2.  Differences between adolescent and adult patterns of use, effects on brain, concerns with detoxification/withdrawal.  Understand top concerns with particular substances  Alcohol  Opiates/opioids  Cannabinoids  Methamphetamine/cocaine/stimulants

3.  Continues to develop until 20s  Back to front

6.  Different patterns of use  Alcohol: binge vs. daily  Polypharmacy as a general rule  Substances effect adolescent differently  The younger age at initiation the more risk for abuse/dependence

7.  Pattern of Use  Binge type  Less likely to be daily drinkers  Less sensitive to the sedating effects of alcohol  Higher BAC  More blackouts  More damage

9.  More likely to overdose than go through medically significant withdrawal  What happens with alcohol overdose?  Increasing BAC leads to increasing sedating effects  Loss of muscle control, stupor, coma, death  Death from aspiration, choking, respiratory depression

10.  Requires significant duration of daily drinking with tolerance  60% who meet criteria for dependence will experience some symptoms of withdrawal (>90% mild to moderate)  6-24 hours from last drink  Changes to major neurotransmitters in brain  Enchances GABA-major inhibitory neurotransmitter  Homeostatic changes  Increase in blood pressure, heart rate, anxiety, n/v, seizure, death

11.  Clinical Institute Withdrawal Assessment  Questionnaire /Assessment done by clinician/nurse  Score 10 or more needs medical treatment/evaluation  What to do if limited nursing?

12. J Clin Psychopharmacol 1991; 11:291-295  Nausea and Vomiting  Tremor  Paroxysmal sweats  Anxiety  Agitation  Tactile disturbances  Auditory disturbances  Visual disturbances  Headache, fullness in head  Disorientation

13.  Heroin  Prescription Drugs  Hydrocodone (vicodin, norco)  Oxycodone  Morphine  Methadone

18.  Sedation  Pupil Constriction  Slurred speech  Impaired attention/memory  Constipation/ urinary retention  Nausea  Confusion/delirium  Seizures  Slowed heart rate  Respiratory depression

19.  Depends on which opiate: ▪ Onset of action. ▪ Hydrocodone (peak.5hr, duration 3-4 hours) ▪ Methadone (peak: 2-4 hours, duration 24 hours) ▪ Tolerance of individual ▪ Tolerance to respiratory depression may be slower than tolerance to euphoric effects  Symptoms of overdose: ▪ Triad: ▪ Altered LOC ▪ Respiratory Depression (RR<12) ▪ Miotic Pupils  Withdrawal  Cows

20.  Basic life support  Assess Ventilation ▪ Support ventilation  Naloxone hydrochloride – opioid antagonist ▪.4mg to.8mg, may have to be repeated ▪ May need higher doses and multiple repeated doses over time

21.  Not life-threatening but so uncomfortable prompts relapse.  Onset of symptoms depends on the duration of use and ½ life of drug used  Heroin: onset 4-6 hours  Methadone: onset: 36 hours  Neurophysiologic rebound in target organs  The generalized CNS suppression during use is replaced by CNS hyperactivity.

23.  Supportive measures  Medication assisted  clonidine

25.  CVS  Ventricular irritability  Hypertension  Tachycardia  Myocardial Infarction  Neurologic  Seizure  Stroke  Hyperthermia  Rhabdomyolysis  Acute Renal Failure  Insomnia

26.  CVS  Cardiomyopathy  Myocardial Infarction  Strokes  Pulmonary  Pulmonary Hypertension  COPD  Neurologic  Memory Impairment  Deficits in judgment  Poor impulse control  Infectious  HIV/Hepatitis C  Skin infections  Complications IVDA

27.  Psychosis  Acute: ▪ Classically paranoid ▪ Persecutory delusions ▪ Ideas of Reference ▪ Heightened awareness  Chronic: ▪ Psychosis can persist after acute episode or recur with little or no further MA use. ▪ Sensitization  Mood Disorder  Mania during intoxication  Depression during withdrawal  Anxiety

28.  Confirm diagnosis by urine toxicology screen  Gastric lavage or activated charcoal for ingestion  Seizures: Diazepam  Psychosis /Agitation: Diazepam +/- antipsychotic  Hyperthermia: external cooling

29.  Hyperarousal  Agitation, severe craving, nightmares  Vegetative Symptoms  Decreased energy, craving sleep, increased appetite  Anxiety-related symptoms  Anxiety, loss of interest, anhedonia, psychomotor retardation  Severe dysphoria, mood volatility, irritability and sleep pattern disruption

30.  Drug of choice- most daily marijuana use  Intake:  Adverse events: paranoia, increased blood pressure/HR  Withdrawal  Symptoms similar to nicotine withdrawal  No real treatment for withdrawal

32.  Mixture of herbs or dried, shredded plant material that is typically sprayed with chemicals that are similar to THC  Street names: Spice, K2, Black Mamba, Blaze, JWH-018, 073, Kronic(added BZ), krypton (added opioid)  Typically smoked  Sold in Europe since 2002-2004. Widely available for purchase on Internet in 2006

33.  2010: states began banning product  2011: schedule 1 drug  First cannibinoid identified was JWH-018 and CP47,497. Now there are well over 20 new synthetic cannabinoids.  10 -100 more potent than THC  Strong affinity to CB1 receptors  Responsible for psychoactive effects  Central and peripheral nervous sx,  Cardiovascular system

34.  Some of herbal ingredients added may have psycho-active potential (opioid-like, Bz,etc)  Onset 3-5 minutes  Duration of action: 1-8 hours

36.  Depends on dose  Mood effects  Euphoria and dysphoria  Hyperactivity, anxiolysis and anxiety  Perceptual effects  Change in time perception  Hallucinations/psychotic states  Paranoia  Depersonalization/dissociation

37.  Cognition effects:  Fragmented thinking  Short term memory impairment  Motor effects  Ataxia, loss of coordination, slurred speech  Immunosuppressive  Cardiovascular effects  Increased heart rate, orthostatic hypotension

38.  Unpredictable toxicology  Adverse effects are dose dependent  Emerging evidence that adverse effects are more severe  Especially in teens (as is Marijuana)

39.  Seizures  Psychosis  Growing acceptance that cannabis use may increase the risk of psychosis and/or psychosis like conditions. Cannabis risk is mild. ▪ 41% increased risk in developing psychosis for cannabis users v. non-cannabis users ▪ 109% increase for heavy cannabis users  Commonly reported in SC users ▪ Clearly associated with both the onset and exacerbation of recurrent psychotic episodes

40.  Mood and Anxiety  Anxiety  Catatonia  Cardiovascular effects  Increased heart rate  Pediatrics: Adolescents presenting with chest pain, confirmed myocardial infarction.