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In a year’s time, we’ve seen a huge increase in the teen use of illicit drugs and the average age is decreasing with kids as young as 16 averaging their start with marijuana. The estimates of use in the U.S. is 14 million Americans are using substances and heroin is increasing in its use because of greater purity and decrease in cost. It’s being marketed by the same people that used to bring you cocaine so cocaine’s desirability is going drug dependency, drug addiction, drug adiction, cocaine adiction
First I want to cover stimulants even though cocaine is being relegated to female, older and mentally ill chemically abusing populations, MICA, and that concept which we’ll cover more tonight if you attend the dual diagnosis seminar, MICA is primarily psychotic severely disabled mentally ill patients who dabble in substance abuse as opposed to people who have primary substance abuse – the majority of people with a substance abuse problem in the U.S. who have secondary symptoms but we’ll talk about that Methamphetamine, big problem in Hawaii, the West Coast. Some East Coast areas now but more in the south. We’re not seeing it really in the Northeast for some reason but easily cooked up in
It does seem to damage dopaminergic and serotonergic terminals in the brain. This is rat brain. We don’t know the clinical significance in humans but it’s important to know that. MDMA, another amphetamine derivative popularly known as ecstasy. Methamphetamine is known as crank, speed, ice. Ecstasy for MDMA. The neurons themselves are damaged in
The big problem with heroin is it’s so pure now that inhaled alone is sufficient to make people dependent. It’s not just a gateway anymore that leads them to IV use. It does lead people to IV use but it’s enough to get people so dependent that I’ve had to refer patients who
Marijuana is now the choice of teenagers throughout the land. It’s been increasing since 1992 and there are lots of combination lacings of marijuana now to improve the marketing. You may have heard of embalming fluid being laced to marijuana and fry is the mixture. Fry. And I think that’s a rye comeback on the advertisement we used to see, "This is your brain on drugs." You know, it was the egg being fried in the frying pan. Now the kids are saying, "Oh, yeah. Let’s do it." So this is one of the crises of
Club drugs. Rohipnol – the date rape drug. Sedative. GHB, gamma hydroxybutyrate. These are mostly sedatives but LSD is being used, MDMA ecstasy, big rave party drug. Raves are these all night nonstop very
Pregnancy. 5.5% of pregnant women in studies are found to be using drugs of abuse which is pretty shocking. Almost 20% alcohol and smoking cigarettes despite all that we know about the effects of fetal alcohol syndrome and low birth weight, low head circumference with smoking. So a lot of important trends and epidemiology and we can talk about that maybe in questions if people are
But I want to stress that some familiarity with this is important. It can appear on the boards but at least have down the basics of diagnosis. Now, there are many syndromes of psychiatric disturbance that are associated with intoxication or withdrawal and so we want to be familiar with these names. So Roman numeral II on your outline which I think is page 279 has the substance induced syndromes and these are listed separately along with
The two to be most aware of are the delusional or psychotic induced syndrome which many of these substances can induce and delirium and hallucinosis which just about all of the hallucinatory, stimulatory and even the sedative substances can produce delusions, delirium… well, at least delirium and hallucinosis. Sometimes in intoxication, in other cases like a sedative withdrawal or alcohol withdrawal during withdrawal. Of course, not caffeine or nicotine. So an easy point to remember. It can easily show up as a multiple choice test with all of the above. You just have to know that the all of the above
But what is abuse? Separate from these substance induced syndromes, abuse is a very simple problem. It’s just any one persisting problem – role failure, use in hazardous situations or recurrent legal or social problems. So it’s a good diagnosis for the alcohol intoxication driving arrest and the patient says, "This has never happened to me before. I drink when I come home from work. At the bar I stop off with my pals and I make it home fine and this arrest has nothing to do with alcoholism." Well, that may be true but it is alcohol abuse to drink and then drive. So that’s an easy diagnosis to make.
Slightly more complex is dependence and the dependence criteria. There are seven different categories but only three criteria to make the diagnosis. So the first two are physiologic – tolerance and withdrawal – but the others are strictly behavioral. You need to know that only three of the behavioral ones can be sufficient to make the dependence diagnosis. You don’t have to have withdrawal. You don’t have to have tolerance.
I have a lovely woman who tells me, "I never get drunk. I do not have increasing use of alcohol. I can control my alcohol. I never have more than three or four drinks and nobody ever says it’s a problem." "So why are you here?" "Well, my doctor thinks that my diabetes is off the wall and blames my drinking and it’s true my weight is up. He says I’m tremulous from it. So what if I am." So we make the diagnosis, she substantially cuts down but is not completely abstinent on a more than two week basis at a time but what she notices is that her golf game has shaved ten points so she says, "Gee, there must be something to that." So it does not have to be a physiologic syndrome to make the diagnosis.
By the way, is there anybody familiar with absolute or relative tolerance? The meaning of those terms. Let me just clarify that because that is something that it’s not nit picking. There is a meaning to it. Absolute tolerance is to get a certain high that I’m seeking I have to drink two drinks initially, then after I’m a full member of the fraternity I have to drink four drinks and by the time I’m an officer I have to
The dopamine agonists – bromocriptine, amantadine, mazindol – this is conclusively disproved now. Amantadine hasn’t done as well as bromocriptine and bromocriptine has had side effects and has had some negative trials now too. So the answer on do we have a
The mu-opioid receptor system is the primary analgesic receptor system. It’s anti nociception. Anti nociception means you don’t feel pain. You can feel pressure but you don’t feel pain when these sites are occupied. Heroin, morphine, methadone, the m’s go with mu. The delta receptors are also supportive for analgesia and the akephalines have the better binding for this. So we have these three major systems. The kappa system you know about. Talwin, pentazocine produces analgesia there but it is also associated with a risk for dysphoria and Talwin is contraindicated in a patient who has mu-opioid dependence – heroin, morphine or methadone. Contraindicated because it will trigger a dysphoric reaction.
The main problem in overdose is brainstem respiratory CO2 sensitivity falls and the patient stops breathing. The purity of heroin on the streets is strong enough now that we’re seeing this even with inhaled and smoked heroin sometimes. Now, tolerance occurs rapidly particularly to the nausea and that kind of discomfort and it becomes purely pleasurable at that point but only one in ten people who try heroin tend to become addicted to it. So we have to be realistic about this and reasonable, not that heroin could ever be thought of as a legalized substance, but not everybody who walks in who says, you know, "I used heroin at a party" is a heroin addict and we have to do some work to tease out "Do we have a criteria of dysfunction being met?"
What’s the withdrawal amount? Well, the locus caeruleus is suppressed by chronic heroin use and when that suppression is released we have up-regulation of noradrenerigic receptors and suddenly the adrenergic arousal goes wild. There isn’t up-regulation of the opioid receptors themselves but there is up-regulation in terms of dopamine activity and the two sides are the ventral tegmental area – VTM – and nucleus accumbens which we talked about before but both of these are involved. Heroin is not a one site reinforcer. It seems to
Anesthesia detox. You actually can get a full blown heroin addict onto full dose naltrexone totally blockaded at the mu-receptor – they can’t become high now – in five hours using anesthesia. The problem is you don’t know if the therapeutic change has happened so that the patient doesn’t go out and then try and overcome naltrexone and dose themselves so badly that they overshoot and go into coma which has happened now a few times.
LAM – levo acetyl methadone. LAM is now FDA approved. It’s just a long acting type of methadone. So you can dose 100 mg Monday, 100 mg Wednesday, 150 mg on Friday and the patient is covered in the intervening days. They have more freedom. They can
Buprenorphine. I hope it’s going to come out this year from the FDA. I keep saying that. The slowdown has been that the FDA is being pushed to allow dispensing in physicians’ offices. Buprenorphine is another long acting opioid like LAM, like methadone, safer and we may get to use it in office practice.
You might hear about ibogaine. Ibogaine is a hallucinogen actually, though it’s a weak one. It’s a serotonergic agent and in preliminary animal studies it seems to reduce self administration for opiates and stimulants. So that’s kind of interesting.
I’m going to skip over concomitant substance abuse except to point out that alcoholism is present in 50% of heroin addicts even treated ones in methadone programs so if you see that question, 50% is huge so it’s called a majority. I would also point out that what if somebody is dependent upon both opiates and benzodiazepines or opiates and alcohol? Well you want to maintain methadone during the alcohol or benzo detox and do the methadone detox later. So that sequence is important.
Now I’m going to cover a couple of other substances. Just nicotine. We’re on the bottom of page 289 and I point out that there has been, in the past five years, a 25% increase in college smoking. Now who wanted that? Well, the advertising industry and the tobacco
There are physiologic effects from smoking. Decreasing muscle tone. Decreasing GI motility. This is the reason that Virginia slims. If I don’t feel like eating because my GI tract ain’t doing much when I smoke I’m going to lose weight and retain my youthful figure. So
So what do we do? Well, we used to think that it was a counseling challenge but the point I want to make and this is on page 290 under letter C, the longitudinal approaches, take a look at item 4. Pharmacotherapy is now the first line approach. Counseling is an important primary issue and can be done in primary care. You don’t have to go to specialized groups but all pharmacotherapies work and they all work about equally well.
Bupropion is showing nice hard numbers – about 30% are abstinent in a year and that means, well, if the patient relapses try them again. Maybe you’ll get a 60% likelihood of success the second time and it’s just a contraindication in a seizure patient. It can be a problem
A couple of other areas. Cannabinols, page 291, there’s some description of what’s going on there. The key thing to know is that this is now the primary leading illicit substance of abuse in America. More than half of high school seniors are trying marijuana. There are many
I want to say something about the hallucinogens. We are seeing LSD nowadays. It’s in lower concentrations than when we were teenagers and so people aren’t flying out the window thinking they can fly like Art Linkletter’s daughter did which is one of the things that turned people off to LSD. But acid is back in a lower concentration and kids are using it at parties and it is producing problems acutely. Tolerance showing it has a serotonergic effect. It can also produce an adrenergic state. PCP, while developed as an anesthetic, has a
The final thing is anabolic steroids. One out of 10 high school kids is using them. Mark McGwire didn’t help because androstenedione, while not excluded from baseball, does increase testosterone levels and the withdrawal is the problem. The stimulus to mania is a problem. Rageful behavioral and aggression on