▪ Tolerance to respiratory depression may be slower than tolerance to
euphoric effects
 Symptoms of overdose:
▪ Triad:
▪ Altered LOC
▪ Respiratory Depression (RR<12)
▪ Miotic Pupils
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Withdrawal
 Cows
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Basic life support
 Assess Ventilation
▪ Support ventilation
 Naloxone hydrochloride – opioid antagonist
▪ .4mg to .8mg, may have to be repeated
▪ May need higher doses and multiple repeated doses
over time
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Not life-threatening but so uncomfortable
prompts relapse.
Onset of symptoms depends on the duration
of use and ½ life of drug used
 Heroin: onset 4-6 hours
 Methadone: onset: 36 hours
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Neurophysiologic rebound in target organs
The generalized CNS suppression during use
is replaced by CNS hyperactivity.
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Supportive measures
Medication assisted
 clonidine
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CVS
 Ventricular irritability
 Hypertension
 Tachycardia
 Myocardial Infarction
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Neurologic
 Seizure
 Stroke
 Hyperthermia
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Rhabdomyolysis
Acute Renal Failure
Insomnia
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CVS
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Neurologic
 Cardiomyopathy
 Memory Impairment
 Myocardial Infarction
 Deficits in judgment
 Strokes
 Poor impulse control
Pulmonary
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Infectious
 Pulmonary
 HIV/Hepatitis C
Hypertension
 COPD
 Skin infections
 Complications IVDA
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Psychosis
 Acute:
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Classically paranoid
Persecutory delusions
Ideas of Reference
Heightened awareness
 Chronic:
▪ Psychosis can persist after
acute episode or recur with
little or no further MA use.
▪ Sensitization
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Mood Disorder
 Mania during
intoxication
 Depression during
withdrawal
 Anxiety
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Confirm diagnosis by urine toxicology screen
Gastric lavage or activated charcoal for
ingestion
Seizures: Diazepam
Psychosis /Agitation: Diazepam +/antipsychotic
Hyperthermia: external cooling
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Hyperarousal
 Agitation, severe craving, nightmares
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Vegetative Symptoms
 Decreased energy, craving sleep, increased
appetite
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Anxiety-related symptoms
 Anxiety, loss of interest, anhedonia, psychomotor
retardation
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Severe dysphoria, mood volatility, irritability
and sleep pattern disruption
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Drug of choice- most daily marijuana use
Intake:
 Adverse events: paranoia, increased blood
pressure/HR
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Withdrawal
 Symptoms similar to nicotine withdrawal
 No real treatment for withdrawal
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Mixture of herbs or dried, shredded plant
material that is typically sprayed with
chemicals that are similar to THC
Street names: Spice, K2, Black Mamba,
Blaze, JWH-018, 073, Kronic(added BZ),
krypton (added opioid)
Typically smoked
Sold in Europe since 2002-2004. Widely
available for purchase on Internet in 2006
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2010: states began banning product
2011: schedule 1 drug
First cannibinoid identified was JWH-018 and
CP47,497. Now there are well over 20 new
synthetic cannabinoids.
10 -100 more potent than THC
Strong affinity to CB1 receptors
 Responsible for psychoactive effects
 Central and peripheral nervous sx,
 Cardiovascular system
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Some of herbal ingredients added may have
psycho-active potential (opioid-like, Bz,etc)
Onset 3-5 minutes
Duration of action: 1-8 hours
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Depends on dose
Mood effects
 Euphoria and dysphoria
 Hyperactivity, anxiolysis and anxiety
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Perceptual effects
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Change in time perception
Hallucinations/psychotic states
Paranoia
Depersonalization/dissociation
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Cognition effects:
 Fragmented thinking
 Short term memory impairment
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Motor effects
 Ataxia, loss of coordination, slurred speech
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Immunosuppressive
Cardiovascular effects
 Increased heart rate, orthostatic hypotension
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Unpredictable toxicology
Adverse effects are dose dependent
Emerging evidence that adverse effects are
more severe
 Especially in teens (as is Marijuana)
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Seizures
Psychosis
 Growing acceptance that cannabis use may
increase the risk of psychosis and/or psychosis like
conditions. Cannabis risk is mild.
▪ 41% increased risk in developing psychosis for cannabis
users v. non-cannabis users
▪ 109% increase for heavy cannabis users
 Commonly reported in SC users
▪ Clearly associated with both the onset and exacerbation
of recurrent psychotic episodes
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Mood and Anxiety
 Anxiety
 Catatonia
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Cardiovascular effects
 Increased heart rate
 Pediatrics: Adolescents presenting with chest
pain, confirmed myocardial infarction.