SUBSTANCE RELATED DISORDERS COCAINE LSD BENZODIAZEPINES BARBITURATES 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 Benzodiazepines Barbiturates Opiates Amphetamines Cannabis Cocaine Hallucinogens Ecstasy(MDMA) Organic solvents Anabolic steroids

Cocaine, a central nervous system stimulant produced by the Erythroxylon coca plant. Cocaine hydrochloride powder is usually snorted through the nostrils, or it may be mixed in water and injected intravenously.

Cocaine hydrochloride powder is also commonly heated (“cooked up”) with ammonia or baking soda and water to remove the hydrochloride, thus forming a gel-like substance that can be smoked (“freebasing”). “Crack” cocaine is a precooked form of cocaine alkaloid that is sold on the street as small “rocks”.

DSM-IV-TR Diagnostic Criteria for Cocaine Intoxication Recent use of cocaine. Clinically significant maladaptive behavioral or psychological changes Two (or more) of the following, developing during, or shortly after, cocaine use: tachycardia Pupillary dilation Elevated blood pressure perspiration or chills /cold sweets nausea or vomiting Hallucinations psychomotor agitation or retardation ,euphoria muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias confusion, seizures, or coma The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

DSM-IV-TR Diagnostic Criteria for Cocaine Withdrawal Cessation of cocaine use that has been heavy and prolonged. Dysphoric mood and two (or more) of the following physiological changes, developing within a few hours to several days fatigue vivid, unpleasant dreams insomnia or hypersomnia increased appetite psychomotor retardation or agitation The symptoms ,clinically significant distress or impairment in social, occupational areas of functioning. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder

Management principle Initiation of abstinence through disruption of binge cycles and Prevention of relapse.

Oxygenation ECG and temperature monitoring Activated charchol to any patients presenting within one hour of oral ingestion, irrespective of the amount. Muscle relaxants Intravenous diazepam for hypertension in doses up to 0.5 mg/kg administered over an 8-h – IV IV nitrate or sodium nitroprusside for HTN with stroke or encephalopathy IV Verapamil for supraventricular tachycardia (no beta blockers) Oral diazepam for psychosis (no haloperidol) Vitamin C to increase excretion Urine screening to differentiate from psychosis.

Cocaine withdrawal features Depression Fatigue Increased appetite Unpleasant dreams

Drugs for cocaine withdrawal Antidepressants like desipramine

Cocaine induced disorders Cocaine Intoxication Delirium Cocaine-Induced Psychotic Disorder Cocaine-Induced Mood Disorder Cocaine-Induced Anxiety Disorder Cocaine-Induced Sexual Dysfunction Cocaine-Induced Sleep Disorder

Drugs for chronic cocaine use These drugs reduce the craving Amantidine Bromocriptine

Hallucinogens & Volatile Inhalants Hallucinogens are subdivided into two major categories: D -lysergic acid diethylamide [LSD], dimethyltryptamine [DMT], psilocin, psilocybin(magic mushroom) 3-4-methylenedioxy methamphetamine (MDMA ,called "ecstasy" on the streets) Phencyclidine (PCP; called "angel dust,“ "crystal,“ "weed," and "hog" on the streets) and ketamine.

Volatile inhalants include aromatic, aliphatic, and halogenated hydrocarbon compounds such as gasoline, solvents (eg, acetone), paints, glues, refrigerants (eg, Freon), and paint thinners (eg, turpentine). Nitrous oxide (an anesthetic) and amyl nitrite (a vasodilator; called "poppers" on the streets

Hallucinogen Intoxication Behavioral or psychological changes Perceptual changes pupillary dilation tachycardia sweating palpitations blurring of vision tremors incoordination

Hallucinogen Intoxication Delirium Hallucinogen-Induced Psychotic Disorders Hallucinogen-Induced Mood Disorder Hallucinogen-Induced Anxiety Disorder

LSD is a synthetic base derived from the lysergic acid nucleus from the ergot alkaloids. compounds was discovered in rye fungus

Treatment Hallucinogen Intoxication oral administration of 20 mg of diazepam Hallucinogen Persisting Disorder clonazepam , carbamazepine and antipsychotic agents

drawings done whilst under its influence of LSD

BARBITURATES Anxiolytics, hypnotics, antiepileptics, anesthetics, anticonvulsants, tranquilizers Commonly used drugs: Secobarbital, pentobarbital, amobarbital slurred speech, staggering gait, sustained vertical or horizontal nystagmus, slowed reactions, lethargy, and progressive respiratory depression, which is characterized by shallow and irregular breathing, leading to coma and possibly death. 600-800mg/day for >1 month

Management Symptomatic Induction of vomiting Give activated charcoal

BENZODIAZEPINES Benzodiazepines are used primarily as anxiolytics, hypnotics, antiepileptics, and anesthetics The indications for their use are anxiety, muscle spasm, seizures, and treatment of acute alcohol withdrawal symptoms Prolonged use of > 4-6 weeks, >60-80mg/day develop dependence. Anxiety, irritability, tremors, insomnia, vomiting, weakness, suicidal ideation

What are common "street names?" Street names for Benzodiazepines include: “blue” “zani” “zanibars” “vallies” “moggies” “rugby balls” “roofies” “peaches “football”

Rx Symptomatic Flumazenil (specific benzodiazepine antagonist) 0.3-1.0 mg IV over 1-2 min if coma. Flumazenil must never be used in patients with a history of convulsions or those who have co-ingested TCA. Diazepam 15mg/day for low dose dependence by reduction of 10% of the dose daily.

MANAGEMENT OF DRUG MISUSE First step, determine whether the patient wishes to stop using the drug. If not, patients need advice about “harm minimization” e.g. use of clean needles, If they do want to stop, initial management is to help them withdraw from the drug. When there are signs of severe physical dependence, withdrawal is best undertaken in hospital.

MANAGEMENT OF DRUG MISUSE Decreasing doses of the relevant drug are given over a period of 1-3 weeks Oral methadone is used as a substitute for heroin in patients with opiate dependence. Good results can be achieved if doctors build a good rapport with the patient. Complicated or relapsing patients should be referred to specialist drug misuse services.