Transcript Clinical features.

Medical and social problems of
the use of psychoactive
substances.
Olena Smashna
Alcohol action
• Alcohol affects virtually every organ system in the
body and, in high doses, can cause coma and
death. It affects several neurotransmitter systems
in the brain, including opiates, GABA, glutamate,
serotonin, and dopamine. Increased opiate levels
help explain the euphoric effect of alcohol, while
its effects on GABA cause anxiolytic and sedative
effects.
Alcohol action
• Alcohol inhibits the receptor for glutamate. Long-term
ingestion results in the synthesis of more glutamate
receptors. When alcohol is withdrawn, the central nervous
system experiences increased excitability. Persons who
abuse alcohol over the long term are more prone to alcohol
withdrawal syndrome than persons who have been
drinking for only short periods. Brain excitability caused
by long-term alcohol ingestion can lead to cell death and
cerebellar degeneration, Wernicke-Korsakoff syndrome,
tremors, alcoholic hallucinosis, delirium tremens, and
withdrawal seizures. Opiate receptors are increased in the
brains of recently abstinent alcoholic patients, and the
number of receptors correlates with cravings for alcohol.
Alcoholism
• also known as alcohol dependence, is a common disorder.
At all ages alcoholism is more common among males than
females; however, given the somewhat later age of onset in
females, the ratio tends to decrease in higher age groups.
Overall the ratio is probably 3:1. Alcoholics and alcohol
abusers are recurrently and persistently beset with an urge
to drink, an urge that is of sufficient compellingness for
them to continue to drink despite the fact that because of
their drinking they sustain substantial damage to their
health and personal or business affairs.
ONSET
• The onset of alcoholism or alcohol abuse is generally
insidious and spans many years. For men, onset is
generally dated to the late teens ; or the early
twenties; however, most alcoholics are not
recognized as such until their late twenties or early
thirties, and many more years may pass before the
alcoholic or someone else recognizes the need for
treatment. Although some otherwise typical onsets
have been described in patients over 60, it is rare for
the onset to occur past the age of 45.
CLINICAL FEATURES
• the urge to drink may be experienced as a craving, an
imperious need, or a compulsion;
• almost all alcoholics deny they have a problem with
drinking or rationalize it one way or another.
• they are often quick to lay blame for their drinking on
situations or other people;
• stressful events may be followed by increased alcohol
consumption, the alcoholic is also intoxicated during the
good times, or simply the neutral times of life.
CLINICAL FEATURES
• Most alcoholics make attempts to control their drinking,
and although they may have some successes, these are
generally short-lived. This "loss of control" was at one
point considered the hallmark of the alcoholic. However, it
may be just as fair to say that the hallmark is rather a sense
of a need to control. Normal people do not experience a
need to control their drinking; they simply stop, without
giving it a second thought.
• When alcoholics do drink, most eventually become
intoxicated, and this recurrent intoxication eventually
brings their lives down in ruins.
CLINICAL FEATURES
• Friends are lost, health deteriorates, marriages are broken,
children are abused, and jobs terminated. Yet despite these
consequences the alcoholic continues to drink Many
undergo a "change in personality." Previously upstanding
individuals may find themselves lying, cheating, stealing,
and engaging in all manner of deceit to protect or cover up
their drinking. Shame and remorse the morning after may
be intense; many alcoholics progressively isolate
themselves to drink undisturbed. An alcoholic may hole up
in a motel for days or a week, drinking continuously. Most
alcoholics become more irritable; they have a heightened
sensitivity to anything vaguely critical. Many alcoholics
appear quite grandiose, yet on closer inspection one sees
that their self-esteem has slipped away from them.
CLINICAL FEATURES
• Most alcoholics also display an alcohol withdrawal
syndrome when they either reduce or temporarily
cease consumption. Awakening with the "shakes"
and with the strong urge for relief drinking is a
common occurrence; many alcoholics eventually
succumb to the "morning drink" to reduce their
withdrawal symptoms.
• Some degree of tolerance occurs in all alcoholics. Here the
alcoholic finds that progressively larger amounts must be
consumed to get the desired degree of intoxication; if the
amount is not increased, the alcoholic finds that the degree
of intoxication becomes less and less.
Alcohol intoxication.
• The intoxicated patient is a familiar sight in any emergency
room, and the determination of a blood alcohol level (BAL)
is a commonplace procedure.
• BAL by convention may be expressed as milligrams per
deciliter, or, as it is often charted, milligrams percent (mg%).
Roughly speaking, in a 70 kg person BAL rises anywhere
from 15 to 25 mg/dl with every 15 ml of rapidly ingested
pure ethyl alcohol. This amount of ethanol is found in 1
ounce of 100 proof liquor, one 12-ounce bottle of beer, or
about one glass (6 ounces) of wine. Given that most "social
drinkers," or alcohol-naive persons, become intoxicated at a
BAL of 100 mg/dl, simple arithmetic shows that for such a
person only about four drinks, or beers, or glasses of wine
are required to produce intoxication.
Alcohol intoxication.
• In mild intoxication most individuals feel somewhat
euphoric, they talk more and tend to shed their
inhibitions. Reckless behavior may be seen; sexual
indiscretion may be evident; irritability may occur. Some
individuals, however, may not so well. A suspicious
person, if intoxicated, may develop ideas of persecution;
a mildly depressed person may become tearful and
morose.
• In moderate intoxication behavior tends to become
coarse; improprieties are commonplace. Thinking is
slow; inattentiveness occurs, and the person is slow in
responding to anything, even dangerous situations. The
face is flushed, the conjunctivae reddened, and the pupils
dilated. Slurred speech, nystagmus, ataxia, and
generalized incoordination are present.
Alcohol intoxication.
• In severe intoxication stupor may occur. Ataxia is so severe that Standing is
impossible. Vertigo is common, and persistent vomiting may occur.
• Eventually if the BAL continues to rise, coma will supervene. Respiratory
depression may occur, and death may ensue from respiratory arrest.
• If sleep should come to the intoxicated person, it tends to be heavy and
dreamless. As the BAL falls the person often wakes up and has trouble
falling back asleep.
• After the intoxication has passed most experience a "hangover." Headache is
common, as is a pervasive dysphoria . Mild tremulousness and diaphoresis may
occur; nausea is common, and the person may vomit. Depending on the degree of
intoxication, a hangover may last anywhere from several hours up to almost the
entire day.
Blackouts(palimpsests).
• Blackouts are characterized by a dense anterograde amnesia. During
the blackout intoxicated individuals appear outwardly unchanged;
however, for the duration of the blackout, events fail to enter their
memory. After "coming to" these individuals have no recollection of
what was said or done during the blackout. Although the vast majority
of blackouts occur during alcohol intoxication, they may also
occasionally be seen in intoxication with other sedative-hypnotics, in
particular high-potency benzodiazepines. Importantly, although most
patients with blackouts are alcoholics, this is not always the case, as
blackouts may also occur in social drinkers who simply consume more
than is typical for them.
Blackouts(palimpsests).
• Upon recovery from a blackout, drinkers often recount that
they remember everything up to a certain time and then
"went blank." Some patients go to sleep during a blackout,
and when they awaken wonder how they got home or got
to bed.
• Upon recovery from a blackout, most patients are worried
about what they did during the blackout. The car may be
checked for evidence of an accident; indirect questions
may be put to others in a discreet effort to find out if
anything untoward happened.
Pathological intoxication.
• |Classically, pathological intoxication is said to occur when,
consuming a relatively small amount of alcohol, drinkers undergo a
marked change in behavior, often becoming agitated or violent,
afterwards having at best a spotty memory for the event.
• Occurring after as little as one or two drinks, the change in behavior
may be dramatic. A polite and unassuming person may start a fist
fight; a well-mannered person may suddenly take offense if a date
happens to look at someone else, flying into a jealous rage. This
change may persist for only a few minutes, or up to hours. Upon
recovery the drinker typically has difficulty in recalling everything
that happened, and occasionally may report complete amnesia for the
event.
Alcohol withdrawal.
• Alcohol withdrawal, commonly known as "the shakes,"
may occur in anyone after excessive, prolonged use of
alcohol.
• In full-blown alcohol withdrawal, drinkers are
apprehensive, anxious, and easily startled; they may pace
agitatedly up and down the hall. Depressed mood and
irritability are common. The tremor is quite characteristic;
it tends to be coarse and is evident not only in the hands
but also in the lips, tongue, and eyelids. In severe cases
drinkers may literally "shake like a leaf" and be unable to
hold things or even at times to stand up. Diaphoresis, at
times profuse, is often present.
Alcohol withdrawal.
• Most have trouble concentrating and thinking
clearly; memory tends to be poor. Although fatigue
is prominent, most are also unable to sleep.
– Headache, dry mouth, anorexia, nausea, and
vomiting are common; diarrhea may occur.
• On examination the temperature, pulse, respirations, and
systolic blood pressure may all be elevated. The pupils are
dilated, and the deep tendon reflexes are hyperactive.
Rarely, one may see transient myoclonus, choreiform
movements or parkinsonism.
• Occasionally patients may have isolated, brief, vague,
visual hallucinations or illusions, or rarely a few auditory
hallucinations. If these do occur they tend to appear as the
withdrawal symptoms reach their height.
Alcohol withdrawal seizures.
• Alcohol withdrawal seizures, also known as "rum fits," are
a rare accompaniment of the alcohol withdrawal syndrome.
They generally occur only after many years of heavy
drinking and repeated episodes of withdrawal and are seen
in from 1% to 3% of patients withdrawing from alcohol.
• For the most part, alcohol withdrawal seizures
present as otherwise unremarkable generalized
tonic-clonic seizures. In about a quarter of the cases,
however, the seizures have a focal onset.
• Most patients have just one seizure; occasionally, however,
patients have a cluster of two or three and rarely as many
as six. Rarely, status epilepticus occurs.
Delirium tremens.
• Delirium tremens, also known as alcohol withdrawal
delirium and more commonly as "DTs," develops in the
setting of the alcohol withdrawal syndrome, and is seen in
about 5% of hospitalized alcoholics. It is characterized by
gross accentuation of the tremor and autonomic signs and
by the development of confusion, disorientation, and
hallucinations.
• the patient is generally agitated, markedly tremulous, and
very easily startled; mydriasis and generalized
hyperreflexia are prominent, as are such autonomic signs
as diaphoresis, tachycardia, elevated blood pressure, and
increased respirations.
Delirium tremens.
• Visual hallucinations are very common; they tend to be
extremely vivid and complex. Often the patient sees insects or
animals: dogs circle the bed; rats eat at the toes; bugs crawl on
the arms and face. They may cringe in fear or try to swat them
away. At times the patient may see simply a benign procession of
animals, which he may watch from the bed as if it were an
amusing procession. Curiously one also often sees a predilection
for hallucinating strings or threads; the patient may pick them out
of the air or warn the physician to avoid running into one
stretched across the hospital room. Often the visual hallucinations
may be provoked by suggestion. In the classic "string test" the
examiner holds her hands about a foot and a half apart, the
thumbs and index fingers apposed, several feet in front of the
patient and asks if the patient sees anything. After the patient
reports seeing nothing, the examiner asks "Don't you see the
string?," whereupon the patient does indeed see a string stretched
between the examiner's hands.
Delirium tremens.
• Tactile hallucinations may accompany the visual
ones: the skin is ripped by teeth; spiders bite; bugs
are felt crawling all over. The patient may complain
of electric shocks or of pins being stuck into the
toes.
• Auditory hallucinations are common. Patients may
hear bells, whistles, or alarms. If voices are heard,
they tend to be critical, persecutory, or warning of
dire events. Patients hear accusations of neglecting
their children; the children are starving because the
patients spent their paychecks on drink. The death
sentence is pronounced; the physician is revealed as
the executioner.
Delirium tremens.
• Delusions are common and tend to be persecutory.
Murderers are outside the door; the nurse is bringing
poison to the patient; other patients talk about and
conspire against the patient.
• Disorientation always occurs, often to both time and
place. At times this disorientation is intensified by
hallucinations. The patient refuses the bedtime
medicine offered by the nurse and announces that it
must be morning as the birds are chirping; if
questioned as to orientation to place, the patient,
seeing the clouds out the window, may report being
in an airplane or perhaps an air ambulance.
Delirium tremens.
• Memory tends to be severely disturbed. The patient is unable to
recall the name of the physician or of the hospital. Recall of
events before admission is also often quite spotty.
• The behavior of these patients is commensurate with their
symptoms. Some may sit tremulously on the bed, picking at the
bed sheets or brushing away insects. They may grasp at strings
in the air and mumble agitatedly about events occurring outside
the window. Others may strike out at their "persecutors"; they
may attempt to escape through the door or jump out the window.
• In contrast one may occasionally encounter a "quiet" delirium
tremens. Here the tremor and autonomic signs and symptoms are
minimal, and the patient, all the while experiencing sometimes
fantastic visual hallucinations, may lie relatively quietly in bed.
Korsakoff’s syndrome
• Korsakoff's syndrome, also known as Korsakoff's
psychosis, is characterized by a striking inability to form
new memories, with the subsequent "blank spots" often
filled in with confabulations.
• The memory loss is of the short-term variety; the patient's
ability to recall anything after a few minutes (such as the
physician's name) is grossly impaired. Long-term memory
is relatively spared, wherein events of the distant past are
better recalled than those that occurred more recently.
Remarkably patients are generally unconcerned with this
inability to remember things.Confabulations are typically
present and may at times be quite fabulous.
Korsakoff’s syndrome
• During casual questioning, these patients may not appear
ill.They may talk appropriately about their surroundings,
comment on the weather as they look out the window, or
compliment the physician's taste in clothing. Some may be
mildly euphoric, others bland and apathetic. A few direct
questions, however, disclose the memory defect and the
tendency to confabulate
Alcoholic dementia
• Alcoholic dementia often presents with a personality
change. Patients become coarse and heedless of
social convention; they may become apathetic, and
judgment is poor. Cognitive deficits eventually
appear; short-term memory fails, and patients
gradually have increasing difficulty in recalling
events of the distant past. Thinking becomes
concrete. With continued drinking the dementia may
become profound. At times, minor "cortical" signs
are seen such as apraxia, agnosia, and aphasia;
however, these are not a prominent part of the
clinical picture.
• CT or MRI studies generally demonstrate both cortical
atrophy and ventricular dilitation.
Alcohol hallucinosis
• Alcohol hallucinosis, also known as alcohol-induced psychotic
disorder with hallucinations, is seen only in alcoholics, and then only
after one or more decades of heavy alcohol consumption.
Hallucinations, generally auditory, are often accompanied by
delusions of reference and persecution and appear relatively suddenly,
persisting for variable periods of time.
• Auditory hallucinations constitute the principal symptom of alcohol
hallucinosis. These are often extremely vivid and clear; the patient has
no doubt as to their reality and does not believe that the physician
does not hear them. For the most part they are critical and often
persecutory. Generally more than one voice is heard, and curiously the
voices often talk among themselves - about the patient. At times one
may observe patients straining to overhear what the voices are saying.
Alcohol hallucinosis
• What the patients hear, or overhear, is often quite distressing or
frightening. They are accused of murder; the food will be poisoned;
their relatives are selling all their goods and will leave them destitute
and in the street.
• Delusions of persecution and reference often accompany the
auditory hallucinations and are generally congruent with them. ;
Family members talk about the patient; they conspire against the
patient to force her to sign documents, but she knows the documents
are in fact cleverly worded confessions and refuses to sign them.
Police follow the patient; they await any excuse to arrest her. Such
patients are often constrained and very watchful. They tend to be
irritable. Should they feel too threatened, they may turn on their
supposed persecutors. Occasionally, visual hallucinations occur, but
these are far less prominent than the auditory ones.
Alcoholic paranoia
Is characterized by delusions of jealousy. The spouse is suspected of
infidelity; absences from the house are seen as proof of it; the spouse's
desire to keep apart from the patient during the patient's intoxicated
rages is seen as a mere excuse. Rules are laid down; the spouse is
neither allowed outside the house alone nor allowed to speak in private
on the telephone. When drunk the patient may turn on the spouse,
sometimes in a murderous fashion. In other cases the illness may be
characterized by persecutory delusions: the police have begun to hound
the patient. Yet another charge of driving under the influence of alcohol
is trumped up; unmarked police cars cruise down the streets. The
neighbors have been recruited to spy on the patient from behind their
shades.
Alcoholic paranoia
• Occasionally hallucinations may occur, but
they play only a minor role. Footsteps and
sirens are heard at night; something moves
in the attic. The food tastes spoiled, rotten,
perhaps even poisoned. Strange people
approach the house in the dead of night.
Alcoholic polyneuropathy
• Paresthesias begin distally, first in the feet and calves, later
in the hands. Associated lancinating pains may occur.
Hyperesthesia may also be present, and even the touch of a
bed sheet on the soles of the feet may be more than the
patient can tolerate. On examination vibratory sense is lost
first, followed by other modalities; the ankle jerks are
diminished or lost and the Romberg test is positive.
• With continued drinking, patients develop motor weakness; this
may be seen in as few as several weeks after sensory symptoms
appear. Distal musculature is affected first, the lower extremities
before the upper. Foot drop with a steppage gait is common; wrist
drop may also occur. Atrophy of the calves and forearms may be
seen. Although motor signs are bilateral, their severity is often
asymmetric.
Treatment
• Use explicit evidence; emphasize the
consequences endured by the patient as a
result of alcohol abuse.
• Be empathic and nonjudgmental.
• Avoid arguments about the diagnosis.
• Avoid use of the word alcoholic.
Treatment
• Treatment of alcohol withdrawal is best accomplished with
benzodiazepines. Avoid fixed-dose therapy, and treat
patients for symptoms. This results in use of lower doses
of benzodiazepines, less patient sedation, and earlier
patient discharge.
• Other agents that have been used with some success in the
treatment of withdrawal include beta-blockers,
phenothiazines, and anticonvulsants. All can be used with
benzodiazepines, but none has been proven to be adequate
as monotherapy. A number of medications have been tried
in the treatment of alcoholism.
Treatment
• Disulfiram (Antabuse) has been used as an adjunct to
counseling. Patients are reminded of the risks of adverse
effects when tempted to drink. Disulfiram causes nausea,
vomiting, and dysphoria with coincident alcohol use. In a
large trial, disulfiram did not increase abstinence. If a
patient asks for disulfiram and thinks it will help, it might
be worth considering.
• Naltrexone blocks opiate receptors and works by
decreasing the craving for alcohol, resulting in fewer
relapses. A recent positron emission tomography study
demonstrated that alcoholic persons have increased opiate
receptors in the nucleus accumbens of the brain and that
the number of receptors correlates with craving.
Treatment
• Opiate antagonists -- Alcohol has been shown to bind to
opiate receptors in the brain. Studies show that blocking
opiate receptors decreases cravings for alcohol.
• Naltrexone (ReVia) -- Patients must be abstinent for 5-7 d
before beginning therapy. Monitor liver function during
treatment.
• Contraindications Documented hypersensitivity, acute
hepatitis, liver failure
• Precautions Nausea/vomiting, abdominal pain, daytime
sleepiness, and nasal congestion were more common vs
placebo in largest randomized trial to date; discontinuation
due to adverse effects was uncommon in most clinical
trials
Treatment
• Aldehyde dehydrogenase inhibitors -- Disulfiram inhibits
aldehyde dehydrogenase, and, as a result, acetaldehyde
accumulates. This leads to nausea, hypotension, and
flushing if a person drinks alcohol while taking disulfiram.
• Disulfiram (Antabuse) -- Decreases number of drinking
days but does not increase abstinence. Directly observed
therapy might be more beneficial but has not been studied
in a good randomized trial.
• Contraindications Documented hypersensitivity, severe
myocardial disease, coronary occlusion
• Precautions Adverse effects are uncommon, but hepatitis,
optic neuritis, neuropathy, and skin rash reported
Treatment of DT
• Benzodiazepines -- By acting on the GABA receptor,
benzodiazepines produce a cross-tolerance to alcohol, thus
reducing the hemodynamic and peripheral symptoms of
alcohol withdrawal. The dose of benzodiazepine used
should be based on the patient's symptoms and signs of
alcohol withdrawal, including vital signs and amount of
agitation. The longer-acting agents appear to be superior
compared to the short-acting agents and may result in a
smoother withdrawal course with less breakthrough and
rebound symptoms, although a risk of excessive sedation
exists in certain patient groups (elderly patients, patients
with liver failure) with the longer-acting agents.
Treatment of DT
• For the treatment of minor or moderate alcohol withdrawal
(patient able to take oral therapy), symptom-triggered therapy
has been shown in prospective, randomized, controlled trials to
be superior to fixed-dose drug therapy, with less medication
use and a shorter duration of therapy.
• For patients with severe withdrawal symptoms, including DTs,
the benzodiazepine dose should be front-loaded. That is, large
doses should be administered intravenously at short intervals
until the patient is calm but easily aroused. Then additional
doses are administered only as needed. Most authorities
recommend intravenous diazepam as the first choice for frontloading treatment of severe alcohol withdrawal. Because of its
long serum half-life, and the even longer half-life of its active
metabolite (desmethyldiazepam), additional doses may not be
required once the patient is calm.
Treatment of DT
• Diazepam (Valium, Diazemuls, Diastat) -- Depresses all levels of CNS
(eg, limbic and reticular formation), possibly by increasing activity of
GABA.
Individualize dosage and increase cautiously to avoid adverse effects.
• Anesthetic agents -- Propofol, an intravenous anesthetic agent, is active
on both the glutamate and GABA-A receptors, similar to the alcohol
itself, whereas benzodiazepines are active only against the GABA
receptors. It may be effective for patients with DTs refractory to
benzodiazepines. Due to its rapid onset of hypnosis and anticonvulsant
properties, propofol is an alternative treatment for intubated patients
with DTs refractory to high-dose benzodiazepines. Advantages to its
use are that it is easily titratable with predictable effects and has a rapid
metabolic clearance
Treatment of DT
• Propofol (Diprivan) -- Phenolic compound unrelated to
other types of anticonvulsants. Has general anesthetic
properties when administered IV. Propofol IV produces
rapid hypnosis, usually within 40 s. Effects are reversed
within 30 min following discontinuation of infusion.
Disorders of personality and
behavior due to drug abuse.
Introduction
• People take various substances because they like the effects. In some,
such use stays at a "recreational" or "social" level; in others, abusive
use occurs; and in still others, addiction, or compulsive use, occurs.
Differentiating among these three forms of use is important not only
with regard to prognosis but also with regard to treatment.
• Most of these substances have the capacity to produce tolerance and
withdrawal, whereas others generally do not. Those that routinely
produce tolerance and withdrawal include the following: caffeine,
cannabis, inhalants, nicotine, amphetamines, cocaine, opioids,
sedative-hypnotics, and alcohol. Those that lack substantial capacity to
produce tolerance and withdrawal include hallucinogens and
phencyclidine.
Tolerance and withdrawal
• Tolerance is said to occur when the patient has to take ever
increasing amounts of the substance to get the desired effect.
Tolerance may also be inferred when, over time, even though
the patient continues to use the same amount, the effect
becomes progressively less.
• Withdrawal symptoms occurring after use is discontinued often
constitute a "rebound" from the effects of intoxication.
• for example, a patient who had taken a benzodiazepine exactly as
prescribed for years, without ever exceeding the dose but who
accidentally left the medicine at home while going on vacation. After a
sleepless night and experiencing tremulousness the next day, the
patient calls the physician who explains to the patient that these
constitute withdrawal symptoms. Such a patient, though desperate for
relief, may nevertheless decide that "it isn't worth it," and because she
has no craving may simply not take anymore, "tough out" the
withdrawal, and then get on with life.
Tolerance and withdrawal
• In the past these phenomena of tolerance and withdrawal
have been termed "physiologic dependence." However,
because the word "dependence" often conjures up the
image of addiction, another term, "neuroadaptation * has
been coined. Neuroadaptation is clearly the preferred term
for two reasons: first, it speaks to the underlying neuronal
mechanism; and second, it is neutral with respect to
addiction, thus emphasizing that tolerance and withdrawal,
though ubiquitous in addiction, can also occur with
abusive use, occasionally with recreational use, and also
during appropriate medical treatment.
RECREATIONAL USE
• Most people, at some point or other, "experiment" with substances,
such as caffeine, nicotine, alcohol, cannabis, and, with ever-increasing
frequency, cocaine. A morning cup of coffee and social drinking are
typical examples. In some cases the substance produces some sort of
dysphoria, and the person never uses it again. An example would be
the teenager who gets "paranoid" the first time he smokes marijuana.
In other cases peer pressure or a certain appreciation for the effects of
the substance may prompt the patient to use the substance
occasionally. Here the person is in the "take it or leave it alone" mode,
and going to get the substance is no more important than, say, going to
a good movie. He can "walk away from it" without a second thought.
RECREATIONAL USE
• In the case of caffeine, alcohol, cannabis, and perhaps also
hallucinogens and phencyclidine, substance use for many
appears to stay at a "recreational" level. Although a
progression to abusive use may occur with any of these, a
progression from recreational to abusive use appears more
common for tobacco, stimulants, and especially cocaine
and opioids. The likelihood of this progression is increased
with intravenous use or with smoking "crack" cocaine.
ABUSIVE USE
• In a minority of those who engage in recreational use, an abusive pattern of
use will emerge. In some cases this progression is due to peer pressure, in
others because neuroadaptation has occurred and "relief" use seems highly
desirable, and in yet a third group abusive use may occur either because the
person gets substantial enjoyment from the substance or because it helps the
patient "cope" with life's problems.
• Peer pressure is particularly important among teenagers and young adults.
Since "everybody" is using, say, cannabis or alcohol to be "one of the crowd,"
these patients go along and use more than might be the case if left to their
own devices.
• The need for "relief" use may occasionally prompt use beyond that which the
patient wishes. A salesperson, for example, may find daily drinking
"necessary" for work as customers are entertained. Eventually, though,
morning shakiness starts to occur, and though not welcoming the idea, such
an individual finds it very difficult to hold off until a drink can be had with
lunch.
ADDICTION
• These patients experience an overpowering compulsion to use the
substance and are driven by that compulsion to repeated use despite
the most disastrous consequences. Despite repeated attempts to
control their use, by either moderating it or stopping it altogether,
addicts find themselves again and again intoxicated.
• The appearance of craving may be gradual and insidious or at times
acute. But in the history of every addict is a time when she "crosses
the line" and is no longer able to stop.
• Once craving develops, denial becomes severe. Cocaine addicts
driven to theft and robbery to support their "habit" may insist that
they are "in charge."
• Eventually, substance use becomes the primary, if not the sole,
motivating factor in the patient's life. Family, friends, and work pale
by importance, and all the patient's efforts become directed to one
thing: ensuring an unbroken supply of the substance.
Caffeine Related Disorders
• A cup of coffee contains about 100 mg of caffeine, tea about 50
mg, and caffeinated soft drinks anywhere from 25 to 200 mg.
Over-the-counter analgesic and "cold" preparations,
"stimulants," anorectics, herbal products and health food
products may contain anywhere from 25 to 200 mg. Caffeine is
almost completely absorbed, reaching peak blood levels in from
30 to 60 minutes. Metabolism is via the cytochrome P450 1A2
hepatic enzyme system, with a half-life ranging from three to
five hours.
CLINICAL FEATURES
• A caffeine-naive patients, about 100 mg of caffeine produces an
increased sense of alertness and decreased fatigue. At doses
between 100 and 500 mg, however, caffeine intoxication begins.
Patients feel apprehensive, restless, and even agitated, and
complain of headache and insomnia. Tremor and tachycardia
may appear. At doses of about 1 g, intense anxiety to the point
of panic occurs. Agitation may be extreme, and tremor and
tachycardia are now quite prominent. Premature beats and
muscle twitches may occur. Significantly higher doses (e.g., 10
g) may produce serious arrhythmias, such as,ventricular
fibrillation, grand mal seizures, respiratory depression and death.
CLINICAL FEATURES
• Provided that no further caffeine is ingested, symptoms of
intoxication tend to clear in a matter of hours, and recovery is
generally complete within 6 to 12 hours. Neuroadaptation may
develop after daily use of only 500 mg of caffeine over a couple
of weeks time. Tolerance is manifest by the ability of the patient
to consume, without ill effect, doses of caffeine that would cause
intoxication in caffeine-naive individuals. Withdrawal tends to
occur in 12 to 24 hours after the last dose and is characterized by
headache, poor concentration, fatigue, anxiety, irritability, and
depressed mood, all gradually clearing in from 2 days up to a
week.
Cannabis Related Disorders
• "Cannabis" comes from the Greek word for hemp and
refers to the flowering tops of the hemp plant, Cannabis
sativa. The two most commonly available preparations of
cannabis are marijuana and hashish. Marijuana (also
known as "grass," "pot," "reefer," "weed," or "Mary
Jane") is simply a dried collection of the flowers and
nearby leaves and sprouts of the hemp plant and is usually
rolled into a cigarette. Hashish, on the other hand, is more
potent and is the resin that is scraped from the leaves and
flowers of the plant.
CLINICAL FEATURES
• Cannabis intoxication is characterized for most individuals by a dreamy
sense of well-being. The senses feel heightened; color and sounds appear
unusually sharp and clear. Time seems to slow down, and minutes may
seem like hours. Thinking becomes less logical, and everyday things may
come to seem ridiculous and amusing. Laughter and giggling may occur,
and although this may leave the unintoxicated unmoved, it often is
infectious to others who are intoxicated.
• While intoxicated, most individuals have difficulty remembering things
and paying attention. The mouth is dry, and most experience increased
hunger, often for cookies or brownies. The conjunctivae are reddened. A
mild degree of ataxia may be seen. The heart rate is generally elevated,
and although the supine blood pressure is often elevated, orthostatic
hypotension may occur upon standing.
CLINICAL FEATURES
• In a minority of cases the intoxication may be complicated by any of a
number of events. Perhaps the most common complication is anxiety, which
at times may be as severe as that seen in a panic attack. This cannabisinduced anxiety generally passes as the intoxication does. Depersonalization
or derealization may also occur during intoxication.
• A less common complication is the development of a psychosis. This
"cannabis-induced psychotic disorder," as it is sometimes called, is
characterized by the fairly abrupt appearance during intoxication of
compelling delusions of persecution, which maybe accompanied by auditory
or visual hallucinations. Extreme anxiety is commonly associated with this,
and although patients rarely attack their "persecutors," many will flee or seek
safety in some other way. The psychosis generally outlasts the intoxication
per se, and indeed may persist for 1 to 3 days.
CLINICAL FEATURES
• These two complications, anxiety and psychosis, may occur after
smoking only a relatively small amount of marijuana. When much
higher doses are taken, a delirium may occur. This cannabis
intoxication delirium is characterized by confusion and, often,
agitation. Thinking is quite illogical, and delusions and hallucinations
often appear. This delirium may clear as the intoxication does or it
may last for up to a few days.
• The pattern of recurrent intoxication is quite different between the "social
user" and the patient with cannabis abuse or dependence. Social use is often
confined to weekends and generally occurs with friends. Cannabis abusers
typically smoke marijuana or hashish on a daily basis, and often do so alone.
The pattern is similar for cannabis addicts, whose entire lives often center on
getting and staying intoxicated and who also develop either tolerance or
withdrawal.
CLINICAL FEATURES
• Tolerance is manifested by a decreased euphoria and a
diminution in the tachycardia and blood pressure changes. If
withdrawal occurs it tends to be mild and to appear anywhere
from 3 to 12 hours after the cannabis was last used. Patients are
anxious, irritable, and restless and almost always complain of
some insomnia. Anorexia and increased sweating are seen, and
some patients may develop a fine tremor. Symptoms generally
peak in 1 to 2 days and resolve spontaneously within 4 to 5 days.
Hallucinogen Related Disorders
• The hallucinogens, also known as psychedelics
or psychotomimetics, may be roughly divided
into two groups: the indolealkylamines, such as
LSD, and the phenylalkylamines, such as
mescaline
CLINICAL FEATURES
• After oral use of most hallucinogens, intoxication begins
gradually within 20 minutes to 1 hour. A certain tension
or apprehension may occur, soon followed by an
alteration in the state of consciousness that is difficult to
describe. Although fully alert and oriented, patients
describe a "cosmic" sense of unity with those around
them.
• Visual illusions and hallucinations are common, and
patients often relate to them as they would to a movie.
Patients acknowledge that they are not real, yet they are
captivated by them. Rippling colors and geometric forms
may occur; bodies may appear distorted, and at times
complex visual hallucinations of people or things may
occur
CLINICAL FEATURES
• Intoxication with MDMA ("Ecstasy") is somewhat different than that seen
with other hallucinogens, being characterized by an initial "rush," followed
by a heightened sense of empathy or connectedness with others.
• Not uncommonly the intoxication may become extremely dysphoric as it evolves
into a "bad trip." Anxiety sets in as the patient vainly attempts to control his
thoughts and perceptions. Some fear dissolution; others are in terror that they are
losing their minds and that the trip will never end. Delusions of reference and
persecution may occur, and the patient, panic-stricken, may be brought to the
hospital.
• On examination of the intoxicated patient one finds mild degrees of tachycardia,
hypertension, mydriasis, fine tremor, poor coordination, and generalized
hyperreflexia: in the case of MDMA, bruxism may also be seen. The temperature
may be elevated.
• Regardless of whether the intoxication is pleasant or not, patients generally recover
within 6 to 24 hours after most hallucinogens.
CLINICAL FEATURES
• A minority of patients develop an hallucinogen-induced mood disorder
shortly after the intoxication resolves, usually within days. Most commonly,
depression is seen with anxiety, insomnia, and an unrelenting fear that the
drug has caused permanent damage. At times, patients are severely agitated,
and suicide attempts have occurred. Less commonly, manic symptoms may
occur, and one may see a heightened mood, hyperactivity, pressured speech,
and a decreased need for sleep. These mood changes tend to be relatively
brief, lasting only a few days; rarely, however, they may persist for much
longer, up to weeks.
• Flashbacks (also known as "hallucinogen persisting perception disorder")
may occur in up to a quarter of all patients. Here, while not intoxicated, the
patient experiences one or more of the symptoms seen in the intoxication.
Generally the flashback itself is quite brief, sometimes lasting only seconds.
Patients may experience complex visual hallucinations, or only shapes,
color, or "trailing" of after-images. Auditory and tactile hallucinations may
also be seen. Flashbacks may occur spontaneously or may be precipitated by
moving into a darkened area, or by the use of alcohol, marijuana, or an
antipsychotic.
Amphetamine (or Amphetamine-Like)
Related Disorders
• Of the many stimulants that have been abused, amphetamine,
dextroamphetamine and methamphetamine are the worst
offenders; methylphenidate has also been abused as have some
of the "diet" drugs, such as diethylpropion, benzphetamine and
phenteramine.
Of
all
these,
amphetamine
and
methamphetamine are the most important clinically.
• These drugs may be taken orally or crushed, dissolved, and taken
intravenously. Occasionally they are also "snorted." Highly purified
methamphetamine ("ice") may also be smoked. Within the central
nervous system the stimulants act primarily as indirect, but also
possibly as direct, sympathomimetics, releasing both norepinephrine
and dopamine; the amphetamines are predominantly noradrenergic
and methylphenidate predominantly dopaminergic.
CLINICAL FEATURES
• Stimulant intoxication may begin almost immediately with inhalation or intravenous
use, producing an intensely pleasurable "rush," whereas an hour or more may pass
after oral use before the user experiences a somewhat less profound elation or sense
of intense well-being. Typically, the user feels more confident, energetic, and ,
active. The user is disposed to talk; there may be some grandiosity.The pupils are
dilated, the blood pressure, both systolic diastolic, is increased, and the heart rate
may be either increased or reflexively slowed. Such a degree of intoxication rarely
brings the user to medical attention.
• A severe degree of intoxication, one seen not uncommonly in the emergency room,
is characterized by agitation and at times bizarre behavior. Often a peculiar interest
in things mechanical is observed, and users may spend hours taking apart and then
to put back together clocks, radios, televisions. Fleeting delusions of persecution
and auditory hallucinations may arise.
CLINICAL FEATURES
• The temperature is raised, and extreme diaphoresis may occur. The user may
experience nausea, vomiting, abdominal cramping, and diarrhea. Occasionally, in
even higher degrees of intoxication, a stimulant-intoxication delirium may occur
with confusion, extreme apprehension, incoherence, and at times violent behavior.
Seizures, hypertensive encephalopathy, and various arrhythmias may also occur.
• Regardless of the degree of intoxication most users recover a few hours later
or perhaps in a day or more.
• In some users a stimulant-induced psychotic disorder may occur, and
although this is typically restricted to chronic users, it has been reported in
normal volunteers given very high oral doses. The user becomes intensely
suspicious, guarded, and watchful. Delusions of persecution develop, as may
both auditory and visual hallucinations. Typically these users remain free of
confusion and incoherence. In extreme cases the user may attack the
"persecutors." With abstinence the symptoms of the psychosis gradually
fade, generally over anywhere from days to weeks.
CLINICAL FEATURES
• Withdrawal symptoms typically occur after extended use of
stimulants. As the intoxication clears, users become dysphoric
and fatigued. They may be irritable, and some users become
agitated. Suicidal ideation, which may be intense, is not
uncommon. Some users experience a dreadful insomnia,
whereas others sleep excessively, at least initially. This acute
withdrawal syndrome, or "crash," as it is often called, may
undergo considerable clearing within days or a week or more;
however, dysphoria and sleep disturbance may last for weeks or
months.
Cocaine Related Disorders
• Several different preparations of cocaine are available illegally.
Cocaine hydrochloride is a white powder that may be "snorted"
into the nasal passages where it is absorbed through the nasal
mucosa; cocaine hydrochloride is also water soluble and may
be injected intravenously. Cocaine hydrochloride is destroyed
by heat, and is thus not suitable for smoking; however, it may
be treated with sodium bicarbonate and then either extracted
with ether to yield a "free base" preparation, or warmed to
create a "rock" of cocaine.
CLINICAL FEATURES
• During intoxication users becomes euphoric, hyperalert,
talkative, and grandiose. Hyperactivity is common, and with
higher doses agitation may occur; some patients may also
experience visual hallucinations, often consisting of insects, the
notorious "cocaine bugs"; some of these patients may also
experience tactile hallucinations, and in such cases patients may
excoriate themselves in an attempt to get rid of the "bugs." The
appetite for food and sleep is routinely lost, and with mild
intoxication sexual desire increases, accompanied by delayed
ejaculation. With greater intoxication, however, partial or
complete impotence may occur.
CLINICAL FEATURES
• Users may experience tachycardia or palpitations; headache, nausea,
and vomiting may also occur. Rarely choreoathetosis ("crack
dancing") may occur. Mydriasis and increased blood pressure are
routinely found; occasionally the user may have fever and chills.
Users often take sedatives, alcohol, or opioids to enhance the
intoxication or dampen the unwanted effects; a favored combination is
the "speedball," a mixture of cocaine and heroin. The duration of the
intoxication, varies with the preparation. Regardless, however, of the
route of administration, the autonomic and cardiovascular effects tend
to persist for 20 to 60 minutes.
CLINICAL FEATURES
• Most users experience a "crash" shortly after using cocaine and this tends to be more
severe after taking cocaine intravenously or smoking it. During the "crash," users
experience fatigue, depression, irritability, and anxiety; the overall dysphoria may be
intense. The crash may come within 15 minutes after IV use or smoking; after
snorting, the crash may not appear for 30 to 60 minutes. Generally this crash
resolves within hours, or a day at the most.
• After 2 years or so of cocaine use, a cocaine-induced psychotic disorder may occur
during intoxication, characterized by delusions of persecution and reference, which
may at times be accompanied by auditory hallucinations.
• During severe intoxication after intravenous use or smoking, some users may
develop a cocaine-induced delirium. Confusion, apprehension, and incoherence may
be seen. The mood is often labile, and delusions and hallucinations are common.
Users in the midst of such a delirium are prone to aggression and violence. In
general the delirium clears within hours; afterward the user may be amnestic for the
event.
CLINICAL FEATURES
• Tolerance appears to occur much more rapidly with IV use or smoking than
if cocaine is snorted. Indeed during a "run" of IV use, tolerance may appear
within a day. Unfortunately such tolerance develops only to the euphoriant
effect of cocaine and not to its cardiovascular effects. Thus the progressively
higher doses required to achieve the euphoria may eventually cause a lethal
event, such as an arrhythmia, before the euphoria can be reached.
• Withdrawal symptoms seem in some sense to be an extension and elaboration of the
frequently occurring post-intoxication "crash," described earlier. Withdrawal tends
to occur only after a minimum of several days of heavy use; the withdrawal
symptoms themselves tend to reach a maximum in several days and then remit
gradually over days or weeks. Typically a user in withdrawal experiences
depression, irritability, fatigue, anhedonia, a tense craving for more cocaine,
insomnia, and occasionally hyperphagia. Suicidal ideation is not uncommon and
suicide attempts may occur.
Opioid Related Disorders
• An opiate is any intoxicant naturally found in opium. The term
"opioid" is more general and refers to any substance, either
synthetic or naturally occurring, that has morphine-like effects.
• Opium is obtained from the juice of the poppy plant, and within
opium are found two opiates, namely morphine and codeine. Synthetic
and semi-synthetic derivatives include heroin, hydromorphone,
merperidine, hydrocodone, oxycodone and pentazocine. Methadone
and buprenorphine are derivatives used, as noted below, in the
treatment of opioid addiction, but these may also be abused. Of all the
opioids, heroin is by far the most commonly abused.
CLINICAL
FEATURES
• The intoxication produced by opioids is intensely seductive.
Within minutes after the intravenous injection of heroin,
morphine, or hydromorphone the user may be rewarded by an
intense rush. The body is suffused with warmth, and orgasmic
sensations may be felt. In less than a minute the rush tends to
pass, to be replaced by a drowsy, vaguely euphoric feeling that
may last for hours. Dysarthria and difficulty with concentration
may occur. The pupils are constricted, peristalsis is slowed, and
constipation ensues; urinary hesitancy or retention may occur.
Some experience generalized pruritus. During the intoxication
most users are slowed down, and some may "nod off."
Aggressiveness and sexual desire are blunted, and an opioidintoxicated user rarely harms others during the actual
intoxication.
•
CLINICAL
FEATURES
• In an overdose the user is stuporous or comatose. Initially the pupils are
pinpoint; however, with respiratory depression and cerebral anoxia pupillary
dilatation may occur. Temperature falls, and the skin is often cold and
clammy. Respirations decrease not uncommonly to less than five
breaths/minute. Pulmonary edema is not uncommon. Intracranial pressure
may rise, and seizures may occur. Death is usually caused by respiratory
arrest.
• In those addicted to heroin or morphine, withdrawal symptoms gradually
emerge anywhere from 6 to 12 hours after the last dose. The user becomes
uneasy and experiences a craving for the drug. Yawning, lacrimation, and
rhinorrhea appear; diaphoresis is also seen. Several hours later the user may
fall into a restless sleep, known as "yen" sleep. Upon awakening, the earlier
symptoms intensify, and the user soon thereafter becomes irritable,
demanding, and intensely dysphoric. Insomnia may be extreme. Nausea,
vomiting, intestinal cramping, and diarrhea occur, and the user begins to
experience waves of goose flesh that may be so severe as to make flesh
resemble that of a plucked turkey, an appearance that
CLINICAL FEATURES
• prompted the phrase "cold turkey." Intense bone and muscle pain in
the back, arms, and legs occurs. Often, seemingly involuntary kicking
movements occur, a phenomenon that prompted another proverbial
phrase "kicking the habit." The pupils are dilated, and the temperature,
pulse, and blood pressure are all increased. Leukocytosis may be
present. Fluid loss secondary to vomiting and diarrhea may lead to
dehydration and rarely circulatory collapse.
• The life of the opioid addict often becomes centered on only one
thing: obtaining the drug. The restless anticipation of the rush, the
deep craving for the drug, and the intense fear of withdrawal
symptoms combine to irresistibly drive the addict to do whatever is
necessary to maintain the supply. Prostitution and murder may occur;
some may sell children.
•
•
Sedative, Hypnotic, or Anxiolytic
Related
Disorders
The sedatives, hypnotics,
and anxiolytics,
including the benzodiazepines, barbiturates, and related drugs, comprise a large group of
agents often referred to as "sedative-hypnotics," all of which have an
effect that is more or less similar to that of alcohol. Although most
commonly used in combination with alcohol or other
substances.Among the benzodiazepines, diazepam, lorazepam, and
alprazolam are currently the most popular among abusers, with
diazepam heading the list.
•
Clinical features.
• In intoxication the user, though often euphoric, may at times display some emotional
lability. Judgment is impaired, and sexual or aggressive urges that are normally
inhibited may be acted upon. . With somewhat more severe intoxication, reaction
time is markedly slowed, and the user may appear drowsy or lethargic. Dysarthria,
poor coordination, ataxia, and nystagmus are common at this point. Severe
intoxication may produce stupor, coma, respiratory depression and death. The onset
of withdrawal symptoms varies according to the ion of the agent's effect. Roughly
speaking, withdrawal may expected in less than 1 day for short-acting agents, 2 to 3
days intermediate-acting agents, and 2 to 6 days for longer-acting agents. For certain
very-long-acting agents, such as diazepam or phenobarbital, a "self-tapering"
process may occur as the blood level falls very slowly, so withdrawal symptoms
may be relatively mild compared with other agents.
• The patient in withdrawal is anxious and irritable and generally craves the drug.
Autonomic signs, such as tremor, tachycardia, and diaphoresis, are common, and
muscle weakness is a typical complaint. Nausea and vomiting may occur, as may
postural hypotension. Insomnia is common and may be quite severe.
Clinical features.
• If seizures occur they generally do so in the context of the withdrawal
syndrome. They are more common in barbiturate than benzodiazepine
withdrawal, and when secondary to barbiturate withdrawal they tend
to be much more severe than those seen in alcohol withdrawal.
Multiple seizures are not uncommon, and status epilepticus may
occur.
Inhalant
Related
Disorders
• These include airplane or model glue, paint thinner, kerosene and gasoline,
various cleaners and industrial solvents, the propellants in aerosol sprays and
spray paints, fingernail polish or polish remover, and typewriter correction
fluid. Each of these products contains various mixtures of aliphatic or
aromatic hydrocarbons.
– Inhalant abuse is sometimes also known as solvent abuse or, more
loosely, "glue sniffing." The actual prevalence of inhalant abuse is not
known; however, over 10% of all high school seniors have at least
"experimented" with inhalants. Inhalant abuse is more common among
males than females.
• substances may be soaked in a rag and held to the face, placed in a plastic or
paper bag; a tell-tale rash may indicate here the bag was positioned.
Intoxication usually begins within minutes. Users often describe a euphoric
dreamy "high." Often some drowsiness, dizziness, dysarthria, diplopia,
nystagmus, can occur. Hallucinations, generally visual, and confusion and
some experience delusions. Some users become irritable, and impulsive. In
severe intoxication stupor or coma may occur. Symptoms of intoxication
subside gradually after about an hour or so.
Treatment of cocaine intoxication
• Benzodiazepines are the first-line therapy in treating patients who are agitated and
intoxicated from cocaine. Typically, benzodiazepines can be titrated until the patient
is calm and the pulse and blood pressure have stabilized.
• Use neuroleptics with caution in acute intoxication. Acute hyperthermia syndromes
associated with acute cocaine intoxication have been reported, and the use of
neuroleptics with the risk of neuroleptic malignant syndrome may confuse this
situation.
• Cocaine-induced chest pain
• Chest pain associated with cocaine use may be from musculoskeletal,
cardiovascular, or pulmonary etiologies.
• Obtain a chest x-ray film to exclude localized infiltrates, pneumothorax,
pneumomediastinum, and pulmonary edema. An ECG and serial cardiac enzyme
evaluation assist in excluding acute myocardial infarction and acute coronary
syndromes.
Treatment of cocaine intoxication
• If an acute coronary syndrome is suggested, then oxygen, aspirin, benzodiazepines,
and nitroglycerin can be administered. Nonselective beta-blockers are best avoided
in all patients who are intoxicated with cocaine.
• Hypertension
• Cocaine-induced hypertension is treated first with benzodiazepines.
Benzodiazepines decrease the cocaine-induced sympathomimetic drive from the
CNS.
• If this fails, phentolamine may be considered. Phentolamine is an alpha-antagonist
and counteracts cocaine's vasoconstrictive effects. Nitroprusside and nitroglycerin
also may be considered.
Treatment of cocaine intoxication
• Seizures
• Cocaine-induced seizures may be either generalized or partial and result from
cocaine toxicity itself or from a cocaine-induced process, such as a cerebral vascular
accident.
• The first-line therapy is benzodiazepines, followed by barbiturates. Consider a head
CT scan for seizures associated with the use of cocaine.
• Diazepam (Valium) -- Depresses all levels of CNS (eg, limbic and reticular
formation) possibly by increasing activity of GABA. Individualize dose and increase
cautiously to avoid adverse effects.
• Antipsychotic agents -- High-potency antipsychotic agents in the butyrophenone
class (eg, haloperidol, droperidol) are used for rapid sedation. Easily titrated and
cause less sedation and orthostasis; however, they cause extrapyramidal symptoms
more often than lower-potency agents. Used short term to rapidly control psychosis.
Treatment of cocaine intoxication
• Newer antipsychotics (eg, risperidone, olanzapine, quetiapine) are
used for long-term management. Improvements over earlier
antipsychotics include fewer anticholinergic effects and less dystonia,
parkinsonism, and tardive dyskinesia. Affect dopamine and serotonin
receptors.
• Haloperidol (Haldol) -- DOC for acute psychosis. Parenteral dosage
form may be admixed in same syringe with 2 mg lorazepam for better
anxiolytic effects.
• Olanzapine (Zyprexa) -- May inhibit serotonin, muscarinic, and
dopamine effects.
Treatment of opioid intoxication
• Opioid analgesics -- Two uses for opioid analgesics are as follows:
(1) Oral substitution therapy or maintenance therapy or opioid agonist
therapy (OAT) refers to substitution of an oral opioid for injected
heroin, with the goal of reducing harmful behaviors associated with
heroin use. (2) Detoxification, or controlled withdrawal with the goal
of abstinence, is based on the principle of cross-tolerance in which
one opioid is replaced with another and then slowly withdrawn.
Treatment of opioid intoxication
• Naloxone is very effective in treating acute overdose, and is first-line treatment.
Give IV naloxone if necessary. Naloxone is a specific opiate antagonist with no
agonist or euphoriant properties. When administered intravenously or
subcutaneously, it rapidly reverses the respiratory depression and sedation caused by
heroin intoxication.
• Methadone, a long-acting synthetic opioid agonist, can be dosed once daily and
replaces the necessity for multiple daily heroin doses. As such, it stabilizes the drugabusing lifestyle, reducing criminal behaviors, and also reducing needle sharing and
promiscuous behaviors leading to transmission of HIV and other diseases.
THANKS FOR UR ATTENTION!