th Last semester section Home by mikeholy




              Dr Y R Bhattarai
Dependence on illegal and prescribed drugs is
a major problem in western countries.

Many drug users take a range of drugs-
”polydrug” misuse
 Commonly misused drugs
  Benzodiazepines          Barbiturates
  Opiates                  Amphetamines
  Cannabis                 Cocaine
  Hallucinogens            Ecstasy(MDMA)
  Organic solvents         Anabolic steroids
Opiates misuse
 The words opiate and opioid come from the
  word opium, the juice of the opium poppy,
 Papaver somniferum, which contains
  approximately 20 opium alkaloids, including
Natural Alkaloid of Opium Synthetic compounds
     Morphine            Heroin
     Codeine             Nalorphine
     Thebaine            Hydromorphone
     Noscapine           Methadone
     Papaverine          Dextropropoxyphene
                          Meperidine
                          Cyclazocine
                          Levallorphan
                          Diphenoxylate
• The most important dependence producing derivatives
are morphine and heroin
   Apart from parenteral mode of administration, heroin can also be
    smoked or chased (chasing the dragon),in an impure form called
    smack, brown sugar
   Tolerance of heroin occurs rapidly within a week and can be
    increased to more then 100 times then the first dose needed
   Heroin gives a rapid intensely pleasurable experience, often
    accompanied by heightened sexual arousal

   The current heroin users 600,000 and 800,000.
   3 million ~ lifetime users
   The male/female : 3/1
   About 90 percent of persons with opioid
    dependence have an additional psychiatric
   15 % of persons with opioid dependence attempt
    to commit suicide at least once.
   About 50 %of urban heroin users are children of
    single parents or divorced parents
Complications of chronic opioid use
 Feeling of warmth, heaviness of the extremities, dry
  mouth, itchy face and facial flushing in IV users
 The initial euphoria is followed by a period of sedation

 The physical effects of opioids include respiratory
  depression, pupillary constriction, smooth muscle
  contraction (including the ureters and the bile ducts),
  constipation, and changes in blood pressure, heart rate,
  and body temperature
 Intravenous users are prone to bacterial infections,
  hepatitis B, HIV infections through needle
DSM-IV-TR Diagnostic Criteria for Opioid
 Recent use of an opioid.
 Clinically significant ,behavioral or
 Pupillary constriction and one of the
  following signs, developing during, or shortly
  after, opioid use:
    ◦   drowsiness or Coma
    ◦   slurred speech
    ◦   impairment in attention or memory
    ◦   Respiratory depression
   The symptoms are not due other mental
Opioid Overdose

   Marked unresponsiveness, coma, slow
    respiration, hypothermia, hypotension, and

   When presented with the clinical triad of coma,
    pinpoint pupils, and respiratory depression ~
    primary diagnosis
DSM-IV-TR Diagnostic Criteria for Opioid
   Either of the following:
    ◦ cessation of opioid use that has been heavy and prolonged
    ◦ administration of an opioid antagonist after a period of opioid
   Three (or more) of the following, developing within minutes
    to several days after use ( usually after 12 hours)
    ◦   piloerection
    ◦   muscle aches, shivering
    ◦   lacrimation or rhinorrhea
    ◦    sweating
    ◦   diarrhea
    ◦   yawning
    ◦   mydriasis
    ◦   Facial flushing
    ◦   Hypertension & tachycardia
   The symptoms clinically significant distress or impairment in
    social, occupational, or other important areas of functioning.
   The symptoms are not due to other mental disorder
Laboratory tests

   Urinary opioid tests: radio-immunoassay, free radical
    assay technique, thin layer chromatography, high
    pressure chromatography, enzyme multiplied immuno-
    assay technique
Treatment of intoxication
   The first task in overdose treatment is to ensure an
    adequate airway.
   Tracheopharyngeal secretions should be aspirated; an
    airway may be inserted.
   Supplementary high flow oxygen should be given.
   Ventilated mechanically as required.
   Naloxone (short half life), the specific opioid antagonist,
    is administered IV at a slow rate initially about 0.8 mg
    per 70 kg of body weight. Initially 2mg followed by
    repeat injectiom in every 5-10 minutes until level of
    conciousness and respiratory rate increases and pupils

 Clonidine (0.1 to 0.3 mg three to four times a day) is
  usually given during the detoxification period or
  withdrawal state to decrease blood pressure.
 Naltrexone (longer half life)100mg PO every alternate
Methadone can be taken orally
 Substitute addictions, longer withdrawal period.
 A daily dosage of 20 to 80 mg is enough to stabilize a
  patient, although daily doses of up to 120 mg have been
Cannabis-Related Disorders
 Cannabis preparations are obtained from the dried
  leaves and flowers of Indian hemp plant Cannabis sativa,
  an annual herb .
 Marijuana refers to any part of the plant used to induce
  effects , and hashish is the dried resign from the flower
Cannabis-Related Disorders

 The primary psychoactive constituent of
  marijuana is delta-9-tetrahydrocannabinol
 When smoked, onset of action is 10-30 mins,
  after ingestion the onset is 1-3 hours
 The cannabis plant has been used in China, India
  and the Middle East for approximately 8,000
 About 33% of adults in the United States have
  used marijuana, and approximately 5% use it on
  a regular basis
Clinical Features
   Dilation of the conjunctival blood vessels (red eye) and
    mild tachycardia.
   Orthostatic hypotension
   Dry mouth
   Euphoria, drowsiness, or sedation
    Sensation of slowed time
    Auditory or visual distortions, dissociation, acute
    paranoid psychosis in high dosages.
   Impaired judgment, motor coordination, attention, or
DSM-IV-TR Diagnostic Criteria for Cannabis
   Impaired motor coordination, euphoria, anxiety,
    sensation of slowed time, impaired judgment,
    social withdrawal.

   Two (or more) of the following signs, developing
    within 2 hours of cannabis use:
    ◦ conjunctival infection
    ◦ increased appetite
    ◦ dry mouth
    ◦ tachycardia
Cannabis induced disorders
•   Psychological dependence is common but
    tolerance and withdrawal symptoms are
•   Cannabis intoxication delirium
•   Cannabis-induced psychotic disorder, with
   Cannabis-induced psychotic disorder, with
   Cannabis-induced anxiety
   Many reports indicate that long-term cannabis
    use is associated with
    Cerebral atrophy,
   Seizure susceptibility,
   Chromosomal damage,
    Birth defects,
   Impaired immune reactivity,
   Alterations in testosterone concentrations, and
   Dysregulation of menstrual cycles
 Serious poisoning from   ingestion is
  extremely rare
 Reassurance or iv diazepam is sufficient
  for drug induced psychossis
 Intravenous fluids for hypotension.
Medical Use of Marijuana
   Nausea secondary to chemotherapy,
   multiple sclerosis (MS)
   chronic pain,
   acquired immune deficiency syndrome (AIDS),
   epilepsy, and
   Glaucoma

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