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Medtox Journal on Drug Abuse Recognition
April 2012
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Dear Andrew,
Thank you for taking the time to read the MEDTOX
Drug Abuse Recognition Journal. We hope you find
this newsletter interesting and educational. This issue
focuses on the marijuana withdrawal syndrome,
health risks for night shift workers, kratom use from
the field, and marijuana-laced wine. As always, we
enjoy hearing your feedback. If you have any
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IN THIS ISSUE
Understanding the Marijuana Withdrawal Syndrome
Attention MEDTOX Journal Night Shift Workers: Growing Evidence of Health Risk
Marijuana Infused Wine Re-Captures the Fancy of Napa Valley Nobles
The Role of Smoking in Exacerbation of Drug Cravings Gets Research Attention
Stories from the Field: Kratom Emerges as Nature's Remedy for Opiate Detoxification
Sure: Gel Can Pectin Mask the Presence of Drugs in Urine?
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Understanding the Marijuana Withdrawal Syndrome
For many years now, addiction professionals have proclaimed of
a noticeable syndrome developing with users who suddenly stop
smoking marijuana. A hallmark phenomenon that occurs with
the use of powerful stimulant and depressant drugs, withdrawal
syndrome is an uncomfortable and often painful experience that
results from extended, chronic administration of a drug.
Typically a withdrawal syndrome presents with symptoms that
appear to be the exact opposite of an abused drug's direct
effects. Until recently, DSM-IV failed to include marijuana
withdrawal as a syndrome worthy of diagnosis and treatment.
But the National Epidemiologic Survey on Alcohol and Related Conditions examined a group
of over 1100 regular marijuana users who did not binge drink or regularly use other drugs or
narcotics. The respondents in the survey pointed to a marked set of symptoms that were
experienced when they suddenly stopped the consumption of marijuana, the symptoms
immediately resolved when marijuana use was restarted [1]. Withdrawal and abstinence
syndrome symptoms are attributed to the action that THC and other cannabinoids have on
sensitive receptors in the mid-brain. Cannabinoid receptors and relevant transmitters are not
entirely understood but are known to influence serotonin, dopamine, acetylcholine and
GABA in the brain.
Respondents to the marijuana withdrawal syndromes survey represented 44% of all those
who admitted to regular use of marijuana. Those who responded to the survey reported
three or more symptoms of cannabis withdrawal syndrome. Two types of withdrawal
symptoms emerged in the survey: somatic and psychological. Somatic-related symptoms of
withdrawal included weakness, psychomotor retardation and sleep disturbances.
Psychological symptoms included depression, hyper anxiety and panic disorder. Respondents
who experienced personality disorders concurrent to the use of cannabis found that the
underlying personality problem was exacerbated and more pronounced upon withdrawal
from marijuana.
This study points to the difficulties that a substantial number of marijuana users have in
trying to stop using the drug and/or in maintaining periods of sobriety or non-use. Not all
marijuana users experience this syndrome when they try to quit, but this survey reveals that
a very substantial minority does have to weather the symptoms and discomfort. Motivated
addicts may find it very difficult to stop marijuana use and may need pharmacologic
assistance in completing the task. Additionally, the research indicates that people seeking to
stop marijuana abuse may switch to other drugs of abuse to ease the discomfort and pain of
withdrawal. Authors and experts associated with this study argue for cannabis withdrawal
syndrome inclusion in DSM-V.
For community corrections and rehabilitation professionals, marijuana abuse is no laughing
matter. Ignoring use and abuse of marijuana as nothing more than a harmless vice is unwise,
especially in light of still increasing purity in THC concentration of commercial grade
marijuana sold on the street. Prior essays in the MEDTOX Journal have cast light on the
profound effects that cannabis use has on the anatomy of the brain and the functioning of
the limbic system. Marijuana abuse should be taken seriously by all professionals who work
with those who smoke it. Efforts should be made to guide marijuana users to programs and
experts who specialize in the treatment of that type of addiction and dependency.
[1] Hasin DS et al. Cannabis withdrawal in the United States: Results from NESARC. J Clin
Psychiatry 2008 Sep; 69:1354.
Attention Night Shift Workers: Growing Evidence of
Health Risk
For many readers of this Journal, shift work is an unavoidable annoyance. For public safety
officers and emergency medical personnel, work does not stop when the sun goes down. In
fact, police work in particular becomes more frenetic and
more risky at night. Now, a growing body of evidence
suggests that even modest stretches of nighttime shift
work can lead to the development of diabetes and heart
disease. The accumulating evidence has serious
consequences for police patrol officers and emergency
responders who find themselves assigned to decried
"graveyard shifts." In some places late night shifts are
called "early morning" shifts, they typically span an eight
hour time block that runs somewhere between 11:00 pm and 7:00 am. With the proliferation
of 10- and 12-hour work days, some of these early morning shifts actually extend from 6:30
pm to 6:30 am. Personnel assigned to 12-hour shifts may work a very disjointed and
fractured schedule that condenses the actual days worked every month down to 12 or so.
The result of this work schedule is that an employee is in constant conflict with the natural
operation of his or her own circadian rhythm. The body's natural clock, alarm clock if you
will, is significantly disrupted by night shift work.
In a study reported in the Journal of Science Translation Medicine[1] researchers found that
when exposed to shift work with as short a duration as one week, subjects demonstrated
noticeably changed levels of insulin and glucose in their bloodstreams. The data established
that pancreatic insulin production had decreased in some cases by 27%. Aggravating this
situation further was that some other organs displayed decreased sensitivity to insulin as
well. In the aggregate, these observations are known precursors to the development of
diabetes. If insulin production and sensitivity levels remain depressed, a worker faces the risk
of unwanted weight gain, metabolic abnormalities, and heart disease. Add these risks to
other studies that link shift work with susceptibilities to certain cancers, and there is a
burgeoning cause for concern.
Exacerbating these findings is the fact that there are prescription drugs now available to help
workers overcome the fatigue and mental cobwebs that attend shift work. In particular,
Provigil is a drug that is specifically targeted to help police, firefighters, and emergency
medicine personnel in overcoming the malaise that can set in while working the early
morning shift. This drug is not a central nervous system stimulant, although among patients
and users it has acquired a street name of "brain speed." With pharmaceutical assistance at
hand for a tired shift worker, a fatigued police officer or emergency room physician can
"power" through the haze of the night shift. Perhaps these employees may even learn to like
working such odd hour . . . or not.
The MEDTOX Journal is devoted to the continuing education and professional development
of our readers. With a substantial number of public safety personnel registered with the
Journal, our staff thought it useful to report on these findings. There are a number of
research outlets that cover the health and fitness aspects of shift work, a quick Internet
search will reveal several sites where additional information can be found.
Readers interested in more information about Provigil (and parent drug Nuvigil) can do so by
searching Journal archives at Medtox Journal Archives.
OM Buxton, et. al., "Adverse Metabolic Consequences in Humans of Prolonged Sleep
Restriction Combined with Circadian Disruption," Science Translational Medicine, 4:1-11,
2012.
[1]
Marijuana Infused Wine Re-Captures the Fancy of
Napa Valley Nobles
For California wine aficionados, marijuana-laced wine is
not a new, vogue varietal experiment. As far back as the
early 1980s, northern California wine growers were
experimenting with the infusion of traditional wines with
leaves from cannabis sativa-l (marijuana). With
marijuana fields being tended nearby, more than a few
vintners have begun again to produce special cuvees
that blend traditional noble grapes, such as cabernet
sauvignon, merlot, and pinot noir with California cultivated weed. To the elites of the winegrowing world, this is an apostasy. Especially for those oenophiles who are devoted to the
finicky pinot noir grape, there is no greater sacrilege than to mangle a good barrel of
burgundy with weed. But in California, anything goes, and that includes wine and drugs. The
end result is called pot wine.
Production of pot wine is relatively easy. A traditionally sized, 60-gallon wine barrel can
produce nearly 300 bottles of 750 ml wine. Into this large vat of fermenting grape juice goes
approximately 1 pound of leafy marijuana. The THC in the leafy marijuana is extracted and
leeches into the fermenting mix of wine. The process of fermentation forms alcohol; the
alcohol is a solvent that separates the THC from the leaf. In the final preparation, each bottle
of finished wine will contain approximately 1.5 grams of marijuana. That amount of THC
present in pot wine is not going to generate a huge marijuana buzz, but it will contribute to
the sedative effect of the alcohol and create a sense of overall relaxation and sociability. The
THC in wine will be absorbed in the gut and travel the same route that alcohol does straight
to the central nervous system. And although the THC high will not be as noticeable as it
would with a few hits on a marijuana pipe, it will still impact the imbiber in an obvious way.
Probably the most untoward part of the pot wine experience is the pungent odor that is
released when the cork is pulled. There is not any real doubt what is in the wine; it does
smell like marijuana. So if you are a wine drinker and you are thinking about what a Spring
Mountain Cabernet Sauvignon might taste and smell like if it were to be mixed with pot,
don't do it. It's not going to have a "nose" of mountain top grape in that bottle.
And although these wines have stirred the curiosity of the locals in Napa and Sonoma
Valleys, there isn't really any commercial value to this blending operation. Most pot wines
are curiosity items, novelty wines that are exchanged among growers and locals who seem
to find the joke in all of this. Rarely do these blends find their way to wine auctions and
shows.
So if you happen to open what you expect to be a good fragrant wine and find it to put off a
marijuana-like "nose," it might be worth pouring the bottle through a strainer. That way
you'll find the remnants of any marijuana that may have been fermenting with it.
The Role of Smoking in Exacerbation of Drug
Cravings Gets Research Attention
Anyone hanging out at an AA meeting knows this to be
a fact: cigarette smoking is a very common component
of addict recovery. Tobacco smoking transmits nicotine
from the tobacco plant leaf directly into a smoker's
bloodstream. Nicotine is a complex drug that has
broad influence over a variety of neurotransmitters,
the chemical messengers that convey both stimulant
and depressant effects across an array of organs and
systems. Nicotine is perhaps the most addictive drug
known to man; in fact, it certainly rivals cocaine, a drug that has proven to be uniquely
alluring and addicting. Many cocaine addicts in recovery are smokers; a good number of
them are chain smokers.
The connection between smoking and recovery from drug addiction is well-established. But
what about the connection between early smoking, smoking that predates drug abuse, and
the later development of an addiction? Does smoking lay a chemical pathway or groundwork
that later makes a smoker more susceptible to drug addiction? Well, that may very well be
the case.
In a study published in the journal Nature, scientists working with mice discovered evidence
that suggests that nicotine can set in motion some global effects in the central nervous
system that stimulate the way the brain responds to cocaine. And although these
experiments were carried out in mice, the concept of "gene priming" here seems to be a
logical consequence of the nicotine's effects in humans. But the evidence at this point is a
little thin. There's a paucity of research on the topic. Nevertheless, research scientists seem
to agree that there is sound logic to the proposition.
In the experiment reported in Nature[1], scientists plied mice with nicotine in advance of
their exposure to cocaine; cocaine was given to the mice seven days later. (Cocaine is a drug
that mice and other mammals often self-administer to death.) In this particular set of
experiments, the mice that had been previously exposed to nicotine were much more likely
to head for areas in their cages that were associated with their cocaine use. These behaviors
were obvious and overwhelming.
This data and investigative reports beg a question: Is nicotine and cigarette smoking a drug
pathway system that poses a particular threat to young smokers who may pick the habit up
early in life? Does nicotine create a predisposition for the development of a substance
dependency later in adulthood? It very well may. It's an old hypothesis that's undergoing a
contemporary analysis. The research team that conducted this investigation also evaluated
some older research data that was collected from a study of 1,160 high school students that
study found that early cigarette smoking was indeed a prognosticator of later adult cocaine
use. This earlier work corroborated the work done in the mice. Nicotine indeed seemed to be
laying groundwork for later dug abuse and dependency.
Use of the term "gateway drug" is full of political and social controversy. To speak of nicotine
as a gateway drug with adolescents and young adults will become less controversial in future
research and publications. And perhaps contemporary efforts to curb teenage smoking will
have positive effects on the rates of adult substance abuse in the future. The adolescent
brain is plastic, it is growing and evolving. If nicotine has epigenetic effects on a young
person's brain, then there is a patent opportunity for the brain to be altered by smoking.
Going forward, it is quite possible that public service announcements and related campaigns
to reduce the incidence of smoking may be an effective use of government funds. Efforts
designed to reduce smoking in all age groups is probably a wise endeavor. But perhaps it can
be no more important than to do it for teenagers and young adults, their brains are still
growing and evolving. Hope for the future of addiction rests with them.
[1]
Robison, A. & Nestler, E. Nature Rev, Neuroscience, 12, 623-636 2011.
Stories from the Field: Kratom Emerges as Nature's
Remedy for Opiate Detoxification
The MEDTOX Journal has recently focused on the impact of new and designer drugs on the
American marketplace of abused substances. To this end, Kratom, a natural opiate-like drug
has become a hot commodity for those drug users who have become addicted or dependent
on prescription opiate medications. This phenomenon has grown to such an extent that
many Journal readers are now communicating to Journal staff that Kratom use has
undergone exponential growth in just the last six months. Powered by social media, Kratom
popularity has burgeoned in those communities where prescription opiates are widely
abused. You might even find Kratom at play in your local doctor's office.
Several weeks ago, a DAR-trained physician contacted the DAR program hotline; he called to
make an inquiry of a product called "Captain Kratom." A member of his office staff had found
an empty "Captain Kratom" plastic baggie in a public area bathroom. The package had
evidently contained Kratom capsules. The doctor and his staff wanted to know what Kratom
was all about. Up to that point, they had heard little of it; they had no idea as to its effects on
users.
The physician in this case is a doctor who specializes in pain
management and addiction medicine treatment services for a very
large patient population. On the addiction medicine side of his
practice, the doctor largely treats prescription opiate addicts. A
good number of his prescription opiate abusers are being treated
with Suboxone, a synthetic opiate that has become a mainstream
therapy for dealing with patients addicted to prescription narcotics
such as Vicodin and Oxycontin. Following this discovery, the
physician and his staff began to make inquiries of patients as to
their habits vis-à-vis Kratom. If a patient was utilizing Kratom, why
were they doing so? If they were using Kratom, how much were
they using and how frequently were they taking it?
Like many reports from other parts of the United States, it appears that this Southern
California clinic is rather typical of addiction medicine practices around the country. Most
Kratom-using patients discovered the drug on the Internet, or they received a tip from other
patients who were seeking treatment. Some found out about the drug from their children.
As a non-regulated substance, Kratom is viewed as a safe and legal drug. That's an
unfortunate development.
The Internet and YouTube provide Journal readers an opportunity to see first hand how
Kratom is prepared and used. The drug can be ingested in a variety of states and forms. Most
users prefer to either take the drug orally in Kratom-filled clear capsules. In the alternative,
Kratom tea will suffice. The drug is absorbed more quickly when taken in a warm tea. The
effects are experienced within minutes of ingestion.
Kratom works on the central nervous system very much like powerful opiates do, such as
hydrocodone and oxycodone. Curiously, Kratom also functions as a quasi anti-depressant.
The active ingredient in Kratom appears to work as a selective serotonin re-uptake inhibitor
(SSRI). In that sense, Kratom can be lumped in with a large class of drugs that include such
pharmaceutical powerhouses as Zoloft, Paxil, and Prozac. But Kratom does not possess the
power and extended effects of those pharmaceutical preparations. Nevertheless, its
widespread availability and lack of government regulation make it a contender for use on the
black market.
In the world of prescription opiate abusers, Kratom fills a critical need that many addicts
need to address: withdrawal. Extended periods of opiate abuse will lead to physical
dependency. That means that when levels of an abused narcotic drop below a daily average
dose in the bloodstream, physical withdrawal symptoms will begin. Think of the symptoms of
withdrawal as being the opposite experience of being high. Withdrawal for an opiate abuser
includes an accelerated heart rate, profuse sweating, anxiousness, insomnia, vomiting, and
diarrhea. An overall sense of joint pain and discomfort will pervade. Withdrawal is not fun
and games at all. It is the never-ending threat of withdrawal that motivates opiate abusers to
continue using drugs.
Kratom's most important contribution to opiate abuse is the role it can play in mitigating
painful withdrawal symptoms. It works in much the same
way as buprenorphine (Suboxone) therapy. Do-it-yourself
opiate dependent patients may use Kratom to power down
and taper off their drugs of choice. Kratom in an
appropriately determined concentration may lessen the
potency of withdrawal and moreover reduce the acute
discomfort of some of the more odious symptoms.
Conversely, Kratom can be used as a supplement to
prescription opiate drugs. A patient wanting more analgesic power from a prescription
narcotic can add Kratom to the regimen. A Kratom-supplemented high may not be a
powerful trip, but for many prescription drug users it makes enough of a difference in getting
high.
So in this case of the Kratom wrapper found on the floor of a doctor's office, it is hard to say
why it is that a pain patient or an addict in recovery would use the drug exactly. But given
Kratom's versatility and its widespread availability, it is a logical choice for legitimate patients
and substance abusers alike who may be seeking a better high, more analgesia, or to assist in
the serious challenge of managing opiate-caused drug withdrawal. Kratom is probably here
to stay . . . for awhile anyway.
Sure Gel: Can Pectin Mask the Presence of Drugs
in Urine?
Recently, stories have reached the DAR program about the
consumption of Sure Gel pectin solution as a means of masking
THC in otherwise positive urine tests. Sure Gel, made up mostly
of dextrose and fruit pectin, can be found in most American
grocery stores. Sure Gel is a powder that easily dissolves in
water. If mixed with modest amounts of water and allowed to
dry, the emulsifying gel will become a substance that can be used
to seal a jar of fruit preservatives for storage. Rumor has it that
by adding Sure Gel to a gallon of water and drinking that water
as quickly as can be tolerated, the solution will impede the release of THC into urine by
somehow altering pH. Plenty of successful test-beaters have reported their triumphs using
Sure Gel. But as many if not more have reported that the technique was useless, a waste of
time and served as a dangerous recommendation to marijuana smokers who had serious
interests in beating an upcoming drug test. In assessing the veracity of this claim, we believe
that any success that is claimed by Sure Gel ingestion is due to the dilution of urine achieved
when gallons of water are consumed before a test. In a case like that, collected urine will
look obviously dilute, if not totally clear. By taking B vitamins, or niacin etc., someone using
the Sure Gel technique can bring color back to what would otherwise be a clear case of
dilution.
Some Sure Gel experimenters cautioned against the use of the substance in as much as they
developed serious cases of constipation following their ingestion of the substance. In one
instance, a Sure Gel user ended up in the emergency room with serious gastric distress. No
information was offered as to whether or not he/she beat the drug test that prompted the
effort.
At this juncture, claims about Sure Gel as a means of masking drugs in urine seems to be a
case of much ado about nothing.
Thank you subscribers. We appreciate your dedicated readership. At MEDTOX we are
committed to providing clients with the service and solutions you need to run successful
drug testing programs. Our Journal is just one way that we show that commitment. We
always encourage feedback from our Journal. Please send your thoughts to
[email protected].
Sincerely,
MEDTOX Journal
MEDTOX Scientific, Inc.
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