Transcript Drug Abuse
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 user’s sense of
well-being
Physical Dependency
Physical
symptoms if intake reduced
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
Lethargy
Respiratory
Pinpoint
Coma
pupils
Bradycardia
Hypotension
Decreased bowel
sounds
Flaccid muscles
depression
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
Restlessness
Irritability
Anorexia
Tremors
Back,
extremity pain
Watery
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 1950’s-60’s 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
speech
Ataxia
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
vision
Vertigo
Nausea
Diarrhea
Chest
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
Body
beta-blockers, including labetolol (Why?)
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
Hypoglycemia
Alcohol,
drug withdrawal
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
Roche
Roofies
Roachies
R2
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
Hallucinations
Anxiety,
Delirium
tension
Numbness, tingling of
extremities
Restlessness, confusion
Loss of identity
Seizures
(up to a week
after cessation)
Shock
Cardiovascular
collapse
Flunitrazepam (Rhohypnol)
Management of withdrawal
Oxygen/ventilation
Intubate
if necessary
EKG
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