Lawrence S. Neinstein, M.D., F.A.C.P.
Professor of Pediatrics and Medicine
USC Keck School of Medicine
Executive Director
University Park Health Center
Associate Dean of Student Affairs
   

 

 

Substance Abuse - Stimulants/Inhalants/Opioids/Anabolic Steroids/Designer and Club Drugs (B8)

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STIMULANTS

Stimulants include nicotine, caffeine, cocaine, and amphetamines.

Cocaine

Cocaine is a stimulant made from an alkaloid contained in the leaves of the coca bush, Erythroxylon coca. Crack or rock cocaine is a ready-to-smoke, potent, relatively inexpensive, and highly addictive freebase forms of cocaine.

  • Prevalence : Cocaine has been tried by about 8.6% of the seniors of the class of 2000 in the national survey results from the Monitoring the Future Study, a decrease from 17.3% in 1985 but an increase from 5.9% in 1994.
  • Cocaine has three major pharmacological actions - Potent stimulant of the central and peripheral nervous systems, local anesthetic activity and vasoconstrictive activity.
  • Symptoms of intoxication: General (hyperalert state, increased talking, restlessness, elevated temperature, anorexia, nausea, dry mouth, dilated pupils, sweating), neurological (seizures, dizziness, paresthesias, hyperactive reflexes, tremor), psychiatric (labile affect, insomnia, delirium, aggression, elation, euphoria, hallucinations, agitation, irritability, anxiety, skin picking), cardiac (arrhythmias, hypertension, tachycardia).
  • Symptoms of overdose - General (dry mouth, nausea, vomiting, anorexia, dilated pupils, excessive sweating, increased talking, flushing, increased temperature, respiratory failure), neurological (seizures, paresthesias, hyperactive reflexes, tremor, pinprick analgesia, facial grimaces, headache, coma), psychiatric (toxic psychosis, skin picking, paranoid behavior, anxiety, delirium, body image change, hallucinations, irritability), cardiac (tachycardia, angina, arrhythmias, chest pain, hypertension, cardiovascular collapse).
  • Complications: Cardiovascular (chest pain, arrhythmias, hypertension, myocardial infarction, cardiomyopathy, myocarditis, stroke), psychiatric (depression, schizophreniform psychosis, toxic delirium, anxiety, paranoia, suicide), neurological (seizures, headaches, cerebral hemorrhage, cerebral infarctions, cerebral vasculitis), malnutrition, hyperpyrexia, obstetric (placental abruption, lower infant weight, prematurity, microcephaly), pulmonary (pneumothorax, pneumomediastinum, pneumopericardium, pulmonary edema, pulmonary hemorrhage), head and neck (erosion of dental enamel, gingival ulceration, keratitis, chronic rhinitis, perforated nasal septum, midline granuloma, altered olfaction, optic neuropathy, osteolytic sinusitis), sexual dysfunction, rhabdomyolysis, hyperprolactinemia, gastrointestinal (acute ischemic syndrome and hepatoxicity)
  • Tolerance - Repeated use leads to rapid development of tolerance
  • Treatment of toxicity includes cardiopulmonary support, stat blood to rule out hypoglycemia, treatment of arrhythmias, treatment of hypertension, treatment of agitation and psychosis with haloperidol or droperidol, treatment of hyperthermia with cooling blanket
Amphetamine/methamphetamine

Amphetamines are central-nervous-system stimulants and work as a sympathomimetic drug. Routes of administration include oral, snorting, and intravenous. The characteristics of amphetamines are similar to those of cocaine.

  • Dose - The most common types of amphetamines include dextroamphetamine sulfate (Dexedrine), methamphetamine (Desoxyn), amphetamine sulfate (benzedrine sulfate) and benzphetamine (Didrex). Smoking methamphetamine is also becoming very common and involves smoking usually methamphetamine ("ice") or when mixed with crack cocaine ("croak").
  • Street names include A's, meth, speed, crystal, whites, white crosses, crank, ice, ups, dexies, bombido, bennies, black beauties, crosses, and crossroads among others.
  • Prevalence: The 2000 Monitoring the Future Study found that 15.6% of high school seniors had tried amphetamines and included a one year prevalence rate of 10.5%.
  • Symptoms of intoxication, overdose, and abstinence are similar to those of cocaine
  • Tolerance and dependence can occur.
  • Complications of amphetamine overdose resemble those of cocaine
  • Treatment is similar to cocaine toxicity and involves cardiopulmonary support, treatment of agitation with droperidol or haloperidol, treatment of hypertension and arrhythmias, treatment of hyperthermia with cooling blanket, treatment of seizures with benzodiazepines, maintain calm supportive environment, and avoid acidification of urine.

Ritaline (methylphenidate)

With the increase in diagnosis of ADHD in children and adults more methylphenidate (Ritalin) is being diverted as a drug of abuse, frequently nasally insufflated by adolescents.

Khat (Cathine, cathinone)

Cathinone is chemically similar to d-amphetamine and cathine (d-norisoephedrine) is a milder form of cathinone. These compounds are the active ingredients in khat leaves (Catha edulis), used as a tea or chewed for its euphoriant and stimulant effects in Africa and the Middle East and also in corresponding immigrant/refugee communities in developed nations. Western physicians are frequently unaware of the widespread use of and availability of khat in certain African and Arabian communities.

Betel Nut

Though unknown to most western physicians, Betel nut is chewed on a daily basis by 15% of the world's population (600 million). This can contain psychoactive phenols and an alkaloid stimulant. Dependence occurs rapidly.

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INHALANTS

Inhalants include spray paints, plastic cement, rubber cement, typewriter-correction fluid, gasoline, nitrites, and nitrous oxide.

  • Prevalence: The 2000 national survey on drug use from the Monitoring the Future Study found that 14.2% of the 12th graders had tried using inhalants, with 5.9% having used them in the past year and 2.2% in the month before the survey.
  • Inhalants are attractive to adolescents because of their rapid onset of action, low cost, and easy availability.
  • Initial effect is stimulation and excitation, which then progresses to a depressant effect on the central nervous system.
  • Symptoms of Intoxication include: General (lacrimation, rhinorrhea, salivation, irritation of the mucous membranes, anorexia, vomiting, sleepiness), neurological (dizziness, headaches, slurred speech, ataxia, diplopia), psychiatric (euphoria, decreased inhibition, decreased judgment)
  • Symptoms of overdose include: slow and shallow respirations, delirium, arrhythmias, stupor, seizures, coma, cardiopulmonary arrest.
  • Complications include: bronchitis, liver and renal damage, CNS damage and cardiac arrhythmias
  • Treatment is aimed at control of arrhythmias and respiratory and circulatory support.

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OPIOIDS

Opioid refers to all drugs, natural and synthetic, with morphine-like activity, and antagonists that bind to opioid receptors. All the opiates are derived from the opium poppy, Papaver somniferum.

From crude opium, morphine, codeine, and heroin are manufactured.

  • Physical toxicity symptoms of all opioids include: Pupillary constriction, drowsiness or coma, decreased respiratory rate and heart rate, pulmonary edema, slurred speech and impairment in attention.
  • Psychiatric toxicity symptoms include: initial euphoria, apathy, dysphoria, psychomotor agitation or retardation, impaired judgment, impaired social functioning and impaired occupational functioning.

Heroin

  • Stronger and faster onset of action than morphine with duration of injected heroin of 3 to 6 hours.
  • Induces analgesia, sedation, narcosis, or stupor, blocks cough reflex, causes vasodilation, induces constriction of pupils.
  • Prevalence: In the Monitoring the Future survey, ever use (lifetime use) increased from 0.9% in 12 th graders in 1991 to 2.4% in 2000. Among seniors use was 1.5% in past year, 0.7% in past 30 days and 0.1% for daily use.
  • Symptoms of intoxication include anxiety, slow comprehension, euphoria, floating feeling, flushing, hypotonia, pinpoint pupils, skin picking, sleepiness, and constipation.
  • Symptoms of narcotic overdose include general (pinpoint pupils, slow and shallow respirations, decreased temperature, pulmonary edema, constipation, cyanosis), neurological (pinprick analgesia, ataxia, stupor, slow comprehension, hypotonia, diminished reflexes, coma), psychiatric (delirium), cardiac (circulatory collapse and hypotension).
  • Symptoms of withdrawal include general (muscle aches, chills, coryza, flulike symptoms, lacrimation, muscle spasms, nausea, vomiting, piloerection, sweating, increased respiratory rate and temperature, yawning, hot and cold flashes, neurological (paresthesia, tremors, ejaculation/orgasm, mydriasis), psychiatric (anxiety, sleep disturbances, supplicating behavior, irritability, restlessness), cardiac (hypertension, tachycardia) and gastrointestinal (abdominal cramps, diarrhea)
  • Complications include: physical and psychological dependence, cutaneous (abscesses, cellulitis, lymphadenitis, phlebitis, and tongue and penile lesions from injections), pulmonary (foreign fibers (talc, cotton), arteritis and thrombosis of the pulmonary vessels, septic emboli, lung abscesses, pulmonary fibrosis, pulmonary hypertension, pneumonia, and respiratory depression), cardiac (pulmonary edema, arrhythmias caused by quinine, and bacterial endocarditis), infections (hepatitis, endocarditis, septic arthritis, osteomyelitis, tetanus, tuberculosis, and acquired immunodeficiency syndrome), myositis ossificans, neurological (coma, seizures, transverse myelitis, polyneuropathy, cerebrovascular accidents, deafness, and infections), crush injuries, nephrotic syndrome, amenorrhea, hypergammaglobulinemia, chronic constipation.
  • Treatment of heroin overdose includes cardiopulmonary support, treatment of pulmonary edema with positive pressure, treatment of hypotension and arrhythmias and also naloxone to counter the effects of opiods. In addition, treatment of hypoglycemia, treating any infectious complications, and treatment of withdrawal.

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DEPRESSANTS

The central-nervous-system depressants include the barbiturates; the nonbarbiturate hypnotic drugs such as glutethimide (Doriden) and methaqualone (Quaalude); the major tranquilizers (phenothiazines) and minor tranquilizers (benzodiazepines), and the carbamates such as meprobamate (Equanil and Miltown). Another depressant drug of concern has been flunitrazepam (Rohypnol).

  • Physical symptoms of sedative-hypnotic intoxication include: slurred speech, incoordination, unsteady gait, nystagmus, decreased reflexes, impaired attention or memory and stupor or coma.
  • Psychiatric symptoms of intoxication include: inappropriate behavior, mood lability, impaired judgment, impaired social functioning and impaired occupational functioning.
Barbiturates

Barbiturates are hypnotic and sedative drugs derived from barbituric acid.

  • Barbiturates are central-nervous-system depressants. Low doses result in mild sedation, higher doses result in hypnosis, and still higher doses result in anesthesia and possible death.
  • Barbiturates are divided into ultrashort-acting, short-acting, intermediate-acting, and long-acting types.
  • Prevalence: The 2000 Monitoring the Future Study found that 9.2% of the seniors had used barbiturates at some time in their life. Of reporting seniors, 5.8% had used barbiturates during the previous 12 months; 3.0% had used them in the previous 30 days.
  • Symptoms of intoxication include: General (muscle aches, anorexia, fatigue, floating feeling, sleepiness, yawning), neurological: Ataxia, slow comprehension, diplopia, dizziness, dysmetria, hypotonia, poor memory, lateral nystagmus, slurred speech), psychiatric (anxiety, delirium, depressed mood, euphoria, irritability, "toxic" psychosis, violent behavior) and orthostatic hypotension.
  • Symptoms of overdose include: pinprick analgesia, ataxia, slow comprehension, delirium, orthostatic hypotension, hypotonia, irritability, lateral nystagmus, slow and shallow respirations, and bradycardia.
  • Tolerance and physical dependence occurs with a severe withdrawal syndrome after the drug is stopped.
  • Treatment of overdose includes cardiopulmonary support, removal of unabsorbed toxins, consideration of use of naloxone if any coexisting narcotics involved, avoidance of CNS stimulants and treatment of withdrawal.
Nonbarbiturate Hypnotic Drugs

This group includes drugs such as glutethimide (Doriden) and methaqualone (Quaalude) that are similar in effect to short-acting barbiturates. These drugs have high abuse potential and are not good therapeutic agents. Tolerance and psychological and physical dependence can all occur. Heavy use leads to intoxication, with unsteadiness, tremors, loss of memory, irritability, and delirium and may result in coma and cardiovascular and respiratory failure. Withdrawal from these drugs is dangerous and can result in seizures, coma, and death. Treatment is similar to that of barbiturate abuse.

Tranquilizers

Tranquilizers include the major tranquilizers, such as the phenothiazines, and the minor tranquilizers, such as diazepam (Valium) and alprazolam (Xanax). The major tranquilizers are not frequent drugs of abuse among adolescents. The minor tranquilizers have the potential for psychological and physical dependence.

Flunitrazepam (rohypnol) and “Date Rape” Drugs

Flunitrazepam (Rohypnol), GHB, and Ketamine are predominantly central nervous system depressants. These drugs are often colorless, tasteless and odorless and thus can be have unfortunately been added to beverages and ingested by individuals unknowingly. These drugs have a reputation as the so-called "date rape" drugs. Flunitrazepam (Rohypnol) probably has the widest reputation as a “date rape” drug.

More information is also available at http://www.nida.nih.gov/Infofax/RohypnolGHB.html

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ANABOLIC STEROIDS

Anabolic steroids are synthetic derivatives of testosterone. Abusers of this class of drug may exhibit tolerance, withdrawal, and psychological dependence. Treatment may require detoxification and a rehabilitation phase comparable to traditional drug treatment. The two basic categories include oral agents that are 17 a methyl derivatives of testosterone, and the injectable agents that are esters of testosterone and 19-nortestosterone. The 2000 Monitoring the Future Study reported a lifetime prevalence in seniors of 2.5%. Side effects include increased HDL cholesterol, hypertension, myocardial ischemia, premature epiphyseal closure, female virilization, hypogonadism, hepatocellular carcinoma, mania and psychosis, depression.

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DESIGNER AND CLUB DRUGS

"Designer drug" is an imprecise term originating with a fentanyl analog that was synthesized in a clandestine laboratory and sold on the street as heroin. Common designer drugs include:

dextromethamphetamine, MDMA ("ecstasy"), and a -Methylfentanyl. Club drugs refer to the synthetic drugs that are preferred by adolescent and young adult attendees at “raves”. These include ecstasy, LSD, ketamine, PCP, crystal methamphetamine, GHB, cocaine and marijuana. Raves are all-night dance party/mass gatherings of thousands of individuals listening to loud, synchopated, “techno” music. Raves also often involve a liberal use of club drugs.

GHB (gamma-hydroxybutyrate):

GHB is a CNS depressant that acts through a metabolite of the inhibitory neurotransmitter gamma-aminobuyric acid and can function as a neurotransmitter itself. Adverse effects include cardiorespiratory depression, hypthermia, confusion, sedation, ataxia, hallucinations, seizures, coma, aggressive behavior, vomiting and mild hyperglycemia.

Ketamine:

Ketamine (“Special K”) is a rapid-acting anesthetic the combines sedative-hypnotic, analgesic, hallucinogenic and amnesic effects. It also produces a “dissociative' state. Ketamine is similar to phencyclidine but has a more rapid onset and is less potent.

Ecstasy (3,4-methylenedioxymethamphetamine):

MDMA shares both amphetamine and hallucinogenic drug effects. For oral dosage the onset is usually within 30-45 minutes and the effects last about 4 to 6 hours but a noticeable decrease in effect occurs within 2 to 3 hours. The use of MDMA by American adolescents has continued to rise sharply and ecstasy is used by more American adolescent at present than cocaine. Adverse effects include tachycardia, elevated blood pressure, fatigue, nausea, faintness, blurred vision, rapid eye movements, rash, confusion, depression and anxiety. Some research suggests long term brain damage.

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Copyright (©) 2004-2013 Lawrence S. Neinstein, University of Southern California . All rights reserved. Republication or redistribution of the text, table, graphs and photos is expressly prohibited. The University of Southern California shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon.