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Commonly Misused Substances Substances Commonly Used in an At-Risk Manner Alcohol • Ethanol, methanol, isopropyl alcohol. Sedative/Hypnotics/Anesthetics • • Benzodiazepines, barbiturates, anesthetics (Gammahydroxybutyrate (GHB), ketamine). Primarily used orally although ketamine may be injected. Opioids • • Heroin, oxycodone, morphine, hydromorphone, methadone, fentanyl, codeine, propoxyphene and others. All of these substances maybe used orally, intranasally or by injection. Long acting formulations and patches may be chewed. Stimulants • • Amphetamines, cocaine, methamphetamine, ephedrine, phencyclidine, methylphenidate. All of these substances may be used orally, intranasally or by injection. SAMHSA, 2005 Substances Commonly Used in an At-Risk Manner Hallucinogens • LSD, mescaline, psilocybin (mushrooms), phenylcyclidine (PCP), ecstasy, methylenedioxymethamphetamine (MDMA). Cannabis/Tetrahydrocannabinol (THC) • Marijuana. • Smoked, vaporized, oral. Steroids • • Dianabol, nandrolone. Typically by injection. Volatile Substances • • Toluene, acetone, butane, fluorocarbons. Inhaled (“Huffed”). cntinue SAMHSA, 2005 Sedative/Hypnotic/Anesthetic Benzodiazepines, barbiturates, anesthetics (GHB, ketamine) Signs/SXS of intoxication: • Altered consciousness • Ataxia • Sexual dysfunction • Death • Confusion • Slurred speech • Stupor/coma • Loss of coordination • Dizziness • Apnea • Memory impairment • Weight gain • Paradoxical/uncharacteristic behavior • Incoordination • Emotional lability • Memory impairment • Poor task completion • Nystagmus with accommodation • Insomnia • Psychosis • Headache • Seizure • Hypersensitivity to stimuli Signs/SXS of chronic use: • Loss of motivation • Poor comprehension • Development of tolerance (barbiturates) Signs/SXS of withdrawal: • Severe anxiety • Autonomic hyperactivity If injected, Ketamine use may present with Signs/SXS common to injection drug use. NIDA, 2008; Stark, 2009 Opioids Heroin, oxycodone, morphine, hydromorphone, methadone, fentanyl, codeine, propoxyphene Signs/SXS of intoxication: • Pinpoint pupils • Respiratory depression • Nausea/vomiting • Bradycardia • Constipation • Coma • Relaxed and/or euphoric state ("nodding“) Signs/SXS of chronic use: • Sexual dysfunction • Amenorrhea • Development of tolerance to euphoria/analgesia (but not to pupillary response) Signs/SXS of withdrawal: • Yawning • Diaphoresis • Diarrhea • Autonomic hyperactivity • Rhinorrhea • Nausea/vomiting • Tremor • Malaise • Lacrimation • Myalgia • Insomnia • Anxiety • Piloerection • Abdominal cramps • Dysphoria, Signs/SXS related to route of administration: Injection: • Embolis • Cellulitis • Endocarditis • HIV • Abscesses • Viral hepatitis • Foreign body emboli • Infections consequences of unsterile injection • Fresh needle marks and scaring (track marks) • Soft tissue necrosis (with injection of pill forms) NIDA, 2008; Stark, 2009 Stimulants Amphetamines, Cocaine, Ephedrine, Phencyclidine Signs/SXS of intoxication: • Hypertension • Diaphoresis • Fine tremor • Muscle spasms • Tachycardia • Agitation • Appetite suppression • Chest pain • Tachypnea • Paranoia • Hyperthermia • Sexual dysfunction • Mydriasis • Brisk reflexes • Formication • Malnutrition • Reduced fertility • Development of tolerance Signs/SXS of chronic use: • Weight loss Signs/SXS of withdrawal: • Muscle pain/tremor • Depression/irritability • Intense persistent drug seeking behavior • Hunger • No specific withdrawal syndrome but cessation of use may be accompanied by fatigue/malaise Signs/SXS related to route of administration: Intranasal: • Rhinorrhea Inhaled: • Bronchitis • COPD/bronchiectasis Injection: • Septal perforation • Eczema localize to nares • Pneumonia • Dry mouth with poor dentition • Burns to the lips and fingers • Embolis • Abscess formation •Infections consequences of unsterile injection • Skin and soft tissue necrosis with chronic wound formation and adjacent or distant osteomyelitis NIDA, 2008; Stark, 2009 Hallucinogens LSD, Ecstasy, Mushrooms Signs/SXS of intoxication: • Tachycardia • Nystagmus • Nausea • Paranoia • Dry mouth • Ataxia • Mood lability • Bruxism • Hyperreflexia • Vomiting • Mydriasis • Autonomic hyperactivity • Visual/auditory hallucinations Signs/SXS of chronic use: • Tolerance develops rapidly to LSD, flashbacks may occur long after heavy or prolonged use Signs/SXS of withdrawal: • No specific withdrawal syndrome Medical Consequences: • Rhabodomyolysis and acute renal failure with large doses, elevated liver enzymes NIDA, 2008: Stark, 2009 Cannabis Marijuana, tetrahydrocannabinol Signs/SXS of intoxication: • Euphoria • Dry mouth • Tachycardia • Poor concentration • Agitation • Anxiety • Hypertension with postural hypotension • Hunger • Memory impairment • Toxic psychosis • Reddened conjunctivae • Paranoia • Impaired manual dexterity • Cough • Chronic bronchitis Signs/SXS of chronic use: • Affect disorders • Dental caries Signs/SXS of withdrawal: • No discrete withdrawal syndrome although cessation of use may be accompanied by disphoria or anxiety • Restlessness and irritability Smoked cannabis is a respiratory irritant. No specific consequences associated with oral or vaporized consumption. NIDA, 2008; Stark, 2009 Volatile Substances Signs/SXS of intoxication: • Solvent smell • Diarrhea • Ataxia • Nausea • Sneezing • Dysphoria • Vomiting • Coughing • Disinhibition • CNS depression • Slurred speech • Coma • Burns • Memory loss • Delusions • Respiratory problems • Weight loss • Psychosis • Perioral eczema (glue sniffer’s rash) • Poor concentration Signs/SXS of chronic use: • Nasal sores • Fatigue • Depression Signs/SXS of withdrawal: • Primarily psychological dependence • HA Inhalation of volatile substances is associated with sudden death from arrhythmia • Drowsiness • Chronic liver and renal failure Stark, 2009