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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 • • • • • 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: – – – – – – – 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§ionRank=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