Transcript No Slide Title

Chemicals of Abuse
Sean Koon, MD
California Academy of Family
Physicians
California Society of Addiction
Medicine
April 14, 2005
Substances
 Stimulants
 Cannabis
 Hallucinogens
 Opiates
 “Club” Drugs
Stimulants
 Used for:
 “High”
 Energy,
increase job
performance, driving, studying
 Sexual enhancement
 Weight loss
Cocaine
 Made from coca plant/leaf “chewed” in
the Andes mountains of South America
 Original Coca-cola contained cocaine
and kola beans
 Proposed by Freud for treatment of
mental illness. He also used this
habitually, finally conceding its
detrimental effects in his last paper on
the subject
Forms of Use
 Cocaine HCL: snorted,
not potent when smoked
 Freebase cocaine:
converted to a base by
removal of HCL with ether
or NH4OH. Can be
smoked or vaporized.
More pure than reg.
cocaine.
 Crack Cocaine: a form of
freebase. Many impurities.
Cheaper
Cocaine Intoxication
 Effects: euphoria, confidence,
decreased inhibitions
 1. Rush (1-5 minutes)
 2. High (10-20 minutes)
 3. Crash
 4. (Binge / cycle)
Clinical Presenting Symptoms
 Chest pain
 Insomnia, fatigue
 Weight loss
More Common
 Paranoia
 Nasal infections
 Headaches
 Sexual Dysfunction
 Magnon’s Syndrome (coke bugs)
“Coke bugs”
Medical Sequelae: Cocaine
 Can cause vasoconstriction or ischemia in
various organs
 Cardiac
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Cocaine is the leading cause of drug related ER
visits, excluding alcohol
Risk of heart attack is increased 2x in the first
60 minutes of ingestion
The amount of cocaine causing heart failure or
dysfunction can vary widely
Tachyarrythmias (v-tach/v-fib)
LVH, abnormal segmental wall motion
Medical Sequelae, cont’d
 ENT: Chronic rhinitis, perf. septum
 Neurologic:
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Seizures with acute intoxication (not
withdrawal)
 CVA, TIA, SAH
 Pulmonary (rare): infarction, alveolar
hemorrhage, pneumothorax
 GI: ischemia, ulcers (most in greater
curvature or near pylorus)
Cocaine and ETOH
 Cocaine + alcohol = cocaethylene
 Enhances the cardiac side effects (MI,
arrythmias, cardiomyopathy)
 Combination increases the risk of
sudden death 25X
Amphetamines
 Originally marketed
for asthma in 1932
as “benzedrine”
 used during WWII by
Japan, US,
Germany, Great
Britain (200 million
tablets supplied to
American troops)
 Taken in pill form,
snorted, smoked,
injected
Amphetamines
 Similar effect to
cocaine, but longer
lasting and cheaper
 Made from industrial
reagents, over 150
methods of “cooking”
 Environmental
impact: lots of toxic
waste in the
production
Amphetamine Intoxication
 Alertness, energy, decreased inhibition,
euphoria, increased confidence, increased
sexual activity
 Confusion, dry mouth, anxiety, HTN,
sensitivity to light and sound, bruxism
 Cardiac and neurological sequelae are similar
to cocaine
 Does not work synergistically with alcohol like
cocaine
Amphetamine Intoxication
 1. Rush (5-30 min)
 2. High (4-16 hours)
 3. Binge (3-15 days)
 4.“Tweaking”(24 hours)
 End of high dose binge:
depression, irritability,
w/paranoia aggression
 5. Crash (1-3 days of
extreme fatigue/sleep)
Compare with
cocaine
1. Rush (1-5
minutes)
2. High (10-20
minutes)
Medical Sequelae
 Psychosis, delusions, hallucinations,
violence, formication “speed bugs,
crank bugs”, stereotypy
 Decay and discoloration of teeth
 Seizures (with intoxication only)
 Withdrawal usually requires no
medical management (symptomatic)
Marijuana
 Used throughout
history for rope,
clothing, food and
oil (from seeds)
 Earliest written
reference: Chinese
Emperor Shen
Nung in 2737
recommended for
gout, constipation
and rheumatism
Marijuana, cont’d
 Found to work on CB1 (in the brain) and CB2
(in the spleen, on macrophages) receptors
 “anandamide” is endogenous ligand that
binds to these receptors.
 Affects memory consolidation d/t effect on
hippocampus
 Via the amygdala, MJ interacts with: novelty,
appetite regulation, pain threshold regulation,
anxiety and fear regulation
Marijuana Intoxication
 Peak high 15-45 minutes
 Acceleration of HR for 10-30 minutes (by 30-
50%), moderate increase in BP
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Poor judgment and motor coordination (for
4-8 hours even after the “high” is gone
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Very significant risk in driving
 Redding of the eyes
 Slight drop in body temp.
 Dryness of mouth and throat, possible
blistering
MJ Intoxication
 Desired effects
 Euphoria
 Relaxation, reduced physical activity
 Rapid mood changes, heightening of humor
 Intensifies ordinary experiences
 Other effects
 Anxiety or panic
 Impaired memory, esp. short term
 Reduced concentration
MJ: Consequences
 Over the years many medical consequences
were suggested but only the lung
consequences are consistently found in the
research:

Bronchitis
 Emphysema
 Lung Cancer
 Many biopsychosocial issues: relationships,
education, anhedonia and mood problems,
legal
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Can serve as a “gateway drug” (3x more
likely to lead to dependency if smoked before
18 years old)
MJ: Medical Applications
 Medical applications:
 Antiemetic
 Pain
management (esp. neuropathic and
inflammatory pain in cancer patients)
 Asthma
 Glaucoma
 Appetite stimulant
Hallucinogens:
LSD
 POTENT: One
ounce=567,000 hits
 Taken on blotter paper,
gels, or sugar cubes
 Effect in 30-60 minutes.
May last for up to 12 hours
It’s believed
that as few
as 10
people
make all of
the LSD
used in the
US!
LSD cont’d
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Perceptual distortion, impaired judgement
Synesthesia: “crossing of senses”
Dilated pupils, increased saliva, increase HR,
BP, RR
Sometimes extreme fear, anxiety and
paranoia with high risk of physical injury: “talk
down”
Flashbacks can be weeks months, or years
after last use
No evidence of physical addiction
PCP
“Dissociative anaesthetic”
 Introduced by Parke-davis (1967) for
anesthetizing large animals
 Usually smoked (“sherms”), sometimes
snorted or swallowed
 Highly variable concentrations
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PCP Intoxication
Onset 2-5 minutes
Peak 15-30 minutes
Lasts 4-6 hours
Fat soluble: sporadic
 Three levels of intoxication concentrations
 Low dose: “drunken state”
 Mod. dose: agitation, hallucinations, muscle
rigidity, poor coordination, marked nystagmus
 Big dose: convulsions, respiratory depression,
cardiac instability, coma
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Possible agitation in withdrawal,
11-15 hrs after last dose
 “Flashbacks” (true chemical)
PCP: Medical Sequelae
 Rhabdomyolysis
 Renal failure
 Intractable seizures
 Hyperthermia
 HTN, CVA
 Psychosis
Opiates: Heroin
 Desired effect: euphoria
 Respiratory depression –
 Sometimes a purchase has greater purity
than expected
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Nearly all heroin OD’s secondary to this
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Often combined with cocaine to make
“speedballs”
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Most medical complications are due
to injection use
 Heavy risks of the “Heroin lifestyle”
Heroin Withdrawal
 Usually peaks in 24-72 hours, gone by 7-10
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days, usual detox is 3-7 days
Dilated pupils
Goosebumps
Nausea, Vomiting, Diarrhea
Increased BP, HR
Muscle pain/spasms
Rhinorrhea, watery eyes
Yawning
(More on withdrawal in Dr. Ey’s lecture)
Medical Concerns with
Injection Drug Users
 Hepatitis, especially Hepatitis C
 Transmitted by blood: needles, syringes, cottons, cookers,
rinsewater
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Studies claim 70+% Heroin users are Hep C+
 Infective endocarditis, typically right sided, 50%
staph, 15% strep
 Pneumonia
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concomitant cigarettes, malnutrition, depressed gag reflex
More often H. flu, S. aureus, Ps. aeruginosa relative to nonIDUs
IDU’s have increased risk of TB activation, unknown why
 Cellulitis, abscesses (mostly staph, often strep)
 HIV
Medical Issues with Injected
Drugs, cont’d
 Necrotizing fasciitis
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Pain way out of proportion to findings
 Medical emergency
 Renal:
 Nephrotic syndrome
 Glomerulonephritis (usually from to
bacterial endocarditis)
Notable RX opiates:
 Meperidine, Propoxyphene, and Pentazocine
(and tramadol the partial agonist)
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Can all cause seizures in OD as well as with
higher therapeutic doses
May cause agitation, confusion, and frank
delirium when given around the clock
 Long acting opiates
 Oxycontin attractive to addicts for its high amount
of oxycodone. Crushed form can be injected or
snorted (ms contin abused as well, but apparently
not as easy to crush/snort/inject)
 Duragesic patches can be chewed or squeezed
and contents injected
Club Drugs
 Used typically by teens/youth
 GHB (Gamma Hydroxybutyric acid)
 Liquid, dosed in “capfuls”
 Rapid onset, ½ life 20 minutes
 Side effects
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Dizzines, nausea, emesis, dec. resp, coma
 Overdose
similar to sedatives,
consciousness returns within 5 hours after
ingestion
Club Drugs
 Ketamine
 Similar to PCP
 SE’s confusion, delirium, psychosis,
coma,seizures
 DMX (dextromethorphan): euphoria,
dissociation, hallucinosis
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May last 3-6 hours
Doses up to 100x therapeutic dose (esp.
“Coricidin HBP”)
Club Drugs: Ecstasy/MDMA
 Desired effects:
 Stimulant/psychedelic
 Altered
time
perception
 Decreased
aggression/sexual
activity
 Empathy, Enhanced
touch
 Light trailers
MDMA Intoxication
 Intox. 30-45 minutes after ingestion
 Intense effects 60-90 minutes after
ingestion
 Most effects wear off by 4-6 hours
 Some effects may persist for days to
longer
MDMA: Adverse effects
 Causes large amounts of serotonin to be
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released, and prevents re-uptake
Serotonin syndrome (elevated body temp.,
sweating, spasm, coma, CV collapse, etc.)
Heat stroke
Fluid & electrolyte imbalances
Anxiety, confusion, sleep disturbance,
paranoia
Muscle tension, bruxism
Depression, perhaps even chronic
depression after few doses (after w/d of drug)
Sedatives
 Interact with GABA Receptor
 Cross-tolerant with alcohol, thus useful for
withdrawal
 Benzodiazepines
 Barbiturates
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SOMA : metabolizes to meprobamate, a
barbiturate-like compound
 Withdrawal may mimic the indication (e.g.
anxiety or insomnia)
 Seizures and delirium are possible in
withdrawal from sedatives
Questions…
Primary Care Workshop
California Academy of Family Physicians
and
California Society of Addiction Medicine
April 14, 2005