110 Minutes Session 24 Drug Combinations.

110 Minutes Session 24 Drug Combinations

Learning Objectives Explain the prevalence of polydrug use among drug impaired subjects and identify common combinations of drugs abused by those subjects Describe the possible effects that combinations of drugs can produce on the major indicators of drug impairment Briefly review the objectives, content and activities of this session. Upon successfully completing this session the participant will be able to: Explain the prevalence of polydrug use among drug impaired subjects and identify common combinations of drugs abused by those subjects. Describe the possible effects that combinations of drugs can produce on the major indicators of drug impairment. CONTENT SEGMENTS LEARNING ACTIVITIES A. The Prevalence of Polydrug Use Instructor-Led Presentations B. Possible Effects of Drug Combinations Interactive Discussions C. Identifying Expected Indicators of Workbook Exercise Specific Combinations Video Presentations

Learning Objectives (Cont.)
Define the terms “Null”, “Overlapping”, “Additive” and “Antagonistic” as they relate to polydrug effects Identify specific effects that are most likely to be observed in persons under the influence of particular drug combinations Define the terms “Null,” “Overlapping,” “Additive” and “Antagonistic” as they relate to polydrug effects. Identify the specific effects that are most likely to be observed in persons under the influence of particular drug combinations.

What is Polydrug Use? Ingesting drugs from two or more drug categories
A. The Prevalence of Polydrug Use Polydrug Polydrug use means ingesting drugs from two or more drug categories.

Prevalence of Polydrug Use
Los Angeles Field Validation Study (1985) 72% of suspects had two or more drug categories in them (including alcohol) 45% had two or more drugs other than alcohol Prevalence of Polydrug Use It is actually more common for a DRE to encounter polydrug users than single drug users. In the Los Angeles Field Study (1985), 72% of the suspects had two or more drugs in them. Point out that 81 of the 173 suspects (47%) in the Los Angeles Field Study had alcohol in combination with one or more other drugs. If we discount alcohol, nearly half (45%) of the Field Study suspects had two or more other drugs in them.

Prevalence of Polydrug Use
The National DRE database indicates that approximately 35% of all DRE reported cases revealed two or more drug categories detected Source: NHTSA/IACP DRE Database (2012) National DRE data collected from the national DRE tracking database from DREs throughout the U.S. indicates that approximately 35% of all cases with toxicology resulted in two or more drug categories detected. Emphasize: Not all states are represented in the database therefore, the 35% may be low. DRE’s nationwide are required to enter their evaluations in the national DRE database. Contact your state coordinator. Solicit participants’ comments and questions about the prevalence of polydrug use.

Common Combinations of Drugs
Cocaine and Cannabis Cocaine and Heroin Common Combinations Cocaine and Cannabis. Cocaine and Heroin. PCP and Cannabis. Many of the subjects you examine will be exhibiting the effects of two or more drugs acting together. PCP and Cannabis Alcohol and practically anything else

Drug Combinations Cocaine and Heroin - “Speedball”
PCP and Heroin - “Fireball” Crack and PCP - “Space base” Crack and Marijuana - “Primo” Crack and Methamphetamine - “Croak” B. Possible Effects of Drug Combinations Combos Let us examine the possible ways in which two or more drug categories might interact. Some common combinations of drug categories and their street names include: Cocaine and Heroin - “Speedball” PCP and Heroin - “Fireball” Crack and PCP - “Space base” Crack and Marijuana - “Primo” Crack and Methamphetamine - “Croak” Point out that there are hundreds of street names for drug combinations and the combinations vary and are always evolving. Solicit drug combination street names from participants.

The Effects of Drug Combinations on Major Indicators of Impairment
Null Effect Overlapping Effect Additive Effect Antagonistic Effect There are four effects of drug combinations on major indicators of impairment: Null Effect Overlapping Effect Additive Effect Antagonistic Effect

Null Effect If neither drug affects a particular indicator of impairment, their combination also will not affect that indicator No action plus no action equals no action Four Effects Null Effect The first effect is called the “Null Effect.” Clarify: “Null Effect” is the combination of no action plus no action equals no action.

Null Effect (Cont.) Example #1: HGN If neither drug affects HGN…
Example: Narcotic Analgesic and Cannabis (Neither category affects HGN) …the combination should also not affect HGN, so HGN will not be present in this combination Example #1: HGN Neither drug affects HGN. The combination would not result in HGN being present. Point out a general principle: if neither drug affects a major indicator, the combination of those two drugs also will not affect that indicator. Example #1 is called the Null Effect. Clarification of “Null Effect” – the combination of no action plus no action equals no action.

Null Effect (Cont.) Example #2: Reaction to Light
If neither drug affects reaction to light… Example: Dissociative Anesthetics and Cannabis (Neither category affects the reaction to light) …the combination will also not affect reaction to light, so reaction to light will be a normal response Example #2: Reactions to Light Another example of the Null Effect: Reaction to Light: neither drug affects reaction to light. Example: a Dissociative Anesthetic and Cannabis. Ask participants to suggest a specific combination of drugs that will exhibit the Null Effect on Pupil Size.

Null Effect (Cont.) Example #3: Body Temperature
If neither drug affects body temperature… Example: CNS Depressants and Cannabis (Neither category affects the body temperature) …the combination should also not affect body temperature, so body temperature will be in the DRE average range Example #3: Body Temperature Another example of the Null Effect: Body Temperature: neither a CNS Depressant nor Cannabis usually affects body temperature; the combination of the two leaves body temperature in the DRE average range. Solicit participants’ questions about the Null Effect.

Overlapping Effect If one drug affects a particular indicator of impairment, and another drug has no effect on that indicator, the combination of those two drugs will affect the indicator, in the same way as the first drug alone Action plus no action equals action Overlapping Effect The second effect is called the “Overlapping Effect.” Clarify: “Overlapping Effect” - action plus no action equals action.

Overlapping Effect (Cont.)
Example #1: Pupil Size One drug affects the pupil size, but the other does not Example: CNS Stimulants and Dissociative Anesthetics (CNS Stimulants dilate pupils, Dissociative Anesthetics don’t affect pupil size) Pupils should be dilated Example #1: Pupil Size Example #1: one drug affects pupil size, but the other does not. Example: CNS Stimulants and Dissociative Anesthetics. CNS Stimulants dilate pupils, Dissociative Anesthetics do not affect pupil size. Therefore, pupils should be dilated.

Example #2: HGN One drug causes HGN, but the other does not Example: CNS Depressants and Narcotic Analgesics (CNS Depressants cause HGN but Narcotic Analgesics don’t) HGN should be present Example #2: HGN (Prior to showing slide) Ask a participant to give an example of a specific combination of drugs that will produce an “Overlapping Effect” on Horizontal Gaze Nystagmus. HGN: a CNS Depressant will cause HGN, but Cannabis will not cause HGN; a person under the combined influence of a CNS Depressant and Cannabis will usually have HGN.

Example #3: Lack of Convergence One drug causes lack of convergence, but the other does not Example: Dissociative Anesthetics and Hallucinogens (Dissociative Anesthetics cause lack of convergence, Hallucinogens don’t) Lack of Convergence should be present Example #3: Lack of Convergence Another example of the “Overlapping Effect”: Lack of Convergence. Dissociative Anesthetics cause Lack of Convergence, Hallucinogens do not. Under the influence, lack of convergence should be present. Ask a participant to give an example of a specific combination of drugs that will produce an “Overlapping Effect” on body temperature.

Additive Effect If two drugs independently affect some indicator in the same way, their use in combination will also affect the indicator and the effect may be reinforced Action plus the same action produces reinforced action Additive Effect The third effect is called the Additive Effect. If two drugs independently affect some indicator in the same way, their use in combination will also affect the indicator and the effect may be reinforced Action plus the same action produces reinforced action Clarification of the “Additive Effect” – action plus the same action produces reinforced action.

Additive Effect (Cont.)
Example #1: Pulse Rate Both drugs affect pulse rate in the same way Example: Cannabis and Inhalants (Cannabis and Inhalants both elevate pulse rate) Pulse rate should be elevated Example #1: Pulse Rate Pulse Rate. Cannabis and Inhalants both elevate pulse rate. Therefore, pulse rate should be elevated, or up.

Example #2: Pupil Size Both drugs affect pupil size in the same way Example: CNS Stimulants and Hallucinogens (CNS Stimulants and Hallucinogens both dilate pupils) Pupils should be dilated Example #2: Pupil Size Pupil Size. CNS Stimulants and Hallucinogens both dilate the pupils; therefore, pupils should be dilated.

Example #3: Blood Pressure Both drugs affect Blood Pressure in the same way Example: CNS Depressants and Narcotic Analgesics (CNS Depressants and Narcotic Analgesics both depress blood pressure) Blood Pressure should be depressed Example #3: Blood Pressure Ask a participant to give an example of a drug combination that will produce an additive effect on blood pressure. Blood Pressure. CNS Depressants and Narcotic Analgesics both depress blood pressure. Therefore, the blood pressure should be depressed or down.

Antagonistic Effect If two drugs affect some indicator in exactly opposite ways, their use in combination could affect that indicator in any possible way Action versus opposite action yields you can’t predict the outcome Antagonistic Effect The fourth effect is called the Antagonistic Effect. Clarification of “Antagonistic Effect” – action versus opposite action: can’t predict the outcome. When two drugs produce an “Antagonistic Effect,” they tend to try to override or compete with the effect of the other drug(s) until the drug with the longest duration of effects prevails. Normally, whichever drug is more psychoactive at the time determines what we’ll see. Point out that a common example is when a person takes a “speedball” (Heroin plus Cocaine), the two drugs try to compete with their effects on the pupil size.

Antagonistic Effect (Cont.)
Whichever drug is more psychoactive at the time determines what we’ll see There is not an Antagonistic Effect for: HGN VGN Lack of Convergence Reaction to Light There is not an Antagonistic Effect for : HGN, VGN, Lack of Convergence and Reaction to Light. Question participants as to why this would be the case.

Example #1: Pulse Rate One drug affects pulse rate one way, the other drug affects pulse rate in the opposite way Example: CNS Stimulants and CNS Depressants (CNS Stimulants elevate pulse rate, CNS Depressants depress pulse rate) Pulse Rate will be up, down or within the DRE average ranges Example #1: Pulse Rate Pulse Rate. CNS Stimulants elevate pulse rate, CNS Depressants depress pulse rate; therefore, pulse rate will be up, down or within the DRE average ranges.

Example #2: Pupil Size One drug affects pupil size one way, the other drug affects pupil size in the opposite way Example: CNS Stimulants and Narcotic Analgesics (CNS Stimulants dilates pupils, and Narcotic Analgesics constricts pupils) Pupils will be dilated, constricted or within the DRE average ranges Example #2: Pupil Size Pupil Size. CNS Stimulants dilate pupils, Narcotic Analgesics constrict pupils. Pupil size will be dilated, constricted or within the DRE average ranges.

Example #3: Body Temperature One drug affects body temperature one way, the other drug affects body temperature in the opposite way Example: Hallucinogens and Narcotic Analgesics (Hallucinogens elevate body temperature, Narcotic Analgesics depress body temperature) Body Temperature will be up, down or within the DRE average ranges Example #3: Body Temperature Body Temperature. Hallucinations elevate body temperature, Narcotic Analgesics depress body temperature. Body temperature will be up, down or within the DRE average ranges. With an “Antagonistic Effect,” we just can’t predict what we will see. Summary When drugs from two or more drug categories are taken together, they tend to produce a combination of Null Effects, Overlapping Effects, Additive Effects and Antagonistic Effects. Solicit participants’ questions about the Null, Overlapping, Additive and Antagonistic Effects. Proceed to the following slides of drug combinations involving the input from the participants.

Cannabis and CNS Stimulant
Impairment Indicator Cannabis CNS Stimulant Type of Effect What We Will See? HGN HGN A specific example: consider a person who is under the influence of a combination of Cannabis and a CNS Stimulant. Ask participants: “will you see HGN with this particular combination?”

Impairment Indicator Cannabis CNS Stimulant Type of Effect What We Will See? HGN None Null No HGN Neither Cannabis nor a CNS Stimulant causes HGN. Point out that the combination of Cannabis and CNS Stimulant produces a Null Effect on HGN. This is a case of no action plus no action equals no action. We will not see HGN with this combination.

Impairment Indicator Cannabis CNS Stimulant Type of Effect What We Will See? HGN None Null No HGN VGN Vertical Gaze Nystagmus Ask participants: “Will we see Vertical Gaze Nystagmus?”

Impairment Indicator Cannabis CNS Stimulant Type of Effect What We Will See? HGN None Null No HGN VGN No VGN Neither Cannabis nor a CNS Stimulant causes VGN. This is another Null Effect. We won’t see VGN.

Impairment Indicator Cannabis CNS Stimulant Type of Effect What We Will See? HGN None Null No HGN VGN No VGN LOC Lack of Convergence Ask participants “What will we see when we examine LOC?”

Impairment Indicator Cannabis CNS Stimulant Type of Effect What We Will See? HGN None Null No HGN VGN No VGN LOC Present Overlapping Cannabis causes Lack of Convergence; a CNS Stimulant does not. Point out that the combination of Cannabis and CNS Stimulant produces an Overlapping Effect on Lack of Convergence. This is a case of action plus no action equals action. We will see Lack of Convergence with this combination.

Impairment Indicator Cannabis CNS Stimulant Type of Effect What We Will See? HGN None Null No HGN VGN No VGN LOC Present Overlapping Pupil Size Pupil Size Ask participants: “What will we see when we examine pupil size?”

Impairment Indicator Cannabis CNS Stimulant Type of Effect What We Will See? HGN None Null No HGN VGN No VGN LOC Present Overlapping Pupil Size Dilated (6) Dilated Overlapping or Additive CNS Stimulants dilate pupils; Cannabis either dilates pupils or has no effect on them. Point out that the combination of Cannabis and CNS Stimulant produces either an Additive Effect or an Overlapping Effect on pupil size. This may be a case of action plus no action equals action. Or it may be a case of action plus same action reinforces action. In either case, we should see dilated pupils with this combination. Point out that the term “normal” in Exception 6 refers to a pupil size within the DRE average ranges. (6) Pupil Size Possibly Normal.

Impairment Indicator Cannabis CNS Stimulant Type of Effect What We Will See? HGN None Null No HGN VGN No VGN LOC Present Overlapping Pupil Size Dilated (6) Dilated Overlapping or Additive Reaction to Light Reaction to Light Ask participants: “What should we see when we examine the pupils’ reaction to light?” (6) Pupil Size Possibly Normal.

Impairment Indicator Cannabis CNS Stimulant Type of Effect What We Will See? HGN None Null No HGN VGN No VGN LOC Present Overlapping Pupil Size Dilated (6) Dilated Overlapping or Additive Reaction to Light Normal Slow CNS Stimulants slow the pupils’ Reaction to Light; Cannabis usually doesn’t affect the pupils’ reaction. Here we have another Overlapping Effect. We should observe a slowed reaction of the pupils. (6) Pupil Size Possibly Normal.

Impairment Indicator Cannabis CNS Stimulant Type of Effect What We Will See? Pulse Rate Pulse Rate Ask participants: “What should we see when we measure this person’s pulse rate?”

Impairment Indicator Cannabis CNS Stimulant Type of Effect What We Will See? Pulse Rate Up Additive Both Cannabis and CNS Stimulants usually elevate pulse rate. This is an Additive Effect. We should see a pulse rate that is up or elevated.

Impairment Indicator Cannabis CNS Stimulant Type of Effect What We Will See? Pulse Rate Up Additive Blood Pressure Blood Pressure Ask participants: “What should we see when we measure this person’s blood pressure?”

Impairment Indicator Cannabis CNS Stimulant Type of Effect What We Will See? Pulse Rate Up Additive Blood Pressure Cannabis usually causes blood pressure to be up or elevated; so does a CNS Stimulant. This is another Additive Effect. We should see a blood pressure that is up or elevated.

Impairment Indicator Cannabis CNS Stimulant Type of Effect What We Will See? Pulse Rate Up Additive Blood Pressure Body Temperature Body Temperature Ask participants: “What can we expect to find when we check this person’s temperature?”

Impairment Indicator Cannabis CNS Stimulant Type of Effect What We Will See? Pulse Rate Up Additive Blood Pressure Body Temperature Normal Overlapping Cannabis usually does not affect body temperature. But CNS Stimulants usually elevate temperature. Point out that Cannabis in combination with CNS Stimulant produces an Overlapping Effect on body temperature. This is another case of action plus no action equals action. We can expect to see an elevated temperature with this combination.

Impairment Indicator Cannabis CNS Stimulant Type of Effect What We Will See? Pulse Rate Up Additive Blood Pressure Body Temperature Normal Overlapping Muscle Tone Rigid Muscle Tone Cannabis usually does not affect muscle tone. CNS Stimulants cause muscle tone to be rigid. Point out that this particular combination produces no Antagonistic Effects. This is another case of action plus no action equals action. We can expect to see rigid muscle tone with this combination.

Dissociative Anesthetic and Narcotic Analgesic
Dissociative Anesthetics and Narcotic Analgesics Another specific example: consider a person under the influence of a combination of a Dissociative Anesthetic and a Narcotic Analgesic.

Impairment Indicator Dissociative Anesthetic Narcotic Analgesic Type of Effect What Will We See? HGN Present None Overlapping HGN Ask participants: “What will we see when we examine this person for HGN?” A Dissociative Anesthetic causes HGN, Narcotic Analgesics do not. This is an Overlapping Effect. We can expect to see HGN with this subject.

Impairment Indicator Dissociative Anesthetic Narcotic Analgesic Type of Effect What Will We See? HGN Present None Overlapping VGN Vertical Gaze Nystagmus Ask participants: “What will we see when we examine this person for VGN?”

Impairment Indicator Dissociative Anesthetic Narcotic Analgesic Type of Effect What Will We See? HGN Present None Overlapping VGN A Dissociative Anesthetic should cause Vertical Gaze Nystagmus, especially at high doses. A Narcotic Analgesic will not cause Vertical Gaze Nystagmus. This is another Overlapping Effect. We should see Vertical Gaze Nystagmus in this subject.

Impairment Indicator Dissociative Anesthetic Narcotic Analgesic Type of Effect What Will We See? HGN Present None Overlapping VGN LOC Lack of Convergence Ask participants: “Can we expect to see a Lack of Convergence?”

Impairment Indicator Dissociative Anesthetic Narcotic Analgesic Type of Effect What Will We See? HGN Present None Overlapping VGN LOC A Dissociative Anesthetic causes Lack of Convergence; Narcotic Analgesics do not. Another Overlapping Effect. We can expect to see Lack of Convergence.

Impairment Indicator Dissociative Anesthetic Narcotic Analgesic Type of Effect What Will We See? HGN Present None Overlapping VGN LOC Pupil Size Pupil Size Ask participants: “What are we likely to see when we check the size of this subject’s pupils?”

Impairment Indicator Dissociative Anesthetic Narcotic Analgesic Type of Effect What Will We See? HGN Present None Overlapping VGN LOC Pupil Size Normal Constricted A Dissociative Anesthetic doesn’t affect pupil size, but a Narcotic Analgesic constricts pupils. This is another Overlapping Effect. We can expect to see constricted pupils with this subject. Remind the participants that the term “Normal” refers to the DRE average ranges for the pupil sizes.

Impairment Indicator Dissociative Anesthetic Narcotic Analgesic Type of Effect What Will We See? Reaction to Light Reaction to Light Ask participants: “What are we likely to observe when we check the reaction of this subject’s pupils to light?”

Impairment Indicator Dissociative Anesthetic Narcotic Analgesic Type of Effect What Will We See? Reaction to Light Normal Little or None Visible Overlapping A Dissociative Anesthetic doesn’t affect pupil’s Reaction to Light; but a Narcotic Analgesic usually produces a “little or none visible” reaction. Point out that the combination of Dissociative Anesthetics and a Narcotic Analgesic produces Overlapping Effects on all major eye indicators of drug impairment. This, too, is an Overlapping Effect. We can expect a “little or none visible” reaction in this subject’s pupils.

Impairment Indicator Dissociative Anesthetic Narcotic Analgesic Type of Effect What Will We See? Reaction to Light Normal Little or None Visible Overlapping Pulse Rate Pulse Rate Ask participants: “What can we expect to find when we check this subject’s pulse rate?

Impairment Indicator Dissociative Anesthetic Narcotic Analgesic Type of Effect What Will We See? Reaction to Light Normal Little or None Visible Overlapping Pulse Rate Up Down Antagonistic Up, Down or Normal A Dissociative Anesthetic usually causes pulse rate to be elevated; a Narcotic Analgesic usually produces a depressed or lower pulse rate. This is our first Antagonistic Effect. We cannot predict what this subject’s pulse rate will be. The pulse rate could be elevated, or depressed, or within the DRE average ranges. This subject’s pulse rate will depend on many factors, including: How much of each drug was taken. How and when each drug was taken. How tolerant the subject is of each drug.

Impairment Indicator Dissociative Anesthetic Narcotic Analgesic Type of Effect What Will We See? Reaction to Light Normal Little or None Visible Overlapping Pulse Rate Up Down Antagonistic Up, Down or Normal Blood Pressure Blood Pressure Ask participants: “What are we likely to find when we check this subject’s blood pressure?”

Impairment Indicator Dissociative Anesthetic Narcotic Analgesic Type of Effect What Will We See? Reaction to Light Normal Little or None Visible Overlapping Pulse Rate Up Down Antagonistic Up, Down or Normal Blood Pressure A Dissociative Anesthetic usually elevates blood pressure; a Narcotic Analgesic usually lowers blood pressure. This is another Antagonistic Effect. We can’t predict what the blood pressure will be. It could be above DRE average ranges, below DRE average ranges, or within the DRE average ranges.

Impairment Indicator Dissociative Anesthetic Narcotic Analgesic Type of Effect What Will We See? Body Temperature Temperature Ask participants: “What are we likely to find when we check this subject’s temperature?”

Impairment Indicator Dissociative Anesthetic Narcotic Analgesic Type of Effect What Will We See? Body Temperature Up Down Antagonistic Up, Down or Normal A Dissociative Anesthetic usually elevates temperature; a Narcotic Analgesic usually lowers it. This, too, is an Antagonistic Effect. The temperature could be elevated (up), or depressed (down) or within the DRE average range. Point out that the combination of a Dissociative Anesthetic and Narcotic Analgesics produce Antagonistic Effects on all three vital signs. Point out that the term “Normal” refers to the DRE average range for body temperature which is 98 degrees plus or minus 1 degree.

Impairment Indicator Dissociative Anesthetic Narcotic Analgesic Type of Effect What Will We See? Body Temperature Up Down Antagonistic Up, Down or Normal Muscle Tone Muscle Tone Ask the participants: What are we likely to find when we check this subject’s muscle tone?

Impairment Indicator Dissociative Anesthetic Narcotic Analgesic Type of Effect What Will We See? Body Temperature Up Down Antagonistic Up, Down or Normal Muscle Tone Rigid Flaccid Normal, rigid, or flaccid A Dissociative Anesthetic usually causes rigid muscle tone. A Narcotic Analgesic usually causes flaccid muscle tone. This could be an Overlapping or Antagonistic Effect. Muscle tone could be normal, rigid, or flaccid. Solicit participants’ comments and questions about the combination of a Dissociative Anesthetic and a Narcotic Analgesic.

Impairment Indicator Dissociative Anesthetic Narcotic Analgesic Type of Effect What Will We See? Body Temperature Up Down Antagonistic Up, Down or Normal Muscle Tone Rigid Flaccid Normal, Rigid, or Flaccid A Dissociative Anesthetic usually causes rigid muscle tone. A Narcotic Analgesic usually causes flaccid muscle tone. This could be an Overlapping or Antagonistic Effect. Muscle tone could be normal, rigid, or flaccid. Solicit participants’ comments and questions about the combination of a Dissociative Anesthetic and a Narcotic Analgesic.

Cannabis, CNS Stimulants and Hallucinogens
Impairment Indicator Cannabis CNS Stimulant Hallucinogen Type of Effect What Will We See? HGN Cannabis, CNS Stimulant and Hallucinogens Another specific example: consider a person under the influence of Cannabis, a CNS Stimulant and a Hallucinogen.

Impairment Indicator Cannabis CNS Stimulant Hallucinogen Type of Effect What Will We See? HGN None Null No HGN HGN None of the three categories causes HGN. This is an example of the Null Effect.

Impairment Indicator Cannabis CNS Stimulant Hallucinogen Type of Effect What Will We See? HGN None Null No HGN VGN No VGN VGN None of the three drug categories cause Vertical Gaze Nystagmus, another example of the Null Effect.

Impairment Indicator Cannabis CNS Stimulant Hallucinogen Type of Effect What Will We See? HGN None Null No HGN VGN No VGN LOC Present Overlapping LOC Cannabis causes a Lack of Convergence while CNS Stimulants and Hallucinogens do not. This is an example of an Overlapping Effect and Lack of Convergence should be present.

Impairment Indicator Cannabis CNS Stimulant Hallucinogen Type of Effect What Will We See? HGN None Null No HGN VGN No VGN LOC Present Overlapping Pupil Size Dilated (6) Dilated Additive/ Overlapping (6) Pupil Size Cannabis usually dilates pupils. CNS Stimulants and Hallucinogens also dilate the pupils. This is an example of an Additive or Overlapping Effect. Ask participants: What effect will take place and the result. The pupils should be dilated. Remind the participants that the term “Normal” refers to pupil sizes within the DRE average ranges. (6) Pupil size possibly normal

Impairment Indicator Cannabis CNS Stimulant Hallucinogen Type of Effect What Will We See? Reaction to Light Normal Slow Normal (3) Overlapping/ Additive (3) Reaction to Light Cannabis does not effect the Reaction to Light. CNS Stimulants will slow down the reaction. Most Hallucinogens, with some exceptions, will cause a normal Reaction to Light. This is an example of either an Overlapping or Additive Effect. Ask participants: What effect would take place and the result. We could probably see a slow Reaction to Light. Remind participants that certain psychedelic amphetamines may cause a slowed reaction to light. (Exception #3) (3) Certain psychedelic amphetamines may cause slowing

Impairment Indicator Cannabis CNS Stimulant Hallucinogen Type of Effect What Will We See? Reaction to Light Normal Slow Normal (3) Overlapping/ Additive (3) Pulse Rate Up Additive Pulse Rate Cannabis will normally elevate the pulse rate as will CNS Stimulants and Hallucinogens. This is an example of an Additive Effect. Ask participants: What effect would take place and the result. The result would be an elevated pulse rate. (3) Certain psychedelic amphetamines may cause slowing

Impairment Indicator Cannabis CNS Stimulant Hallucinogen Type of Effect What Will We See? Reaction to Light Normal Slow Normal (3) Overlapping/ Additive (3) Pulse Rate Up Additive Blood Pressure Blood Pressure All three drug categories will elevate blood pressure. This is an example of an Additive Effect. Ask participants: What effect would take place and the result. Blood pressure should be elevated with this combination. (3) Certain psychedelic amphetamines may cause slowing

Impairment Indicator Cannabis CNS Stimulant Hallucinogen Type of Effect What Will We See? Body Temperature Normal Up Additive/ Overlapping Body Temperature Cannabis usually causes a body temperature in the average range. CNS Stimulants and Hallucinogens elevate body temperature. This would be an example of an Additive or Overlapping Effect. Ask participants: What effect would take place and the result. The body temperature should be elevated with this combination.

Impairment Indicator Cannabis CNS Stimulant Hallucinogen Type of Effect What Will We See? Body Temperature Normal Up Additive/ Overlapping Muscle Tone Rigid Muscle Tone Cannabis causes a normal muscle tone, while CNS Stimulants and Hallucinogens will cause rigid muscle tone. This would be an example of an Additive or an Overlapping Effect. Ask participants: What effect would take place and the effect. The muscle tone should be rigid with this combination.

Identifying Expected Indicators of Specific Combinations
The Drug Symptomatology Matrix outlines the expected results of the drug influence evaluation for each drug category Identifying Expected Indicators of Specific Combinations Direct the participants’ attention to the Cumulative Drug Symptomatology Matrix, found in Session 24 of their Participant’s Manual. A copy also appears for your reference in Appendix A located in your Instructor Guide, Session 24 folder. Drug Symptomatology Matrix The Matrix outlines the expected results of the drug influence evaluation for each drug category. We will refer to the Matrix to help us interpret what we are likely to see when we examine drug combinations. Remind participants that we “never say never” and we “always avoid saying always” when it comes to signs and symptoms of drugs. The Matrix summarizes what we usually see but doesn’t guarantee we will always see exactly that, or every indicator. Show the video of subjects under the influence of specific drug combinations. Point out the Null, Overlapping, Additive and Antagonistic Effects exhibited by the subjects.

Worksheets Worksheet Exercises
Assign the participants to work in three member teams. Direct the participants’ attention to the three worksheets located at the end of Session 24 in their Participant’s Manual. Instruct the teams that they have only 15 minutes to fill out all three worksheets (5 minutes per worksheet). Worksheet #1: Dissociative Anesthetic and a Hallucinogen. Worksheet #2: Cannabis and CNS Depressant. Worksheet #3: CNS Depressant and CNS Stimulant. Solicit participants’ questions about this assignment. Tell the teams to start working. Terminate their work after 15 minutes. Discussion of Worksheets For each worksheet, select a team member to lead the discussion. Critique and correct the participants’ analyses of the drug combinations, as appropriate.

Questions? Solicit participants’ comments and questions about drug combinations.

110 Minutes Session 24 Drug Combinations.

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