1. SUBSTANCE RELATED DISORDERS
COCAINE
LSD
BENZODIAZEPINES
BARBITURATES
Dr. Y R Bhattarai
TMU

2. 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

3. 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.

4. 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”.

7. 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.

8. 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

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

11. 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.

12. Cocaine withdrawal features
Depression
Fatigue
Increased appetite
Unpleasant dreams

13. Drugs for cocaine withdrawal
Antidepressants like desipramine

14. 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

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

16. 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.

17. 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

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

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

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

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

22. drawings done whilst under its influence of LSD

23. 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.
mg/day for >1 month

24. Management
Symptomatic
Induction of vomiting
Give activated charcoal

25. 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

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

27. Rx
Symptomatic
Flumazenil (specific benzodiazepine antagonist) 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.

28. 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.

29. 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.