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Other substance use disorders

Dr. Priya Ranjan Avinash


Associate Professor
Dept. of Psychiatry
HIMS, SRHU
Drugs
• Licit
• Illicit
Drugs
• Use
• Intoxication
• Abuse
• Harmful use
• Misuse
• Dependence
• Addiction
Cannabis
• After alcohol ,2nd most widely used
psychoactive substance world –wide
• Largest use in the youth
• Increasing trend in the western world
• Legalized in 23 states of US, Canada, Australia
and some European countries
Terminology
• Cannabis: Cannabis is the preferred designation of the plant Cannabis
sativa, Cannabis indica, and of minor significance, Cannabis ruderalis.

• Cannabinoids: Cannabinoids are basically derived from three sources:


• (a) Phytocannabinoids are cannabinoid compounds produced by plants
Cannabis sativa or Cannabis indica;
• (b) Endocannabinoids are neurotransmitters produced in the brain or in
peripheral tissues, and act on cannabinoid receptors;
• (c) Synthetic cannabinoids, synthesized in the laboratory
Cannabis
• Complex alkaloid mixture of more than 400
compounds derived from the Cannabis sativa
plant
• Most abundant cannabinoids are
– Delta-9 tetrahydrocannabinol (most psychoactive)
– Cannabidiol
– Cannabinol
Phytocannabinoids
• Cannabis sativa : commonest – highest THC
• Some agricultural process can increase THC’s
concentration , like “Sinsemilla” technique
• Gradually leading to high THC and low CBD
• THC: psychoactive
• CBD may have opposite effect to THC
Endocannabinoids
• Naturally in the human body
• G- protein coupled receptor family
• CB1 & CB2
• Two most studied endocannabinoids are
1. Anandamide( N- arachidonoylethanolamine)
2. 2- arachidonoylglycerol (2-AG)
Natural Antagonism
THC CBD
euphoria no (or less) euphoria
anxiety anti-anxiety
psychosis anti-psychotic
cognitive impairment neuroprotective
tachycardia bradycardia

Loss of antagonism may lead to


increased side effects and poor tolerability.
THC: CBD Ratio on the Rise…
Wrong Direction for Medicinal Use!

%
THC

time

J Forensic Sci, September 2010, Vol. 55, No. 5


Effects of Cannabis on the Brain

https://www.drugabuse.gov/publications/drugfacts/marijuana
Synthetic
• Pharmaceutical preparation for research and
clinical purposes
• Some of them are
1. Dronabinol/ Marinol- 1985, oral FDA approved
(1st)
2. Cesamet/ Nabilone- more potent than THC
3. Cannador- capsule , 2:1 ( THC:CBD)
4. Nabiximols/ Sativex- oromucosal spray, 1:1
5. Epidiolex- 99% CBD, undergoing research, may
soon be in the market
Cannabis “raw materials”

marijuana concentrate (40-80%)


marijuana (up to 20%+ THC) “budder,” “butane honey oil”

cannabidiol oil
hashish (~2-20%)
hash oil, marijuana concentrate (40-80%) Photo Source: www.dea.gov and cureepilepsy.org
Route of Administration
• Inhalation (smoking, vaporizing)
– onset: immediate
– bioavailability: 20-37%

Source:http://www.drugabuse.gov/publications/drugfacts/marijuana Source: www.dea.gov

Source:http://www.doh.wa.gov/YouandYourFamily/Tobacco/OtherTobaccoProducts/ECigar
ettes

Source:http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm172906.htm
Route of Administration
• Oral
– Onset: 30-60 minutes
– Bioavailability: 10-20%
• Oro-mucosal: similar to oral; highly variable

Source: www.containerstore.com

Source: www.dea.gov
Route of Administration
• Topical
– Onset: ? ~1-2h
– Bioavailability: ?
• Bypasses first pass
• Crossing aqueous layer is the rate limiting step,
then perfuses well

Source: www.containerstore.com Source:


http://www.jupitercompounding.com/
Opioid
• Very common in this belt
• Consumed in many forms
• Highly addictive
• Misuse is also rampant
• Often associated with other morbidities
• Endogenous opioids
1. Endorphins
2. Enkephalins
3. Dynorphins
4. Endomorphins

• Exogenous opioids (Reisine and Pasternak


1996)
1. According to source
a) Natural alkaloids - morphine, codeine
b) Synthetic - pethidine, fentanyl,
methadone, sulfentanil
2. According to the action on the opioid
receptor
a) Opioid agonists - they bind to opioid
receptors and mimic the effect of
morphine; heroin, methadone.
b) Opioid antagonists - These drugs binds to
opioid receptors but inhibit action of
morphine eg. Naloxone and naltrexone.
c) Partial agonists - Even at full saturation of
the receptor these compounds have less
than the maximal effect obtained with
morphine e.g. Buprenorphine,
pentazocine
10
0
Full Agonists: Heroin,
morphine, methadone,
codeine
Size of Opiate Agonist Effect.

Threshold for
respiratory
depression

Partial Agonists:
Buprenorphine

Antagonists: Naltrexone,
naloxone
0
Drug
Dose
Physiological factors
• Four major subtypes of opioid receptors: μ, κ
, δ and Orphan receptor
• μ receptor causes:
• Analgesia,
• Euphoria,
• Respiratory depression,
• Drowsiness, Decreased ability to
concentrate
• Itching,
• Reduced blood pressure,
• Miosis
• constipation
• κ-opioid receptor
analgesia, sedation, Miosis,
dysphoria, Psychomimetic
symptoms

• δ-opioid receptor
analgesia, may also associated with mood
change

• Orphan receptor
now commonly designated OFQ/N- analgesic
and pro-nociceptive
Routes of Abuse
• Oral: Codeine containing cough syrups
(Corex, Dextropropoxyphene, phensidyl)
(spasmoproxyvon)
Raw opium (afim)
khus-khus, poppy
seeds
• Parenteral: Heroin , Morphine, Pethidine,
Buprenorphine(tidigesic,
norphine), Pentazocine (fortwin),
• Chasing: Heroin (brown sugar)
CLINICAL MANIFESTATIONS

• Analgesia
• Sedation
• Euphoria
• Dry skin, mouth, ⇩urine
• Constipation
• During overdose/intoxication- coma,
respiratory depression, pinpoint pupils
• May also frothing at mouth, fall in BP,
cardiac arrhythmias
•Withdrawal
• In less severe cases or early in withdrawal-
dysphoria, irritability, restlessness, and general
achiness; craving, anxiety, dysphoria, yawning,
perspiration, lacrimation, rhinorrhoea, and restless
and broken sleep
• In more severe cases or as the syndrome
progresses- dilated pupils,
piloerection/gooseflesh/cold turkey and hot and
cold flashes with visible diaphoresis
• In severe syndromes, the patient may also
experience nausea, vomiting, diarrhoea, fever
(usually low grade), and increased blood pressure,
pulse, and respiratory rate
Intoxication (overdose)
• medical emergency
• Ensure airway, clear secretions
• two approved opioid antagonists
(naloxone, nalmefene)
• Naloxone – 0.8 mg/70 kg body wt IV,
repeat if required
• Nalmefene – single dose 0.5 – 1 mg IV –
longer duration of action – prolonged
withdrawal
Withdrawal (detoxification)
• 3 medications approved: Methadone, LAAM,
and buprenorphine
• Other off label
1. Clonidine based
2. Clonidine-naltrexone for rapid Detoxification
3. Ultrarapid Detoxification
4. Tramadol based
Three FDA-approved medications are commonly used
to treat opioid addiction:
• Methadone – Prevents withdrawal symptoms and reduces cravings
in people addicted to opioids. It does not cause a euphoric feeling
once patients become tolerant to its effects. It is available only in
specially regulated clinics.
• Buprenorphine – Blocks the effects of other opioids, reduces or
eliminates withdrawal symptoms and reduces cravings.
Buprenorphine treatment (detoxification or maintenance) is
provided by specially trained and qualified physicians, nurse
practitioners and physician assistants (having received a waiver
from the Drug Enforcement Administration) in office-based
settings.
• Naltrexone – Blocks the effects of other opioids preventing the
feeling of euphoria. It is available from office-based providers in pill
form or monthly injection.
Inhalants
• Easily available
• Very cheap
• Highly addictive
• Causes many psychological and behavioral
problems
• Tip of the iceberg
INHALANTS-
CATEGORIE
S

Volatile Aerosols Gases Nitrites


solvents
COMMONLY ABUSED INHALANTS
Volatile solvents
Glues (n-hexane, toluene, xylene)
Correction fluids & Marker pens(1,1,1 trichloroethane,
toluene)
Paint thinners & removers (dichloro methane, toluene, xylene)
Dry cleaning fluids (trichloroethylene, 1,1,1 trichloroethane)
Nail polish remover (acetone esters)
Petrol (benzene, n-hexane, toluene, xylene)
COMMONLY ABUSED INHALANTS
Aerosols
Deodorants, hair spray,
refrigerants (freons, flurocarbon
propellant)
Gases
Lighter fluids (butane, propane)
Propellants in whipped
creams (nitrous oxide)
Anesthetic gases (NO, ether etc.)
Nitrites
Room odorizers and liquid
incense (amyl, butyl, isobutyl
nitrites)
MODES OF ABUSE

sniffing bagging huffing

spraying glading dusting


WHY SOLVENTS ?

A rapid high - much faster than drugs or


alcohol.

Relatively cheap, easy to buy.


Not illegal, easily available.

Escape from reality and conflicts.


Novelty seeking and peer influence.

As a replacement for other substances.


NEUROBIOLOGICAL CONSIDERATIONS
• An abuser intakes 20-30 times exposure of
substances than an accidental exposure (>6000
ppm).

• Solvents are highly lipophilic thus cross


biological membranes easily.

• Affect cell membranes in a similar way to anesthetics.

• Not known to have any unique receptors or mimic


an endogenous ligands.
Stages of inhalant intoxication
Stage 1-Excitatory stage (euphoria
, excitation )

Stage 2-Stage of early CNS


depression (slurred speech , visual
hallucination )

Stage 3-Stage of medium CNS


depression (ataxia, confusion , delirium )

Stage 4-Stage of late CNS


depression (stupor ,seizure ,coma
NEUROPSYCHIATRIC SEQUELAE
• Subcortical dementia
• Low IQ
• Memory retrieval delay
• Poor attention & concentration
• Insomnia, apathy,
• Aggression with trivial provocation
• Depression
• Psychosis ( florid hallucinations)
(Mathew etal, Addict Sci clin Pract 2011, Jul; 6(1):18-31)
Party drugs
• Rave parties
• Club drugs
Club drugs are the drugs most commonly
used in the club scene – including parties,
drugs, concerts, and bars
Club drugs are most commonly used by
teenagers and young adults
MDMA
LSD
Rohypnol
GHB
Ketamine
Ecstasy is a synthetic drug – altering mood and
perception
Can be categorized as both a stimulant and
hallucinogen
People using ecstasy may experience feelings of
energy, pleasure, and distorted sensory and time
perception
Also known as Molly and Ecstasy
Can be taken through pill, snorting, or liquid form
Also known as Acid
Categorized as a hallucinogen
LSD alters perception, thoughts, and feelings
Most commonly used by teens and young
adults
Also known as the “Date rape drug”
Often used for perpetrators to rape their
victims
Causes sedation and incapacitation
Commonly ingested through swallowing a
tablet
Colorless liquid and white powder form
Categorized as a depressant
Causes drowsiness, confusion, memory loss,
hallucinations, slowed heart rate, coma, and
death
Sometimes used as a date rape drug
Helps the user feel disconnected from reality
Often used on animals
Dissociative drug
Often injected, smoked, or snorted
White powder
The legal highs
Issues
- readily available in retail stores and online
- cheap
- highly attractive packaging
- perceived as safe drugs
- party pills / herbal highs / legal highs /
nutritional supplements

- not easily detectable in urine or blood


samples
Synthetic / emerging drugs

• Synthetic cannabinoids

• Synthetic cathinones

• Novel psychedelics / synthetic LSD


Synthetic cannabinoids
Synthetic
cathinones
Red Dove

Blue Silk

Cloud Nine

Ocean Snow

Lunar Wave

Vanilla Sky

Ivory Wave

White Lightning

Scarface

Purple Wave
Novel psychedelics or synthetic
LSD

25B-NBOMe / 25I-NBOMe

derivatives of the 2C family of phenethylamine


psychedelics

very potent partial agonists 5HT – 2A receptor

snorted or dissolved into a liquid and placed on blotter


paper under the tongue
❑ Also known as New psychoactive substances (NPS).
❑ Internet being a global marketplace, and to the problems of legal
regulations
❑ They are sold inexpensively as “legal highs” or are deceptively
labeled as “bath salt”, “plant food”, “incense”, “spice” and many
others.
❑ Currently used designer drugs can be classified on the basis of
1. psychoactive properties
2. chemical structure
3. biological targets
❑ The most frequently used drugs can be divided into following
major groups (Madras, 2012)
Stimulants Cannabinoids (CB)
synthetic cathinones and
amphetamines : synthetic CB1 agonists (e.g.
[eg. mephedrone, MDPV, JWH-018,073; CP-47,497;
pentedrone, Am-694; HU-210, and
methylone, naphyrone, hundreds of other molecules);
4-MEC (4-methylethcathinone),
and many,
many others];

Synthetic opioids
Hallucinogens MPPP
phenethylamines, (1-Methyl-4-phenyl-4-propion
benzylphenethylamines oxypiperidine), dextrorphan,
(e.g. 2C-Bfly, Br-fly, Br-dragonfly); dezomorphin
(crocodile).
Prescription drugs
• Psychotropics
• Benzodiazpines ( alprazolam commonest-
similar withdrawal symptom as alcohol)
• Schedule X
• NDPS 1985 drugs
E-Cigarette-
Vaping
E-CigaretteComponents
1. Cartridge:
This holds the liquid solution called
e-liquid.

2. Automizer:
This is heating element that
allows vaporization.

3. Battery:
Largest part of E-Cigarette
usually lithium-ion and
rechargeable.
4. LED Light:
This glows when you inhale.
How it works?
E-Cigarette which is a
powered-battery device

convert liquid nicotine into
vapor with no fire and no
smoke.

● At end there is an LED


light that glows as you
inhale.

● There is a battery, a
heating element and a
cartridge that holds the
nicotine and other liquid
flavoring.
Trend
• The prevalence of most drug use is increasing
• The age of onset is decreasing
• The gender gap is narrowing
• Vaping
Thank you