Gangguan Terkait Zat dan

Drug Abuse

Prof.Dr.dr.M T Kamaluddin,M.Sc.,SpFK

Bagian Farmakologi
Fakultas Kedokteran Unsri
2012

SUBSTANCE ABUSE
- What, why and how to
- Scope dealing with genetic and
environment
- How to handle
- Is there any chance for doctor to do..

Drug Abuse
Self administration of drug or drugs
in manner not in accord with
accepted medical or social patterns

Six reasons why today drug use

and abuse is a serious problem
since 1960 to the present, drug use,
and/or abuse has increased dramatically
illicit drugs are more potent than in the
past
drugs have become commonplace and a
multibillion-dollar-a-year business

Six reasons why today drug use

and abuse is a serious problem

drug use physically harms members of

society
drug use and drug dealing by violent
gangs are steadily increasing at an
alarming rate
serious accidents caused by drug users is
greater as people become more
dependent on technology

Biology/Genes

Environment

DRUG

Neurobiology
Behavior

Addiction

Rethinking the Social Environment: Integrating

Social and Genetic Epidemiology
Social Epi

Genetic Epi

November 2002:
Understanding the social
epidemiology of drug abuse
J anuary 2007:
Special Supplement AJ PM
Fall 2006:
Mapping the social environment
2007:
Recommendations from
participants

Summer-Fall 2004:
Portfolio & literature review
Fall 2004:
Small meeting
Spring 2005: Phenotype Special
Issue J SA

Social Epi

Neuroscience

Transdisciplinary Meeting

Future Initiative?

Genetic Epi

A persons social environment includes

their human relationships, living and
working conditions, income level,
educational background and the
communities they are a part of. All of
these are shown to have a powerful effect
on health.

Epidemiological Triad

Biological explanations for the

use and abuse of drugs.

Genetic theory

predisposition to drug use can be found in

the gene structure

Addiction to pleasure

it is biologically normal to continue a

pleasure stimulation when drugs are
proven to be a pleasurable experience

Biological explanations for the

use and abuse of drugs.
Q. All the major biological explanations
related to drug abuse assume that
these substances exert their
psychoactive effects by altering brain
chemistry. Drugs of abuse interfere
with chemical messengers of the
brain called
.
A. neurotransmitters

Biological explanations for the

use and abuse of drugs.
Q. It is generally believed that most
drugs with abuse potential
enhance the pleasure centers by
causing the release of what
specific brain neurotransmitter?
A. dopamine

Drugs can be Imposters of

Brain Messages

Movement
Motivation

Dopamine

Addiction

Reward & well-being

The Neuron: How the Brains

Messaging System Works
Dendrites
Cell body
(the cells
life
support
center)
Neuronal Impulse

Donald Bliss, MAPB, Medical Illustration

Myeli
n
shea
th

Axon
Terminal
branches
of
axon

dopamine
transporters

Natural Rewards Elevate

Dopamine Levels

% of Basal DA Output

200

DA Concentration (% Baseline)

Food
NAc shell

150

100

50

Empty
Box Feeding

0
0

60

Time (min)

120

180

Sex
200

150

100

Sample 1
Number

Female Present

Di Chiara et al., Neuroscience, 1999.,Fiorino and Phillips, J. Neuroscience, 1997.

Effects of Drugs on Dopamine Release

Accumbens

DA
DOPAC
HVA

100

Time After Drug

Di Chiara and Imperato, PNAS, 1988

250 Accumbens

150

DA
DOPAC
HVA

100

5 hr

Accumbens
Caudate

3 hr

Cocaine

200

Nicotine

200

Accumbens

300

250

% of Basal Release

400

% of Basal Release

1100
1000
900
800
700
600
500
400
300
200
100
0

% of Basal Release

% of Basal Release

Amphetamine

5 hr

Morphine
Dose
0.5 mg/kg
1.0 mg/kg
2.5 mg/kg
10 mg/kg

200
150
100

Time After Drug

5 hr

But Dopamine is only Part of the Story

Scientific research has shown that other

neurotransmitter systems are also affected:

Serotonin
Regulates

mood, sleep, etc.

Glutamate
Regulates

learning and memory, etc.

Genetic explanations for

contribution to drug abuse
vulnerability
psychiatric disorders that are genetically

determined may be relieved by drugs

of abuse, this encouraging their use
in some people, reward centers of the
brain may be genetically determined

Genetic explanations for

contribution to drug abuse
vulnerability
character traits, such as insecurity and

vulnerability, may be genetically

determined
factors that determine how difficult it
will be to break a drug addiction may
be genetically determined

Psychological explanations for

the use and abuse of drugs.

The American Psychiatric Association

classifies severe drug dependence as
a form of psychiatric disorder.
Drugs that are abused can cause mental
conditions that mimic major
psychiatric illnesses.

Psychological explanations for

the use and abuse of drugs.
Because of the similarities between, and
coexistence of, substance-related and
psychiatric disorders, it is sometimes
difficult to distinguish between the
two problems.

Psychological explanations for

the use and abuse of drugs.

substance use (or abuse) disorder can be

identified by the presence of the
following features and their associate
criteria:

substance dependence

substance abuse
substance intoxications
substance withdrawal

Psychological explanations for

the use and abuse of drugs.

personality and drug use

introversion

extroversion

Bringing the
Full Power of Science
to Bear on

Drug Abuse
& Addiction

Neurotoxicity
AIDS, Cancer
Mental illness

Homelessness
Crime
Violence

Health care
Productivity
Accidents

What is Addiction?
Addiction is A Brain Disease

Characterized by:

Compulsive Behavior
Continued abuse of drugs despite negative consequences
Persistent changes in the brains structure and function

Advances in science have

revolutionized our fundamental
views of drug abuse and addiction.

Your Brain on Drugs Today

YELLOW
shows places in
brain where
cocaine binds
(e.g., striatum)

Fowler et al., Synapse, 1989.

Addiction is Like Other Diseases

It is preventable
It is treatable
It changes biology
If untreated, it can last a lifetime

Decreased Brain Metabolism

in Drug Abuser

Decreased Heart Metabolism

in Heart Disease Patient
High

Healthy Brain

Diseased Brain/
Cocaine Abuser

Low

Healthy
Heart

Research supported by NIDA addresses all of these

components of addiction.

Diseased Heart

Addiction Involves Multiple Factors

% in each age group who

develop first-time dependence

Addiction Is A Developmental Disease

that starts in adolescence and childhood
1.8%
1.8%

TOBACCO

1.6%
1.6%
1.4%
1.4%

CANNABIS
ALCOHOL

1.2%
1.2%
1.0%
1.0%
0.8%
0.8%
0.6%
0.6%
0.4%
0.4%
0.2%
0.2%
0.0%
0.0%

55

10
10 15
15

21
21 25
25 30
30 35
35 40
40 45
45 50
50 55
55 60
60 65
65

Age

Age at tobacco, alcohol, and cannabis dependence per DSM IV

National Epidemiologic Survey on Alcohol and Related Conditions, 2003.

definition of drug dependence

Unusual mental state
Constraint
Continuity or regularity
mental effect
to avoid malaise
toleration

43

Narrow definition of drug abuse:

psychological dependence
physiological dependence
mental disorder
aberrant behavior

44

Key Concepts and

Terms
physical dependence/ physiological
dependence
psychic dependence/ psychological
dependence
cross-dependence

45

Danger signals of drug abuse

Do those close to you often ask about
your drug use? Have they noticed any
changes in your moods or behavior?
Are you defensive if a friend or relative
mentions your drug or alcohol use?
Are you sometimes embarrassed or
frightened by your behavior under the
influence of drugs including alcohol?

Effects on society
National health problem
More deaths,illness,accidents,disabilities than any
other health problem
15 million dependent on alcohol
500,000 between ages 9-12
7 million persons between 12-20
binge drink
(Narconon,2005)

Effects on the family

# of babies born with physiologic &
emotional consequences of crack & alcohol
---Increasing at an alarming rate
43% of US families exposed to alcoholism
50% persons who seek tx have at least one
parent w/ alcoholism hx.

Culture and Substance abuse

Attitudes vary in cultures
Muslims no alcohol consumption
Jewish use wine for religious rites
Native Americans use payote (religious
ceremonies)
Genetic traits found predispose or protect
Flushing reaction Asians

Genetics & substance abuse

Variations is structure & activity levels of enzymes

involved in metabolism of ETOH
Variations among Asians, Africian Americans and
whites
Japanese enzyme produces faster elimination of
alcohol
Native Americans- etoh use one of five leading
causes of death(75% accidents)
Japan ETOH consumption quadrupled since 1960

Effects of addiction
Abuse
Tolerence
Physical dependence - addiction
Psychologic dependence mind-body
connection
Alcoholism chronic progressive potentially
fatal
Blackouts

WHO classification
Suppressant of central nerve
Nicotine or tobacco
Opioid
antimelancholic
cannabis
hallucinogenic drug
Fugitive compound

52

drug tolerance
Definition
Repeated medication
Characteristic
Different tolerance
Reversability
Cross resistance :
analogic chemcial constitution
mechanism of action
drug dependence
toleration
53

Classification of drug to cause

dependence
narcotic drug
psychotropic drug

54

Narcotic drug
Consecutive application to bring about
physiological dependence and addiction
Including:
opioids, cocaine, cannabis

55

psychotropic drug
Definition
Repeated medication,
Affect C.N.S excited/inhibited
to bring about psychological dependence
1 Sedativehypnotics / antianxietic:
Barbiturates, benzodiazepines
2 psychostimulant
Amphetamines, ritalin, caffeine
3 psychodelic
Cannabinol, cannabidiol
56

Appearance of drug dependence

Craving re-medication
Constraint drug seeking behavior

Withdrawal reaction

57

Characteristic of drug dependence

Opioid
discontinuation 8-16h, 24-36h
Suppressant of central nerve
Benzodiazepine withdrawal 36h
Barbiturates withdrawal 12-24h
Cannabis
Antimelancholic
#phenamine
#Cocaine
58

Disservice of drug abuse

Individual
physical and mental health
Intoxation
death
immunity
infection
Society
Common family life destroy
Criminality
hold-back development
59

Control of drug abuse

International
1961 convention
1971 convention
1981 strategy
National
institute system
Education
medical establishment of withdrawal

60

Drug Abuse

Psychological Dependency (Habituation)

Drug necessary to maintain users 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

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

Lethargy
Pinpoint pupils
Bradycardia
Hypotension
Decreased bowel
sounds
Flaccid muscles

Severe

Respiratory depression
Coma
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 1950s-60s 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

Overdose produces sudden, prolonged apnea

Highly addictive
Withdrawal resembles barbiturate withdrawal
Only Placidyl, Doriden remain available in U.S.

Placidyl (ethchlorvynol)

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)

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 beta-blockers, including labetolol (Why?)

Body 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 rocha

Roofenol

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
Anxiety, tension
Numbness, tingling of
extremities
Restlessness, confusion
Loss of identity

Hallucinations
Delirium
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, nearly tasteless
Tremors
Seizures
Death

Alcohol and other drugs are

associated with:

Up to 50% spousal abuse

50% traffic accidents
49% murders
68% manslaughter charges
69% drownings
38% child abuse
52% rapes
62% assaults
20-35% suicides
(Johnson-1997)

Similarities & Differences

Alcohol
Intended effect
Alcohol- CNS
Depressant/relaxation, loss of
inhibition

Intoxication
Slurred
speech;loss of
coordination;
ataxia; decreased
coordination,
attention/concentration, memory
judgment

W/d detox
4-12n hrs. p last
drink
Course hand
tremor,sweating
T, P,B/P, R
Insomnia, anxiety,
N/V
If no tx.= DTs

Sedatives /Hypnotics
Anxiolytics
Induced effect
Benzodiazapines
& Barbituates
Use: to produce
Drowsiness,
anxiety

Intox-OD
Benzos rarely
fatal when taken
alone; sxs =
Lethergy,
Confusion;
Barbs fatal in
OD-coma,resp
cardiac arrest

W/d detox
Ativan-10 hrs
W/d sxs-6-8 hrs
p last dose
Valium w/d up
to 1 wk
W/d= v/s
Need to taper off
drug

Stimulants amphetamines/cocaine
Intended effect
Excite CNS
Limited clinical
use high abuse
potential
Cocaine-highly
addictive

Intox- OD
High-euphoric
feeling;hyperactivity/vigilance
Talkativeness,
grandiosity,hallucin
ations, anxiety
Repetitive
behaviors, anger ,
fighting

W/d detox
Occurs-few hrsdays
C/b marked
dysphoria;
fatigue; vivid &
unpleasant
dreams; hyper or
insomnia;
psychomotor act.

Opioids: morphine,
heroin,meperidine,codeine,hydromorphone,
Induced effect
Popular for
abuse
desensitize user
to both
physio/psych
pain-induce
euphoria, wellbeing

Intox OD
Intox- develops
quickly c/b apathy,
lethergy,listlessness,
judgment, psychomotor retardation or
agiation, constricted
pupils,slurred speech
Severe o d coma,
Resp. arrest/death

W/d detox
Drug intake ceases
or markedly; c/b
anxiety/restless.,
aching back,legs,
craving for opioids
Heroin w/d
6-24hr;
peak 2-3 days;
Ends=5-7 days

Hallucinogens
Intended
effect
Distort users
perception of
reality

Intoxification/OD
Intox= (Psychologic)
anxiety,depression,
Paranoid delusions,
hallucinations
(Physio) B/P,T,P
dilated pupils,sweating,
blurred vision,tremors,
decreased coordination

Withdrawal/Detox
No withdrawal
symptoms known
-may crave drug
Produce flashbacks
May continue up to
5 years after use.

Pharmacologic treatment
substance abuse
Disulfiram(antabuse)-maintain abstinence
from alcohol
Teach client to read all labels avoid any
product containing alcohol
Lorazepam(ativan) for w/d fro etoh
Monitor V/S/client safety/assess effectiveness

Pharmacologic treatment

Clonidine(catapres) suppresses opiate

withdrawal symptoms check B/P prior to
administration withhold if hypotensive

Thiamine(vitamin B1) Folic acid (folate),

B12 = tx nutritional deficiencies teach re:
proper nutrition; darkened urine may result
w/folate.

prevention and cure

Insulate to withdrawal
Substitution therapy
Barbiturates Phenobarbital
Alcohol clormethiazole clorazepate
Opioid methadone

140

Substitution therapy of methadone

pharmacologic action of methadone
methadone 1mg
replace
morphine 4mg; heroin 2mg; dolantin 20mg
detoxification
convalescent care

141

Therapy of clonidine
pharmacologic action of clonidine:
Excitomotor of2 adrenoceptor
Inhibit NC excitation of NE nucleus ceruleus
to control abstinent symptom
therapy
detoxification
convalescent care
142

Therapy of the drug abuse

Detoxification
to prevent relapse
Return to social life

143

The Impact of Addiction Can Be Far

Reaching
Cardiovascular disease
Stroke
Cancer
HIV/AIDS
Hepatitis B and C
Lung disease
Obesity
Mental disorders

Continued drug abuse- a voluntary behavior?

The initial decision to take drugs is mostly voluntary.

However, when drug abuse takes over, a person's ability to
exert self control can become seriously impaired. Brain
imaging studies from drug-addicted individuals show
physical changes in areas of the brain that are critical to
judgment, decision making, learning and memory, and
behavior control. Scientists believe that these changes alter
the way the brain works, and may help explain the
compulsive and destructive behaviors of addiction.

How Does the Brain Become Addicted?

Typically it happens like this:
A person takes a drug of abuse, be it marijuana or cocaine or
even alcohol, activating the same brain circuits as do behaviors
linked to survival, such as eating, bonding and sex. The drug
causes a surge in levels of a brain chemical called dopamine,
which results in feelings of pleasure. The brain remembers this
pleasure and wants it repeated.
Just as food is linked to survival in day-to-day living, drugs
begin to take on the same significance for the addict. The need to
obtain and take drugs becomes more important than any other
need, including truly vital behaviors like eating. The addict no
longer seeks the drug for pleasure, but for relieving distress.

How Does the Brain Become Addicted?

Eventually, the drive to seek and use the drug

is all that matters, despite devastating
consequences.
Finally, control and choice and everything that
once held value in a person's life, such as
family, job and community, are lost to the
disease of addiction.

Repeated drug exposure changes brain function. Positron emission tomography (PET) images are illustrated showing similar brain
changes in dopamine receptors resulting from addiction to different substances - cocaine, methamphetamine, alcohol, or heroin. The
striatum (which contains the reward and motor circuitry) shows up as bright red and yellow in the controls (in the left column), indicating
numerous dopamine D2 receptors. Conversely, the brains of addicted individuals (in the right column) show a less intense signal, indicating
lower levels of dopamine D2 receptors.

Source: From the laboratories of Drs. N. Volkow and H Schelbert

Addiction is similar to other diseases, such as heart disease.

Both disrupt the normal, healthy functioning of the
underlying organ, have serious harmful consequences, are
preventable, treatable, and if left untreated, can last a
lifetime.

No single factor determines whether a person

will become addicted to drugs
Scientists estimate that genetic factors account for 40-60% of a persons
vulnerability to addiction including the effects of environment on these factors
The influence of the home environment is usually most important in childhood.
Parents or older family members who abuse alcohol or drugs, or who engage in
criminal behavior, can increase children's risks of developing their own drug
problems
The earlier a person begins to use drugs the more likely they are to progress to
more serious abuse
Method of administration. Smoking a drug or injecting it into a vein increases its
addictive potential
Some people will never develop diabetes because they never go over a certain
weight much like some people will never become drug dependent because they
never try drugs. If they did they would in both cases

Does drug abuse cause mental disorders, or vice versa?

Drug abuse and mental disorders often co-exist. In

some cases, mental diseases may precede
addiction; in other cases, drug abuse may trigger or
exacerbate mental disorders, particularly in
individuals with specific vulnerabilities.

2004 National Survey on Drug Use and Health found that

the percentage of the nation's estimated 600,000 monthly
meth users who met the criteria for dependence rose from
27.5 percent (164,000) in 2002 to 59.3 percent (346,000)
in 2004

 The first meth epidemic occurred in Japan following

WWII when the government released large stockpiles of
meth that had been held for use by factory workers during
the war
Amphetamines were used by Allied and Axis armed forces
during WWII and 1991 Operation Desert Storm
In Japan, meth use has surpassed that of all other drugs
-meth users exceed users of all other substances combined
Worldwide, amphetamine and methamphetamine are the
most widely abused illicit drug after cannabis- more use
than cocaine or heroin
From the WHO- over 35 million individuals regularly
use/abuse amphetamine/meth
As of 2003, according to the National Survey on Drug Use
and Health, 12.3 million Americans had tried meth at least
once -up nearly 40% over 2000 and 156% over 1996

Methamphetamine The Drug

Speed, Ice, Meth, Crystal, Crank

Clandestine labs
Easily synthesized
Readily obtainable
Sold through networks
Abusers range widely in age, educational level,
socioeconomic status and ethnic background

Forms of Meth
Speed usually comes in the form of white or yellow powder

People usually sniff it through the nose (snort), smoke or inject it.
It can also be swallowed, in the form of tablets or capsules

Speed is often mixed or cut with other things that look the same to make the
drug go further
Some mixed-in substances can have unpleasant or harmful effects

ICE
Making ice, the smokable form of methamphetamine, from standard quality
methamphetamine HCl is essentially a purification process. Methamphetamine HCl is
added slowly to water that has been heated 80-100C until a supersaturated solution is
obtained. When the slurry is cooled, pure HCl salt of methamphetamine (ice)
precipitates. Methamphetamine HCl, unlike cocaine HCl, is volatile and can be
smoked. Other solvents, such as isopropanol, have been used in place of water to
speed the process. Uncontrolled variations of this process can result in unreliable
removal or addition of impurities. The physical characteristics of the final product
depend on the quality and type of reagents used and on contaminants that may have
been introduced. The lack of significant further processing of methamphetamine HCl
has resulted in increased availability and popularity of smoking the drug.
One reason for the popularity of smoked methamphetamine is the immediate
clinical euphoria that results from the rapid absorption in the lungs and deposition
in the brain.
Smoking methamphetamine HCl powder, crystals, or ice occurs first by placing
the substance into a piece of aluminum foil that has been molded into the shape
of a bowl, a glass pipe, or a modified light bulb and heating it over the flame of a
cigarette lighter or torch. Then, the volatile methamphetamine fumes are inhaled
through a straw or pipe.
From emedincine.com

Methamphetamine

Toxicity: Moderate
Flammability: Low
Reactivity: Very Low
OH
CHCHNHCH
CH

EPHEDRINE

CH CHNHCH
2
CH
METHAMPHETAMINE

3
3

Powerful CNS
stimulant
Highly addictive
Usually smoked or
injected
High lasts longer
than cocaine
Prescribed for weight
loss, ADD-type
behaviors

Atlanta DEA Seizes Record Amount

of Crystal Meth
large-scale Mexican drug ring with
members believed to be in the Atlanta
area, involving importation and
distribution of multi-kilogram quantities
of methamphetamine and cocaine from
Mexico, moved through California and
Texas, distributed into the United States
41 kilograms of suspected cocaine and
in excess of 187 pounds of suspected
crystal methamphetamine

How is Methamphetamine Used?

May be smoked, snorted, orally ingested,

injected or used rectally or vaginally
Alters moods in different ways depending
on how it is taken

Acute Positive Effects of Meth

Well-being to Euphoria
Increased Energy
Enhanced Mental Activity
Increased Sex Drive
Decreased Need for Sleep
Decreased Appetite
Increased Sensory Awareness and Alertness
Feeling of Omnipotence
Intensify Emotions
Alter Self-esteem
Increased aggressiveness

Reasons for First Use of Methamphetamine

March 1998- Nov 1998

Easily Available (strongest reason)

66% females

59% males

2nd reported reason

Females: to be more productive

Males: curiosity
Males more likely because parents use drugs
Review article M. Cretzmeyer, et al J. Substance Abuse Treatment
24(2003) 267-277

Binge Pattern of Abuse Cycle

Meth vs. Cocaine

Man-made
Daily use
Longer binges
Smoking produces
a high that last 8-24
hours
50% of the drug is
removed from the
body in 12 hours

Plant-derived
Recreational use
Intermittent binges
Smoking produces
a high that lasts 2030 minutes
50% of the drug is
removed from the
body in 1 hour

Meth vs. Cocaine Effects on the Brain

Cocaine

Methamphetamine

Measuring Pleasure
Stimulants boost the normal brain levels of the neurotransmitter
dopamine, which produces feelings of pleasure and increases
energy. Methamphetamines causes an excessive spike in
dopamine. Scientists say the excessive release contributes to the
drug's destruction of the brain.

Dopamine Index
Cheeseburger
1.5
Sex
2.0
Nicotine
2.0
Cocaine
4.0
Methamphetamine 11.0
Source: UCLA Integrated Substance Abuse Programs. Michael Mode/The Oregonian

Effects of Methamphetamine Use on the Brain

Direct dopamine effects:

Changes in mood
Excitation
Intensification of
emotions
Elevation of self esteem
Sensory perception
Decreased appetite
Elevation of libido
Unusual motor
movements
Paranoia

Suspected serotonin effects:

Increase feelings of
empathy
Feelings of closeness
Bizarre mood changes
Psychotic behavior
Aggressiveness
Bruxism
Lack of appetite
Inability to sleep

Depleted dopamine
transporter levels in
methamphetamine
abusers show recovery
after prolonged
abstinence.
In these brain scans,
high dopamine
transporter levels appear
as red, while low levels
appear as yellow/green.
Dr. Nora Volkow, Director of
NIDA
(National Institute on Drug
Abuse)

Brain Changes with Meth Use

PET scans comparing control, Meth users with 6 mo-5 years

abstinence, and patients with Parkinsons Disease, showing
decreased dopamine transporter activity in the caudate and
putamen. 25% decrease for Meth users, and 60% for PD.
(McCann 1998)

Cognitive Deficits

Axons dont always grow back correctly

Different parts of brain recover at different rates
Impairment of word and picture recall
Impaired ability to manipulate information
Ignore information
Inability to filter irrelevant information
Studies show impairment worse at 12 weeks
of non-use than is evident in current user
Word recall gets worse, picture recall gets
better

Neurotransmitter Depletion

Behavior Changes
Psychotic Features

Paranoia
Visual and auditory hallucinations
Mood disturbances
Delusions (ex. The sensation of insects
creeping on the skin)
Homicidal thoughts
Suicidal thoughts
Out of control rages
Can persist for years after use discontinued

Other Effects of Chronic Meth Use

Tooth decay
Hepatitis B and C
STDs : sexually transmitted disease
HIV : associated with needle use and unprotected sex
Sexual Impotence
Cognitive impairment (reduced ability to process
information)
Unplanned pregnancy, victims of domestic violence

Matrix Institute on Addictions

Cognitive Impairment in Individuals Currently
Using Methamphetamine
Active MA users demonstrate impairments in:
the ability to manipulate information
the ability to make inferences
the ability to ignore irrelevant information
the ability to learn
the ability to recall material

Effects of Methamphetamine Use - Addiction

Chronic, relapsing disease

Characterized by compulsive drug-seeking and
drug use
Functional and molecular changes in the brain
Stronger potential for addiction
rapid-acting routes of administration
higher dosages
higher purity

Effects of Methamphetamine Use - Tolerance

Take higher doses

Dose more frequently
Change their method of drug intake
Run - forego food and sleep while binging
No tolerance for effects on judgment,
impulsivity, aggression, and susceptibility to
paranoia, delusions, and hallucinations
opposite reaction

Effects of Methamphetamine Use - Withdrawal

Physical:
Polyphagia (excessive hunger)
Hypersomnolence (sleepiness)
Psychological:
Depression
Anxiety/agitation Free floating anxiety
Delusional state lasting up to a week
Fatigue/malaise
Paranoia
Hallucinations
Aggression
Intense craving for the drug

Abstinence Syndrome
After awaking from the crash, symptoms continue:

Psychological/Behavioral Symptoms
Dysphoric mood--that may deepen into clinical depression

and suicidal ideation

Persistent and intense drug craving
Anxiety and irritability
Impaired memory
Anhedonia--loss of interest in pleasurable activities
Interpersonal withdrawal
Intense and vivid drug-related dreams

Abstinence Syndrome

Physiological symptoms
Thin, gaunt appearance with reported weight loss
or anorexia
Dehydration
Fatigue and lassitude, with lack of mental or
physical energy
Dulled sensorium
Psychomotor lethargy and retardation--may be
preceded by agitation
Hunger
Chills
Insomnia followed by hypersomnia

Special Issues for Women and Methamphetamine

Affordable
Available
Appetite suppressor
Energy enhancer
Weight loss
Mood elevator
Libido enhancer
The growing illicit drug of choice among young
women
47% of those presenting for meth treatment females,
other substances 20-25% females

The impact on children may be connected to the

fact that women are more likely to use meth than
other illegal drugs.
For one thing, the drug is associated with weight
loss.
One federal survey of people arrested for all
crimes found that 11.3 percent of women had used
meth within the prior month compared with 4.7
percent of men.

Parenting Issues with Meth Involvement

Neglect during long periods of sleep

Inconsistent, paranoid behavior
Irritability, short fuse, potentially leading to
physical abuse
Exposure to violence, unsavory characters
Generally poor parenting skills
Mental health issues

Substance Abuse Affects Parenting

Impaired judgment and

priorities
Inability to provide the
consistent care,
supervision and guidance
children need
Substance abuse is a
critical factor in child
welfare
[Blending Perspectives and Building Common Ground, A Report to Congress
on Substance Abuse and Child Protection, April 1999]

Children of Parents
with Substance Abuse Problems

Have poorer developmental outcomes

(physical, intellectual, social and emotional)
than other children
Are at an (eight-fold) increased risk of
substance abuse themselves

Substance Abuse and Child Abuse and Neglect

Substance abuse causes or exacerbates 7 out

of 10 cases of child abuse and neglect
Children whose parents use drugs and alcohol
are:
3x more likely to be abused
More than 4x more likely to be neglected

Basic Meth Patient Treatment Considerations

Many stimulant dependent individuals demonstrate

1. Low Impulse Control
2. Low Tolerance for Frustration
3. High Likelihood of Psychiatric Complications
(paranoia, delusions, agitated depression)
4. High Risk for Explosive, Violent Behavior
5. High Risk of Depression and High Risk of Suicide
6. Very Strong Craving
7. Cognitive and Memory Impairment
8. Brief Attention Span

Implications for practice

Try to find time for a quick phone call or a quick little note of
reassurance and encouragement. This will go a long way in
helping the addict be successful and will help the case move
quicker towards safe case closure.
You can take exception to the persons behavior but you must
accept the person in order to make progress.
Determine the priorities for intervention in a case and then
move slowly forward to implementation.
Provide parent/child visitation
Provide support and encouragement
If we take away their only solution to lifes problems we
need to follow that up with some other means of coping.

Can addiction be treated successfully?

Yes. Addiction is a treatable disease. Discoveries in the
science of addiction have led to advances in drug abuse
treatment that help people stop abusing drugs and
resume their productive lives.
Can addiction be cured?
Addiction need not be a life sentence. Like other
chronic diseases, addiction can be managed
successfully. Treatment enables people to counteract
addiction's powerful disruptive effects on brain and
behavior and regain control of their lives.

Relapse rates for drug-addicted patients are compared with those suffering from diabetes,
hypertension, and asthma. Relapse is common and similar across these illnesses (as is adherence
to medication). Thus, drug addiction should be treated like any other chronic illness, with relapse
serving as a trigger for

Relapse rates for drug-addicted patients are compared with those suffering from
diabetes, hypertension, and asthma. Relapse is common and similar across these
illnesses (as is adherence to medication). Thus, drug addiction should be treated
like any other chronic illness, with relapse serving as a trigger for renewed
intervention.

People Can and Do Recover from Meth Addiction

Outcomes data provided by SSAs confirm that people can and do recover from meth
addiction. Examples include:
Colorados Alcohol and Drug Abuse Division reported in FY 2003 that 80% of
meth users were abstinent at discharge.
Iowas Division of Behavioral Health and Professional Licensure found, in a 2003
study, that 71.2% of meth users were abstinent 6 months after treatment.
Tennessees Bureau of Alcohol and Drug Abuse reported in a 2002-2003 study that
over 65% meth clients were abstinent 6 months after discharge.
The Texas Department of State Health Services examined outcomes data for
publicly funded services from 2001-2004 and found that approximately 88% of
meth clients were abstinent 60 days after discharge.
Utahs Division of Substance Abuse and Mental Health reported that in State Fiscal
Year 2004, 60.8% of meth clients were abstinent at discharge.
National Association of State Alcohol and Drug Abuse Directors, Inc.

Pre-Recovery Behaviors/Excuses
Occur with Increased Frequency
Old playmates and
old playgrounds
Person not following
through with AA/NA
meetings or recovery
steps
Cross-addictions

I will just stop over at

Jims and if they have
drugs, I will just
leave
Im too busy/tired to
got to a meeting,
I dont have a problem
with alcohol so it is
OK for me to drink.

Reuse
can be the use of a drug out of the blue
person may be working an excellent
recovery program
may have had a long period of sobriety
may be avoiding the old friends and old
playgrounds
They may be doing everything right but still
have used

Relapse Prevention Steps

Self-knowledge and identification
warning signs. This process teaches
clients to identify the sequence of
problems that has led from stable
recovery to chemical use in the past, and
then to synthesize those steps into future
circumstances that could cause relapse.

Types of Relapse-Prone Clients

Transition- does not accept/recognize their
addiction and are not able to accurately perceive
reality due to chemical effects.
Unstabilized- lacks addiction interruption skills,
recovery program support, and positive lifestyle
change.
Stabilized- is aware of their addiction and the
necessity for ongoing recovery program to
maintain abstinence. However, they tend to
develop dysfunctional symptoms over time
leading back to substance usage.

Relapse or Reuse?

It is important to distinguish relapse from

reuse. They are two different things.
Relapse is a progressive psychological and
behavioral change
Can start hours, days, weeks or months
before a person uses mood-altering
chemicals

Relapse Treatment Failure

Recurrence of substance use can happen at any point during
recovery
Recognize the difference between a lapse (a period of substance
use) and relapse (the return to problem behaviors associated with
substance use)
Work with the client to re-engage in treatment as soon as possible

Relapse Treatment Failure

Part of effecting long-term change includes working with clients to
identify the specific factors that preceded their substance use
What were the emotional, cognitive, environmental, situational, and
behavioral precedents to the relapse?

Relapse Treatment Failure

One element in the process of recovery is to
develop a relapse prevention plan and strategies to
avoid relapse
Plan for the potential of relapse and for ensuring
safety of the child(ren)
Parents who learn triggers can become empowered
to plan proactively for the safety of their children
and to seek healthy ways to neutralize or mitigate
the trigger
Relapse prevention includes: What can a client do
differently?

Implications for Practice

Make sure factors critical for recovery are
addressed by making client accountable.
Relapse does not necessarily mean the
discontinuation of visitation. Dont stop visits as
punishment if the childs safety and well-being
can be assured.
Provide client with accurate information about
relapse process and the means to avoid it.
Encourage client through motivational
interviewing and affirmations

Stages of Change in Substance Abuse &

Dependence: Intervention Strategies
Maintenance
Stage

Precontemplation
Stage

Contemplation
Stage

Preparation
Stage

Action
Stage

Relapse
Stage
Motivational
Enhancement
Strategies

Assessment
& Treatment
Matching

Relapse
Prevention
& Relapse
Management

Treating a Biobehavioral Disorder Must Go

Beyond Just Fixing the Chemistry
We Need to Treat the
Whole Person!
Pharmacological
Treatments
(Medications)

Medical Services

Behavioral Therapies

Social Services

In Social Context

Basic Research

Medication

Opiate agonists stabilize brain

function in heroin addicts

Agonist Therapy
Methadone
Buprenorphine

CB1 KO mice have decreased

responses to multiple drugs of abuse

CB1 Antagonists

Smokers who are poor nicotine

metabolizers smoke less

Stress triggers relapse in animal models

of addiction and CRF antagonists
interfere with the response to stress

Inhibitors of
metabolizing enzymes

CRF Antagonists

Thank you

poppy flower of California (1998.5)

208

opium
poppy

209

marijuana

210