Download Illicit Drugs: What the Primary Provider Needs to Know

Illicit Drugs: What the Primary
Provider Needs to Know
Deborah A. McMahan, MD
Health Commissioner
Andy McCanna, MD, FACEP, FAAEM
Medical Director for Emergency Services,
Lutheran Hospital of Indiana
Agenda
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Brief Overview of the Addicted Brain
Heroin
Methamphetamine
Spice (Synthetic Cannabinoids)
Marijuana
Overview of the Addicted Brain
The Brain and Addiction
• The abnormalities that produce addiction are wideranging, complex, and long-lasting.
• They involve an interaction of environmental effects
including:
–
–
–
–
stress
the social context of initial opiate use
psychological conditioning
a genetic predisposition in the form of brain pathways that
were abnormal even before the first dose of opioid was taken.
• Such abnormalities can produce craving that leads to
relapse months or years after the individual is no longer
opioid dependent.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851054/
Other Drug Effects on the Brain
• Drug addiction causes lasting changes in brain
function that are difficult to reverse.
• Chronic exposure to drugs disrupts the way critical
brain structures interact to control and inhibit
behaviors.
• Just as continued abuse may lead to tolerance or
the need for higher drug dosages to produce an
effect, it may also lead to addiction, which can drive
a user to seek out and take drugs compulsively.
• Drug addiction erodes a person’s self-control and
ability to make sound decisions, while producing
intense impulses to take drugs.
https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drugs-brain
The Addicted Brain
• Through different mechanisms all drugs set in
motion a biological process that results in flooding
the nucleus accumbens with dopamine (reward
system).
• Dopamine is responsible for the good feelings or
pleasure we have when we perform an action that
satisfies a need or fulfills a desire.
• This flooding causes a reduction in the natural
capacity to produce dopamine in the reward
system is reduced, but the need persists and the
drug seems to be the only way to fulfill it.
http://www.health.harvard.edu/mind-and-mood/the_addicted_brain
Limbic System
• The limbic system contains the brain’s
reward circuit.
• It is the feeling pleasure that motivates
us to repeat behaviors
• The limbic system is activated by
healthy, life-sustaining activities such as
eating and socializing—but it is also
activated by drugs of abuse.
• Responsible for our perception of other
emotions, both positive and negative,
which explains the mood-altering
properties of many drugs.
https://www.drugabuse.gov/publications/dr
ugs-brains-behavior-scienceaddiction/drugs-brain
Drugs and the Brain
• Marijuana and
heroin, activate
neurons because
their chemical
structure mimics
that of a natural
neurotransmitter.
https://www.drugabuse.gov/publications/drugs-brains-behavior-scienceaddiction/drugs-brain
Drugs and the Brain
• Amphetamines cause
the neurons to release
abnormally large
amounts of natural
neurotransmitters or
prevent the normal
recycling of these brain
chemicals.
• This produces a greatly
amplified message,
ultimately disrupting
communication
channels.
https://www.drugabuse.gov/publications/drugs-brains-behavior-scienceaddiction/drugs-brain
Drugs and the Brain
• Most drugs of abuse directly or indirectly target
the brain’s reward system by flooding the circuit
with dopamine.
• Dopamine regulates movement, emotion,
motivation, and feelings of pleasure.
• At normal levels, this system rewards our natural
behaviors.
• Overstimulating produces euphoric effects, which
strongly reinforce the behavior of drug use—
teaching the user to repeat it.
https://www.drugabuse.gov/publications/drugs-brains-behavior-scienceaddiction/drugs-brain
Why are Drugs so Addictive?
• Drugs of abuse release 2 to 10 times the
amount of dopamine that natural rewards
such as eating and sex do.
• This occurs almost immediately and the
effects can last much longer than those
produced by natural rewards.
• The resulting effects on the brain’s pleasure
circuit dwarf those produced by naturally
rewarding
https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drugs-brain
https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drugs-brain
Long Term Impact.,
• For the brain, the difference between normal rewards
and drug rewards can be described as the difference
between someone whispering into your ear and
someone shouting into a microphone.
• The brain adjusts to the overwhelming surges in
dopamine (and other neurotransmitters) by producing
less dopamine or by reducing the number of receptors
that can receive signals.
• As a result, dopamine’s impact on the reward circuit of
the brain of someone who abuses drugs can become
abnormally low, and that person’s ability to
experience any pleasure is reduced.
https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drugs-brain
Long Term Impact
• A person who abuses drugs eventually feels flat,
lifeless, and depressed, and is unable to enjoy
things that were previously pleasurable.
• The person needs to keep taking drugs again and
again just to try and bring his or her dopamine
function back up to normal—which only makes
the problem worse, like a vicious cycle.
• Also, the person will often need to take larger
amounts of the drug to produce the familiar
dopamine high—an effect known as tolerance.
https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drugs-brain
Other Drug Effects on the Brain
• Glutamate is another neurotransmitter that
influences the reward circuit and the ability to
learn.
• When the optimal concentration of glutamate is
altered by drug abuse, the brain attempts to
compensate for this change, which can cause
impairment in cognitive function.
https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drugs-brain
The Addicted Brain
Changes in the reward system alone
cannot explain why addiction persists
• The hippocampus lays down memories of
the rapid sense of satisfaction, and the
amygdala creates a conditioned response
to certain stimuli.
• These memories can be retrieved when
they are exposed to any reminder of
those circumstances — moods,
situations, people, places, or the
substance itself.
• A single small dose of the drug itself is
one of the most powerful reminders
http://www.health.harvard.edu/mind-and-mood/the_addicted_brain
Other Drug Effects on the Brain
• Conditioning is one example of this type of
learning, in which cues in a person’s daily
routine or environment become associated with
the drug experience and can trigger
uncontrollable cravings whenever the person is
exposed to these cues, even if the drug itself is
not available.
• This learned “reflex” is extremely durable and
can affect a person who once used drugs even
after many years of abstinence.
https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drugs-brain
The Addicted Brain and Stress
• Addicts are hypersensitive to
stress, either congenitally or as a
result of past addiction.
• Levels of corticotropin releasing
hormone (CRH) often rise in
addicts just before a relapse,
while the amygdala becomes
more active.
http://www.health.harvard.edu/mind-and-mood/the_addicted_brain
What part of the brain was not functioning
well when this decision was made?
The Addicted Brain – Prefrontal
Cortex
• The prefrontal cortex (CEO
of brain) helps to
determine the adaptive
value of pleasure
recorded by the nucleus
accumbens and checks the
urge to take the drug when
it would be unwise.
• Predicts consequences of
actions
• May not be fully
functioning in addiction
http://www.health.harvard.edu/mind-and-mood/the_addicted_brain
Mental Illness and Addiction
• Because the prefrontal cortex is not fully
developed in adolescence, teens may be
more susceptible to developing
addictions at that time of life.
• Ninety (90) percent of all adults with a
substance use disorder started using
under the age of 18 and half under the
age of 15.
http://www.drugfree.org/wp-content/uploads/2010/08/Drug-Alcohol-Overview-PDF.pdf
The Addicted Brain - Genetics
• Twin and adoption studies show that
about 50% of individual variation in
susceptibility to addiction is
hereditary.
http://www.health.harvard.edu/mind-and-mood/the_addicted_brain
The Addicted Brain and Mental
Illness
For those with depression, anxiety, schizophrenia,
or personality disorders:
• Their reward system may be more vulnerable
• May have more intense responses to stress, or
• May form addictive habits quicker than others.
http://www.health.harvard.edu/mind-and-mood/the_addicted_brain
Common Illicit Drugs in Allen
County
Andy McCanna, MD, FACEP, FAAEM
Medical Director for Emergency
Services, Lutheran Hospital of Indiana
Heroin
Heroin
• Heroin is processed from morphine, a naturally
occurring substance extracted from the seed pod
of certain varieties of poppy plants.
• It is typically sold as a white or brownish powder
that is “cut” with sugars, starch, powdered milk,
or quinine.
• Pure heroin is a white powder with a bitter taste
that predominantly originates in South America
and, to a lesser extent, from Southeast Asia,
https://www.drugabuse.gov/publications/research-reports/heroin/what-heroin
Heroin
• “Black tar” heroin is sticky
like roofing tar or hard
like coal and is
predominantly produced
in Mexico
• Impure heroin is usually
dissolved, diluted, and
injected into veins,
muscles, or under the
skin.
Past Month Heroin Use
https://www.drugabuse.gov/publications/research-reports/heroin/what-heroin
Initial Effects of Heroin
After the initial effects, users usually will:
• Be drowsy for several hours
• Clouded mental function
• Slow heart rate
• Slow breathing
– sometimes enough to be life-threatening, lead to
coma or cause permanent brain damage
https://www.drugabuse.gov/publications/research-reports/heroin/what-heroin
Long Term Effects of Heroin
• Repeated use changes the physical structure
and physiology of the brain, creating longterm imbalances in neuronal and hormonal
systems that are not easily reversed.
• Studies have shown some deterioration of the
brain’s white which may affect:
– decision-making abilities
– the ability to regulate behavior
– responses to stressful situations
https://www.drugabuse.gov/publications/research-reports/heroin/what-heroin
Long Term Effects of Heroin
• Repeated heroin use often results in addiction—a
chronic relapsing disease that goes beyond physical
dependence and is characterized by uncontrollable
drug-seeking no matter the consequences.
• Heroin is extremely addictive no matter how it is
administered, although routes of administration that
allow it to reach the brain the fastest increase the
risk of addiction.
• Once a person becomes addicted to heroin, seeking
and using the drug becomes their primary purpose in
life.
https://www.drugabuse.gov/publications/research-reports/heroin/what-heroin
Medical Effects of Heroin
Medical complications include:
• Insomnia
• Constipation
• Lung complications (including various types of
pneumonia and tuberculosis)
• Mental disorders such as depression and
antisocial personality disorder
• Spontaneous abortion
https://www.drugabuse.gov/publications/research-reports/heroin/what-heroin
Medical Effects of Heroin
Medical complications include:
• Men often experience sexual dysfunction and
women’s menstrual cycles often become irregular
• People who repeatedly snort heroin can damage the
mucosal tissues in their noses as well as perforate
the nasal septum
https://www.drugabuse.gov/publications/research-reports/heroin/what-heroin
Medical Effects of Injection
Medical consequences of chronic injection use
include:
• Scarred and/or collapsed veins
• Infectious disease (e.g., HIV, hepatitis B and C)
• Bacterial infections of the blood vessels and
heart valves, skin abscesses other soft-tissue
infections
https://www.drugabuse.gov/publications/research-reports/heroin/what-heroin
Infective Endocarditis
• Estimates of the incidence of infective endocarditis
(IE) in injection drug users (IDUs) are approximately
2 to 4 cases per 1000 years of IDU have been
described
• IE among IDUs is more common in males (ratio 3:1)
• The average age of patients with IE and IDU is
generally younger than for the age of patients with
IE and no history of IDU (31 versus 42 years in one
study)
• IE is more common in HIV-infected IDUs than in
HIV-uninfected IDUs
http://www.uptodate.com/contents/infective-endocarditis-in-injection-drug-users
Causes of Infective Endocarditis
• Particulate matter injected with the heroin can
cause endothelial damage to the valves
• Patients may also inject bacteria or fungi
present on the surface of the skin, in the drug
itself, or in diluents, fillers, or filters used to
prepare drugs for injection
– Illicit drugs in contaminated syringes may contain up
to 108 organisms/mL
http://www.uptodate.com/contents/infective-endocarditis-in-injection-drug-users
Infective Endocarditis
• IDUs have higher rates of nasal and cutaneous
colonization with Staphylococcus aureus than patients
who use illicit drugs by the oral route exclusively
• Cocaine injection may carry an extra risk of IE due to
associated vasospasm, which can result in skin or other
tissue damage
• Use of saliva as a drug diluent and/or on injection
equipment increases risk for infection from
oropharyngeal flora, including Haemophilus
parainfluenzae, Eikenella corrodens, and Streptococcus
milleri.
–
http://www.uptodate.com/contents/infective-endocarditis-in-injection-drug-users
Clinical features of IE in IDUs
• Patients with tricuspid valve IE often do not have a
detectable heart murmur
• Pneumonia and septic pulmonary emboli are common.
Mycotic aneurysm of the pulmonary artery can also occur;
rupture can lead to hemoptysis [2
• Metastatic infection is common in IDUs with IE due to S.
aureus and can involve the kidney, brain, eye, and spine or
other bones.
• Peripheral manifestations, such as splinter or conjunctival
hemorrhages, are observed less frequently
• IDUs with IE often have coinfections with HIV or hepatitis C
or B that may affect their clinical presentation,
complications, or outcomes.
http://www.uptodate.com/contents/infective-endocarditis-in-injection-drug-users
HIV/Hepatitis
• Injection drug users (IDUs) are the highest-risk group
for acquiring HCV infection
• Each IDU infected with HCV is likely to infect 20 other
people.
• One in three of US AIDS deaths are related to drug
use.
• Hepatitis B infection in IDUs was reported to be as
high as 20 percent in the United States in 2010
– Despite having a vaccine
https://www.drugabuse.gov/publications/research-reports/heroin/what-heroin
Other Medical Effects of Injection
• Many of the additives in street heroin may include
substances that do not readily dissolve and result in
clogging the blood vessels that lead to the lungs,
liver, kidneys, or brain.
• This can cause infection or even death of small
patches of cells in vital organs.
• Immune reactions to these or other contaminants
can cause arthritis or other rheumatologic problems.
http://www.uptodate.com/contents/infective-endocarditis-in-injection-drug-users
Neonatal Abstinence (NAS)
• NAS occurs when heroin passes through the placenta
to the fetus during pregnancy, causing the baby to
become dependent along with the mother.
• Symptoms include:
–
–
–
–
–
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Excessive crying
Fever, irritability
Seizures
Slow weight gain
Tremors
Diarrhea, vomiting
Possibly death
https://www.drugabuse.gov/publications/research-reports/heroin/what-heroin
Laboratory Evaluation
• Metabolites of morphine and heroin can be
detected on a standard urine drug screen for one
to three days after the last use and occasionally
longer in chronic users.
• The presence of 6-monoacetylmorphine (6MAM), a metabolite specific to heroin, on a urine
test distinguishes the use of heroin from other
opioids.
– 6-MAM is a short-lived metabolite. Failure to detect it
in urine positive for opioids does not rule out the use
of heroin or distinguish between heroin and
pharmaceutical opioids.
https://www.uptodate.com/contents/opioid-use-disorder-epidemiology-pharmacology-clinicalmanifestations-course-screening-assessment-anddiagnosis?source=machineLearning&search=heroin+diagnosis&selectedTitle=1~150&sectionRank=1&anc
hor=H134294768#H13
Treatment
• Patients with opioid use disorder who achieve
abstinence through medically supervised opioid
withdrawal or other means often require longterm treatment to prevent relapse.
• Opioid agonist treatment –
Methadone, buprenorphine
• Opioid antagonist treatment – Naltrexone.
• Psychosocial treatment – Psychosocial
interventions are often used in conjunction
with medication.
Meth
Methamphetamine
• Methamphetamine, also called "meth," "crystal meth,"
and "ice," is a stimulant drug that is similar in structure
to amphetamine.
• It is often abused for its long-lasting euphoric effects,
which can increase sexual desire and thus has
contributed to its reputation as an aphrodisiac.
• Meth can be found in various different forms, including
a crystalline form (shown) that can be smoked, a
powder that can be snorted, and a pill that can be
ingested and can also be mixed with liquids and
injected intravenously (IV).
http://reference.medscape.com/features/slideshow/drug-abusemanifestations?src=wnl_clinfoc_160629_mscpref&uac=220761HZ&impID=1139812
&faf=1#page=2
Methamphetamine
Common short-term effects of
methamphetamine include:
• Tachycardia
• Arrhythmia
• Hypertension
• Hyperthermia
• Convulsions
http://reference.medscape.com/features/slideshow/drug-abusemanifestations?src=wnl_clinfoc_160629_mscpref&uac=220761HZ&impID=1139812
&faf=1#page=2
Methamphetamine
Common long-term effects of methamphetamine
include:
• Agitation
• Insomnia
• Anxiety
• Seizures
• Psychotic behavior
Overdoses can result in death from stroke, myocardial
infarction, and hyperthermia-related multiorgan
complications
http://reference.medscape.com/features/slideshow/drug-abusemanifestations?src=wnl_clinfoc_160629_mscpref&uac=220761HZ&impID=1139812
&faf=1#page=2
Dental Effects
• Meth abusers have higher
rates of dental disease with
those who inject the drug
affected more often than
those who inhale and/or
smoke it.
Manifestations:
• Missing, broken, or loose
teeth
• Dental caries
• Periodontal disease
http://reference.medscape.com/features/slideshow/drug-abusemanifestations?src=wnl_clinfoc_160629_mscpref&uac=220761HZ&impID=1139812&faf=1#page=2
Cutaneous Effects
• Due to delusional
parasitosis,
• Other cutaneous
effects include
hyperhidrosis as
well as druginduced allergic
eruptions.
http://reference.medscape.com/features/slideshow/drug-abusemanifestations?src=wnl_clinfoc_160629_mscpref&uac=220761HZ&impID=1139812
&faf=1#page=2
Complications
• Body stuffers (individuals who ingest meth to avoid arrest)
and body packers (individuals who internally conceal large
volumes of drug for transport) are at special risk.
• Body stuffers who present with a heart rate above 120
beats per minute or a temperature over 38°C are at greater
risk of severe outcomes (including: seizures, altered mental
status requiring intubation, creatine kinase
>50,000 U/L, increased troponin, liver transaminase
increase >1000 U/L, and death).
• The number of packets ingested, their size, the wrapping
used, the time from ingestion, and abdominal complaints
(eg, constipation, obstipation, distention, and vomiting) do
not correlate as closely with severe morbidity
https://www.uptodate.com/contents/methamphetamineintoxication?source=search_result&search=methamphetamine&selectedTitle=5~103
Diagnosis and Testing
• Although urine drug tests may support the diagnosis of
acute methamphetamine intoxication, the results of
such a "tox screen" have little clinical utility.
• Work up
– Basic serum electrolytes (ie, sodium, chloride, potassium,
bicarbonate)
– Serum lactate
– Creatinine phosphokinase (CPK)
– Aminotransferases (ie, ALT, AST)
– Clotting times (ie, prothrombin time, activated partial
thromboplastin time)
– Renal function studies (ie, creatinine, BUN)
https://www.uptodate.com/contents/methamphetamineintoxication?source=search_result&search=methamphetamine&selectedTitle=5~103
Meth - Treatment
• Control of agitation and hyperthermia
comprise the core of the acute management
of meth intoxication.
• Some patients also require pharmacologic
therapy for control of hypertension.
• Patients who appear hypovolemic may need
fluid resuscitation.
https://www.uptodate.com/contents/methamphetamineintoxication?source=search_result&search=methamphetamine&selectedTitle=5~103
Meth - Treatment
• Control of violent behavior is of critical importance.
• Treat severely intoxicated patients immediately with IV
benzodiazepines which will blunt the hyperadrenergic
effects of methamphetamine, an outcome associated
with increased survival.
• Second generation antipsychotic agents given IM or
IV), or combinations of these agents can be used as
adjunctive therapy when benzodiazepines do not
adequately control symptoms.
• Physical restraints can be associated with lactic
acidosis, hyperthermia, sudden cardiac collapse, and
death.
https://www.uptodate.com/contents/methamphetamineintoxication?source=search_result&search=methamphetamine&selectedTitle=5~103
Meth - Treatment
• Some patients with severe meth intoxication will
sustain sudden cardiovascular collapse.
• No predisposing factors rigorously predict
collapse
• A direct-acting vasopressor, such
as norepinephrine is preferred for management
of shock associated with methamphetamine
intoxication.
https://www.uptodate.com/contents/methamphetamineintoxication?source=search_result&search=methamphetamine&selectedTitle=5~103
Synthetic Cannabinoids
Spice
• Synthetic cannabinoids (Spice) are analogs of
natural cannabinoids that are chemically
synthesized.
• They were available in Europe as early as
2004, and were first reported in the United
States in December 2008.
• They are classified as Class I controlled
substances by the United States DEA and are
illegal to possess, sell, and use
https://www.uptodate.com/contents/synthetic-cannabinoids-acuteintoxication?source=search_result&search=spice&selectedTitle=1~99
Spice – Signs and Symptoms
• The clinical effects can be similar to natural
marijuana intoxication but may also result in
more severe life-threatening symptoms.
• Because they are constantly changing to avoid
oversight, the changes may introduce
additional toxic effects.
https://www.uptodate.com/contents/synthetic-cannabinoids-acuteintoxication?source=search_result&search=spice&selectedTitle=1~99
Signs of Spice Intoxication
• Compared with cannabis, Spice has a greater
potential for serious neuropsychiatric toxicity
including hallucinations, delirium, and
psychosis.
• Also life-threatening toxicity causing severe
agitation or seizures
• Deaths have been reported, including sudden
death after first-time use of inhaled synthetic
cannabinoids in a 17-year-old adolescent.
https://www.uptodate.com/contents/synthetic-cannabinoids-acuteintoxication?source=search_result&search=spice&selectedTitle=1~99
Signs of Spice Intoxication
•
•
•
•
•
•
Tachycardia
Conjunctival injection (red eyes)
Increased appetite
Nystagmus
Ataxia
Slurred speech
https://www.uptodate.com/contents/synthetic-cannabinoids-acuteintoxication?source=search_result&search=spice&selectedTitle=1~99
Signs of Spice Intoxication
Neurologic findings include:
• Severe psychomotor agitation
• Psychosis
• Seizures
• Hallucinations
• Delirium
• Dystonia
• Paranoia
• Marked motor activity from agitation or seizures may
also cause hyperthermia and rhabdomyolysis.
https://www.uptodate.com/contents/synthetic-cannabinoids-acuteintoxication?source=search_result&search=spice&selectedTitle=1~99
Complications of Spice Intoxication
Spice has also been associated with:
• Ischemic stroke
• Subarachnoid hemorrhage
• Chest pain
• Myocardial ischemia and infarction in
adolescents and young adults without risk
factors for these events
https://www.uptodate.com/contents/synthetic-cannabinoids-acuteintoxication?source=search_result&search=spice&selectedTitle=1~99
Complications of Spice Intoxication
• Inhalation and breath holding during synthetic
cannabinoid use may cause a pneumothorax
or pneumomediastinum with sharp, pleuritic
chest pain and subcutaneous crepitus.
• Can also cause chest tightness with
bronchospasm and wheezing.
https://www.uptodate.com/contents/synthetic-cannabinoids-acuteintoxication?source=search_result&search=spice&selectedTitle=1~99
Diagnosis of Spice Intoxication
• This is a clinical diagnosis
• Rapid urine drug screens will not detect
synthetic cannabinoids
• Confirmatory reference laboratory tests via
liquid chromatography and mass spectrometry
are available but do not return in a timely
manner and will not help with immediate
diagnosis
https://www.uptodate.com/contents/synthetic-cannabinoids-acuteintoxication?source=search_result&search=spice&selectedTitle=1~99
Treatment of Spice Intoxication
• Mild to moderate intoxication with dysphoria
can often be managed with a dimly lit room,
reassurance, and decreased stimulation.
– Benzodiazepines can be helpful with the anxiety.
• Agitation and psychosis — Patients with severe
agitation from synthetic cannabinoid intoxication
usually do not respond to verbal de-escalation
and require sedation with benzodiazepines
– Medical personnel should take precautions to protect
themselves from violent behavior including a security
presence and the application of physical restraints.
https://www.uptodate.com/contents/synthetic-cannabinoids-acuteintoxication?source=search_result&search=spice&selectedTitle=1~99
Treatment of Spice Intoxication
• Hyperthermia — should be managed
aggressively with mechanical cooling
measures.
• Other complications managed as usually
would.
https://www.uptodate.com/contents/synthetic-cannabinoids-acuteintoxication?source=search_result&search=spice&selectedTitle=1~99
Cannabis
Cannabis
• Cannabis is the most commonly used illegal substance
worldwide.
• Approximately four percent of the world’s population
between the ages of 15 and 64 years, have been
estimated to use cannabis at least once in the past
year.
• The psychoactive properties of cannabis are primarily
due to delta-9-tetrahydrocannabinol (THC).
• The THC content of marijuana has increased
significantly since the late 1960s from 1 to 5 percent to
as much as 10 to 15 percent.
https://www.uptodate.com/contents/cannabis-use-disorder-clinical-features-anddiagnosis?source=search_result&search=marijuana+abuse&selectedTitle=2~41
Cannabis
• The cannabinoid
receptor is a G-protein
linked receptor, which
inhibits adenylyl cyclase
and stimulates
potassium conductance.
• There are two known
cannabinoid receptors:
CB1 and CB2
https://www.uptodate.com/contents/cannabis-use-disorder-clinical-features-anddiagnosis?source=search_result&search=marijuana+abuse&selectedTitle=2~41
Routes of Administration
• Inhaled marijuana – After inhalation of
marijuana smoke, onset of psychoactive
effects occurs rapidly with peak effects felt at
15 to 30 minutes and lasting up to four hours.
• Ingested marijuana – Ingestion has a delayed
onset of psychoactive effects that ranges from
30 minutes to three hours.
– Clinical effects may last up to 12 hours.
https://www.uptodate.com/contents/cannabis-use-disorder-clinical-features-anddiagnosis?source=search_result&search=marijuana+abuse&selectedTitle=2~41
Routes of Administration
• Use often consists of smoking in the
form of rolled cigarettes (joints) and
water bongs.
• THC is also extracted using various
solvents (butane, ethanol, hexane,
isopropanol) to create highly
concentrated products (60 to 99 percent
of weight) including oils and tinctures
called "wax," "dabs," "budder," and
"shatters“.
– In addition to being smoked, these highly
concentrated products are also
vaporized (eg, using electronic
cigarettes) or mixed in food products
(such as brownies, cakes, candies, and
beverages) and ingested
https://www.uptodate.com/contents/cannabis-use-disorder-clinical-features-anddiagnosis?source=search_result&search=marijuana+abuse&selectedTitle=2~41
Medical Marijuana
• No controlled studies demonstrate the efficacy of
inhaled marijuana as an adjunct to traditional pain
medications for patients with cancer-related pain.
• Trials in patients with multiple sclerosis have failed to
show consistent pain reduction.
• Although inhaled, buccal, or ingested marijuana has
shown some efficacy for refractory nausea and
vomiting or glaucoma consensus expert guidelines do
not support its use.
• Anecdotal reports of the antiseizure effects of
cannabis (marijuana) however safety and efficacy data
are quite limited.
https://www.uptodate.com/contents/cannabis-use-disorder-clinical-features-anddiagnosis?source=search_result&search=marijuana+abuse&selectedTitle=2~41
Cannabis Intoxication
• Clinical manifestations of acute cannabis
intoxication vary according to age.
• Neurologic abnormalities are more
prominent in children and include:
– Ataxia
– Excessive and purposeless motor activity of the
extremities
– Lethargy
– Prolonged coma, which may be life-threatening
https://www.uptodate.com/contents/cannabis-use-disorder-clinical-features-anddiagnosis?source=search_result&search=marijuana+abuse&selectedTitle=2~41
Cannabis Intoxication
• Adolescent and adult who present for care
are more likely to have hyperemesis or
behavioral problems (eg, dysphoria or
agitation) or medical emergencies (eg,
bronchospasm or pneumothorax) associated
with the method of inhalation.
https://www.uptodate.com/contents/cannabis-use-disorder-clinical-features-anddiagnosis?source=search_result&search=marijuana+abuse&selectedTitle=2~41
Signs of Cannabis Intoxication
• Tachycardia
• Increased blood pressure or, especially in the
elderly, orthostatic hypotension
• Increased respiratory rate
• Conjunctival injection (red eye)
• Dry mouth
• Increased appetite
• Nystagmus
• Ataxia
• Slurred speech
https://www.uptodate.com/contents/cannabis-use-disorder-clinical-features-anddiagnosis?source=search_result&search=marijuana+abuse&selectedTitle=2~41
Complications of Cannabis
Intoxication
• Acute exacerbations and poor symptom
control in patients with asthma.
• Pneumomediastinum and pneumothorax
caused by deep inhalation with breath
holding.
• Rarely, angina and myocardial infarction.
– The risk for myocardial infarction among regular
cannabis users has been found to be as high as
4.8 times baseline
https://www.uptodate.com/contents/cannabis-use-disorder-clinical-features-anddiagnosis?source=search_result&search=marijuana+abuse&selectedTitle=2~41
Neuropsychiatric Effects of Cannabis
Intoxication
• Mood, perception, thought content –
Ingestion typically leads to feeling "high,"
marked by a euphoric, pleasurable feeling
and a decrease in anxiety, alertness,
depression, and tension.
• Cognition, psychomotor performance –
Cannabis use decreases reaction time and
impairs attention, concentration, short term
memory, and risk assessment.
– lasts much longer than the "high."
https://www.uptodate.com/contents/cannabis-use-disorder-clinical-features-anddiagnosis?source=search_result&search=marijuana+abuse&selectedTitle=2~41
Diagnosis of Cannabis Intoxication
• Standard urine drug screens consist of
immunoassays that detect delta-9
tetrahydrocannabinol (THC) metabolites,
primarily THC carboxylase.
– False positives for cannabinoids are rare.
• Chest x-ray or ECG if indicated
https://www.uptodate.com/contents/cannabis-use-disorder-clinical-features-anddiagnosis?source=search_result&search=marijuana+abuse&selectedTitle=2~41
Managment of Cannabis Intoxication
• The management of cannabis (marijuana)
intoxication consists of supportive care of
symptoms except .
• Children — Children with are much more likely
to demonstrate severe or life-threatening
toxicity consisting of excessive and purposeless
motor activity (hyperkinesis) or deep coma.
– Consultation with a regional poison control center
and a medical toxicologist is encouraged for all
symptomatic exposures.
https://www.uptodate.com/contents/cannabis-use-disorder-clinical-features-anddiagnosis?source=search_result&search=marijuana+abuse&selectedTitle=2~41