RMH Field Care Audit 01-24-13

1. Chasing the Dragon:
Drugs of Abuse
Drugs of Abuse
Veronica Bonales, M.D.
Pre-Hospital Care Medical Director
RMH
CEP America Emergency Physician

2. Objectives
Anatomy
Why
Drugs
Effects

3. The
Brain

4. Brains
• Composed of nerve cells (neurons)
• Send information via nerve impulses

5. Brains
• Central nervous system = brain & spinal cord
• 100 billion neurons
• Divided into 3 main sections
– Cerebrum
– Diencephalon
– Brainstem
• Cerebellum – coordinates muscle movements

6. Brain

7. Cerebral
Cortex
• “mammalian brain”
• Interpretation of sensory input
• Stores information
• Reasons
• Four lobes
– Frontal – motor fxn, impulse,
personality, memory
– Parietal – sensory integration,
visuospatial processing
– Occipital – visual processing center
– Temporal – hearing, language,
comprehension

8. Brain

9. Diencephal
on
• “reptilian brain”
• Thalamus – relay center
• Hypothalamus –
homeostasis regulator
– HR, BP, H2O, hunger,
alertness
• Mammilary bodies –
tracts to connect
memory
• Optic tract
• Pituitary gland

10. Brain

11. Brainstem
• “earthworm brain”
• Stimulus / response
• Basic functions
– Midbrain – reflex fxns
– Pons – breathing, sensory
tracts from PNS
– Medulla oblongata – nerve
tracts, cardiac, vasomotor,
respiratory centers
– Reticular formation –
communications
throughout brain,
sleep/wakefulness **

12. Neurotransmitter
s
• Acetylcholine - voluntary movement of the muscles
• Norepinephrine - wakefulness or arousal
• Dopamine - voluntary movement and emotional arousal
• Serotonin - memory, emotions, wakefulness, sleep and
temperature regulation
• GABA (gamma aminobutyric acid) - motor behaviour
• Glycine - spinal reflexes and motor behaviour
• Neuromodulators - sensory transmission-especially pain

13. Neurotransmitte
rs
• Can either be excitatory or inhibitory
• Effect of drugs will either increase a
reaction or allow for an unwanted
reaction to be prolonged

14. Why?
• Gain for the individual
– Loss of pain
– Feeling of euphoria
– Heightened sensory experience
– Sedation

15. Why?
– Heredity
– Disease
– Availability
– Increased stress
– Peer or societal acceptance

16. Terminolog
• y
Abuse – impairs a person’s functional ability
• Addiction – compulsion that leads to
detriment
• Dependence
– Physical – withdrawal if substance not
given
– Psychological – feel need substance to
function
• Tolerance – need more of substance to obtain
effect

17. Questions?

18. Pharmacopoeia
of Drugs
• History of the drug
• Effects on the brain
• SSx
• Overdose / toxic effects
• Treatments

19. Plant – Based
Drugs

20. Opium

21. Opiu
m
• Comes from the poppy plant
• Opi – “drunken”; Um – “mind”
• Early references from 879 BC
• Popular 17th & 18th centuries in China as madak -
mixed w/tobacco & smoked
• Opium dens en vogue
• Addict more socially acceptable than alcoholic
• Known as a painkiller & sedative

22. Opiu
m
• Binds to opioid receptors (releases endorphins)
– Activates the μ-receptor which leads to:
• analgesia, sedation, reduced blood pressure,
itching, nausea, euphoria, decreased respiration,
miosis (constricted pupils) & decreased bowel
motility
• Tolerance develops over time
• Overdose will lead to respiratory depression
• Tx – naloxone blocks receptor

23. Opiu
m
• Examples of opioids
– Morphine – good for coronary pts
– Codeine
– Tincture of Opium
• Used to treat diarrhea
• Synthetic opioids: fentanyl,
propoxyphene (Darvocet)

24. Cocaine

25. Cocain
•
e
Derived from leaves of coca plant
• Originally used by the natives of South America (esp.
Peru)
– Chewing gave a feeling of strength and energy; appetite
suppressant
• Spaniards took back to Europe, alkaloid isolated by
Germans in 1855
• Quickly used medicinally as an anesthetic &
commercially (Vin Mariani & Coca-Cola)
• Outlawed in 1914 w/concern about addictive
properties

26. Cocain
e
• Binds to DA reuptake channels
• DA related to reward centers
• CNS stimulant, anesthetic
• Effect can last 20 minutes to several hours
• Hyperactivity, restlessness, increased BP,
increased HR and euphoria; enhanced
sexual interest & pleasure

27. Cocain
• Placental abruption
e
• OD can be fatal 2o to:
– Tachyarrhythmias (24x inc. in risk for AMI during 1st hour)
– Elevated BP’s
– Hyperthermia (inc. heat w/vasoconstriction)
– SZ’s lead to medullary depression
• Tolerance develops
• Depressive “crash” after chronic use
• Used in medicine as an anesthetic in dental &
ophthalmological surgeries

28. Marijuana /
Hashish

29. Personal
Bong
Way to enjoy the Tractor
Parade with the kids...

30. Cannab
• is
Originated in the Himalayas
• Used in bonfires during religious
ceremonies
• Spread around the world esp. in the 60’s &
70’s counterculture
• Hashish popular in Middle East while MJ
popular in U.S. as a recreational drug
• Assassin comes from “hashashin” Islamic
militant sect

31. Cannabi
s
• Active ingredient – THC (tetrahydrocannabinol)
• Binds to cannabinoid receptors CB1 in brain (euphoric
effects) CB2 in spleen (anti-inflammatory effects)
• Anti-emetic, analgesic at low doses, relaxation;
euphoria; altered space-time perception; alteration of
visual, auditory, and olfactory senses; disorientation;
fatigue; & appetite stimulation
• No fatalities have ever been recorded; no CB1 receptors
in the medulla; however...

32. Cannab
is
• Used medically
– Glaucoma
– Multiple sclerosis pain
– Anti-emetic in CA pts
– Appetite stimulant
– Tourette’s Syndrome

33. Peyote

34. Peyote
• Discovered by the indians of Northern Mexico (Mescal)
& the Navajo of the SW U.S.
• Used in religious ceremonies for centuries
– Gives “deep introspection” & insight; auditory & visual
hallucinations
• By federal law, only legal for Indians performing
“legitimate” ceremonies
• Mescaline active ingredient – effect lasts up to 12 hours
• Non-addictive properties

35. Mushrooms -
Psilocybe

36. Psilocyb
e
• Mushrooms used in ceremonies date to
7000 BC
• Used by Mayans in 500 BC, named
teonanacatl ("flesh of the gods"), healing,
divination & communication with spirits
• Plant is ingested
• Effects last 4 – 6 hrs
• Visual & auditory hallucinations

37. Easter Lily

38. Tobacco

39. Tobacc
o
• 1 BC – Inhabitants of the Americas use tobacco by smoking,
chewing & as enemas
• Mayans move to SE region of NA, pipe smokers & cigar smokers
(sik’ ar)
• Columbus given a gift of dried leaves which were “prized”; crew
throws them away
• 1st smoker jailed by the Spanish Inquisition as the smoke from
his nose & mouth scares neighbors
• Monk w/Columbus on 2nd trip brings tobacco to Europe
• Snuff & chew habits observed by Vespucci
• Tobacco trade routes established

40. Tobacco
• Nicotine active ingredient
• T1/2 about 60 minutes
• Activates nicotinic acetylcholine receptors
– Increased adrenaline => inc. HR, inc. BP, inc.
SBG
– Feeling of both relaxation & invigoration
– Temporary increase of basal metabolic rate
• Increased DA => reward centers
• Increased glutamate => memory loop

41. •
Tobacco each cigarette
40 – 60 mg thought to be lethal,
smoked delivers 1 mg, higher if ingested
• OD – NV, HA, SOB, palpitations, SZ’s,
weakness
• Not carcinogenic
• Thought to be responsible for SIDS
• Schizophrenics thought to self-medicate
• Used as Tx for addiction, ulcerative colitis &
SZ’s
• Tx – Wellbutrin  Zyban

42. Questions??

43. Man-made
Drugs

44. Heroin

45. Heroin
• Created from Morphine in 1874
• Marketed by Bayer in 1898 as a
“cure” for morphine addiction,
marketing blunder 1910 (heroin =>
MSO4)
• Banned in the U.S. 1914, except for
addicts; totally banned in 1924

46. Heroin
• Highly lipid soluble – able to rapidly cross
blood brain barrier
• Converted quickly to morphine – μ opioid
receptors => release of neurotransmitters
(endorphins)
• Highly addictive, tolerance develops quickly

47. Heroin
• Snorting 10 – 15 minutes
• IM 5 – 8 minutes
• Inhaling “chasing the dragon” within a minute
• IV 7 – 8 seconds

48. Heroin
• Sudden pleasurable feeling, warm flush, sedation
• Can react with nausea, vomiting, itching
• Inc. risk of HIV & Hep C from needles, bacterial
abscesses, heart valve damage (tricuspid), fetal
death/addiction
• OD – respiratory depression
• Can be poisoned by “cutting” agents

49. Heroin
• Withdrawal SSx: restlessness, muscle and bone pain,
insomnia, diarrhea, vomiting, cold flashes w/goose
bumps ("cold turkey"), & leg movements.
– Peak between 24 - 48 hrs after last dose; subside ~ week
• Tx – Narcan (Naloxone); dry to wet

50. Heroin
• Methadone
– Made in 1937 as an analgesic
– Derivative of morphine
– Replaces “need” for heroin
– $20 for 1 month’s supply
– Can be taken orally
– Withdrawal more severe & prolonged, naloxone gtt
– Used in extreme & chronic pain conditions

51. Methamphetamine

52. Methamphetamin
es
• Made in 1919 in Japan
• WWII – Germans give to pilots in chocolate
bars
• Made in labs until 1980’s when ingredients
banned
• Pseudoephedrine & ephedrine principle
ingredients
• Still made in clandestine labs – highly
flammable

53. Methamphetamines
• Causes increase of norepinephrine & dopamine
• Blocks reuptake & breakdown of both
• Increased HR, BP, glucose release,
vasoconstriction
• Increased focus, mental alertness, appetite
suppressant
• Short term tolerance (2 – 3 days) due to
production overload
• Side effects: jitteriness, twitches, repetitive
motions (“tweaking”), teeth grinding, insomnia,
ED

54. Methamphetamines
• “meth mouth” – dec. production of saliva
=> inc. thirst, met w/high sugar drinks =>
cavities & tooth decay
• “speed bumps” – tracts, abscesses
• OD – arrhythmias, hyperthermia, stroke,
SZ
– Formication “skin crawling”, paranoia,
hallucinations, cognitive deficits
• Used medically for ADHD, wt. loss

55. PCP –
phenylcyclohexylpiperidin
e

56. PCP
• 1950’s - Parke-Davis
pharmaceuticals
– Initially developed as anesthetic, but
too many SE’s (hallucinations, SZ’s)
– Developed into a recreational drug
– Binds to NMDA receptor (ie: nicotinic
ACh receptor) & causes continued
firing

57. PCP
• Leads to psychotic symptoms (heightened
senses & experiences)
• Aggression or sexual frenzy, feeling of
“super powers”
• Schizophrenic ideations - delusions,
hallucinations, paranoia, disordered
thinking
• Death by suicide or accidental injury

58. Ketami
ne Developed 1962, alternative
•
to PCP
• Given to soldiers in Vietnam
war
– Emergence phenomenon
• Use in Veterinary medicine
as analgesic & anesthetic
• Dissociative properties
similar to PCP but shorter-
lasting
• Popular at Raves

59. LSD –
lysergic acid diethylamide
• Developed in 1938
– Inventor discovered psychoactive
properties 5 yrs later
• 1950’s use by intelligence
agencies
• Given free to researchers in the
60’s
– Harvard experiment lead to counter
culture
• Banned in U.S. 1967

60. LSD
• Highly potent – 20 – 30 μg for effect,
typical “hit” 125 μg
• Acts on DA & serotonin receptors
• Psychological dependence, uterine
contractions
• SE – “bad trip,” distant flashbacks
• Tx w/BDZ’s
• No known cases of OD

61. MDMA –
3,4-methylenedioxymethamphetamine
Ecstasy, XTC
Ecstasy, XTC
• Made in 1912, inventor died 1916,
not used by humans x 50 yrs,
production of styptic
• Used in the 1970’s for psychotherapy
– Made pts more communicative,
increased introspection, dec.
inhibitions
• Recreation use started in discos, gay
clubs, spread to raves
• Made illegal in 1985

62. MDMA –
3,4-methylenedioxymethamphetamine
Ecstasy, XTC
• Binds to receptors => inc. in DA, NE, & serotonin
– Leads to feelings of well-being, openness, dec. inhibitions,
visual enhancement
• Dehydration, inc. HR & BP, nystagmus, pupil dilation,
insomnia
• OD – similar to amphetamines – hyperthermia,
dehydration  hyperpyrexia  rhabdomyolysis 
renal failure, arrhythmias, water toxicity 
hyponatremia

63. Inhalan
ts
• Include:
– glues, paint thinners, dry
cleaning fluids, gasoline, felt-
tip marker fluid, hair spray,
deodorants, spray paint, &
whipped cream dispensers
• Intoxication effect

64. Inhalan
ts
• Sniffing - open container
vapors
• Huffing - spray onto rag and
then place over nose/mouth
• Bagging - spray into bag and
then place over face/mouth
• Dusting - inhaling from
aerosols

65. Inhalan
ts
• Organic or chemical solvents enter
bloodstream
• Cause effects similar to EtOH intoxication
• Death can occur (Sudden Sniffing Death
Syndrome), suffocation
• Brain & organ damage, loss of smell,
respiratory problems

66. Didn’t stop
someone
from trying it

67. GHB γ-hydroxybutarate
• Found naturally in the body –
protects cells from oxygen
deprivation
• Precursor to GABA
– Wakefulness, physical activity,
sleep
• 1960’s synthesized
• Used – anesthetic, insomnia Tx,
depression

68. GHB
• Mode of action still not well-known
• Acts at GABA receptors => sedation
– Low dose:
• State of euphoria, inc. libido, inc. social interaction, intoxication
– High dose:
• Nausea, dizziness, sedation, amnesia, unconsciousness, dec. breathing,
visual changes
– Effects can last 1.5 - 3 hrs
• Deaths from oversedation, esp. when used w/EtOH

69. Bath Salts - Mephedrone,
MPDV
Sold over the counter as
“vanilla sky” or “white knight”
Increased in popularity 2011
Multiple reported cases of
overdose including some deaths

70. Bath Salts -
Mephedrone
Act as a “cocaine substitute”
Pleasurable high, easy to overdose
Unknown additives
Triggers intense cravings, high
potential for abuse & addiction

71. Bath Salts -
Mephedrone
Visits to ED for
Chest pain
Elevated blood pressure
Tachycardia
Hallucinations
Agitation
Paranoia

72. Steroids
• Synthetic version of
testosterone
• Psychological dependence
due to body image
• Abuse dosage 10 – 100x
greater than medical Tx
uses
• Used for muscle-wasting
diseases, testerone-deficient
diseases

73. Steroids
SE:
Stunted growth in adolescents
Masculinization of women
Altered sex characteristics of men (gonadotrophy)
Risks
Premature heart attacks, strokes
Liver tumors
Kidney failure
Psychiatric phenomenon – steroid psychosis
HIV or hepatitis.

74. Questions???

75. EtOH –
ethanol

76. Beer
• Fermented beverages have been around since people
stopped being nomadic and settled in certain regions
• Beer invented in the Mesopotamia about 6,000 yrs ago
– Left people feeling "exhilarated, wonderful and blissful."
• Beer “bibere” (L) = to drink
• Cerveza from the Greek goddess of agriculture, Ceres
• Chang = Tibetan beer
• Chicha = corn beer
• Kumis = fermented camel milk

77. Wine
• 2700 BC wine symbols found in Egyptian
drawings
• No vineyards, but traded with other
cultures for grapes
• Soon developed their own lines of grapes
• Wine-making quickly spread

78. Tequila
• Mezcal wine made in 1521 from agave plant
• Originally for bandits & rancheros
• Tequila from Nahuatl word “place of harvesting plants”
• Tequila village founded 1656, export grew in 1700’s along trade
route to ocean
• 1758 – Jose Cuervo granted royal license to cultivate in region, 1880
selling 10,000 barrels/yr to local market alone
• 1944 Mexican government began regulating
– Only beverages brewed in region could be called tequila
– Had to have at least 51% blue agave
– Top brands are 100% blue agave

79. EtOH -
Ethanol
• Ethanol very simple molecule
• Metabolized to acetaldehyde
• Enzyme (aldehyde dehydrogenase) in liver & GI tract
breaks down to acetic acid (non-toxic)
– By-product used for energy (NADH + H+) in electron transport
chain, lipogenesis, and pyruvic acid to lactic acid cycle
– Genetic defect in some Asian populations leads to EtOH
intolerance – facial flushing syndrome
– Women have less gastric aldehyde dehydrogenase

80. Acetaldehyd
• e bloodstream
Excess spills over into
– Inhibits mitochondrial fxns (DH)
• Dec. metabolism of acetaldehyde to acetic
acid, more acetaldehyde accumulates, &
causes further liver damage
• Dec. oxidation of fatty acids leads to
build-up
– Interferes with activation of vitamins (esp.
B)

81. EtOH • Problems
w/excess
NADH
– Overweight
– Fat
breakdown
(ETC)
– Lactic
acidosis
– Takes
pyruvate from
glucose cycle
=>
hypoglycemia

82. Fatty
liver
• Weekend fatty liver
– Bingers
– Acute, reversible fatty changes

83. Hepatiti
s
• Acute alcoholic hepatitis
– Due to mitochondrial damage, toxic
effects of acetaldehyde (reduced
antioxidants)
– Necrotic areas form, hypoxia-induced
– Fever, liver tenderness, jaundice
– Initially reversible

85. Cirrhosi
s
• Irreversible liver damage
• Hard, shrunken liver
– Fibrosis from chronic damage
– Weakness, muscle wasting, ascites, GI
hemorrhage, coma

87. Other effects
• Wernicke’s encephalopathy
– Thiamine deficiency – poor nutrition
– Ataxia, nystagmus
• Korsakoff syndrome
– Mammilary bodies
– Confabulation
• CV effects
– Cardiomyopathy
– Cardio-protective, inc. HDL & dec. platelet aggregation
• GI effects

88. EtOH
Intoxication
• State legal limits vary (0.08 – 0.10 mg/dl)
– 3 oz of ethanol in a 70 kg person
• = 12 oz wine, 8-12 oz bottle of beer, 6
oz of whiskey
– Occasional drinker will be inebriated w/a
level = 0.2, coma/death/resp. arrest at
levels of 0.3 – 0.4 mg/dl
– Alcoholics can reach levels of 0.7 mg/dl &
be functional

89. FAS
• Fetal alcohol syndrome
– Acetaldehyde crosses the placenta
• Most damaging in first trimester
– Even one drink per day can cause
– Growth & developmental defects, facial
dysmorphology (FAS facies),
malformations of brain, CV system &
reproductive organs

90. FAS

91. EtOH withdrawal
• Usually starts 3 – 4 days after last drink
– Mild symptoms
• Shakiness, anxiety, depression, fatigue, insomnia
– Moderate symptoms
• Headache, sweating, NV, tachycardia, tremor, clammy
skin
– Severe symptoms
• Agitation, fever, convulsions, delirium tremens
(confusion, hallucinations)
• Can be fatal

92. EtOH Tx
– Banana Bag
• Thiamine, folate, MVI in 1L of fluid
– Disulfuram (antabuse)
• Inhibits acetaldehyde dehydrogenase
• Negative reinforcement

93. CAGE questions
• Have you ever felt you should CUT down on your
drinking?
• Have people ANNOYED you by criticizing your
drinking?
• Have you ever felt bad or GUILTY about your
drinking?
• Have you ever had a drink first thing in the morning
(EYE OPENER) to steady your nerves or get rid of a
hangover?

94. Questions????

95. Thank you!
veronicabonales@cep.com
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