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									Understanding Medications
  and Interactions with
     Illicit Drug Use
                   by
         Paul L. Doering, M.S.
    Distinguished Service Professor
           of Pharmacy Practice
         College of Pharmacy
          University of Florida
  Pharmacists Know a Lot
  About Drugs, but………
• Many curricula do not contain coursework
  in substance abuse
• Thus, they are not schooled in this “other”
  use of pharmaceutical products
• Most have limited personal experience
  with recreational drugs (thankfully)
• But, pharmacists are often sought out by
  parents, family members, etc. for help
  THREE DRUG EXPERTS
     FROM THE 1960s




James Marshall    Paul Louis Doering   Janis Lyn Joplin
    Hendrix         Born- 2/25/49       Born- 1/19/43
 Born- 11/27/42     Not Dead Yet        Died- 10/4/70
 Died- 9/18/70
Mental Health and Drugs
• About 1/3 of adults with any mental
  disorder also have a co-occurring substance
  abuse disorder, including:
  •   Depression
  •   Schizophrenia
  •   Bipolar disorder
  •   Anxiety disorder
Key Point:
• The neurotransmitters, receptor sites, and
  other brain mechanisms involved in mental
  and emotional problems and illnesses are
  the same ones affected by psychoactive
  drugs
“Don’t it seem odd…….”
• That people with normal brain chemistry
  are trying desperately to get theirs out of
  whack while,

• Those with abnormal brain chemistry are
  trying just as hard to get theirs back to
  normal??
Psychiatric Medications
• Antipsychotics
  • e.g., Haldol, Thorazine, Zyprexa, Prolixin
• Antidepressants
  • e.g., tricyclic antidepressants, selective
    serotonin reuptake inhibitors (SSRIs)
• Bipolar medications
  • e.g., lithium, valproic acid
• Antianxiety agents
  • e.g., benzodiazepines, buspirone, barbiturates
        Serotonin imbalances

Normal Functions        Street Drugs that Associated       Examples of
                        Disrupt the       Mental           Meds to
                        Neurotransmitter Illness           Reblance
                                                           Neurotransmitter

Mood stability,         Alcohol, nicotine,   Anxiety       Prozac, Zoloft,
appetite, sleep         amphetamine,         disorders,    Effexor, Elavil,
control, sexual         cocaine, PCP,        obsessive-    Desyrel, etc.
activity, aggression,   LSD, MDMA            compulsive
self-esteem                                  disorder,
                                             generalized
                                             anxiety,
                                             depression
         Dopamine imbalances

Normal Functions Street Drugs that Associated     Examples of
                 Disrupt the       Mental Illness Meds to
                 Neurotransmitter                 Reblance
                                                  Neurotransmitter

Muscle tone, motor     Cocaine, nicotine,   Psychotic        Risperdol,
behavior, energy,      PCP,                 disorders, e.g., phenothiazine,
reward mech.,          amphetamine,         schizophrenia, olanzapine, etc.
attention span,        caffeine, LSD,       schizoaffective
pleasure, mental       marijuana,           disorder,
stability,             alcohol, opioid      Parkinson’s
hunger/thirst/sexual                        disease
satiation
   Norepinephrine, epinephrine
Normal Functions            Street Drugs that Associated      Examples of
                            Disrupt the       Mental          Meds to
                            Neurotransmitter Illness          Reblance
                                                              Neurotransmitter

Energy, motivation,         Cocaine, nicotine,   Anxiety      Burporion,
eating, attention span,     amphetamine,         disorders,   desipramine,
pleasure, heart rate,       caffeine,            mood         methylphenidate,
blood pressure, dilation    marijuana,           disorders,   clonidine, beta
of bronchi,                 MDMA, etc.           narcolepsy   blockers
assertiveness, alertness,
confidence
Other neurotransmitters
 •   Endorphin, enkephalin
 •   GABA
 •   Acetylcholine
 •   Cortisone
 •   Histamine
 •   Anandimide
Two Types of Substance-
related Disorders

• Substance use disorders
  • Substance dependence
  • Substance abuse
• Substance-induced disorders
  • Intoxication
  • Withdrawal
  • Delerium, amnestic disorder, sleep disorder
Susceptibility
• Some are born with brain chemistry that
  makes them susceptible to certain mental
  illnesses

• If the genetically susceptible brain is then
  stressed by a hostile environment or
  psychoactive drug use, there is an increased
  likelihood of developing mental illness
Example
• Heredity can affect the formation of
  dopamine receptor sites and the ability of
  the brain to produce dopamine.

  • Schizophrenia- brain has too much dopamine
  • Cocaine stimulates release of dopamine, thus
    long-term or high-dose use can induce a
    schizophrenia-like psychosis
Environmental factors
• Continued stress depletes norepinephrine
  and that can cause depression

  • Some react by running away, falling apart,
    becoming extremely angry, or using
    psychoactive drugs
Examples of substance-induced
mental disorders

 • Stimulant-induced psychotic disorders

 • Alcohol-induced mood disorders

 • Marijuana-induced delirium
Pre-existing Mental Illness
• Has a clearly defined mental illness and
  then gets involved in drug
  • e.g., the teen with major depression who
    discovers methamphetamine
The difficulty

“A neurotic is the person who builds a castle
  in the air. A psychotic is the person who
  lives in it. And the psychiatrist is the
  person who collects the rent.”
Brain Disorders in Americans
(1-year prevalence)
                                     Adults   Adults
  Diagnosis                          18-54    >55

  Schizophrenia                      1.3%     0.6%

  Mood disorders                     7.1%     4.4%
   Bipolar disorder                  1.1%     0.2%
   Major depressive episode          5.3%     3.8%
   Unipolar major depression         5.3%     3.7%

  Anxiety disorders                  16.4%    11.4%
    Obsessive-compulsive disorder    2.4%     1.5%
    Panic disorder                   1.6%     0.5%
    Simple phobia                    8.3%     7.3%
    Posttraumatic stress disorder    3.6%     ----
    Agoraphobia                      4.9%     4.1%

  Any brain disorder (may have >1)   21.0%    19.8%
Drugs that mimic schizo-
phrenia and psychosis
•   Cocaine and amphetamine- toxic psychosis
•   Steroid psychosis
•   CNS stimulants- paranoia
•   Psychedelics- dissociation
•   Barbiturate withdrawal- extreme agitation
Temporary drug-induced
depression associated with:
• Excessive alcohol use
• Stimulant withdrawal (cocaine and
  amphetamine)
• Comedown phase of psychedelic (e.g.,
  LSD) drug use
Bipolar disorder or drug reaction?


• Toxic effects of:

  • Stimulant abuse

  • Psychedelic
Anxiety disorder or drug effects?

  • Toxic effects of stimulant drugs

  • Withdrawal from opioids

  • Withdrawal from opioids

  • Withdrawal from alcohol
Alcohol-induced mental illnesses
•   Impulse control problems
•   Sleep disorders
•   Anxiety
•   Depression
•   Psychosis
•   Dementia
Stimulant-induced mental illness
•   Impulse control problems
•   Mania
•   Panic disorder
•   Depression
•   Anxiety
•   Psychosis
•   Cognitive impairment
Marijuana-induced mental illness
• Delerium

• Psychosis

• Panic

• Amotivational syndrome
1
2
3
Groovin’ to the Beat……...




           ...at the Dean’s
           Disco
Serotonin cells in red




                         4
Neurons release serotonin




                            6
Serotonin vesicles




                     7
Serotonin Receptors




                      11
Peak effect (about 1 hour)




                             12
Serotonin Reuptake Transporters




                              13
Monoamine Oxidase




                    14
Coming down from XTC




                       15
Coming down some more




                        16
The “Serotonin Factory”




                          17
Down regulation of receptors




                               18
Pharmaceutical Drugs are “In”

•   Obtained from legal prescriptions
•   Given or sold among friends
•   Stolen from medicine cabinets
•   Stolen from pharmacies
 Prescription Drug Abuse

• DAWN data suggest that prescription
  drugs account for about 25-30% of all
  drug abuse
Pharmaceutical vs Street Drugs
• Safer
  • identity
  • purity
  • less HIV / hepatitis risk
• Safer because "it's just a prescription drug"
• Low or no acquisition cost
  • Medicaid, Workers’ Comp, private insurance,
    VA, Indian Health Service
Pharmaceutical vs Street Drugs

• Less legal risk than illicit drugs
• Easily obtainable from practitioners
 Prescription Drug Abuse
• Effective controlled substances are
  commonly prescribed for legitimate patients
• As controlled substances are prescribed
  more often, there is greater availability of
  the drug
• Thus, there is greater opportunity for
  diversion
Prescription Drug Abuse

• Street value dependent on
  •   brand vs generic
  •   quick onset
  •   intensity
  •   short duration of action
  •   whether a product can be injected or
      snorted successfully
Methamphetamine and other
stimulants
• Synonyms:
   • crank, ice, meth, crystal, speed
• Mental Effects:
   • euphoria, irritability, anxiety, confusion,
     paranoia, poor judgment
• Physical Effects:
   • increased HR, BP, pulse, RR, temp,
• Dangers:
   • cardiovascular toxicity, seizures, psychosis
Ephedrine Products
Stimulant
Identification
Stimulant
Identification
The Different Faces of “Ritalin”



  Concerta ER 18 mg     Concerta ER 36            Concerta ER 54 mg
                        mg




  Ritalin 10 mg            Ritalin 5 mg             Ritalin SR 20
                                                    mg




        Ritalin LA 20             Ritalin LA 30            Ritalin LA 40
        mg                        mg                       mg
OxyContin (oxycodone HCl)
Morphine
Codeine
Hydrocodone
Oxycodone
Methadone
Meperidine
Comparisons



  Codeine    Morphine    Hydrocodone




Meperidine   Methadone    Oxycodone
Narcotics Identification
Narcotics Identification
Narcotics Identification
Narcotics Identification
Depressants: Benzodiazepines
and non-benzodiazepines



  Valium 2 mg     Valium 5 mg   Valium 10
                                mg




      Xanax 0.5   Xanax 1 mg    Xanax 2 mg
      mg
'Skittling' New Drug Of Choice For Some
Teens: Product Sold On Store Shelves
October 22, 2003




                   Ingredients:
                   Dextromethorphan
                   Chlorpheniramine
                   Maleate
Other Products Containing
Dextromethorphan
Buying DXM in Bulk

								
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