FCA 0113 - Drugs of Abuse


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RMH Field Care Audit 01-24-13

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FCA 0113 - Drugs of Abuse

  1. 1. Chasing the Dragon: Drugs of Abuse Drugs of Abuse Veronica Bonales, M.D.Pre-Hospital Care Medical Director RMHCEP America Emergency Physician
  2. 2. ObjectivesAnatomyWhyDrugsEffects
  3. 3. TheBrain
  4. 4. Brains• Composed of nerve cells (neurons)• Send information via nerve impulses
  5. 5. Brains• Central nervous system = brain & spinal cord• 100 billion neurons• Divided into 3 main sections – Cerebrum – Diencephalon – Brainstem• Cerebellum – coordinates muscle movements
  6. 6. Brain
  7. 7. Cerebral Cortex • “mammalian brain” • Interpretation of sensory input • Stores information • Reasons • Four lobes – Frontal – motor fxn, impulse, personality, memory – Parietal – sensory integration, visuospatial processing – Occipital – visual processing center – Temporal – hearing, language, comprehension
  8. 8. Brain
  9. 9. Diencephal on • “reptilian brain” • Thalamus – relay center • Hypothalamus – homeostasis regulator – HR, BP, H2O, hunger, alertness • Mammilary bodies – tracts to connect memory • Optic tract • Pituitary gland
  10. 10. Brain
  11. 11. Brainstem• “earthworm brain”• Stimulus / response• Basic functions – Midbrain – reflex fxns – Pons – breathing, sensory tracts from PNS – Medulla oblongata – nerve tracts, cardiac, vasomotor, respiratory centers – Reticular formation – communications throughout brain, sleep/wakefulness **
  12. 12. Neurotransmitter s• Acetylcholine - voluntary movement of the muscles• Norepinephrine - wakefulness or arousal• Dopamine - voluntary movement and emotional arousal• Serotonin - memory, emotions, wakefulness, sleep and temperature regulation• GABA (gamma aminobutyric acid) - motor behaviour• Glycine - spinal reflexes and motor behaviour• Neuromodulators - sensory transmission-especially pain
  13. 13. Neurotransmitte rs• Can either be excitatory or inhibitory • Effect of drugs will either increase a reaction or allow for an unwanted reaction to be prolonged
  14. 14. Why?• Gain for the individual – Loss of pain – Feeling of euphoria – Heightened sensory experience – Sedation
  15. 15. Why?– Heredity– Disease– Availability– Increased stress– Peer or societal acceptance
  16. 16. Terminolog• y Abuse – impairs a person’s functional ability• Addiction – compulsion that leads to detriment • Dependence – Physical – withdrawal if substance not given – Psychological – feel need substance to function• Tolerance – need more of substance to obtain effect
  17. 17. Questions?
  18. 18. Pharmacopoeia of Drugs• History of the drug• Effects on the brain• SSx• Overdose / toxic effects• Treatments
  19. 19. Plant – Based Drugs
  20. 20. Opium
  21. 21. Opiu m• Comes from the poppy plant• Opi – “drunken”; Um – “mind”• Early references from 879 BC• Popular 17th & 18th centuries in China as madak - mixed w/tobacco & smoked• Opium dens en vogue• Addict more socially acceptable than alcoholic• Known as a painkiller & sedative
  22. 22. Opiu m• Binds to opioid receptors (releases endorphins) – Activates the μ-receptor which leads to: • analgesia, sedation, reduced blood pressure, itching, nausea, euphoria, decreased respiration, miosis (constricted pupils) & decreased bowel motility• Tolerance develops over time• Overdose will lead to respiratory depression• Tx – naloxone blocks receptor
  23. 23. Opiu m• Examples of opioids – Morphine – good for coronary pts – Codeine – Tincture of Opium • Used to treat diarrhea• Synthetic opioids: fentanyl, propoxyphene (Darvocet)
  24. 24. Cocaine
  25. 25. Cocain• e Derived from leaves of coca plant• Originally used by the natives of South America (esp. Peru) – Chewing gave a feeling of strength and energy; appetite suppressant• Spaniards took back to Europe, alkaloid isolated by Germans in 1855• Quickly used medicinally as an anesthetic & commercially (Vin Mariani & Coca-Cola)• Outlawed in 1914 w/concern about addictive properties
  26. 26. Cocain e• Binds to DA reuptake channels• DA related to reward centers• CNS stimulant, anesthetic• Effect can last 20 minutes to several hours• Hyperactivity, restlessness, increased BP, increased HR and euphoria; enhanced sexual interest & pleasure
  27. 27. Cocain• Placental abruption e• OD can be fatal 2o to: – Tachyarrhythmias (24x inc. in risk for AMI during 1st hour) – Elevated BP’s – Hyperthermia (inc. heat w/vasoconstriction) – SZ’s lead to medullary depression• Tolerance develops• Depressive “crash” after chronic use• Used in medicine as an anesthetic in dental & ophthalmological surgeries
  28. 28. Marijuana /Hashish
  29. 29. Personal BongWay to enjoy the Tractor Parade with the kids...
  30. 30. Cannab• is Originated in the Himalayas• Used in bonfires during religious ceremonies• Spread around the world esp. in the 60’s & 70’s counterculture• Hashish popular in Middle East while MJ popular in U.S. as a recreational drug• Assassin comes from “hashashin” Islamic militant sect
  31. 31. Cannabi s• Active ingredient – THC (tetrahydrocannabinol)• Binds to cannabinoid receptors CB1 in brain (euphoric effects) CB2 in spleen (anti-inflammatory effects)• Anti-emetic, analgesic at low doses, relaxation; euphoria; altered space-time perception; alteration of visual, auditory, and olfactory senses; disorientation; fatigue; & appetite stimulation• No fatalities have ever been recorded; no CB1 receptors in the medulla; however...
  32. 32. Cannab is• Used medically – Glaucoma – Multiple sclerosis pain – Anti-emetic in CA pts – Appetite stimulant – Tourette’s Syndrome
  33. 33. Peyote
  34. 34. Peyote• Discovered by the indians of Northern Mexico (Mescal) & the Navajo of the SW U.S.• Used in religious ceremonies for centuries – Gives “deep introspection” & insight; auditory & visual hallucinations• By federal law, only legal for Indians performing “legitimate” ceremonies• Mescaline active ingredient – effect lasts up to 12 hours• Non-addictive properties
  35. 35. Mushrooms -Psilocybe
  36. 36. Psilocyb e• Mushrooms used in ceremonies date to 7000 BC• Used by Mayans in 500 BC, named teonanacatl ("flesh of the gods"), healing, divination & communication with spirits• Plant is ingested• Effects last 4 – 6 hrs• Visual & auditory hallucinations
  37. 37. Easter Lily
  38. 38. Tobacco
  39. 39. Tobacc o• 1 BC – Inhabitants of the Americas use tobacco by smoking, chewing & as enemas• Mayans move to SE region of NA, pipe smokers & cigar smokers (sik’ ar)• Columbus given a gift of dried leaves which were “prized”; crew throws them away• 1st smoker jailed by the Spanish Inquisition as the smoke from his nose & mouth scares neighbors• Monk w/Columbus on 2nd trip brings tobacco to Europe• Snuff & chew habits observed by Vespucci• Tobacco trade routes established
  40. 40. Tobacco• Nicotine active ingredient• T1/2 about 60 minutes• Activates nicotinic acetylcholine receptors – Increased adrenaline => inc. HR, inc. BP, inc. SBG – Feeling of both relaxation & invigoration – Temporary increase of basal metabolic rate• Increased DA => reward centers• Increased glutamate => memory loop
  41. 41. • Tobacco each cigarette 40 – 60 mg thought to be lethal, smoked delivers 1 mg, higher if ingested • OD – NV, HA, SOB, palpitations, SZ’s, weakness• Not carcinogenic• Thought to be responsible for SIDS• Schizophrenics thought to self-medicate• Used as Tx for addiction, ulcerative colitis & SZ’s• Tx – Wellbutrin  Zyban
  42. 42. Questions??
  43. 43. Man-made Drugs
  44. 44. Heroin
  45. 45. Heroin• Created from Morphine in 1874• Marketed by Bayer in 1898 as a “cure” for morphine addiction, marketing blunder 1910 (heroin => MSO4)• Banned in the U.S. 1914, except for addicts; totally banned in 1924
  46. 46. Heroin• Highly lipid soluble – able to rapidly cross blood brain barrier• Converted quickly to morphine – μ opioid receptors => release of neurotransmitters (endorphins)• Highly addictive, tolerance develops quickly
  47. 47. Heroin• Snorting 10 – 15 minutes• IM 5 – 8 minutes• Inhaling “chasing the dragon” within a minute• IV 7 – 8 seconds
  48. 48. Heroin• Sudden pleasurable feeling, warm flush, sedation• Can react with nausea, vomiting, itching• Inc. risk of HIV & Hep C from needles, bacterial abscesses, heart valve damage (tricuspid), fetal death/addiction• OD – respiratory depression• Can be poisoned by “cutting” agents
  49. 49. Heroin• Withdrawal SSx: restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes w/goose bumps ("cold turkey"), & leg movements. – Peak between 24 - 48 hrs after last dose; subside ~ week• Tx – Narcan (Naloxone); dry to wet
  50. 50. Heroin• Methadone – Made in 1937 as an analgesic – Derivative of morphine – Replaces “need” for heroin – $20 for 1 month’s supply – Can be taken orally – Withdrawal more severe & prolonged, naloxone gtt – Used in extreme & chronic pain conditions
  51. 51. Methamphetamine
  52. 52. Methamphetamin es• Made in 1919 in Japan• WWII – Germans give to pilots in chocolate bars• Made in labs until 1980’s when ingredients banned• Pseudoephedrine & ephedrine principle ingredients• Still made in clandestine labs – highly flammable
  53. 53. Methamphetamines• Causes increase of norepinephrine & dopamine• Blocks reuptake & breakdown of both• Increased HR, BP, glucose release, vasoconstriction• Increased focus, mental alertness, appetite suppressant• Short term tolerance (2 – 3 days) due to production overload• Side effects: jitteriness, twitches, repetitive motions (“tweaking”), teeth grinding, insomnia, ED
  54. 54. Methamphetamines• “meth mouth” – dec. production of saliva => inc. thirst, met w/high sugar drinks => cavities & tooth decay• “speed bumps” – tracts, abscesses• OD – arrhythmias, hyperthermia, stroke, SZ – Formication “skin crawling”, paranoia, hallucinations, cognitive deficits• Used medically for ADHD, wt. loss
  55. 55. PCP –phenylcyclohexylpiperidine
  56. 56. PCP• 1950’s - Parke-Davis pharmaceuticals – Initially developed as anesthetic, but too many SE’s (hallucinations, SZ’s) – Developed into a recreational drug – Binds to NMDA receptor (ie: nicotinic ACh receptor) & causes continued firing
  57. 57. PCP• Leads to psychotic symptoms (heightened senses & experiences)• Aggression or sexual frenzy, feeling of “super powers”• Schizophrenic ideations - delusions, hallucinations, paranoia, disordered thinking• Death by suicide or accidental injury
  58. 58. Ketamine Developed 1962, alternative • to PCP • Given to soldiers in Vietnam war – Emergence phenomenon • Use in Veterinary medicine as analgesic & anesthetic • Dissociative properties similar to PCP but shorter- lasting • Popular at Raves
  59. 59. LSD –lysergic acid diethylamide• Developed in 1938 – Inventor discovered psychoactive properties 5 yrs later• 1950’s use by intelligence agencies• Given free to researchers in the 60’s – Harvard experiment lead to counter culture• Banned in U.S. 1967
  60. 60. LSD• Highly potent – 20 – 30 μg for effect, typical “hit” 125 μg• Acts on DA & serotonin receptors• Psychological dependence, uterine contractions• SE – “bad trip,” distant flashbacks• Tx w/BDZ’s• No known cases of OD
  61. 61. MDMA –3,4-methylenedioxymethamphetamine Ecstasy, XTC Ecstasy, XTC • Made in 1912, inventor died 1916, not used by humans x 50 yrs, production of styptic • Used in the 1970’s for psychotherapy – Made pts more communicative, increased introspection, dec. inhibitions • Recreation use started in discos, gay clubs, spread to raves • Made illegal in 1985
  62. 62. MDMA – 3,4-methylenedioxymethamphetamine Ecstasy, XTC• Binds to receptors => inc. in DA, NE, & serotonin – Leads to feelings of well-being, openness, dec. inhibitions, visual enhancement• Dehydration, inc. HR & BP, nystagmus, pupil dilation, insomnia• OD – similar to amphetamines – hyperthermia, dehydration  hyperpyrexia  rhabdomyolysis  renal failure, arrhythmias, water toxicity  hyponatremia
  63. 63. Inhalan ts• Include: – glues, paint thinners, dry cleaning fluids, gasoline, felt- tip marker fluid, hair spray, deodorants, spray paint, & whipped cream dispensers• Intoxication effect
  64. 64. Inhalan ts• Sniffing - open container vapors• Huffing - spray onto rag and then place over nose/mouth• Bagging - spray into bag and then place over face/mouth• Dusting - inhaling from aerosols
  65. 65. Inhalan ts• Organic or chemical solvents enter bloodstream• Cause effects similar to EtOH intoxication• Death can occur (Sudden Sniffing Death Syndrome), suffocation• Brain & organ damage, loss of smell, respiratory problems
  66. 66. Didn’t stop someonefrom trying it
  67. 67. GHB γ-hydroxybutarate• Found naturally in the body – protects cells from oxygen deprivation• Precursor to GABA – Wakefulness, physical activity, sleep• 1960’s synthesized• Used – anesthetic, insomnia Tx, depression
  68. 68. GHB• Mode of action still not well-known• Acts at GABA receptors => sedation – Low dose: • State of euphoria, inc. libido, inc. social interaction, intoxication – High dose: • Nausea, dizziness, sedation, amnesia, unconsciousness, dec. breathing, visual changes – Effects can last 1.5 - 3 hrs• Deaths from oversedation, esp. when used w/EtOH
  69. 69. Bath Salts - Mephedrone,MPDVSold over the counter as“vanilla sky” or “white knight”Increased in popularity 2011Multiple reported cases ofoverdose including some deaths
  70. 70. Bath Salts -MephedroneAct as a “cocaine substitute”Pleasurable high, easy to overdoseUnknown additivesTriggers intense cravings, highpotential for abuse & addiction
  71. 71. Bath Salts - MephedroneVisits to ED for Chest pain Elevated blood pressure Tachycardia Hallucinations Agitation Paranoia
  72. 72. Steroids• Synthetic version of testosterone• Psychological dependence due to body image• Abuse dosage 10 – 100x greater than medical Tx uses• Used for muscle-wasting diseases, testerone-deficient diseases
  73. 73. SteroidsSE: Stunted growth in adolescents Masculinization of women Altered sex characteristics of men (gonadotrophy)Risks Premature heart attacks, strokes Liver tumors Kidney failure Psychiatric phenomenon – steroid psychosis HIV or hepatitis.
  74. 74. Questions???
  75. 75. EtOH –ethanol
  76. 76. Beer• Fermented beverages have been around since people stopped being nomadic and settled in certain regions• Beer invented in the Mesopotamia about 6,000 yrs ago – Left people feeling "exhilarated, wonderful and blissful."• Beer “bibere” (L) = to drink• Cerveza from the Greek goddess of agriculture, Ceres• Chang = Tibetan beer• Chicha = corn beer• Kumis = fermented camel milk
  77. 77. Wine• 2700 BC wine symbols found in Egyptian drawings• No vineyards, but traded with other cultures for grapes• Soon developed their own lines of grapes• Wine-making quickly spread
  78. 78. Tequila• Mezcal wine made in 1521 from agave plant• Originally for bandits & rancheros• Tequila from Nahuatl word “place of harvesting plants”• Tequila village founded 1656, export grew in 1700’s along trade route to ocean• 1758 – Jose Cuervo granted royal license to cultivate in region, 1880 selling 10,000 barrels/yr to local market alone• 1944 Mexican government began regulating – Only beverages brewed in region could be called tequila – Had to have at least 51% blue agave – Top brands are 100% blue agave
  79. 79. EtOH - Ethanol• Ethanol very simple molecule• Metabolized to acetaldehyde• Enzyme (aldehyde dehydrogenase) in liver & GI tract breaks down to acetic acid (non-toxic) – By-product used for energy (NADH + H+) in electron transport chain, lipogenesis, and pyruvic acid to lactic acid cycle – Genetic defect in some Asian populations leads to EtOH intolerance – facial flushing syndrome – Women have less gastric aldehyde dehydrogenase
  80. 80. Acetaldehyd• e bloodstream Excess spills over into – Inhibits mitochondrial fxns (DH) • Dec. metabolism of acetaldehyde to acetic acid, more acetaldehyde accumulates, & causes further liver damage • Dec. oxidation of fatty acids leads to build-up – Interferes with activation of vitamins (esp. B)
  81. 81. EtOH • Problems w/excess NADH – Overweight – Fat breakdown (ETC) – Lactic acidosis – Takes pyruvate from glucose cycle => hypoglycemia
  82. 82. Fatty liver• Weekend fatty liver – Bingers – Acute, reversible fatty changes
  83. 83. Hepatiti s• Acute alcoholic hepatitis – Due to mitochondrial damage, toxic effects of acetaldehyde (reduced antioxidants) – Necrotic areas form, hypoxia-induced – Fever, liver tenderness, jaundice – Initially reversible
  84. 84. Cirrhosi s• Irreversible liver damage• Hard, shrunken liver – Fibrosis from chronic damage – Weakness, muscle wasting, ascites, GI hemorrhage, coma
  85. 85. Other effects• Wernicke’s encephalopathy – Thiamine deficiency – poor nutrition – Ataxia, nystagmus• Korsakoff syndrome – Mammilary bodies – Confabulation• CV effects – Cardiomyopathy – Cardio-protective, inc. HDL & dec. platelet aggregation• GI effects
  86. 86. EtOH Intoxication• State legal limits vary (0.08 – 0.10 mg/dl) – 3 oz of ethanol in a 70 kg person • = 12 oz wine, 8-12 oz bottle of beer, 6 oz of whiskey – Occasional drinker will be inebriated w/a level = 0.2, coma/death/resp. arrest at levels of 0.3 – 0.4 mg/dl – Alcoholics can reach levels of 0.7 mg/dl & be functional
  87. 87. FAS• Fetal alcohol syndrome – Acetaldehyde crosses the placenta • Most damaging in first trimester – Even one drink per day can cause – Growth & developmental defects, facial dysmorphology (FAS facies), malformations of brain, CV system & reproductive organs
  88. 88. FAS
  89. 89. EtOH withdrawal• Usually starts 3 – 4 days after last drink – Mild symptoms • Shakiness, anxiety, depression, fatigue, insomnia – Moderate symptoms • Headache, sweating, NV, tachycardia, tremor, clammy skin – Severe symptoms • Agitation, fever, convulsions, delirium tremens (confusion, hallucinations) • Can be fatal
  90. 90. EtOH Tx– Banana Bag • Thiamine, folate, MVI in 1L of fluid– Disulfuram (antabuse) • Inhibits acetaldehyde dehydrogenase • Negative reinforcement
  91. 91. CAGE questions• Have you ever felt you should CUT down on your drinking?• Have people ANNOYED you by criticizing your drinking?• Have you ever felt bad or GUILTY about your drinking?• Have you ever had a drink first thing in the morning (EYE OPENER) to steady your nerves or get rid of a hangover?
  92. 92. Questions????
  93. 93. Thank you! veronicabonales@cep.comwww.slideshare.net/docmonte y hcemsgroup.blogspot.com