LECT Drugs of abuse/opiates - MacIntyre

Question 1

methamphetamine effects

Answer 1

this is an amphetamine

Highly addictive & toxic to dopamine nerve terminals → brain damage, esp in frontal cortex (teens > adults)

Can cause ↑BP/HR/temperature,

dilated pupils,
irregular heartbeat, muscle twitching (“tweaking”),

mood disturbances, wt loss, psychosis, dental problems, teeth grinding, insomnia, violence and extreme agitation

Question 2

Prescription stimulants

Answer 2

type of amphetamine

Abuse or overuse can cause anxiety, ↑ BP/HR, irritability, psychosis (esp paranoia), weight loss, insomnia, cardiovascular effects, teeth grinding

abuse is on the rise, especially college age

don’t give benzo’s for patients who are agitated and having side effects. lower the dose

Women are using AD/HD medication at notably higher rates than girls, with those in the 26-to-34 age range posting a staggering 85 percent jump in the use of such drugs in just five years

Question 3

bath salts effects

Answer 3

Surge in serotonin, norepinephrine, and dopamine (10x more dopamine than cocaine?)**

(↑risk Serotonin Syndrome)

Can cause: chest pains, ↑BP/pulse, agitation, hallucinations, suicidality, extreme paranoia, delusions, and extreme violence***

Question 4

effects of marijuana

Answer 4

Causes euphoria, ↑appetite, sense of relaxation;

can also cause tachycardia, injected conjunctivae, dry mouth, paranoia, distorted perceptions, and difficulty with memory or complex tasks

May accelerate psychosis in those predisposed

Gateway drug?

Question 5

substance in bath salts

Answer 5

Contain amphetamine-like chemicals:
methylenedioxypyrovalerone (MDPV),

mephedrone

pyrovalerone

Question 6

Spice , K2

Answer 6

fake weed
synthetic cannabinoids

Causes effects similar to marijuana;

in some cases, can be more potent and cause anxiety &/or psychosis.

Can also cause ↑ heart rate & BP, vomiting, pulmonary irritation

May contain heavy metal elements…and…really whatever else you could think of

schedule 1 drug

Question 7

effects of cocaine

Answer 7

“Blow, snow, coke”

Causes psychomotor agitation (“crack dance”),
dilated pupils,

↑BP/HR/energy/speech,

euphoria,
sinus problems;
chest pain,
risk of HIV or hepatitis transmission;

can also cause MI thru vasoconstriction (24-fold increased risk!)

Surge of dopamine release (150x more powerful than orgasm…?) ** uses a lot of available dopamine –> depletion –> depression, usu temporary but can be profound (“crash”) & accompanied by hypersomnia

Question 8

Name 3 hallucinogens

Answer 8

Psilocybin (shrooms)
LSD
Ecstasy (MDMA, X, XTC, love drug, molly, adam, rave drug)

Question 9

Psilocybin

Answer 9

Shrooms

cholinergic rush…
Causes distorted perceptions, dilated pupils, hallucinations, cholinergic excess, ↑BP/HR/temperature, anxiety, nausea

LSD frequently in play

Question 10

effects of LSD

Answer 10

Produces vivid hallucinations and distorts reality;

can also cause ↑BP/HR/temp and insomnia

Can produce “bad trips-” and “flashbacks”

lasts 8-12 hrs

Question 11

ecstasy (3,4-methylenedioxymethamphetamine)

Answer 11

aka MDMA, X, XTC, love drug, Molly, Adam, rave drug

↑serotonin release (↑ risk Serotonin Syndrome)

Causes intense feelings of mental stimulation, emotional warmth, connection to others, energy;

can also disrupt temperature homeostasis (↓thirst signal), cause nausea, chills, muscle cramps, teeth clenching, ↑HR/BP, pupillary dilation.

Death can occur thru dehydration

Question 12

what can happen with long term use of ecstasy

Answer 12

Use can lead to destruction of serotonergic neurons. Long-term use theorized to –> depression

Question 13

inhalants?

high effects

Answer 13

Causes rapid high; can resemble EtOH intoxication. Inhaling greater quantities can result in feelings of sensation loss and/or unconsciousness

Question 14

what are the adverse outcomes of inhalants

Answer 14

Extremely dangerous and/or deadly:

many contain heavy metals; can cause kidney failure, suffocation (inhalants displace O2), hearing loss, limb spasms, bone marrow damage, organ damage, or death

Question 15

PCP

Answer 15

aka angel dust, wet, embalming fluid, sherms, ozone, wack. Original name/use: Sernyl

Mimics schizophrenia-like ***(psychosis (NMDA antagonist)

Dissociation
detachment
increased BP/HR
nystagmus
sensation of heat
unusual strength 
anesthetic effects
volatility and unpredictability 
pt's can be highly agitated 

making “ssssss’ noise

“Everything must go”

Question 16

Ketamine effects

Answer 16

aka Special K, vitamin K, jet, cat tranquilizer

Sx incl dreaminess, ataxia, ↓sensations, emotional warmth, epiphanies**, hallucinations, near-death experiences, blackouts, etc.

“arms are 40 feet long”

could eventually be used for depression !! under intense study

30-60 min duration of effects

Question 17

chronic benzodiazepine use

Answer 17

much like alcohol use, leads to ↑regulation of NMDA receptors, and ↓regulation of GABA receptors –> CNS hyperactivity in withdrawal.

Risk of seizure from benzo withdrawal just like EtOH withdrawal. Withdrawal can present as a delirium. These pts need detox

Careful w/Flumazenil: can precipitate acute, severe withdrawal

Question 18

benzo’s and alcohol? benzo’s and other sedatives?

Answer 18

Wide therapeutic window; however, be very careful if/when prescribing benzos to someone on other sedatives or opiates (risk of respiratory depression, delirium). Should not be given to those abusing alcohol. Period.

Question 19

abuse of benzos looks like what in a pt?

Answer 19

Abuse can cause sedation, lethargy, memory problems, ataxia, slurred speech & sent 123,000 people to the ED in 2011

Question 20

barbituates

Answer 20

low therapeutic window

Abuse  tolerance. If drug is stopped abruptly, withdrawals and seizure can occur.

Intoxication similar to benzo picture and carries same risk of seizures

These pts also need detox

Question 21

dextromethorphan

Answer 21

Dextromethorphan (aka “Robotripping” and “DXM”)

Popular among younger set
Dissociative
Dangerous w/serotonin agents, other anticholinergics, risk of Olney’s Lesions?

Question 22

why don’t you give a benzo to someone with acute agitation from alcohol (substance abuse)

Answer 22

b/c its making them more drunk/toxic

Question 23

which pt’s (substance abuse) require detox

Answer 23

benzo’s
barbs
etoh
opiates

Question 24

what is speedball

Answer 24

cocaine mixed with heroin

energy and relaxed combo
heart pounding
sympathomimetic response

heroin is an opiate and causes the relaxing part

Question 25

methamphetamine route of admin

Answer 25

Can be swallowed, snorted, injected or smoked

Question 26

Rx stimulants route of admin

Answer 26

Can be swallowed, snorted, or injected

Question 27

bath salts route of admin

Answer 27

po, inhale, IV, vape

Question 28

synthetic cannabinoids route of admin

Answer 28

Smoked or used as herbal infusion in drink

Question 29

route of admin of cocaine

Answer 29

Can be smoked (“crack”), snorted or injected; Can be mixed w/heroin (“speedball”)

Question 30

route of admin of psilocybin

Answer 30

Swallowed or used in tea

Question 31

route of admin of LSD

Answer 31

Tablets, capsules, liquid, or absorbent paper. Lasts 8-12 hrs

Question 32

route of admin of ecstasy

Answer 32

Taken orally

Question 33

PCP route of admin

Answer 33

Usually smoked; can be swallowed or snorted

Question 34

ketamine route of admint

Answer 34

snorted, ingested or IM

Question 35

how many people die per day from opioid OD

Answer 35

44 that's b/c these are so addictive Physiologic dependence is pure misery for most people. It robs them of life and livelihood and can lead to incarceration due to criminal acts pursued to obtain the drug (prostitution, theft, etc)

Question 36

people who die of drug OD often have combo of what in their bodies

Answer 36

benzos and opioids

Question 37

what percent of pt's prescribed opiates for 30 days are taking them 3 years later

Answer 37

1/2 !

Question 38

MC opiates and routes of admin

Answer 38

Oxycontin Vicodin (acetominophen/hydrocodone) Percocet (Oxycodone/Acetaminophen) Swallowed or crushed and snorted, sometimes injected as well

Question 39

effects of opiate "high"

Answer 39

Leads to feelings of euphoria and sedation. Causes constricted pupils, slurred speech, impaired coordination. Can cause ↓BP/HR and respiratory depression*** Consider drug-drug interactions and CYP-450 system (most of these are metabolized thru liver)  possible ↑ risk of respiratory depression if you are taking a 3A4 inhibitor then the level of opiates will go up

Question 40

aka H, horse, dope, junk, smack

Answer 40

Heroin full opiate agonist IV, IM, snorted (sometimes smoked but not efficient, $$), “skin popping”

Question 41

effects of heroin "high"

Answer 41

Euphoria, sedation, constricted pupils, impaired coordination, can cause ↓BP/HR, respiratory depression (dangerous when combined w/other substances) IV use  shared/dirty needles  risk of HIV, HCV, HBV, cellulitis, sepsis, bacterial endocarditis, etc Street heroin can be “cut” w/adulterants; some can be harmful/deadly (Fentanyl, barbiturates, household powders, etc)

Question 42

Intoxication symptoms of opiates ****

Answer 42

``` Intoxication symptoms Pupillary constriction Flushing Sedation Slurred speech Bradycardia Hypotension Respiratory depression Hypothermia Constipation (nausea/vomiting are rarer) ``` Intoxication rapid if IV, delayed if po. Duration of effect depends on the drug (wide variety available) Typically, users always yearn for that first high that can never be recreated (“chasing the dragon”)

Question 43

Withdrawal symptoms of opiates ****

Answer 43

``` Withdrawal symptoms Pupillary dilation Piloerection Nausea Vomiting Diarrhea Lacrimation Rhinorrhea Joint/muscle pain Abdominal cramps Yawning ``` Withdrawal peaks in 3-4 days (for short-acting opiates, longer for others), but symptoms can continue for weeks, even months Won’t kill you…but it’s very unpleasant

Question 44

how do you prevent opioid-related death

Answer 44

Watch for co-morbid respiratory conditions (asthma, PNA, flu, OSA). Reduce opiate dose 20-30% in the presence of these Do not use extended-release opioids for acute pain. Period. Avoid benzos! If they must be used, consider reduction of opioid dose. Benzos enhance opioid toxicity and runs risk of resp depression Rx Naloxone when/where appropriate

Question 45

Naloxone (Narcan)

Answer 45

Now available for patients, friends, family (check your State law). In CO, anyone who is an interested party in someone’s care can obtain a Rx for it If a patient is using ≥100mg morphine equivalents/day, this is recommended The same drug that the ED uses to reverse opiate OD (opiate antagonist) Available as shown, in “Epi-Pen”-like format, or intranasal as well

Question 46

what are detox treatment options (detox is the first step in opiate treatment)

Answer 46

“Cold turkey” Methadone: start w/approx 20-25mg/day and decrease by 5mg/day Buprenorphine: start w/4mg upon 1st signs of withdrawal and, if sx persist in 1 hr, give another 2-4mg dose. For the next couple of days, give 8-12mg daily and then begin to taper Supportive medications: Trimethobenzamide (for nausea/vomiting), Dicyclomine (stomach cramps), Loperamide (diarrhea), Ibuprofen (muscle/joint pain) all used during withdrawal period Clonidine is very useful both as monotherapy for mild withdrawal or as adjunct tx for “supportive medication” option above. Good at treating tremor, diaphoresis, and agitation

Question 47

why is maintenance required after detox

Answer 47

Detox does absolutely nothing to address cravings (physiological and psychological) Other agents are usually required after the detox period to assist the patient in remaining sober. Many patients are simultaneously both detoxed and transitioned to new treatment (methadone, etc.) Patients who do not transition to maintenance treatment have an extremely high likelihood of returning to drug use

Question 48

pros of using methadone

Answer 48

long ½ life --> once daily dosing Safety Safe in pregnancy (fetal withdrawal can be fatal) Intoxicating effects are less euphoric and less sedating than heroin Pts may eventually be allowed to utilize daily tablets from home

Question 49

cons of using methadone

Answer 49

Usu have to go to clinic daily Can’t leave clinic vicinity > 1 day (“the methadone chain”) Prolongs QT Multiple drug-drug interactions Use is restricted only to certain facilities Patient is still opioid-dependent

Question 50

LAAM Levo-α-acetylmethadol

Answer 50

Very similar to Methadone treatment except that the dosing is less (2-3x/week vs. daily) Many of the same problems with Methadone exist

Question 51

buprenorphine

Answer 51

High affinity for opioid receptors mu (as partial agonist) and kappa (as antagonist) prevents binding of other opiates Can cause nausea/vomiting Lower potential for abuse because partial activation produces much less effect (↓euphoria) and ↓risk of resp depression as partial agonist don't need to go to the clinic every day to get the drug, you can take it at home

Question 52

route of admin of buprenorphine

Answer 52

Sublingual d/t poor oral bioavailability | Still can be abused, esp if taken IV. Can still be fatal

Question 53

Suboxone

Answer 53

Combo of Buprenorphine/Naloxone Buprenorphine: partial agonist, quick onset, prevents binding of other opiates--> sublingual so works very quick Naloxone: opiate antagonist w/poor sublingual bioavailability Can still be abused In combination: Poor oral bioavailability, needs sublingual release When taken sublingually, only the buprenorphine is absorbed (not naloxone) If crushed and injected, pt goes into withdrawal Office-based, portable allows outpatient treatment of opioid dependence

Question 54

Naltrexone MOA uses

Answer 54

Synthetic opiate antagonist Begin 7-10 days after last opiate use to avoid precipitation of withdrawal Comes in IM depot form Also effective for EtOH and possibly cocaine

Question 55

Naltrexone ADR's

Answer 55

Hepatotoxic: baseline liver fxn tests & monitor LFTs Requires that the patient carry an alert card notifying medical personnel that they are on an opiate antagonist and add’l higher doses of opiates may be needed in an emergency to overcome blockade