Chemicals of Abuse

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Chemicals of Abuse
Sean Koon, MD California Academy of Family
Physicians California Society of Addiction
Medicine April 14, 2005
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Substances

• Stimulants
• Cannabis
• Hallucinogens
• Opiates
• Club Drugs

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Stimulants

• Used for
• High
• Energy, increase job performance, driving,
  studying
• Sexual enhancement
• Weight loss

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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

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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

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Cocaine Intoxication

• Effects euphoria, confidence, decreased
  inhibitions
• 1. Rush (1-5 minutes)
• 2. High (10-20 minutes)
• 3. Crash
• 4. (Binge / cycle)

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Clinical Presenting Symptoms

• Chest pain
• Insomnia, fatigue
• Weight loss
• Paranoia
• Nasal infections
• Headaches
• Sexual Dysfunction
• Magnons Syndrome (coke bugs)

More Common
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Coke bugs
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Medical Sequelae Cocaine

• Can cause vasoconstriction or ischemia in various
  organs
• Cardiac
• 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

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Medical Sequelae, contd

• ENT Chronic rhinitis, perf. septum
• Neurologic
• 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)

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Cocaine and ETOH

• Cocaine alcohol cocaethylene
• Enhances the cardiac side effects (MI,
  arrythmias, cardiomyopathy)
• Combination increases the risk of sudden death
  25X

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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

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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

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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

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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)

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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)

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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

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Marijuana, contd

• 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

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Marijuana Intoxication

• Peak high 15-45 minutes
• Acceleration of HR for 10-30 minutes (by 30-50),
  moderate increase in BP
• Poor judgment and motor coordination (for 4-8
  hours even after the high is gone
• Very significant risk in driving
• Redding of the eyes
• Slight drop in body temp.
• Dryness of mouth and throat, possible blistering

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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

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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
• Can serve as a gateway drug (3x more likely
  to lead to dependency if smoked before 18 years
  old)

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MJ Medical Applications

• Medical applications
• Antiemetic
• Pain management (esp. neuropathic and
  inflammatory pain in cancer patients)
• Asthma
• Glaucoma
• Appetite stimulant

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HallucinogensLSD

• POTENT One ounce567,000 hits
• Taken on blotter paper, gels, or sugar cubes
• Effect in 30-60 minutes. May last for up to 12
  hours

Its believed that as few as 10 people make all
of the LSD used in the US!
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LSD contd

• 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

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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 concentrations

• Three levels of intoxication
• Low dose drunken state
• Mod. dose agitation, hallucinations, muscle
  rigidity, poor coordination, marked nystagmus
• Big dose convulsions, respiratory depression,
  cardiac instability, coma
• Possible agitation in withdrawal, 11-15 hrs
  after last dose
• Flashbacks (true chemical)

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PCP Medical Sequelae

• Rhabdomyolysis
• Renal failure
• Intractable seizures
• Hyperthermia
• HTN, CVA
• Psychosis

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Opiates Heroin

• Desired effect euphoria
• Respiratory depression
• Sometimes a purchase has greater purity than
  expected
• Nearly all heroin ODs secondary to this
• Often combined with cocaine to make
  speedballs
• Most medical complications are due to
  injection use
• Heavy risks of the Heroin lifestyle

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Heroin Withdrawal

• Usually peaks in 24-72 hours, gone by 7-10 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. Eys lecture)

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Medical Concerns with Injection Drug Users

• Hepatitis, especially Hepatitis C
• Transmitted by blood needles, syringes, cottons,
  cookers, rinsewater
• Studies claim 70 Heroin users are Hep C
• Infective endocarditis, typically right sided,
  50 staph, 15 strep
• Pneumonia
• concomitant cigarettes, malnutrition, depressed
  gag reflex
• More often H. flu, S. aureus, Ps. aeruginosa
  relative to non-IDUs
• IDUs have increased risk of TB activation,
  unknown why
• Cellulitis, abscesses (mostly staph, often strep)
• HIV

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Medical Issues with Injected Drugs, contd

• Necrotizing fasciitis
• Pain way out of proportion to findings
• Medical emergency
• Renal
• Nephrotic syndrome
• Glomerulonephritis (usually from to bacterial
  endocarditis)

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Notable RX opiates

• Meperidine, Propoxyphene, and Pentazocine (and
  tramadol the partial agonist)
• 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

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Club Drugs

• Used typically by teens/youth
• GHB (Gamma Hydroxybutyric acid)
• Liquid, dosed in capfuls
• Rapid onset, ½ life 20 minutes
• Side effects
• Dizzines, nausea, emesis, dec. resp, coma
• Overdose similar to sedatives, consciousness
  returns within 5 hours after ingestion

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Club Drugs

• Ketamine
• Similar to PCP
• SEs confusion, delirium, psychosis,
  coma,seizures
• DMX (dextromethorphan) euphoria, dissociation,
  hallucinosis
• May last 3-6 hours
• Doses up to 100x therapeutic dose (esp.
  Coricidin HBP)

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Club Drugs Ecstasy/MDMA

• Desired effects
• Stimulant/psychedelic
• Altered time perception
• Decreased aggression/sexual activity
• Empathy, Enhanced touch
• Light trailers

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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

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MDMA Adverse effects

• Causes large amounts of serotonin to be 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)

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Sedatives

• Interact with GABA Receptor
• Cross-tolerant with alcohol, thus useful for
  withdrawal
• Benzodiazepines
• Barbiturates
• 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

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Questions

• Primary Care Workshop
• California Academy of Family Physicians
• and
• California Society of Addiction Medicine
• April 14, 2005