Presentation on theme: "Illicit Drug Use in Medicine"— Presentation transcript:
1 Illicit Drug Use in Medicine Nithya SwamyResident’s ConferenceOctober 7, 2008
2 Introduction4.7% of the world’s population participate in illicit drugsIn the US, of those 12 years or older8-9% of individuals in the US abuse illicit drugs46.1% have tried it in their lifetimeDrug use or drug withdrawal can be the cause of a presenting illness or it can mask an underlying illnessIt is important to recognize the symptoms of drug intoxication and how to treat it
3 Goals of Presentation Drug Use Stats in the US How Drugs Work Cases/Common Recreational DrugsStreet LingoDrug EffectsManagement and Treatment
4 Drug Use in the USDrug use at least once in the last 30 days among those 12 and older22.5 million > 12y were classified with drug abuse or drug dependence. This includes tobacco, alcohol and illicit drugs.26% American Indian or Alaska Native12.2% for mixed races11.1% Caucasian10.2% Hispanic9.3% African-American6.0% AsianRandom Scary Fact: By eighth grade, 52 percent of teenagers have consumed alcohol, 41 percent have smoked cigarettes, and 20 percent have used marijuana.
5 Drug Use in the US25-40% of hospitalizations in the US involve substance abuse10-16% of outpatients have substance use problems16,000 deaths/year are due to illicit drug use whether directly or indirectly (HIV/AIDS, hepatitis, tuberculosis, homicides, and other violent crimes and incidental injuries)Cost: $531 billion dollars annually ($181 billion in illicit drugs, $168 billion for tobacco and $185 billion for alcohol)ER visits each year
6 Drug Use in the US6-7% of senior citizens admitted exhibit symptoms of alcoholism. Prevalence of problem drinking in the nursing homes is high as 49%In this subpopulation, the majority are women.They are more prone to dependence on prescription medications 2/2 overmedication by their own physiciansOpiods for pain and sedative/hypnotics for anxiety or insomniaRandom Scary Fact #2: Health care workers are at increased risk of addiction due to high stress jobs and access to drugs.Anesthesiologists, surgeons, and emergency room physicians are at highest risk for drug dependence.Have more resources to conceal their addiction so it may be well advanced before the dependence is discovered (ie using someone else’s rx)
7 How Drugs Work Acute Drug Use: Release and Prolonged action of dopamine and serotonin within the reward circuit.Reward Circuit (mesolimbic system)Addictive drugs lead to the release of dopamine. Dopamine binds to D1 receptor triggering a signaling cascade that leads to a pleasurable response.There is also a 2nd cascade activated involving a cAMP dependent PK which activated a CREB tf which when activated inhibits dopamine release.In drug users this pathway is chronically active resulting in the need for larger doses to achieve the same pleasurable response.VTA consists of dopaminergic neurons which respond to glutamate. These cells respond to stimuli when a reward is present. Virtually all drugs that cause addiction increase dopamine release in the mesolimbic pathway towards the NA. The nucleus accumbens consists of GABA neurons which is associated with acquiring and eliciting conditioned behaviors and involved in the increased sensitivity to drugs as addiction progresses. The prefrontal cortex is important for the integration of information which contributes to whether a behavior will be elicited. It appears to be the area in which motivation originates and the salience of stimuli are determined.Dopamine binds to the D1 receptor which activates the cAMP dependent protein kinase wh/ phosphorylates the CREB trascription factor. The CREB TF releases proteins which cuts off dopamine release and inhibits the reward circuit. Chronic drug abuse leads to sustained release of CREB and its subsquent inhibiting proteins. Therefore larger doses are needed to overcome this sustained CREB release and to achieve the benefit/pleasurable response.
11 Short Term Effects Euphoria: BAC = 0.03 to 0.12% Lethargy: BAC = 0.09 to 0.25%Confusion: BAC = 0.18 to 0.30%AtaxiaStupor: BAC = 0.25 to 0.40%Anterograde amnesiaComa: BAC = 0.35 to 0.50%Death: BAC more than 0.50%Alcohol->Acetylaldehyde->Acetic Acid->fats, CO2, WaterDeath in the acute phase:Alcohol poisoning and respiration depression, loss of gag reflex and asphyxiationWernicke encephalopathy: ataxia, ophthaloplegia, confusion and impairment of short-term memory. Lesions in the CNS & PNS. Heavy alcohol use interferes with thiamine breakdown.Tx: Thiamine IV/IMOphthaloplegia: paralysis of the Extraocular musclesAs blood alcohol levels increase, there is increasing levels of somnolence and decreased responsiveness
12 Long Term Effects Brain Heart: GI: mucosal damage Impairs brain development and neurogenesisMyopathy in the proximal muscles: 50%PolyneuropathyWernicke-Korsakoff:Korsakoff’s psychosis: progression from Wernicke’s; anterograde and retrograde amnesia, anisocoria, confabulation, ataxia, tremors & lack of insight.Long-term tx with thiamine but at this point, may never return to their baseline.Heart:Dilated cardiomyopathy and CHFTx: ACE I, BB, Diuretics, or heart transplantGI: mucosal damageInflammation of GI tractImpairs esophageal motility, esophagitis, Barrett’s, esophageal Ca, Mallory WeissSteatohepatitisAlcoholic hepatitis: Inflammatory response to fatty accumulation: jaundice, ascites, AST>ALT, encephalopathy, increased PTTx: cortiocosteroids, sometimes pentoxyfillineCirrhosis: fibrosis and altered architecturePortal HTN: gastric & esophageal varicesCoagulopathyAscites, encephalopathy and hepatorenal syndromeTx: symptomatic: lactulose, vitamin K or FFP, nadalolModerate alcohol us has proven benefits in CAD, PVD, Angina, dementia, metabolic syndrome kidney stones, RA. But b/c we the detriment of the negative aspects, that is what I’m focusing oneAnisocoria: unequal pupilsPatients with discriminant fxn score>32, pentoxifilline: >32 and one of palpable tender hepatomegaly, fever, leukocytosis, hepatic encephalopathy, or hepaticsystolic bruit)Hepatorenal syndrome is thought to be an alteration in blood flow and blood vessel tone in the circulation that supplies the intestines (the splanchnic circulation) and the circulation that supplies the kidney. End stage of perfusion
13 Alcohol Withdrawal High mortality rate if not effectively treated. Alcohol’s primary effect is the stimulation of GABA and promotes CNS depressionWhen abruptly stopped, the CNS undergoes uncontrolled synapse firing.Leads to anxiety, shakiness, diaphoresis, insomnia, tachycardia, tremor and in more severe cases seizures & delirium tremensDT: autonomic instability, hallucinationsTreatment: symptomatic and supportive:Benzodiazepines followed by taper, vitamin and fluid replacementAdrenergic storm: tachycardia, hypertension, hyperthermia, hyperreflexia, diaphoresis, Heart attack, arrythmias, anxiety or panic attacks.
14 CaseA 35 year old male presents to the ER and is hyperactive and tremulous. His girlfriend brought him in for AMS. He keeps saying he is “the authority of the human mind” and that because of that, people are trying to kill him. His girlfriend reports he has not slept much in days.Physical Exam:H: 5’9; 95lb. T: 103.6, HR: 115, BP: 178/110,Pupils are equal but dilated, dry membranes with very poor dentitionCV: Irregular rhythm and tachycardicWhat drug has he been taking?
17 Routes: smoking, injection, snorting and rectally Intoxication: Amphetamines are stimulants that increase levels of the neurotransmitters: norepinephrine, serotonin and dopamine.It stimulates NT release and at high doses inhibits NT uptakeRoutes: smoking, injection, snorting and rectallyIntoxication:Short term: mydriasis, hyperactivity, increased physical activity, decreased appetite, tachypnea, tachycardia, irregular heartbeat, hypertension & hyperthermia.symptomatic tx with benzos and antipsychoticsLong term: extreme weight loss, hypoglycemia, severe dental problems, anxiety, confusion, insomnia, intracerebral hemorrhage, mood disturbances, and violent behavior. Also, psychotic features, including paranoia, visual and auditory hallucinations, and delusions.It can bind to the pre-synaptic membrane of dopaminergic neurones and induce the release of dopamine from the nerve terminal; (2) amphetamine can interact with dopamine containing synaptic vesicles, releasing free dopamine into the nerve terminal; and (3) amphetamine can bind to the dopamine re-uptake transporter, causing it to act in reverse and transport free dopamine out of the nerve terminal.
18 Overdose: Withdrawal: Treatment: Sympathetic overload: diaphoresis, tachycardia, vasoconstriction, hypertension, hyperthermiaHyperthermia and vasoconstriction can lead to rhabdomyolysis, renal failure, CV collapse & death.Withdrawal:7 -10 daysHypersomniaDepressionHyperphagiaTreatment:No medications, primarily behavioral rehab
19 Chronic use: Noninvasive human brain imaging studies have shown alterations in the activity of the dopamine system that are associated with reduced motor performance and impaired verbal learning. Recent studies revealed severe structural and functional changes in areas of the brain associated with emotion and memory
20 CaseA 37 yo female presents drowsy and disinhibited. She keeps trying to get out of bed and when she does, she is staggering. She is difficult to understand as her speech is slurred and she is obviously confused. She becomes more somnolent and soon becomes difficult to arouse. He breathing decreases and she requires intubation. Her husband says “she takes some pills everyday. She has to take them because if she stops, she has a fit”PE:T: 95, P: 85, R 18, BP: 76/50Eye: lateral nystagmusWhat kind of drug is she on?
22 Amobarbital: Pentobarbital: Phenobarbital: Secobarbital: Tuinal: COMMON BARBITURATES:Amobarbital:Downers, blue heavens, blue velvet, blue devilsPentobarbital:Nembies, yellow jackets, abbots, Mexican yellowsPhenobarbital:Purple hearts, goof ballsSecobarbital:Reds, red birds, red devils, lilly, F-40s, pinks, pink ladies, seggyTuinal:Rainbows, reds and blues, double trouble, gorilla pills, F-66s
23 Barbiturates are CNS depressants: mild sedation and anesthesia. Anxiolytics, hypnotics and anticonvulsantsPotentiates inhibitory GABA receptor and a glutamate receptorUpregulates CYP 450 in the liverRoutes: Oral and IV/IMSx: Respiratory depression, hypotension. Fatigue, hypothermia, irritability, dizziness, sedation, lateral & vertical nystagmus, confusion and ataxia.Drug users often abuse barbiturates to counteract the symptoms of stimulants like cocaine or methCommonly abused barbiturates are short actingcytochrome P450, leading to a reduction in the breakdown of other exogenous and endogenous substances (including steroids), while stimulating other enzyme systems, so that some drugs have a reduced effect (incl. chlorpromazine, griseofulvin and coumarines).
24 Overdose can lead to respiratory failure and death Tx: symptomatic and charcoalWithdrawal: h after the last dose. Symptoms include anxiety, irritability, elevated heart and respiration rate, muscle pain, nausea, tremors, nightmares, insomnia, vivid dreams, hallucinations, confusion, and seizuresTx: stabilization with an intermediate acting barbiturate like pentobarbital. Newer techniques involve loading doses of phenobarbital titrated to the clinical or toxic effects. Eventually they require a gentle taper and rehab
25 CaseA 45 year old physician presents complaining of anxiety, palpitations and profuse sweating. He did not sleep the night before. He has his sunglasses on and he’s asking you to whisper b/c anything louder hurts his yearsPE: He seems anxious and agitated.T:98.6, P: 110, R: 33 BP: 150/95What drug is he withdrawing from?
28 Psychoactive drugs with hypnotic, sedative, anxilytic, anticonvulsant, muscle relaxant and amnesic properties mediated by slowing of the CNS.Tolerance develops quickly and higher doses are required to achieve the same effect.Often, by 4-6 months, benzos have little efficacyBenzodiazepines can give rise to physiologic and psychologic dependence based on the drug's dosage, duration of therapy and potency.Benzos are rarely the sole drug of abuse. An estimated 80 percent of benzodiazepine abuse is part of polydrug abuse, most commonly with opioids.Thus, dependence will develop sooner (such as in one to two months) in a patient who is taking a high dosage of a high-potency agent such as alprazolam than in a patient who is receiving a relatively low dosage of a long-acting, low-potency agent such as chlordiazepoxide
29 Overdose: respiratory depression, hallucinations, coma Overdose: respiratory depression, hallucinations, coma. Mortality rates are not as high as barbituratesTx: supportive; flumazenil is used only for severe cases, as it can cause acute withdrawal and subsequent seizures.Flumazenil should only be used if Benzodiazepines is the only drug of abuse.Withdrawal: Anxiety, tachycardia, hypertension, diaphoresis, insomnia and sensory hypersensitivity.Tx: Taper with a longer acting benzo like chlordiazepoxide
30 CaseA 26 year old male presents to the ED complaining of progressively worsening productive cough and shortness of breath for 3 days. He does have chest pain but attributes it to his persistent cough. His sputum is productive of white foamy sputum.When you are assessing him, his breathing becomes more labored and eventually he has to be intubated. He progressively becomes hypotensive and requires pressors. An TTE is done at the bedside and reveals severe dilated cardiomyopathy with an EF of 15%.What is the offending drug?
32 Common Street Names: Routes: Blow, C, California Cornflakes, Nose candy, Coke, Columbian foot soldiers, Flake., Lady C, snowball, tornado, wicky stick, Showbiz Sherbert, White Lady, ShnazzleRoutes:Freebase: smoking the base form of cocaine. Absorbed directly into the bloodstream from the lungs. Rush is more intense than snorting.Crack/Cocaine: smokable. Freebase form of cocaine that is made from a reaction between cocaine and sodium hydroxide.Insufflation (snorting, sniffing, blowing)Oral: rubbed along gum line: "numbies", "gummers" or "cocoa puffs"
33 Strong CNS Stimulant: increase levels of dopamine through the reward circuit Acute:Moderate amounts: vasoconstriction, dilates pupils, hyperthermia, tachycardia, hypertension, euphoriaLarge amounts: Intensify the user’s high, but may also lead to bizarre, erratic, and violent behavior. Arrhythmias, tremors, vertigo, muscle twitches, paranoia, or with overdose, cardiac and respiratory arrestChronic:bronchospasm, pruritus, fever, diffuse alveolar infiltrates without effusions, dilated cardiomyopathy, stroke, MI, degradation of septum nasi, shortness of breath, tooth decay, renal failureWithdrawalDepressed mood, Fatigue, Generalized malaise, Vivid and unpleasant dreams, Agitation and restless behavior, Slowing of activity and Increased appetiteLow to non-existent mortality; high risk of relapseTreatment:Supportive, behavioral treatment and detox
34 Cocaine and ACSRisk of MI is increased 24-fold in the 1st hour after cocaine use.6% of patients with cocaine-associated chest pain are having an AMI.An additional 15% meet the criteria for ACS.Ischemia may be delayed for up to 24 hrs after use.Acute:VasoconstrictionImmediate and delayed coronary vasoconstrictionVasoconstriction may be worsened if cocaine is used with tobaccoHypercoaguabilityPlatelet activation & aggregationIncreased oxygen consumptionChronic:Early atherosclerosis and coronary ectasiaCardiomyopathyEKG: may be normal, non-specific or show ST changes56-84% of patients will have an abnormal EKG.Up to 43% meet EKG criteria for reperfusion therapy.
35 CaseA 17 year old female presents to ED with altered mental status. She has rapid speech and discussing her important role in the universe. She is trying to hug/kiss/grope your male resident.PE:T: 105, P: 120 R: 25, BP: 140/90Difficult to assess as she can’t stop moving, but you do note she grinding her teeth.Her lab values are significant for a Na 115 and a Cr 2.0
37 Routes: oral as capsule or tablet Common street names:Ecstasy, Adam, Beans, Ex, hug drug,Jack and Jills, Mandy, Smartees, Sweets,Vitamin ERoutes: oral as capsule or tabletSemi-synthetic member of amphetaminesSub-class of phenylethylaminesConsidered a stimulant, psychedelic, empathogen (emotional lability)Affinity for SERTs (serotonin transporter)MDMA inhibits the reuptake of serotonin and it reverses the action of the transporter so that it begins pumping serotonin into the synapse from inside the cellStimulates norepinephrine and dopamine release
38 Chronic: Serotonergic change Acute:Euphoria, decreased anxiety, intimacy, decreased appetite, urinary retention, pupil dilation, increased energy, tachycardic, hypertensive, also, oral fixation such jaw clenching and teeth grinding.Danger signs: Hyperthermia, Dehydration, Hyponatremia and Serotonin syndromeChronic: Serotonergic changeOverdose: Serious adverse events in MDMA users may be an interaction of the drug with a preexisting medical condition.Risk of adverse event after MDMA consumption is thought to be increased by preexisting cardiovascular problems, such as cardiomyopathy, hypertension, viral myocarditis, and congenital cardiac conduction abnormalitiesNeuro: subarachnoid hemorrhage, intracranial bleeding, cerebral infarction due to MDMA-induced increases in blood pressure may occur in people with preexisting congenital AVMs or cerebral angiomas.Hyperpyrexia: resulting rhabdomyolysis and renal failureHyponatremia: ConvulsionsTx: SSRIs prevent neurotoxicity. Symptomatic with benzos or dantroleneCognitive effects: mental confusion, hypomania, hallucinations, agitation, headache, comaAutonomic effects: shivering, sweating, fever, hypertension, tachycardia, nausea, diarrhea.Somatic effects: myoclonus/clonus (muscle twitching), hyperreflexia, tremor.Severe symptoms include severe hypertension and tachycardia that may lead to shock. Severe cases often have agitated delirium as well as muscular rigidity and high muscular tension. Temperature may rise to above 41.1 °C (106.0 °F) in life-threatening cases. Other abnormalities include metabolic acidosis, rhabdomyolysis, seizures, renal failure, and disseminated intravascular coagulation, these effects usually arise as a consequence of hyperthermia.MDMA causes release of ADH from pituitary which causes excessive thirst and water intake. This leads to water intoxication and subsequent hyponatremiaChronic: the brains of animals who are given high or repeated doses of MDMA show long-term decreases in all measures of serotonergic functioning, including concentrations of serotonin, tryptophan hydroxylase, and binding of the serotonin transporter protein. Although measures of serotonin are decreased, there are no decreases in the number of cells in the dorsal raphe, which indicates that the serotonin neurons have not died.
39 CaseA 42 year old cachectic male presents with a RR of 4 and is unresponsive. His pupils were constricted but reactive. The paramedics gave him a medication in which he woke up and reported he took some “cheeba”. Later, he reported he was freezing and had rigors. He also had diffuse abdominal cramping, vomiting and persistent diarrhea.Name that drug!
41 Other: Speedball or snowball Common Street Names:Black, Brown Sugar, Cheeba, Diesel, Hero, Horse, Junk, Lady H, Poppy, SmackRoutes:IVInsufflationSmokingOther: Speedball or snowballCocaine plus heroin leading to a more intense rush than one alone
42 Synthetic opiod synthesized from morphine Crosses blood brain barrier, is converted to morphine and binds opiod receptorsSymptomsInjection leads to rush of euphoria followed by dry mouth, periods of wakefulness and sleep, mental slowing. Other routes have the same symptoms without the intense rushRisks:Infections, HIV, Hepatitis,collapsed veins, endocarditis, pericarditisrenal insufficiencychronic constipationpulmonary complications (pneumonia, respiratory depression).Vascular and organ damage from toxic contaminants in the heroin
43 Overdose: Respiratory depression, constricted pupils, hypotension, coma, delirium, muscle spasticity Treatment: Naloxone or NaltrexoneWithdrawalOccurs 6-24h after last doseRebound hyperactivity of the sympathetic nervous systemSweating, malaise, anxiety, depression, cramps, excessive yawning or sneezing, insomnia, chills, rigors, vomiting, diarrhea, restless legTx:longer-acting opiod such as methadone or buprenorphine.Benzos can be used for symptomatic treatment of anxiety, insomnia and muscle spasms. Loperamide is used for diarrhea and Clonidine for hypertension.Pure heroin overdose is not associated with death. Mortality is associated with toxins in the heroin, concomitant use with other drugs, malnourishment from chronic use, aspiration and asphyxiation from vomit/respiratory depressionTreatment: Naloxone or Naltrexoneopiod receptor competitive antagonist, can lead to rapid withdrawal symptoms; usually have to give in repeated doses as pts can slip back intoRespiratory depression 2/2 the opiodTx with longer acting opiod has less of acute strong effects. It prevents horrible withdrawal symptoms
44 Prescription Opioids Commonly abused prescription opioids OxyContinHydrocodoneMethadoneMorphineHydromorphoneFentanylBuprenorphineSimilar symptoms to heroin but lack heroin’s potency and therefore its severe intoxication and withdrawal.Age makes up its largest population
45 CaseA 35 year old male presents with a knife in his left shoulder. He does not seem to be in pain, but is very agitated and has to be restrained. According to the police, he started a fight by attacking a large group of people. On admission, he continuously yells the aliens are going to abduct him and that they are talking to him through the TV.PE: T: 98.6, P: 122, R: 28, BP: 185/115Diffusely erythematousSubconjunctival hemorrhage, Dilated pupils, non-reactiveDry mucous membranesDoes not withdraw to pain
47 Common Street Names Routes: angel dust, illy, water, BrainTree, fry, dumb dust, rocket fuel, cake, nature boy, love boat, elephant tranquilizer cornbread, Hairy Jerry, George JeffersonRoutes:Powder: insufflatedLiquid: dipped on cigarettes and marijuana and smoked. IV/IM as well.
48 Dissociative drug causing hallucinogenic and neurotoxic effects. Blocks conscious mind from other parts of the brain. Depersonalization, derealization and anesthesia.NMDA receptor antagonist similar to ketamine and dextromethorphan.AnestheticAssociated with memory deficits, psychotomimetic effects similar to psychosis. Confusion, difficulty concentrating, agitiation, nightmares, catatonia and ataxiaEffects:Acute: Diaphoresis, HTN, tachycardia. Also, numbness in the extremities and intoxication, characterized by staggering, unsteady gait, slurred speech, bloodshot eyes, and loss of balance. More prone to physical injury as they can’t feel pain.Psych: resembles schizophrenia: unpredictable and driven by their delusions. Auditory hallucinationsRED DANES: Rage, Erythema, Dilated pupils, Delusions, Amnesia, Nystagmus, Excitation, Skin Dry.Rarely, cardiac failure can result.
49 CaseA 68 year old female presents to the ED. She reports seeing “beautiful colors swirling around” as well as being able to “smell the lovely music”. She otherwise will not answer any questions.PE: T: 94.7, P 50, R 18 BP 120/80Drooling, staring at something/nothing in the air.Pupils dilated but sluggishly reactiveNeuro: Reflexes are 4+ bilaterallyAnd the drug is……
51 Common Street Names: Route: Acid, Alice, California Sunshine, Trip, Timothy Leary Ticket, Sugar cubers, TabsRoute:Tabs, LSD blotter paper dissolved in LSD/Water/Alcohol solutionIV/IM
52 Synthesized from lysergic acid derived from ergot, a grain fungus that grows on rye. Unknown mechanism of action, but thought to bind dopamine and serotonin receptors promoting their releasePhysical Sx:Hypothermia, fever, hyperglycemia, bradycardia, goose bumps, perspiration, pupil dilation, saliva production, mucus production, sleeplessness, paresthesia, euphonia, hyperreflexia, tremorsPsychological Sx:Varies person to person.Synesthesiaradiant colors, objects and surfaces appearing to ripple or "breathe," colored patterns behind the eyes, a sense of time distorting, crawling geometric patterns, morphing objectsloss of a sense of identity, powerful, and sometimes brutal, psycho-physical reactions interpreted by some users as reliving their own birth.Lasts 6-14hWithdrawal:Minimal: Diarrhea, chills, tremorsRisks: Minimal as it is non-addictive. In patients who take Lithium, SSRIs or tricyclics with antidepressants, there is an increased risk of a dissociative fugue. They are unaware of their actions and can harm themselves.perceptual experience in which a stimulus in one modality gives rise to an experience in different sensory modality. Hear smells, see sounds, taste sights
53 This is your brain after this presentation. The EndThis is your brain after this presentation.Any Questions ??????