Substance Abuse

2EXAMS

3EXAM

OS 215

Lec 2A: Pathology of the Female Genital Tract (Vulva and Vagina)

OS 211

Substance Abuse

Casti, Franco, Migz, Lance

\

I.

Introduction

3.4 million Filipino illeicit drug users (2002) 8,189 admissions (2003) Discrepancy in the incidence and admissions

underscores the possibility of addressing the magnitude of the problem at the tip of the iceberg.

Drugs presently available for use and abuse:- Alcohol- Amphetamine type stimulants (Ritalin for ADHD)- Cannabis- Inhalants (rugby)- Cough/cold preparations- Datura, mushroons, areca- Sedative-hypnotics- Narcotics/analgesics- Nicotine

II. Substances Abused

Pinang, nga-nga (Areca Nut)

Cultural meaning: - Used in important ritual in restoring harmony and

peace between individuals or within a community Common uses and properties:

- Stimulant and euphoriant effects Causes teeth to turn black-brown and strains the tongue

and oral mucosa Use has been associated with oral cancer Arecoline: a cholinomimetic alkaloid

- A potent diaphoretic- Stimulates the salivary, lacrimal, gastric, pancreatic,

intestinal and the mucosal cells of the respiratory tract

- Increase muscle tonus and muscle movement throughout the body

Mimics the action of acetylcholine in the body- Slows the heart rate, constrict the pupils of the eyes

Aga, Shrooms (Amanita Muscaria)

Context of use:- Food- Religious ceremonies- Medication by herbal healers- Substance of abuse

Adverse effects: - Dizziness, vomiting, abdominal pain, movement

disorders, muscle cramps, psychic stimulation, followed by deep sleep, confusion, mania, unconsciousness, coma and, death

Contain cholinergic alkaloid muscarine (structurally similar to acetylcholine)

Many cases of poisoning occur in individuals who deliberately seek and ingest the mushroom for its hallucinogenic properties (purposeful ingestion of urine from people who have eaten these mushrooms has been reported as a way to elicit the psychoactive effects of the excreted muscimol).

Datura metel (angel’s trumpet, talampunay)

Common uses and properties: - Asthma

Adverse effects: - Hallucinogenic, anticholinergic effects

Plants- Family Solanaceae: Genera Atropa, Datura,

Hyoscyamus, Lycium, and Solanum - Principal alkaloids: solaninine, atropine and

scopolamine Pharmaceuticals

- Antiparkinsonian agents: trihexyphenidyl and benztropine mesylate (euphora and hallucinogenic effects): Have potent dopamine reuptake inhibition with excess in dopamine (craving)

- Note that as dopamine increases, acetycholine decreases; this stimulates the brain’s pleasure center, causing the “high”

Cannabis sativa and indica plants

Alleged anti-emetic, anti-convulsant, anti-anxiety, analgesic, anti-inflammatory properties.

The Misuse of Drugs Act 1971 - Cannabis oil (class A)- Cannabis resin or grass (class B)

Nicotine

Effects mediated through nicotinic cholinergic receptors (nAChRs) in the brain. Important areas include the ventral tegmental area (VTA) and the nucleus accumbens (NA), considered as the pleasure centers.

Exposure results to activation then desensitization of nAChR > tolerance

Chronic exposure: - Increased nAChR (slower turnover of desensitized

receptors) > recovery (desensitization) > hyperexcitable nicotinic system

- 1st cigarette: most pleasurable Nicotine releases…

- Dopamine - Pleasure, appetite suppression- Norepinephrine - Arousal, appetite suppression- Acetylcholine - Arousal, cognitive enhancement- Vasopressin - Memory improvement- Serotonin - Mood modulation, appetite suppression- Beta-endorphins - Reduction of anxiety and tension

Alcohol

Beer: still a favorite among Filipinos Accounts for 15% of the Philippine’s 4 billion-bottles-a-

year market. Native Drinks

- Confined to small scale production due to influx and supremacy of commercial drinks–Lambanog (coconut wine)–Tapuy (rice wine)–Basi (sugar cane wine)–Tuba (palm wine)

The impact databank, a US alcoholic beverage research firm, cited the Filipinos as the world’s top gin drinker.

Ginebra San Miguel is the top gin brand in the world in terms of sales at 27.4 million cases or P12 billion.

Mechanism of Action:- Action on µ receptor sites in the VTA- Action on GABA receptors resembles that of

benzodiazepines (increase in GABA neurotransmission). This is the reason why the depressed usually resort to alcohol first.

Reproduction and Hormonal Regulation

Augustina D. Abelardo, MD, FPSP, MIAC

Patho 1

Psychiatry

Dr. J. Pascual 3

WED, 19 Dec. 2011 Page 1 of 4

OUTLINEI. IntroductionII. Substances AbusedIII. Why Drugs?IV. Epidemiology of Use: Initiation of UseV. Epidemiology of Use: Categories of Use VI. Dopaminergic Pathways of the Brain VII. CONCLUSION: The DOWNSIDE of Recreational

Drug Use

2EXAMS

3EXAM

OS 215


OS 211

Substance Abuse


\- Antagonist effect of some receptors for the

excitatory neurotransmitter glutamate (NMDA)- Increase release of dopamine in nucleus

accumbens- Stimulation of 5-HT receptors (serotonin)- Note: Speed-balling is the method used by drug

users to achieve the desired high: a stimulant is taken to counteract the sedating effect of alcohol.

Opiates

Sedative-hypnotics Binding to GABA A receptor GABA coupling to

Transducer (G protein) Opening of Chloride ion channels Neuron hyperpolarization; RMP stabilization Dampening of Neuronal Excitability

CLUB DRUGS

Amphetamines

Stimulating properties of Ephedrine by the Chinese 5000 years ago

Introduction of amphetamine, a synthetic analogue of ephedrine in 1932 as an appetite suppressant

Limited therapeutic use to the treatment of attention deficit-hyperactivity disorder (ADHD) - Ritalin

Mechanism of Action- Indirect monoamine agonists with both central and

peripheral actions - Release of norepinephrine, serotonin, dopamine

from presynaptic terminals

Ketamine

K, Special K, Vit K, Cat valiums High doses: delirium, amnesia, impaired motor function,

respiratory depression Low doses: impaired attention, learning ability and

memory

Ecstasy

(3,4- methylenedioxy-n- methylamphetamine) XTC, X, E, Adam, Clarity, Lover’s Speed Euphoria, comfort, empathy Users become hypersexual. HR and BP,cognitive impairment Given to rape victims 1 hours prior to therapy to help

patient talk about their experience

Cocaine (benzoylmethylecgonine)

Mood elevating High doses: irritability, psychosis, seizure,

unconsciousness, coma

If you want a lifetime supply of Red Horse, contact 09167974321

If you want a lifetime supply of San Mig Light, contact 09228555102

If you want a lifetime supply of cocaine, contact0922855101

For other concerns, e-mail Lance Isidore Catedral at bottledbrain.com

III. Why Drugs?

Fig.1 Effects of Drugs

Drug addicts want to experience the Rush Phase or the Normal Phase.

IV. Epidemiology of Use: Initiation of Use

As a normal consequence of development of adolescents attempt to assert their individuality while conforming to peer norms- Separation from family- Membership within a social group- Peer-sanctioned illicit activities - Life transitions

Substance use is a progressive process beginning with alcohol and cigarettes, progressing to recreational licit and illicit drug use, marijuana, and then to hard-core drug use (each stage not invariably followed by the next).

Social forces (peers, parents, siblings, family dynamics, psychological profile and popular culture).

Popular Culture Creation of several images of drug use driven by

advertisements, television, movies and music videos Tanduay, Red horse, San Miguel

Drugs of Abuse: Sought After Effects weight reduction anti-fatigue, activity – sustaining effect performance enhancing effects

Marked individual differences Relief of anxiety Intoxication and relaxation Alertness Mood elevation“Some individuals who use drugs in ordinary circumstances eventually increase their dosage to develop misuse”

V. Epidemiology of Use: Categories of Use

Those who inject intravenously or smoked “ICE”- Individuals who switched to amphetamines from

other IV drugs;- Polysubstance abusing individuals; - Those who previously used oral amphetamines;- Experimenting adolescents and young adults



Patho 1

Psychiatry

Dr. J. Pascual 3


2EXAMS

3EXAM

OS 215


OS 211

Substance Abuse


\Drug, drugs and drugs: Polysubstance use Polysubstance abuse is very dangerous because users

run the risk of having adverse drug-drug interactions. Self-detoxification is also dangerous because users can

have deadly withdrawal symptoms Stimulants: Benzodiazepines and alcohol taken to

alleviate stimulant withdrawal Alcohol: to modulate and enhance effects

The Medical paradigm in Substance: Use, Misuse and Dependence Anxiety Depression Psychosis

VI. Dopaminergic Pathways of the Brain

Fig. 2 Dopaminergic Pathway

Increased levels of dopamine in the NA critical in mediating rewarding effects or positive reinforcement for drugs of misuse (Koob and Le Moal, 2004)

Mesolimbic dopamine pathway is the most important pathway because it involves the emotion center, the nucleus accumbens.

Fig. 3 The Downside of Drug Use

Amphetamine Reduced dopaminergic functioning in the mesolimbic

system, ↓D2 receptor levels (withdrawal, early abstinence up to 4 months)

Dysphoria, anhedonia, irritability, craving, drug-seeking behaviour.

Specific symptoms encountered with Recreational Amphetamine Use Hypertension

- Amphetamine- Cocaine- MDMA- Methamphetamine

Hypotension- Heroin- Opiates

Diaphoresis Mydriasis Miosis

- Opiates- Sedative hypnotics

Bradycardia - Opiates/narcotics

Tachycardia Respiratory depression

- Opiates/narcotics

Reasons for entry into Health System Associated trauma Overdose (accidental, suicidal) Panic reaction ( “bad trip” ) or significant intoxication Inappropriate behavior Drug-seeking behavior (withdrawal) “Coerced” by the legal system

Specific symptoms encountered with Recreational Substance Use Disorientation Confusion Destructive and assaultive behavior Depression Hallucinations Delusions Trauma

Recognition of Problem History Questionnaires Biological markers Toxidrome

General Approach Emergency stabilization Clinical evaluation Elimination of the drug/drugs Excretion of the absorbed drug/drugs Administration of antidotes and/or pharmacotherapy Supportive therapy and observation Disposition

Intoxication and Overdose Proceed with basic ABCs of life support Management of medical emergency Emergency stabilization:

- airway obstruction, breathing difficulties, - circulatory inadequacies, drug-induced CNS

stimulation or depression, electrolyte or metabolic abnormalities

Establish etiology General management: Diazepam 5 mg IV for agitation,

restlessness or seizures

Psychic agitation:- Diazepam 5 mg oral/parenteral- 1st generation antipsychotic: Haloperidol 2 mg deep

im



Patho 1

Psychiatry

Dr. J. Pascual 3


2EXAMS

3EXAM

OS 215


OS 211

Substance Abuse


\- 2nd generation antipsychotic: Olanzepine 5 mg

deep im- Risperidone quicklet SL

Depression and Suicide- Basic suicide precautions (physical restraints)- Drug induced or autonomous?- Careful evaluation by an experienced health worker

Clinical Issues with Drug Use Single drug or a mixture? Illicit amphetamine or prescriptions or both? Drug-drug interaction or cocktail of death?

Long-Term Issues with Drug Use Psychological deterioration Psychosocial deterioration

Real Issues with Recreational Drug Use Returning to environment associated with previous

substance use after many years of abstinence can induce withdrawal symptoms and initiate drug taking behavior, especially if the reformed user is under STRESS;

CUES in the environment may renew addiction even years after abstinence;

Qoute from Dr. Pascual:“You can have closure but you can never forget”

It is nearly impossible to “detoxify” long-term memories of the context of use.

CONCLUSION: The DOWNSIDE of Recreational Drug Use

While rates of drug use have remained stable or declined, recreational drug use among Filipinos has reflected current trends in recreational drug use in Filipino society.

Although young Filipinos may limit their recreational drug use, which is associated with lower rates of impairment and addiction, such recreational use may progress to use of higher-risk drugs.

Recreational use may progress to higher doses Theories of addiction have mainly been developed from

neurobiological evidence and data from studies of learning behaviours and memory mechanisms.

They overlap in some aspects and are not mutually exclusive.

Continued use induces adaptive changes in the central nervous system that lead to tolerance, physical dependence, sensitization, craving, and relapse.

This session discussed substance abuse as well as the dangerous side effects of recreational use, some of which are irreversible.

It is hoped that this may eventually encouraged health workers to persuade users to quit and prevent individuals from initiating use.



Patho 1

Psychiatry

Dr. J. Pascual 3


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Substance Abuse