Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Drug Abuse
Prof.Dr.dr.M T Kamaluddin,M.Sc.,SpFK
Bagian Farmakologi
Fakultas Kedokteran Unsri
2012
SUBSTANCE ABUSE
- What, why and how to
- Scope dealing with genetic and
environment
- How to handle
- Is there any chance for doctor to do..
Drug Abuse
Self administration of drug or drugs
in manner not in accord with
accepted medical or social patterns
Biology/Genes
Environment
DRUG
Neurobiology
Behavior
Addiction
Genetic Epi
November 2002:
Understanding the social
epidemiology of drug abuse
J anuary 2007:
Special Supplement AJ PM
Fall 2006:
Mapping the social environment
2007:
Recommendations from
participants
Summer-Fall 2004:
Portfolio & literature review
Fall 2004:
Small meeting
Spring 2005: Phenotype Special
Issue J SA
Social Epi
Neuroscience
Transdisciplinary Meeting
Future Initiative?
Genetic Epi
Epidemiological Triad
Genetic theory
Addiction to pleasure
Movement
Motivation
Dopamine
Addiction
Myeli
n
shea
th
Axon
Terminal
branches
of
axon
dopamine
transporters
% of Basal DA Output
200
DA Concentration (% Baseline)
Food
NAc shell
150
100
50
Empty
Box Feeding
0
0
60
Time (min)
120
180
Sex
200
150
100
Sample 1
Number
Female Present
DA
DOPAC
HVA
100
250 Accumbens
150
DA
DOPAC
HVA
100
5 hr
Accumbens
Caudate
3 hr
Cocaine
200
Nicotine
200
Accumbens
300
250
% of Basal Release
400
% of Basal Release
1100
1000
900
800
700
600
500
400
300
200
100
0
% of Basal Release
% of Basal Release
Amphetamine
5 hr
Morphine
Dose
0.5 mg/kg
1.0 mg/kg
2.5 mg/kg
10 mg/kg
200
150
100
5 hr
Glutamate
Regulates
substance dependence
substance abuse
substance intoxications
substance withdrawal
extroversion
Bringing the
Full Power of Science
to Bear on
Drug Abuse
& Addiction
Neurotoxicity
AIDS, Cancer
Mental illness
Homelessness
Crime
Violence
Health care
Productivity
Accidents
What is Addiction?
Addiction is A Brain Disease
Characterized by:
Compulsive Behavior
Continued abuse of drugs despite negative consequences
Persistent changes in the brains structure and function
YELLOW
shows places in
brain where
cocaine binds
(e.g., striatum)
It is preventable
It is treatable
It changes biology
If untreated, it can last a lifetime
Healthy Brain
Diseased Brain/
Cocaine Abuser
Low
Healthy
Heart
Diseased Heart
TOBACCO
1.6%
1.6%
1.4%
1.4%
CANNABIS
ALCOHOL
1.2%
1.2%
1.0%
1.0%
0.8%
0.8%
0.6%
0.6%
0.4%
0.4%
0.2%
0.2%
0.0%
0.0%
55
10
10 15
15
21
21 25
25 30
30 35
35 40
40 45
45 50
50 55
55 60
60 65
65
Age
43
44
45
Effects on society
National health problem
More deaths,illness,accidents,disabilities than any
other health problem
15 million dependent on alcohol
500,000 between ages 9-12
7 million persons between 12-20
binge drink
(Narconon,2005)
Effects of addiction
Abuse
Tolerence
Physical dependence - addiction
Psychologic dependence mind-body
connection
Alcoholism chronic progressive potentially
fatal
Blackouts
WHO classification
Suppressant of central nerve
Nicotine or tobacco
Opioid
antimelancholic
cannabis
hallucinogenic drug
Fugitive compound
52
drug tolerance
Definition
Repeated medication
Characteristic
Different tolerance
Reversability
Cross resistance :
analogic chemcial constitution
mechanism of action
drug dependence
toleration
53
54
Narcotic drug
Consecutive application to bring about
physiological dependence and addiction
Including:
opioids, cocaine, cannabis
55
psychotropic drug
Definition
Repeated medication,
Affect C.N.S excited/inhibited
to bring about psychological dependence
1 Sedativehypnotics / antianxietic:
Barbiturates, benzodiazepines
2 psychostimulant
Amphetamines, ritalin, caffeine
3 psychodelic
Cannabinol, cannabidiol
56
Withdrawal reaction
57
60
Drug Abuse
well-being
Physical Dependency
Physical symptoms if intake reduced
Drug Abuse
drug effects
Tolerance
Increasing doses needed to obtain drug effect
Drug Abuse
Addiction
Includes
Psychological dependence
Physical dependence
Compulsive use
Tolerance
Drug Abuse
Drug Abuse
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
Lethargy
Pinpoint pupils
Bradycardia
Hypotension
Decreased bowel
sounds
Flaccid muscles
Severe
Respiratory depression
Coma
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
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 1950s-60s 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
Barbiturates
As overdose progresses
Depth of coma increases
Hypotension, shock
Hypothermia
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
Placidyl (ethchlorvynol)
Doriden (gluthethimide)
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
Benzodiazepines
Benzodiazepine-like non-benzos
BuSpar (buspirone)
Used for generalized anxiety disorder
Less sedating than diazepam
Less potentiation by other CNS depressants
Neuroleptics
Antipsychotics, major tranquilizers
Used in treatment of schizophrenia, other psychoses
Examples
Haldol
Mellaril
Thorazine
Stellazine
Compazine
Neuroleptics
of skeletal muscles
Reversible with Benadryl
Neuroleptics
Neuroleptics
Neuroleptics
Hyperthermia
Muscular rigidity
Altered LOC
Tachycardia, hypotension
Neuroleptics
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 beta-blockers, including labetolol (Why?)
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
Hallucinogens
Moderate Intoxication
Tachycardia
Mydriasis
Diaphoresis
Short attention span
Tremor
Hypertension
Hyperreflexia
Fever
Hallucinogens
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
Hypoglycemia
Alcohol, drug withdrawal
Infection
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
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
Flunitrazepam (Rhohypnol)
Street names
Rophies
Roche
Roofies
Roachies
R2
La rocha
Roofenol
Rope
Rib
Flunitrazepam (Rhohypnol)
Benzodiazepine
Similar to Valium but 10x more potent
Produced, sold legally in Europe, South
America
Uses
Flunitrazepam (Rhohypnol)
Effects
Disinhibition and amnesia
Onset within 30 minutes, peak within 2 hours,
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
Anxiety, tension
Numbness, tingling of
extremities
Restlessness, confusion
Loss of identity
Hallucinations
Delirium
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
Gamma hydroxybutyrate
Effects
Odorless, nearly tasteless
Tremors
Seizures
Death
Intoxication
Slurred
speech;loss of
coordination;
ataxia; decreased
coordination,
attention/concentration, memory
judgment
W/d detox
4-12n hrs. p last
drink
Course hand
tremor,sweating
T, P,B/P, R
Insomnia, anxiety,
N/V
If no tx.= DTs
Sedatives /Hypnotics
Anxiolytics
Induced effect
Benzodiazapines
& Barbituates
Use: to produce
Drowsiness,
anxiety
Intox-OD
Benzos rarely
fatal when taken
alone; sxs =
Lethergy,
Confusion;
Barbs fatal in
OD-coma,resp
cardiac arrest
W/d detox
Ativan-10 hrs
W/d sxs-6-8 hrs
p last dose
Valium w/d up
to 1 wk
W/d= v/s
Need to taper off
drug
Stimulants amphetamines/cocaine
Intended effect
Excite CNS
Limited clinical
use high abuse
potential
Cocaine-highly
addictive
Intox- OD
High-euphoric
feeling;hyperactivity/vigilance
Talkativeness,
grandiosity,hallucin
ations, anxiety
Repetitive
behaviors, anger ,
fighting
W/d detox
Occurs-few hrsdays
C/b marked
dysphoria;
fatigue; vivid &
unpleasant
dreams; hyper or
insomnia;
psychomotor act.
Opioids: morphine,
heroin,meperidine,codeine,hydromorphone,
Induced effect
Popular for
abuse
desensitize user
to both
physio/psych
pain-induce
euphoria, wellbeing
Intox OD
Intox- develops
quickly c/b apathy,
lethergy,listlessness,
judgment, psychomotor retardation or
agiation, constricted
pupils,slurred speech
Severe o d coma,
Resp. arrest/death
W/d detox
Drug intake ceases
or markedly; c/b
anxiety/restless.,
aching back,legs,
craving for opioids
Heroin w/d
6-24hr;
peak 2-3 days;
Ends=5-7 days
Hallucinogens
Intended
effect
Distort users
perception of
reality
Intoxification/OD
Intox= (Psychologic)
anxiety,depression,
Paranoid delusions,
hallucinations
(Physio) B/P,T,P
dilated pupils,sweating,
blurred vision,tremors,
decreased coordination
Withdrawal/Detox
No withdrawal
symptoms known
-may crave drug
Produce flashbacks
May continue up to
5 years after use.
Pharmacologic treatment
substance abuse
Disulfiram(antabuse)-maintain abstinence
from alcohol
Teach client to read all labels avoid any
product containing alcohol
Lorazepam(ativan) for w/d fro etoh
Monitor V/S/client safety/assess effectiveness
Pharmacologic treatment
140
141
Therapy of clonidine
pharmacologic action of clonidine:
Excitomotor of2 adrenoceptor
Inhibit NC excitation of NE nucleus ceruleus
to control abstinent symptom
therapy
detoxification
convalescent care
142
143
Repeated drug exposure changes brain function. Positron emission tomography (PET) images are illustrated showing similar brain
changes in dopamine receptors resulting from addiction to different substances - cocaine, methamphetamine, alcohol, or heroin. The
striatum (which contains the reward and motor circuitry) shows up as bright red and yellow in the controls (in the left column), indicating
numerous dopamine D2 receptors. Conversely, the brains of addicted individuals (in the right column) show a less intense signal, indicating
lower levels of dopamine D2 receptors.
Forms of Meth
Speed usually comes in the form of white or yellow powder
People usually sniff it through the nose (snort), smoke or inject it.
It can also be swallowed, in the form of tablets or capsules
Speed is often mixed or cut with other things that look the same to make the
drug go further
Some mixed-in substances can have unpleasant or harmful effects
ICE
Making ice, the smokable form of methamphetamine, from standard quality
methamphetamine HCl is essentially a purification process. Methamphetamine HCl is
added slowly to water that has been heated 80-100C until a supersaturated solution is
obtained. When the slurry is cooled, pure HCl salt of methamphetamine (ice)
precipitates. Methamphetamine HCl, unlike cocaine HCl, is volatile and can be
smoked. Other solvents, such as isopropanol, have been used in place of water to
speed the process. Uncontrolled variations of this process can result in unreliable
removal or addition of impurities. The physical characteristics of the final product
depend on the quality and type of reagents used and on contaminants that may have
been introduced. The lack of significant further processing of methamphetamine HCl
has resulted in increased availability and popularity of smoking the drug.
One reason for the popularity of smoked methamphetamine is the immediate
clinical euphoria that results from the rapid absorption in the lungs and deposition
in the brain.
Smoking methamphetamine HCl powder, crystals, or ice occurs first by placing
the substance into a piece of aluminum foil that has been molded into the shape
of a bowl, a glass pipe, or a modified light bulb and heating it over the flame of a
cigarette lighter or torch. Then, the volatile methamphetamine fumes are inhaled
through a straw or pipe.
From emedincine.com
Methamphetamine
Toxicity: Moderate
Flammability: Low
Reactivity: Very Low
OH
CHCHNHCH
CH
EPHEDRINE
CH CHNHCH
2
CH
METHAMPHETAMINE
3
3
Powerful CNS
stimulant
Highly addictive
Usually smoked or
injected
High lasts longer
than cocaine
Prescribed for weight
loss, ADD-type
behaviors
Well-being to Euphoria
Increased Energy
Enhanced Mental Activity
Increased Sex Drive
Decreased Need for Sleep
Decreased Appetite
Increased Sensory Awareness and Alertness
Feeling of Omnipotence
Intensify Emotions
Alter Self-esteem
Increased aggressiveness
59% males
Man-made
Daily use
Longer binges
Smoking produces
a high that last 8-24
hours
50% of the drug is
removed from the
body in 12 hours
Plant-derived
Recreational use
Intermittent binges
Smoking produces
a high that lasts 2030 minutes
50% of the drug is
removed from the
body in 1 hour
Methamphetamine
Measuring Pleasure
Stimulants boost the normal brain levels of the neurotransmitter
dopamine, which produces feelings of pleasure and increases
energy. Methamphetamines causes an excessive spike in
dopamine. Scientists say the excessive release contributes to the
drug's destruction of the brain.
Dopamine Index
Cheeseburger
1.5
Sex
2.0
Nicotine
2.0
Cocaine
4.0
Methamphetamine 11.0
Source: UCLA Integrated Substance Abuse Programs. Michael Mode/The Oregonian
Depleted dopamine
transporter levels in
methamphetamine
abusers show recovery
after prolonged
abstinence.
In these brain scans,
high dopamine
transporter levels appear
as red, while low levels
appear as yellow/green.
Dr. Nora Volkow, Director of
NIDA
(National Institute on Drug
Abuse)
Cognitive Deficits
Neurotransmitter Depletion
Behavior Changes
Psychotic Features
Paranoia
Visual and auditory hallucinations
Mood disturbances
Delusions (ex. The sensation of insects
creeping on the skin)
Homicidal thoughts
Suicidal thoughts
Out of control rages
Can persist for years after use discontinued
Tooth decay
Hepatitis B and C
STDs : sexually transmitted disease
HIV : associated with needle use and unprotected sex
Sexual Impotence
Cognitive impairment (reduced ability to process
information)
Unplanned pregnancy, victims of domestic violence
Physical:
Polyphagia (excessive hunger)
Hypersomnolence (sleepiness)
Psychological:
Depression
Anxiety/agitation Free floating anxiety
Delusional state lasting up to a week
Fatigue/malaise
Paranoia
Hallucinations
Aggression
Intense craving for the drug
Abstinence Syndrome
After awaking from the crash, symptoms continue:
Psychological/Behavioral Symptoms
Dysphoric mood--that may deepen into clinical depression
Abstinence Syndrome
Physiological symptoms
Thin, gaunt appearance with reported weight loss
or anorexia
Dehydration
Fatigue and lassitude, with lack of mental or
physical energy
Dulled sensorium
Psychomotor lethargy and retardation--may be
preceded by agitation
Hunger
Chills
Insomnia followed by hypersomnia
Affordable
Available
Appetite suppressor
Energy enhancer
Weight loss
Mood elevator
Libido enhancer
The growing illicit drug of choice among young
women
47% of those presenting for meth treatment females,
other substances 20-25% females
Children of Parents
with Substance Abuse Problems
Relapse rates for drug-addicted patients are compared with those suffering from diabetes,
hypertension, and asthma. Relapse is common and similar across these illnesses (as is adherence
to medication). Thus, drug addiction should be treated like any other chronic illness, with relapse
serving as a trigger for
Relapse rates for drug-addicted patients are compared with those suffering from
diabetes, hypertension, and asthma. Relapse is common and similar across these
illnesses (as is adherence to medication). Thus, drug addiction should be treated
like any other chronic illness, with relapse serving as a trigger for renewed
intervention.
Pre-Recovery Behaviors/Excuses
Occur with Increased Frequency
Old playmates and
old playgrounds
Person not following
through with AA/NA
meetings or recovery
steps
Cross-addictions
Reuse
can be the use of a drug out of the blue
person may be working an excellent
recovery program
may have had a long period of sobriety
may be avoiding the old friends and old
playgrounds
They may be doing everything right but still
have used
Relapse or Reuse?
Precontemplation
Stage
Contemplation
Stage
Preparation
Stage
Action
Stage
Relapse
Stage
Motivational
Enhancement
Strategies
Assessment
& Treatment
Matching
Relapse
Prevention
& Relapse
Management
Medical Services
Behavioral Therapies
Social Services
In Social Context
Basic Research
Medication
Agonist Therapy
Methadone
Buprenorphine
CB1 Antagonists
Inhibitors of
metabolizing enzymes
CRF Antagonists
Thank you
208
opium
poppy
209
marijuana
210