SUBSTANCE RELATED DISORDERS OPIOID CANNABIS Dr Y R Bhattarai TMU

Dependence on illegal and prescribed drugs is a major problem in western countries. Many drug users take a range of drugs- ”polydrug” misuse Commonly misused drugs BenzodiazepinesBarbiturates OpiatesAmphetamines CannabisCocaine HallucinogensEcstasy(MDMA) Organic solventsAnabolic steroids

Opiates misuse The words opiate and opioid come from the word opium, the juice of the opium poppy, Papaver somniferum, which contains approximately 20 opium alkaloids, including morphine.

Natural Alkaloid of Opium Morphine Codeine Thebaine Noscapine Papaverine Heroin Nalorphine Hydromorphone Methadone Dextropropoxyphene Meperidine Cyclazocine Levallorphan Diphenoxylate Synthetic compounds

The most important dependence producing derivatives are morphine and heroin The most important dependence producing derivatives are morphine and heroin Apart from parenteral mode of administration, heroin can also be smoked or chased (chasing the dragon),in an impure form called smack, brown sugar Tolerance of heroin occurs rapidly within a week and can be increased to more then 100 times then the first dose needed Heroin gives a rapid intensely pleasurable experience, often accompanied by heightened sexual arousal

Epidemiology The current heroin users 600,000 and 800, million ~ lifetime users The male/female : 3/1 About 90 percent of persons with opioid dependence have an additional psychiatric disorder 15 % of persons with opioid dependence attempt to commit suicide at least once. About 50 %of urban heroin users are children of single parents or divorced parents

Complications of chronic opioid use Feeling of warmth, heaviness of the extremities, dry mouth, itchy face and facial flushing in IV users The initial euphoria is followed by a period of sedation The physical effects of opioids include respiratory depression, pupillary constriction, smooth muscle contraction (including the ureters and the bile ducts), constipation, and changes in blood pressure, heart rate, and body temperature Intravenous users are prone to bacterial infections, hepatitis B, HIV infections through needle contamination.

DSM-IV-TR Diagnostic Criteria for Opioid Intoxication Recent use of an opioid. Clinically significant,behavioral or psychological Pupillary constriction and one of the following signs, developing during, or shortly after, opioid use: ◦ drowsiness or Coma ◦ slurred speech ◦ impairment in attention or memory ◦ Respiratory depression The symptoms are not due other mental disorder

Opioid Overdose Marked unresponsiveness, coma, slow respiration, hypothermia, hypotension, and bradycardia. When presented with the clinical triad of coma, pinpoint pupils, and respiratory depression ~ primary diagnosis

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

Laboratory tests Urinary opioid tests: radio-immunoassay, free radical assay technique, thin layer chromatography, high pressure chromatography, enzyme multiplied immuno- assay technique

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

Treatment…… Clonidine (0.1 to 0.3 mg three to four times a day) is usually given during the detoxification period or withdrawal state to decrease blood pressure. Naltrexone (longer half life)100mg PO every alternate day Methadone can be taken orally Substitute addictions, longer withdrawal period. A daily dosage of 20 to 80 mg is enough to stabilize a patient, although daily doses of up to 120 mg have been used.

Cannabis-Related Disorders Cannabis preparations are obtained from the dried leaves and flowers of Indian hemp plant Cannabis sativa, an annual herb. Marijuana refers to any part of the plant used to induce effects, and hashish is the dried resign from the flower tips.

The primary psychoactive constituent of marijuana is delta-9-tetrahydrocannabinol When smoked, onset of action is mins, after ingestion the onset is 1-3 hours The cannabis plant has been used in China, India and the Middle East for approximately 8,000 years About 33% of adults in the United States have used marijuana, and approximately 5% use it on a regular basis Cannabis-Related Disorders

Clinical Features Dilation of the conjunctival blood vessels (red eye) and mild tachycardia. Orthostatic hypotension Dry mouth Euphoria, drowsiness, or sedation Sensation of slowed time Auditory or visual distortions, dissociation, acute paranoid psychosis in high dosages. Impaired judgment, motor coordination, attention, or memory

DSM-IV-TR Diagnostic Criteria for Cannabis Intoxication Impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgment, social withdrawal. Two (or more) of the following signs, developing within 2 hours of cannabis use: ◦ conjunctival infection ◦ increased appetite ◦ dry mouth ◦ tachycardia

Cannabis induced disorders Psychological dependence is common but tolerance and withdrawal symptoms are unusual. Cannabis intoxication delirium Cannabis-induced psychotic disorder, with delusions Cannabis-induced psychotic disorder, with hallucinations Cannabis-induced anxiety

Complications Many reports indicate that long-term cannabis use is associated with Cerebral atrophy, Seizure susceptibility, Chromosomal damage, Birth defects, Impaired immune reactivity, Alterations in testosterone concentrations, and Dysregulation of menstrual cycles

Treatment Serious poisoning from ingestion is extremely rare Reassurance or iv diazepam is sufficient for drug induced psychossis Intravenous fluids for hypotension.

Medical Use of Marijuana Nausea secondary to chemotherapy, multiple sclerosis (MS) chronic pain, acquired immune deficiency syndrome (AIDS), epilepsy, and Glaucoma

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