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Differences between adolescent and adult patterns of use, effects on brain, concerns with detoxification/withdrawal. Understand top concerns with particular substances Alcohol Opiates/opioids Cannabinoids Methamphetamine/cocaine/stimulants Continues to develop until 20s Back to front Different patterns of use Alcohol: binge vs. daily Polypharmacy as a general rule Substances effect adolescent differently The younger age at initiation the more risk for abuse/dependence Pattern of Use Binge type Less likely to be daily drinkers Less sensitive to the sedating effects of alcohol Higher BAC More blackouts More damage More likely to overdose than go through medically significant withdrawal What happens with alcohol overdose? Increasing BAC leads to increasing sedating effects Loss of muscle control, stupor, coma, death Death from aspiration, choking, respiratory depression Requires significant duration of daily drinking with tolerance 60% who meet criteria for dependence will experience some symptoms of withdrawal (>90% mild to moderate) 6-24 hours from last drink Changes to major neurotransmitters in brain Enchances GABA-major inhibitory neurotransmitter Homeostatic changes Increase in blood pressure, heart rate, anxiety, n/v, seizure, death Clinical Institute Withdrawal Assessment Questionnaire /Assessment done by clinician/nurse Score 10 or more needs medical treatment/evaluation What to do if limited nursing? Nausea and Vomiting Tremor Paroxysmal sweats Anxiety Agitation Tactile disturbances Auditory disturbances Visual disturbances Headache, fullness in head Disorientation J Clin Psychopharmacol 1991; 11:291-295 Heroin Prescription Drugs Hydrocodone (vicodin, norco) Oxycodone Morphine Methadone Sedation Pupil Constriction Slurred speech Impaired attention/memory Constipation/ urinary retention Nausea Confusion/delirium Seizures Slowed heart rate Respiratory depression Depends on which opiate: ▪ Onset of action. ▪ Hydrocodone (peak .5hr, duration 3-4 hours) ▪ Methadone (peak: 2-4 hours, duration 24 hours) ▪ Tolerance of individual ▪ Tolerance to respiratory depression may be slower than tolerance to euphoric effects Symptoms of overdose: ▪ Triad: ▪ Altered LOC ▪ Respiratory Depression (RR<12) ▪ Miotic Pupils Withdrawal Cows Basic life support Assess Ventilation ▪ Support ventilation Naloxone hydrochloride – opioid antagonist ▪ .4mg to .8mg, may have to be repeated ▪ May need higher doses and multiple repeated doses over time Not life-threatening but so uncomfortable prompts relapse. Onset of symptoms depends on the duration of use and ½ life of drug used Heroin: onset 4-6 hours Methadone: onset: 36 hours Neurophysiologic rebound in target organs The generalized CNS suppression during use is replaced by CNS hyperactivity. Supportive measures Medication assisted clonidine CVS Ventricular irritability Hypertension Tachycardia Myocardial Infarction Neurologic Seizure Stroke Hyperthermia Rhabdomyolysis Acute Renal Failure Insomnia CVS Neurologic Cardiomyopathy Memory Impairment Myocardial Infarction Deficits in judgment Strokes Poor impulse control Pulmonary Infectious Pulmonary HIV/Hepatitis C Hypertension COPD Skin infections Complications IVDA Psychosis Acute: ▪ ▪ ▪ ▪ Classically paranoid Persecutory delusions Ideas of Reference Heightened awareness Chronic: ▪ Psychosis can persist after acute episode or recur with little or no further MA use. ▪ Sensitization Mood Disorder Mania during intoxication Depression during withdrawal Anxiety Confirm diagnosis by urine toxicology screen Gastric lavage or activated charcoal for ingestion Seizures: Diazepam Psychosis /Agitation: Diazepam +/antipsychotic Hyperthermia: external cooling Hyperarousal Agitation, severe craving, nightmares Vegetative Symptoms Decreased energy, craving sleep, increased appetite Anxiety-related symptoms Anxiety, loss of interest, anhedonia, psychomotor retardation Severe dysphoria, mood volatility, irritability and sleep pattern disruption Drug of choice- most daily marijuana use Intake: Adverse events: paranoia, increased blood pressure/HR Withdrawal Symptoms similar to nicotine withdrawal No real treatment for withdrawal Mixture of herbs or dried, shredded plant material that is typically sprayed with chemicals that are similar to THC Street names: Spice, K2, Black Mamba, Blaze, JWH-018, 073, Kronic(added BZ), krypton (added opioid) Typically smoked Sold in Europe since 2002-2004. Widely available for purchase on Internet in 2006 2010: states began banning product 2011: schedule 1 drug First cannibinoid identified was JWH-018 and CP47,497. Now there are well over 20 new synthetic cannabinoids. 10 -100 more potent than THC Strong affinity to CB1 receptors Responsible for psychoactive effects Central and peripheral nervous sx, Cardiovascular system Some of herbal ingredients added may have psycho-active potential (opioid-like, Bz,etc) Onset 3-5 minutes Duration of action: 1-8 hours Depends on dose Mood effects Euphoria and dysphoria Hyperactivity, anxiolysis and anxiety Perceptual effects Change in time perception Hallucinations/psychotic states Paranoia Depersonalization/dissociation Cognition effects: Fragmented thinking Short term memory impairment Motor effects Ataxia, loss of coordination, slurred speech Immunosuppressive Cardiovascular effects Increased heart rate, orthostatic hypotension Unpredictable toxicology Adverse effects are dose dependent Emerging evidence that adverse effects are more severe Especially in teens (as is Marijuana) Seizures Psychosis Growing acceptance that cannabis use may increase the risk of psychosis and/or psychosis like conditions. Cannabis risk is mild. ▪ 41% increased risk in developing psychosis for cannabis users v. non-cannabis users ▪ 109% increase for heavy cannabis users Commonly reported in SC users ▪ Clearly associated with both the onset and exacerbation of recurrent psychotic episodes Mood and Anxiety Anxiety Catatonia Cardiovascular effects Increased heart rate Pediatrics: Adolescents presenting with chest pain, confirmed myocardial infarction.