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2. Define stimulants, depressants and
hallucinogens
Discuss their
◦ Mechanism of action
◦ Symptoms of intoxication
◦ Symptoms of withdrawal
◦ Short and long term effects
◦ Common street names
Differential diagnosis
3. Method of administration greatly effects the
intensity and duration of onset for various
drugs
◦ Oral (slowest)
◦ Inhalation/Snorting
◦ Inhalation/Smoking
◦ Injection
◦ Rectal suppository
◦ Skin patches
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4. Drugas affect everyone differently, based on:
◦ Size, weight and health
◦ Whether the person is used to taking it
◦ Whether other drugs are taken concurrently
◦ The amount taken
◦ The strength of the drug (varies from batch to
batch with illegally produced drugs)
5. Stimulants are substances that act to excite
the central nervous system
◦ Caffeine
◦ Amphetmines
◦ Cocaine
6. Stimulants increase alertness, attention, and
energy, as well as elevate blood pressure,
heart rate, and respiration.
Used to treat asthma and other respiratory
problems, obesity, neurological disorders,
ADHD, narcolepsy, and occasionally
depression
7. Stimulants enhance norepinephrine and
dopamine.
Increase in dopamine can induce a feeling of
euphoria when stimulants are taken
nonmedically.
Norepinepherine also increases blood pressure
and heart rate, constricts blood vessels, increases
blood glucose, and opens up breathing passages.
8. Mechanism of action
◦ Increase noradrenaline/norepinepherine &
dopamine in the brain in 4 ways
Bind to the presynaptic membrane causing the
release of dopamine
Interact with dopamine containing synaptic vesicles,
releasing free dopamine into the nerve terminal
9. Mechanism of action
◦ 4 ways cont…
Bind to monoamine oxidase in dopaminergic
neurons and prevent the degradation of
dopamine, leaving free dopamine in the nerve
terminal
Bind to the dopamine re-uptake transporter,
causing it to act in reverse and transport free
dopamine out of the nerve terminal.
10. Generalized State Of
Euphoria
Increased Energy
Confidence
Mental Alertness
Sexual Arousal
Itching And
Scratching
Large Pupils
Dry Mouth
Fast Heart Beat And
Breathing
Teeth Grinding
Reduced Appetite
Excessive Sweating
11. Restlessness
Anxiety
Agitation, irritability
Insomnia.
Tolerance to the positive effects while the
negative effects, such as a dysphoric,
depressed state, steadily intensify.
12. In the 4 to 6 days after stimulant use, the
following effects may be experienced:
◦ Restless sleep and exhaustion
◦ Headaches
◦ Dizziness and blurred vision
◦ Paranoia, hallucinations and confusion
◦ Irritability, mood swings and depression3
◦ Anxiety
◦ Insomnia
13. Methamphetamine has a substantially longer
half-life than cocaine, thus leading to more
intense and protracted withdrawal.
Chronic methamphetamine users may have
episodes of violent behavior, paranoia,
anxiety, confusion, and insomnia.
14. A study in April, 2015 analyzed 21 supplements
labelled as containing Acacia rigidula, a type of
shrub native to Texas.
◦ Eleven of them were found to contain beta-
methylphenylethylamine, or BMPEA, an isomer of
amphetamine whose effect on humans has never been
studied.
◦ Only 3 in which the chemical was found indicated its
presence on their labels, and none of them specified the
amount of BMPEA in each pill, according to the study.
http://onlinelibrary.wiley.com/doi/10.1002/dta.1793/abstract
DoD list of Supplements to Avoid
15. Toxic doses, over 5 grams per day for an
adult,
◦ A cup of coffee contains 80–175 mg of caffeine,
depending on the bean and preparation method
◦ Redbull: 80mg
◦ Monster: 86mg
◦ Starbucks (short) brewed coffee 8oz: 180mg
◦ Stacker II (1capsule) 200mg
◦ Vivarin (1 tablet) 200mg
16. Possible side effects for stimulants, include:
◦ Hostility
◦ Paranoia
◦ Psychotic symptoms
◦ Unsafely elevated body temperature
◦ Irregular heartbeat, heart failure
◦ Seizures
◦ Exacerbation of existing anxiety
18. Amphetamines
◦ R-ball
◦ Skippy
◦ The smart drug
◦ Vitamin R
◦ Kibbles and bits
◦ Speed
◦ Truck drivers
◦ Bennies
◦ Black beauties
◦ Crosses
◦ Hearts
◦ LA turnaround
◦ Uppers
◦ Amps
◦ Pick-me-ups
Cocaine and Crack
◦ coke
◦ Snow
◦ 8-ball
◦ flake
◦ powder
◦ dust
◦ candy
◦ white
◦ kryptonite
◦ cookies
◦ strong
◦ Speedball is cocaine + heroin
19. Depressants exert the opposite effect of
stimulants.
◦ They s-l-o-w everything down
20. Mechanism of Action
◦ Depressants exert their effects through a number of
different pharmacological mechanisms, the most
prominent of which include facilitation of GABA,
and inhibition of glutamatergic or monoaminergic
(dopamine, noradrenaline and serotonin) activity
25. Opiates may be detected in urine for 2-4 days
Heroin contains acetylcodeine
Codeine is metabolized to morphine, both
substances may appear in the urine following
codeine ingestion
Oxycodone does not produce a positive response
to routine screens for opiates, which generally
target morphine and/or codeine
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26. If patients are taking opiates or benzos for a
medical purpose, send urine to the lab and
monitor levels.
Buprenorphine can be abused, although it has a
ceiling effect.
Buprenorphine needs to have it’s own test as it
produces a unique metabolite.
Suboxone is buprenorphine + naloxone and is
harder, but not impossible to abuse
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27. Short term impact (up to 5 hours)
◦ Depends heavily on the dose of morphine or heroin, the
route of administration, and previous exposure
◦ Including
Psychological: Euphoria, feeling of well-being, relaxation,
drowsiness, sedation, disconnectedness, delirium.
Physiological: Analgesia, depressed heart rate and
respiration depression, constipation, flushing of the skin,
sweating, pupils fixed and constricted, diminished reflexes
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28. Complications and Side Effects
◦ Medical complications among abusers arise
primarily from adulterants and in non-sterile
injecting practices
◦ Include skin, lung and brain abscesses, collapsed
veins, endocarditis, hepatitis and HIV/AIDS.
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29. Complications and Side Effects
◦ Alcohol or depressants such as benzodiazepines,
hypnotics, and antihistamines increase the CNS
effects of opiates such as:
Sedation/drowsiness
Decreased motor skills.
Respiratory depression, hypotension
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30. Long term impact
◦ Vein collapse
◦ Depression
◦ Brain changes/damage
◦ Reduction of the production of natural pain killers
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32. Symptoms of withdrawal
◦ Begin within 6-12 hours; last 5-10 days; peak
between 48-72 hours
◦ Yawning
◦ Drug Craving
◦ Irritability/dysphoria/depression
◦ Flu like Symptoms: Runny nose, sweating. vomiting,
chills, abdominal cramps, body aches, muscle and
bone pain, muscle spasms, insomnia.
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33. Detoxification Issues
◦ Tolerance decreases rapidly, so overdosing during
relapse is easy
◦ Biggest focus during opiate withdrawal is to provide
palliative care
◦ In general, opiate withdrawal is not life threatening
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34. Current state of Use/Abuse
◦ Fentanyl is 30-50x stronger than heroin. Overdose
rates are
◦ Difficulty getting prescription opioids has led to
increases in demand for heroin
◦ Nearly 6% of 12th graders report using narcotics
other than heroin for recreational purposes
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35. Class of Drugs: Antianxiety/Depressant
◦ Sedative, hypnotic (sleep-inducing), anxiolytic (anti-
anxiety), anticonvulsant, and muscle relaxant properties.
Types of Drugs
◦ Short acting
◦ Long Acting
Benzodiazepines enhance the effect of the
neurotransmitter gamma-aminobutyric acid
(GABA) at the GABAA receptor
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Duration Onset Peak Half-Life Dose
Librium Long 30m 3hr 30hr 5-25mg 4x/day
withdrawal symptoms of acute
alcoholism up to 300 mg/day
Valium Long 15m 1hr 50hr 2-10mg 4x/day
Xanax Medium 30m 1hr 20hr 0.25-1.25mg 3x/day up
to 7mg/day for panic
Ativan Medium 30m 1hr 20hr 1-10mg/day in divided
doses
Restoril Medium 1hr 1hr 20hr 7.5-30mg before bed for
7-10 days (insomnia)
Halcion Short 30m 1hr 5hr 0.125mg before bed for
7-10 days (insomnia)
http://www.vhpharmsci.com/vhformulary/tools/benzodiazepines-comparison.htm
37. Ingestion of therapeutic dosages may be detectable
for 1-3 days while extended usage over a period of
months or years can extend excretion times up to 4-
6 weeks after cessation of use
Different tests are required to identify different
benzos
benzodiazepines such as alprazolam (Xanax®),
lorazepam (Ativan®), and clonazepam (Klonopin®) do
not share this metabolic pathway
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38. Due to individual differences between people
and drugs, a standard therapeutic level is
often hard to identify
Many abusers accentuate the effects of
benzodiazepines by the using alcohol or
other CNS depressants
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40. Short term impact in the elderly
◦ Confusion
◦ The appearance of dementia
◦ Benzodiazepine overdose
Combining with other depressants has an
exponential additive effect
Rohypnol is a benzodiazepine
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41. Long term impact
◦ Impairment in several cognitive domains, such as
visuospatial ability, speed of processing, and verbal
learning J Clin Psychiatry. 2005;66 Suppl 2:9-13.
◦ Benzodiazepine use for 3 months or more was
associated with an increased risk of Alzheimer's
disease of up to 51%. Benzodiazepine use and risk
of Alzheimer’s disease: case-control study BMJ
2014; 349
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42. Long term impact
◦ Despite benzodiazepines being added to the
American Geriatrics Society's list of inappropriate
drugs for older adults in 2012, almost 50% of older
adults continue to use them
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43. Symptoms of withdrawal
◦ Sleep disturbance
◦ Irritability, increased tension and anxiety, panic attacks,
hand tremor, sweating, palpitations
◦ Difficulty in concentration
◦ Dry heaves and nausea, headache, muscular pain and
stiffness
◦ Seizures
◦ Psychosis
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44. Detoxification Issues
◦ Symptoms appear around the end of the half-life
period
◦ Rebound anxiety and insomnia peak within a couple
of days
◦ Withdrawal symptoms can last for 2-4 weeks
depending on the drug
◦ Protracted withdrawal is not uncommon in heavy
and/or long-term users.
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45. Detoxification Issues
◦ “A grand mal seizure may occur in as many as 20-30% of
individuals undergoing untreated withdrawal from these
substances.” Diagnostic and Statistical Manual of Mental Disorders, 5th Ed.
◦ Flumazenil (Romazicon) is a competitive antagonist that
can reverse the sedative and overdose effects of
benzodiazepines but not of alcohol or other sedative-
hypnotics. (SAMHSA TIP 45)
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46. Current state of Use/Abuse
Most frequently used class of drugs for
anxiety disorders. An estimated past year
prevalence of use in the USA has been
reported at 12.9% Archives of Clinical Neuropsychology Volume 19, Issue 3,
April 2004, Pages 437–454
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47. GHB (gamma-Hydroxybutyric acid)
◦ Acts on GHB and GABAB Receptors
◦ Some athletes also use GHB, as GHB has been
shown to elevate human growth hormone
◦ Date-rape drug
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48. Non-benzodiazepine sleep medications, such as
Ambien, Lunesta, and Sonata, have a different
chemical structure, but act on some of the same
brain receptors as benzodiazepines.
Barbiturates (-barbitals) i.e. phenobarbital are
used to reduce anxiety or to help with insomnia.
◦ Readily available in many hospice-involved patients
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51. Hallucinogens are a class of drugs that cause
hallucinations—profound distortions in a
person’s perceptions of reality.
Hallucinogens can be found in some plants and
mushrooms (or their extracts) or can be man-
made
Commonly divided into two broad categories
◦ classic hallucinogens (such as LSD)
◦ dissociative drugs (such as PCP).
52. Hallucinogens interfere with the action serotonin
and/or glutamate, which regulate:
◦ Mood
◦ Sensory perception and response
◦ Sleep
◦ Hunger
◦ Body temperature
◦ Sexual behavior
◦ Muscle control
◦ Pain perception
◦ Learning and memory
53. ◦ PCP (Phencyclidine)—
Also known as ozone, rocket fuel, love boat, hog,
embalming fluid, or
Usually sold as a liquid or powder.
PCP can be snorted, smoked, injected, or swallowed.
54. Ketamine—also known as K, Special K, or cat Valium—is
odorless and tasteless and has amnesia-inducing and
dissociative properties. (Can facilitate sexual assault.)
DXM (Dextromethorphan)—also known as robo—is a cough
suppressant and expectorant
Salvia divinorum—also known as diviner’s sage, Maria
Pastora, Sally-D, or magic mint—is a psychoactive plant
typically ingested by chewing fresh leaves or by drinking their
extracted juices.
55. LSD (d-lysergic acid diethylamide)
◦ AKA: acid, blotter, doses, hits, microdots, sugar cubes, trips, tabs,
or window panes
◦ Potent mood & perception-altering hallucinogenic drugs
◦ It is a clear or white, odorless, water-soluble material
◦ Produced as
Tablets known as “microdots”
Thin squares of gelatin called “window panes.”
Diluted with water or alcohol and sold in liquid form.
LSD-soaked paper punched into small individual squares, known as
“blotters.”
56. Peyote (Mescaline)
◦ Also known as buttons, cactus, and mesc—
◦ Is a small, spineless cactus with mescaline as its
main ingredient.
◦ The top, or “crown,” of the peyote cactus has disc-
shaped buttons that are cut out, dried, and usually
chewed or soaked in water to produce an
intoxicating liquid.
57. The effects of hallucinogens can begin within 20 to 90 minutes
and can last as long as 6 to 12 hours.
Other short-term general effects include:
• Increased heart rate
• Nausea
• Intensified feelings and
sensory experiences
• Changes in sense of time
(for example, time passing
by slowly)
• Increased bp, respiration,
or body temperature
• Loss of appetite
• Dry mouth
• Sleep problems
• Mixed senses (such as
"seeing" sounds or
"hearing" colors)
• Spiritual experiences
• Feelings of relaxation or
detachment
• Uncoordinated
movements
• Excessive sweating
• Panic
• Paranoia—extreme and
unreasonable distrust
• Psychosis—disordered
thinking detached from
reality
58. Repeated use of PCP can result in long-term
effects that may continue for a year or more
after use stops, such as:
◦ speech problems
◦ memory loss
◦ weight loss
◦ anxiety
◦ depression and suicidal thoughts
59. Though rare, long-term effects of some
hallucinogens include the following:
◦ Persistent psychosis—a series of continuing mental
problems, including:
visual disturbances
disorganized thinking
paranoia
mood changes
Flashbacks—recurrences of certain drug experiences.
hallucinogen persisting perceptual disorder (HPPD).
60. Stimulants range from caffeine to methamphetamine and “amp
up” the system
Opiates, benzodiazepines, barbiturates, alcohol, inhalants are all
CNS depressants
Combinations of depressants have an exponential additive effect
Evaluate patients for exposure to all CNS depressants intentional
and incidental
Hallucinogens include LSD, PCP, Peyote, Ketamine and
Dextromethorphan
Recent research has indicated that HPPD is not due to “traces of
the drug being freed up”
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