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Drug Abuse
Self administration of drug or drugs
in manner not in accord with accepted
medical or social patterns
Drug Abuse

Psychological Dependency (Habituation)
 Drug
necessary to maintain user’s sense of
well-being

Physical Dependency
 Physical
symptoms if intake reduced
Drug Abuse

Compulsive Drug Use
 Preoccupation
with obtaining drug
 Rituals of preparing, using drug as important as
drug effects

Tolerance
 Increasing
doses needed to obtain drug effect
Drug Abuse

Addiction
 Includes
 Psychological
dependence
 Physical dependence
 Compulsive use
 Tolerance
 Plus,
complete absorption with obtaining, using
drug to exclusion of all else
Drug Abuse

Suspect drug-related problem in patients with:
 Altered LOC
 Bizarre behavior
 Seizures
Drug Abuse

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Ask EVERY patient about recreational drugs.
Be non-judgmental.
Keep drug box/cabinet secured.
Use discretion.
If held up, give them what they want!
Narcotics
Opium
 Opium derivatives
 Synthetic opium substitutes

Narcotics

Examples
 Opium
 Morphine
 Heroin
 Codeine
 Dilaudid
 Oxycodone
(Percodan)
 Meperidine (Demerol)
 Propoxyphene (Darvon)
 Talwin
 Fentanyl
Narcotics

Effects
 Analgesia
 CNS
depression
 Euphoria
 Drowsiness
 Apathy
 Antidiarrheal
action
 Antitussitive action
Narcotics

Overdose
 Mild
to Moderate
 Severe
 Lethargy
 Respiratory
 Pinpoint
 Coma
pupils
 Bradycardia
 Hypotension
 Decreased bowel
sounds
 Flaccid muscles
depression
 Aspiration
 Seizures
with certain
compounds (meperidine,
propoxyphene, tramadol)
Narcotics

Overdose
 Management
 Support
oxygenation/ventilation
 Vascular access
 D50W 50cc
 Narcan 0.4 to 2.0 mg
• Improve respirations
• Do NOT awaken completely
• Restrain before giving
Narcotics

Associated Dangers
 Skin
abscesses
 Phlebitis
 Sepsis
 Hepatitis
 HIV
 Endocarditis
 Adulterant
toxicity
 “Cotton fever”
 Malnutrition
 Tetanus
 Malaria
Narcotics

Withdrawal
 Insomnia
 Restlessness
 Irritability
 Anorexia
 Tremors
 Back,
extremity pain
 Watery
eyes
 Yawning
 Rhinorrhea
 Sneezing
 Diarrhea
 Diaphoresis
Resembles Severe Influenza
Narcotics

Withdrawal
 Lasts
7 to 10 days
 NOT life threatening
Sedative-Hypnotic Drugs
Categories
Barbiturates
 Benzodiazepine
 Barbiturate-like non-barbiturates
 Chloral hydrate

Mechanism of Action
Most overdoses of sedative-hypnotics are
from benzodiazepines, barbiturates
 Both enhance effects of gammaaminobutyric acid (GABA)
 GABA enhancement results in downregulation of CNS activity

Sedative-Hypnotics
Use more then a week leads to tolerance to
effects on sleep patterns
 Withdrawal after long term results in
“rebound” increase in frequency of
occurrence, duration of REM sleep.
 In high doses, sedative-hypnotics depress
CNS to point of Stage III or general
anesthesia

Sedative-Hypnotics

Tolerance
 Happens
with all sedative-hypnotics
 Appears very quickly even during short-term
use.
 Discontinuation will bring receptor response
back to normal after drug has been metabolized
 Withdrawal symptoms may take up to a week
to see in some patients
Chloral hydrate
“Micky Finn” when mixed with alcohol
 Rapidly absorbed, acts quickly
 Drowsiness, sleep
 Alcohol, chloral hydrate compete for
metabolism by same enzyme
 Prolonged action for both when mixed
 Not commonly abused

Barbiturates
Introduced in 1903
 Replaced older sedative-hypnotics
 Quickly became major health problem
 In 1950’s-60’s barbiturates were implicated
in overdoses; were responsible for majority
of drug-related suicides

Barbiturates

Short-acting
 Amytal
 Pentathiol

Intermediate-acting
 Nembutal
 Seconal
 Tuinal

Long-acting
 Phenobarbital
Barbiturates

Initial overdose presentation
 Slurred
speech
 Ataxia
 Lethargy
 Nystagmus
 Headache
 Confusion
Barbiturates

As overdose progresses
 Depth
of coma increases
 Patient
anesthetized with loss of neurologic function
 EEG may mimic brain death
 Respiratory
depression occurs
 Peripheral vasodilation occurs
 Hypotension,
shock
 Hypothermia
 Blisters
(bullae) form on skin
Barbiturates

Early deaths
 Respiratory
arrest
 Cardiovascular collapse

Delayed deaths
 Acute
renal failure
 Pneumonia
 Pulmonary edema
 Cerebral edema
Barbiturates

Overdose management
 Secure
airway
 Support oxygenation/ventilation
 IV with LR or NS
 Prevent heat loss secondary to vasodilation
 Bicarbonate to alkalinize urine (long-acting
only)
Barbiturates

Withdrawal signs/symptoms
 Apprehensiveness
 Anxiety
 Tremulousness
 Diarrhea
 Nausea
 Vomiting
 Seizures
Barbiturate-like, non-barbiturates

Examples
 Doriden
(glutethimide)
 Quaalude (methaqualone)
 Placidyl (ethchlorvynol)
 Noludar

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Overdose produces sudden, prolonged apnea
Highly addictive
Withdrawal resembles barbiturate withdrawal
Only Placidyl, Doriden remain available in U.S.
Placidyl (ethchlorvynol)
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“Pickles”, “jelly beans”, “Mr. Green Jeans”
Produces vinyl-like odor on breath
Concentrates in CNS, slow hepatic metabolism
Half-life >100 hrs
Prolonged deep coma (100 to 300 hrs),
hypothermia, respiratory depression, hypotension,
bradycardia
EEG is flatline
Keep patient on life support for a few days; they
wake up, are ok
Doriden (gluthethimide)
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Abused in combination with codeine
“sets”, “hits”, “loads”, “fours and doors”
Prolonged coma (average 48 hours)
Hypotension, shock common
Anticholinergic signs: dilated pupils, tachycardia,
dry mouth, ileus, urinary retention, hyperthermia
Benzodiazepines
Developed due to overdoses, deaths related
to barbiturates, barbiturate-like nonbarbiturates
 Relatively few deaths
 In 1993, prescription rate for barbiturates
dropped to one-sixth that of benzos

Benzodiazepines

Examples
 Valium
(diazepam)
 Ativan (lorazepam)
 Versed (midazolam)
 Librium (chlorodiazepoxide)
 Tranxene (chlorazepate dipotassium)
 Dalmane (flurazepam)
 Halcion (triaxolam)
 Restoril (temazepam)
Benzodiazepines

Adverse Effects
 Weakness
 Headache
 Blurred
vision
 Vertigo
 Nausea
 Diarrhea
 Chest
pain
Benzodiazepines

Overdoses
 Relatively
safe taken by themselves, even in overdose
 Can be lethal with other CNS depressants especially
alcohol
 Look like other CNS depressant overdoses
 Antidote is Romazicon ( flumazenil )
 Only recommended in known, controlled situations
 Can lead to seizures that cannot be controlled
Benzodiazepines

Produce withdrawal syndrome similar to
barbiturate withdrawal
Benzodiazepine-like non-benzos

BuSpar (buspirone)
 Used
for generalized anxiety disorder
 Less sedating than diazepam
 Less potentiation by other CNS depressants

Ambien, Stilnox (zolpidem)
 Used
for short-term insomnia treatment
 Toxic effects similar to benzos
Neuroleptics
Antipsychotics, major tranquilizers
 Used in treatment of schizophrenia, other
psychoses
 Examples

 Haldol
 Mellaril
 Thorazine
 Stellazine
 Compazine
Neuroleptics

Extrapyramidal muscle contractions
(dystonias)
 Bizarre,
acute, involuntary movements, spasms
of skeletal muscles
 Reversible with Benadryl
Neuroleptics

Acute Overdose Presentation
 CNS
depression
 Hypotension
 Anticholinergic symptoms: flushing, dry
mouth, hyperthermia, tachycardia, urinary
retention
 Ventricular arrhythmias, including Torsades
 Seizures
Neuroleptics

Acute Overdose Management
 ABCs
 Fluid,
vasopressors for hypotension
 Lidocaine, phenytoin for ventricular arrhythmia
 Magnesium, isoproterenol for Torsades
 Benzodiazepines, phenobarbital for seizures
Neuroleptics

Neuroleptic malignant syndrome
 Life-threatening
reaction
 Signs, symptoms
 Hyperthermia
 Muscular
rigidity
 Altered LOC
 Tachycardia, hypotension
Neuroleptics

Neuroleptic malignant syndrome
 Management
 ABCs
 Oxygen
 Assist
ventilation, as needed
 Benzodiazepines
 Rapid cooling
 Volume for hypotension
Stimulants

Examples
 Cocaine
 Amphetamines
 Benzedrine
(bennies)
 Dexedrine (dexies, copilots)
 Methamphetamine (ice, black beauties)
 Ephedrine
 Caffeine
 Ritalin
Stimulants

Produce
 euphoria
 hyperactivity
 alertness
 sense
of enhanced energy
 anorexia
Stimulants

Overdose signs/symptoms
 Euphoria,
restlessness, agitation, anxiety
 Paranoia, irritability, delirium, psychosis
 Muscle tremors, rigidity
 Seizures, coma
 Nausea, vomiting, chills, sweating, headache
 Elevated body temperature
 Tachycardia, hypertension
 Ventricular arrhythmias
Stimulants

Overdose complications
 Hyperthermia,
heat stroke
 Hypertensive crisis
 CVA
 Acute MI
 Intestinal infarctions
 Rhabdomyolysis
 Acute renal failure
Stimulants

Chronic effects
 Weight
loss
 Cardiomyopathy
 Paranoia
 Psychosis
 Stereotypic behavior: picking at skin
(“cocaine bugs”)
Stimulants

Overdose management
 Oxygen,
monitor, IV
 Activated charcoal for decontamination in first
hour
 Valium for sedation
 Hypertension control
 Nipride
 Phentolamine
 Avoid
 Body
beta-blockers, including labetolol (Why?)
temperature reduction
Stimulants

Withdrawal
 Drowsiness
 Profound
depression (“cocaine blues”)
 Increased appetite
 Abdominal cramps, diarrhea, nausea
 Headache
Hallucinogens

Examples
 Indole
hallucinogens
 LSD (acid)
 Morning-glory
seeds
 Psilocybin
 DMT
 Amphetamine-like
hallucinogens
 Peyote
 Mescaline
 DOM
 MDA
 MDMA (ecstasy)
Hallucinogens
Produce altered/enhanced sensation
 Effects highly variable depending on patient
 Increased dose does not intensify effect
 Toxic overdose virtually impossible

Hallucinogens
Some patients may experience “bad trips”
 Depends on surroundings, emotional state
 Signs and symptoms

 Paranoia,
fearfulness, combativeness
 Anxiety, excitement
 Nausea, vomiting
 Tachycardia, tachypnea
 Tearfulness
 Bizarre Reasoning
Hallucinogens

Moderate Intoxication
 Tachycardia
 Mydriasis
 Diaphoresis
 Short
attention span
 Tremor
 Hypertension
 Hyperreflexia
 Fever
Hallucinogens

Life-threatening toxicity (rare)
 Seizures
 Severe
hyperthermia
 Hypertension, arrhythmias
 Obtunded, agitated, or thrashing about
 Diaphoretic, hyperreflexic
 Untreated hyperthermia can lead to hypotension,
coagulopathy, rhabdomyolysis and multiple organ
failure
Hallucinogens

Management of “bad trip”
 Rule
out other causes of hallucinations
 Hypoglycemia
 Alcohol,
drug withdrawal
 Infection
 Quiet,
supportive environment
 Benzodiazepines, haldol for agitation, anxiety
Phencyclidine (PCP)


Street names
 Angel dust
 Peace Pill
 Hog
 Krystal
 Animal tranquilizer
Used as veterinary anesthetic
Phencyclidine (PCP)

Actions
 Dissociative anesthesia
 Generalized loss of pain perception
 Little or no depression of airway reflexes or
ventilation
 CNS-stimulant, anticholinergic, opiate, and
alpha-adrenergic effects
Phencyclidine (PCP)

Low Doses
 Lethargy,
euphoria, hallucinations
 Slurred speech
 Blank stare
 Insensitivity to pain
 Midposition to dilated pupils
 Vertical and horizontal nystagmus
 Occasionally bizarre or violent behavior
Phencyclidine (PCP)

High Doses
 Diaphoresis

 Salivation

 Hypertension

 Tachycardia

 Hyperthermia
Localized dystonic reactions
Wide-eyed coma
Rigidity
Seizures
Phencyclidine (PCP)

Treatment
 Maintain
airway
 Assist ventilations, as needed
 Treat coma, seizures, hypertension,
hypothermia as needed
 Quiet environment
 Sedation if needed to control agitation
 Haldol
 Benzodiazepines
Inhalants

Examples
 Hydrocarbons
(solvents, paints, aerosols)
 Gases (freon, halon fire extinguishing agent)
 Metallic paints (“huffing”)
Inhalants

Effects
 Dysrhythmias
including VF
 CNS depression
 Seizures
 Respiratory irritation
 Epinephrine may increase risk of dysrhythmias

Treatment
 Oxygen
 Treat
symptomatically
“Date rape” drugs
Flunitrazepam (Rhohypnol)
 Gamma hydroxybutyrate

Flunitrazepam (Rhohypnol)

Street names
 Rophies
 Roche
 Roofies
 Roachies
 R2
 La
 Roofenol
rocha
 Rope
 Rib
Flunitrazepam (Rhohypnol)
Benzodiazepine
 Similar to Valium but 10x more potent
 Produced, sold legally in Europe, South
America
 Uses

 Short-term
treatment of insomnia
 Sedative hypnotic
 Preanesthetic medication
Flunitrazepam (Rhohypnol)

Effects
 Disinhibition
and amnesia
 Onset within 30 minutes, peak within 2 hours,
may persist 8 hours or more
 Frequently abused with alcohol or other drugs
 Enhances high produced by heroin
Flunitrazepam (Rhohypnol)

Adverse Effects
 Drowsiness
 Dizziness
 Confusion
 Decreased
BP
 Memory impairment
 GI disturbances
 Excitability, aggressive behavior
Flunitrazepam (Rhohypnol)

Management of overdose
 Lethal
overdose very unlikely
 Oxygenate, ventilate
 Intubate if necessary to control airway
 Vascular access
 ECG
 Fluid for hypotension
 Dextrostick (rule out hypoglycemia)
 Treat trauma resulting from assault
Flunitrazepam (Rhohypnol)

Withdrawal
 Headache
 Hallucinations
 Anxiety,
 Delirium
tension
 Numbness, tingling of
extremities
 Restlessness, confusion
 Loss of identity
 Seizures
(up to a week
after cessation)
 Shock
 Cardiovascular
collapse
Flunitrazepam (Rhohypnol)

Management of withdrawal
 Oxygen/ventilation
 Intubate
if necessary
 EKG
 Vascular
access
 Fluid for hypotension
 Dextrostick
 Diazepam for seizures
Gamma hydroxybutyrate

Street names
 Cherry
meth
 Liquid X
 Liquid ecstacy
Originally developed as anesthetic
 Banned in 1991 because of side effects
 Promoted as aphrodisiac

Gamma hydroxybutyrate

Effects
 Odorless,
 Tremors
 Seizures
 Death
nearly tasteless