Psychoactive drug intoxication and withdrawal

Question 1

Depressants

Answer 1

Nonspecific: mood elevation, DEC anxiety,
sedation, behavioral disinhibition, respiratory
depression.

Nonspecific: anxiety, tremor, seizures, insomnia.

Question 2

Alcohol

Answer 2

Depressants

Emotional lability, slurred speech, ataxia, coma, blackouts.

Serum γ-glutamyltransferase
(GGT)—sensitive indicator of alcohol use.

AST value is twice ALT value.

WITHDRAWAL

Mild alcohol withdrawal: symptoms similar to other depressants.

Severe alcohol withdrawal
can cause autonomic hyperactivity and *DTs
(5–15% mortality rate).

TX for DTs:
benzodiazepines.

Question 3

Opioids

Answer 3

Depressants

Euphoria, respiratory and CNS depression, DEC gag reflex, pupillary constriction (pinpoint pupils), seizures (overdose).

Most common cause of drug overdose death.

TX: naloxone, naltrexone.

WITHDRAWAL
Sweating, dilated pupils, piloerection (“cold turkey”), fever, rhinorrhea, yawning, nausea, stomach cramps, diarrhea (“flu-like” symptoms).

TX: long-term support, methadone, buprenorphine.

Question 4

Barbiturates

Answer 4

Depressants

Low safety margin, marked respiratory depression.

TX: symptom management
(eg, assist respiration, INC BP)

WITHDRAWAL
Delirium, life-threatening cardiovascular collapse.

Question 5

Benzodiazepines

Answer 5

Depressants

Greater safety margin. Ataxia, minor respiratory depression.

TX: flumazenil
(benzodiazepine receptor antagonist, but rarely used as it can precipitate seizures)

WITHDRAWAL
Sleep disturbance, depression, rebound anxiety, seizure.

Question 6

Stimulants

Answer 6

Nonspecific: mood elevation, psychomotor agitation, insomnia, cardiac arrhythmias,
tachycardia, anxiety.

WITHDRAWAL
Nonspecific: post-use “crash,” including depression, lethargy, INC appetite, sleep
disturbance, vivid nightmares

Question 7

Amphetamines

Answer 7

Stimulants

Euphoria, grandiosity, pupillary dilation, prolonged wakefulness and attention,
hypertension, tachycardia, anorexia, paranoia, fever.

Severe: cardiac arrest, seizures.

TX: benzodiazepines for agitation and seizures.

WITHDRAWAL
Anhedonia, INC appetite, hyper somnolence, existential crisis

Question 8

Cocaine

Answer 8

Stimulants

Impaired judgment, pupillary dilation, hallucinations (including tactile), paranoid
ideations, angina, sudden cardiac death.

TX: α-blockers, benzodiazepines.
β-blockers not recommended.

WITHDRAWAL
hyper somnolence, malaise, sever psychological craving, depression/suicidality

Question 9

Caffeine

Answer 9

Stimulants

Restlessness, INC diuresis, muscle twitching.

WITHDRAWAL
Headache, difficulty concentrating, flu-like symptoms

Question 10

Nicotine

Answer 10

Restlessness

WITHDRAWAL
Irritability, anxiety, restlessness, difficulty concentrating.

TX: nicotine patch, gum, or lozenges; bupropion/varenicline.

Question 11

Phencyclidine (PCP)

Answer 11

Hallucinogens

Violence, impulsivity, psychomotor agitation,
nystagmus, tachycardia, hypertension, analgesia, psychosis, delirium, seizures.

Trauma is most common complication.

Treatment: benzodiazepines, rapid-acting antipsychotic

WITHDRAWAL
depression, anxiety, irritability, restlessness, anergia, disturbances of thought and sleep

Question 12

Lysergic acid diethylamide (LSD)

Answer 12

Hallucinogens

Perceptual distortion (visual, auditory), depersonalization, anxiety, paranoia, psychosis, possible flashbacks.

Question 13

Marijuana (cannabinoid)

Answer 13

Hallucinogens

Euphoria, anxiety, paranoid delusions, perception of slowed time, impaired judgment, social withdrawal,  INC appetite, dry mouth,
conjunctival injection, hallucinations.

Pharmaceutical form is dronabinol
(tetrahydrocannabinol isomer): used as antiemetic (chemotherapy) and appetite
stimulant (in AIDS).

WITHDRAWAL
Irritability, anxiety, depression, insomnia, restlessness, DEC appetite.

Generally detectable in
urine for up to 1 month.

Question 14

MDMA (ecstasy)

Answer 14

Hallucinogens

euphoria, disinhibition, hyperactivity.

Life-threatening effects include hypertension, tachycardia, hyperthermia, hyponatremia, serotonin
syndrome.

WITHDRAWAL
Depression, fatigue, change in appetite, difficulty concentrating, anxiety

Question 15

Delirium tremens (DT)

Answer 15

*Life-threatening alcohol withdrawal syndrome that peaks 2–4 days after last drink.

Characterized by autonomic hyperactivity (eg, tachycardia, tremors, anxiety, seizures).

Classically occurs in hospital setting (eg, 2–4 days postsurgery) in alcoholics not able to drink as inpatients.

TX: benzodiazepines.

*Alcoholic hallucinosis is a distinct condition characterized by *visual hallucinations 12–48 hours after last drink.

TX: benzodiazepines (chlordiazepoxide, lorazepam, diazepam).