UNIVERSITY OF CEBU- BANILAD CAMPUS S

College of Nursing Batch 2025

NCM 106- PHARMACOLOGY .
1st Semester | A.Y. 2022-2023

DRUGS OF ABUSE
Addiction
CONTEXT OF DRUG ABUSE - (a compulsive, uncontrollable craving for and dependence
on a substance to such a degree that cessation causes
Cultural Considerations severe reactions) results from the prolonged effects of
● Cultural and social expectations influence the
addictive drugs on the brain. Repeated use of drugs
definitions and perception of drug abuse versus
remodels the neural circuitry of the brain and reduces the
acceptable usage.
responsiveness of receptors.
- In Moslem Middle Eastern populations, any use
Tolerance
of alcohol or mind altering drugs any be
- The need for a larger dose of a drug to obtain the original
considered abuse.
euphoria. - Without the drug, the individual may experience
- In many European cultures, alcohol use is
depression, anxiety, and/or irritability.
expected and present at all family and social
Craving
gatherings.
- Is another characteristic of addiction
● Sociocultural factors arising from unemployment,
- Cue-induced craving which occurs in the presence of
poverty, or adverse social conditions affect the
people, places, or things patients have previously associated
incidence of substance abuse.
with drug use. May occur after long periods of abstinence
● Individual factors, such as age, educational status, and
and is a common cause of relapse.
geographic region, also affect rates of use.
Abstinence
● A major responsibility of nurses in addressing drug
- Sustained avoidance of substance abuse.
abuse in ethnic and cultural groups is to assess and
Relapse
treat patients within their cultural perspectives.
- Return to substance use during abstinence.

DRUG MISUSE
OVERVIEW OF ADDICTIVE STATES
– generally refers to indiscriminate or recreational use of a
Intoxication
chemical substance or its use for purposes other than those
- Is a state of being influenced, or affected by a drug or other
for which it is intended.
toxic substances.
DRUG ABUSE
- This may a be very small amount of drug in the drug-naïve
- is culturally defined and may be considered drug use
person, or a potentially lethal amount in the chronic user.
inconsistent with medical or social norms.
Detoxification
- It generally refers to an overindulgence of a chemical
- Involves treating an intoxicated patient to diminish or
substance that results in a negative impact on the
remove drugs or their effects from the body.
psychological, physical, or social functioning of an individual.
- Treatments may involve administration of antagonistic
- Chronic abuse of a drug may lead to addiction.
drugs, promotion of metabolism and elimination of the drug,
DRUG ADDICTION
or intensive supportive care until the drug is naturally
- a complex disease of the CNS characterized by a
eliminated.
compulsive, uncontrolled craving for and dependence on a
Withdrawal Syndrome
substance to such a degree that cessation causes severe
- Is a group of signs and symptoms that occurs in physically
emotional, mental, and/or physiologic reactions.
dependent persons when drug use is stopped.
- Drugs abused most often are psychoactive agents that
- The symptoms are often opposite the effects the drug
result in pleasure or modify thinking and perception. They
produced before it was withdrawn.
include legal substances such as alcohol, tobacco, and
- Withdrawal syndrome is treated is slow weaning of the
prescription drugs such as analgesics,
drugs , or use of “cross-tolerant” drugs to control
sedative-hypnotics, tranquilizers, and amphetamines.
symptoms, and supportive care.
- Common illegal substances that are abused include
Cessation and Maintenance of Abstinence
marijuana, cocaine, MDMA
- To promote cessation and abstinence of the abused drug,
(methylenedioxymethamphetamine) popularly known as
treatment with other drugs may be used to decrease craving
Ecstacy.
and prevent withdrawal syndrome.
NEUROBIOLOGY OF ADDICTIVE DRUGS
- Specific receptor blockers, less potent drugs of the same
Most addictive drugs increase the availability of dopamine
class, or nonaddicting substitutes are treatment options.
and other neurotransmitters in the mesolimbic system of the
brain. This area has been identified as the “pleasure center”
STIMULANTS
or brain reward system, an ancient system that creates the
Nicotine
sensation of pleasure for certain behaviors necessary for
Nicotine is the alkaloid in tobacco that causes dependence
survival, such as eating and sexual behavior.
and is the most rapidly addicting of the drugs of abuse.
● Nicotine, alcohol, marijuana, amphetamines, and
Cigarette smoke contains more than 400 chemicals and
caffeine are also believed to increase dopamine
gasses, including at least 45 cancer-causing or
activity at the synapse.

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tumor-promoting agents and a number of hydrocarbons or
solvents.
● Although nicotine is not believed to be
carcinogenic, it is an addictive substance and has
no therapeutic value.
Pharmacokinetics
● Nicotine is rapidly absorbed into the blood through the
lungs in smoking and more slowly through the buccal
mucosa in chewing and the nasal mucosa in snuffing.
● It crosses membranes easily and is widely distributed
throughout the body.
● Nicotine passes freely into breast milk and may be toxic
to the nursing infant.
● Plasma protein binding of nicotine is less than 5% The
liver is the major site of nicotine metabolism and
elimination half-life is 1 to 2 hours.
Pharmacodynamics
- In low doses, nicotine activates nicotinic receptors.
- Most effects occur from activated receptors in
autonomic ganglia and the adrenal medulla.
- In the CNS nicotine rapidly acts on the mesolimbic
reward of the brain, promoting the release of dopamine
and mimicking the effects of cocaine and other highly
addictive substances.
Side Effects and Adverse Reactions
● Marked cardiovascular stimulation and increased
myocardial oxygen consumption
● General CNS stimulation
- Increased RR and tremors
- Increased alertness and arousal
- Increased GI secretion and smooth-muscle tone
Nicotine causes a very strong psychological dependence.
Withdrawal symptoms may occur within the first few hours
after stopping smoking, peak in 24 to 48 hours, and last from
a few weeks to several months.
Treatment
● Chronic smoking can affect nearly every organ of the
body.
● In addition to cardiovascular disease, chronic lung
disease, and cancers of the larynx, lung, esophagus,
oral cavity, and bladder, smoking is now associated with
leukemia, cataracts, abdominal aortic aneurysm, and
cancers of the cervix, kidney, pancreas, and stomach.
● Nurses must be proactive in identifying and talking with
tobacco users and providing them with information on
ways to stop the use of tobacco.
● NRT (nicotine replacement therapy) are recommended
for all tobacco users in addition to behavioral and
support therapies.
-Five NRTs in the form of gum, lozenges,
transdermal patches, nasal spray, and inhalers
have been approved by FDA to reduce the craving
and withdrawal symptoms associated with tobacco
cessation.
- These agents enable a smoker to reduce nicotine
previously obtained from cigarettes with a system
that provides slower delivery of the drug and
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eliminates the carcinogens and gasses associated
with tobacco smoke.
Bupropion
is an antidepressant unrelated to nicotine that has been
approved by the FDA for smoking cessation.
- it is thought to inhibit neuronal reuptake of dopamine, and
to a lesser degree norepinephrine, and this reduces the urge
to smoke and minimizes some symptoms of nicotine
withdrawal.
Varenicline (Chantix)
is a novel drug approved for smoking cessation that is an
alternative to NRT and buproprion.
- It is a nicotinic receptor partial agonist that reduces
cravings for nicotine and decreases the pleasurable effects
of cigarettes and other tobacco products if tobacco is used. -
The approved course of varenicline treatment is 12 weeks,
and those who successfully quit smoking during treatment
may continue with an additional 12 weeks to increase
long-term cessation.
Nortryptyline (Aventyl, Pamelor)
Clonidine (Catapres)
are used as second-line drugs to reduce nicotine withdrawal
symptoms and promote cessation. - These drugs are not
approved by the FDA for this purpose, and their action in
nicotine addiction is not clearly understood.
Cocaine
• Cocaine is a naturally occurring potent stimulant, an
alkaloid that was originally obtained from the leaves of the
coca plant but today can be prepared synthetically.
• Historically, cocaine was used as a local anesthetic, but it
has been largely replaced by synthetic agents with no abuse
potential.
• Illicit cocaine is available as white powder (cocaine
hydrochloride) and as cocaine base, a crystalline substance.
“Crack” is popular because it is less expensive, readily
available, and easy to use, and has increased purity over
cocaine hydrochloride.
Pharmacokinetics
- Absorption rates of cocaine depend on the route of
administration.
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- Cocaine hydrochloride is usually “snorted” intranasally. -
Cocaine can also be smoked as crack cocaine or in
“free-base” form, injected IV, taken orally, or absorbed
through the mucous membranes.
- Smoking and IV methods result in the fastest absorption
and the highest “rush”.
- Peak blood levels develop within 5 to 30 minutes with most
methods of administration.
- The longest effects occur following intranasal use because
absorption is delayed by vasoconstriction of the nasal
vessels.
- Cocaine is rapidly metabolized by the liver.
- Elimination half-lives by oral, intranasal, and IV routes are
50, 80, and 60 minutes, respectively.
- Cocaine readily crosses the placenta in pregnant patients
and accumulates in the fetal circulation.
Pharmacodynamics
- Cocaine inhibits the neuronal uptake of dopamine in the
brain and increases the activation of dopamine receptors in
the brain reward system.
- This action magnifies pleasures and lead to rapid
dependence.
- Cocaine also increases norepinephrine at postsynaptic
receptor sites, producing intense vasoconstriction and
cardiovascular stimulation.
Side Effects and Adverse Reactions
● At usual doses, cocaine produces euphoria and
increased energy and alertness.
● In addition to CNS stimulation, effects include peripheral
adrenaline-like actions.
● A cocaine psychosis usually progresses from paranoid
delusions to visual hallucinations of “snow lights”
(colored lights when cocaine is administered) and tactile
hallucinations of bugs crawling under the skin.
● Skin excoriations from scratching ; needle marks; and
elevated BP, heart rate, and temperature are findings
that help differentiate a stimulant psychosis from
schizophrenia.
● Acute cocaine toxicity may be manifested by cardiac
palpitations, tachycardia, increased respiratory rate, and
fever.
● At high levels of overdose, grand mal seizures,
hypertension, and dysrhythmias or myocardial ischemia
can occur. The patient experiences restlessness,
paranoia, agitated delirium, and confusion.
● Bizarre, erratic, and violent behavior may occur. Death
is often related to cerebrovascular accident, fatal
dysrhythmias, or myocardial infarction.
● Some users report little or no evidence of physical
withdrawal with abstinence, but others report symptoms
similar to those associated with amphetamine
withdrawal: dysphoria, fatigue, depression, and a need to
sleep.
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Treatment
● Treatment may be complicated by the possibility that the
patient has combined the use of cocaine with heroin,
alcohol, or PCP (Phencyclidine)
● There is no specific antidote for cocaine toxicity, but
during an overdose most symptoms can be controlled
with a variety of drugs.
● Cognitive-behavioral therapies are often the only
effective approach to cocaine addiction, but maintenance
of cocaine abstinence with behavioral therapies has
been difficult to achieve in most users.
● No drugs are currently approved to promote cocaine
abstinence; however, disulfiram (Antabuse), a
well-established medication for treatment of alcoholism,
has helped nonalcoholic people addicted to cocaine
reduce drug use from 2.5 days per week to 0.5 days per
week on average.
● It has also been found that when modafinil (Provigil), a
CNS stimulant used for treatment of narcolepsy, is
combined with behavioral therapy, the likelihood of
cocaine abstinence increases.
● The anticonvulsant topiramate (Topamax) and the
antiemetic ondansetron (Zofran) have shown some
efficacy for treating cocaine addiction and amy benefit
some individuals, but they are not approved for this use
by the FDA.
● Research shows promise for a vaccine that works by
stimulating the production of cocaine-specific antibodies
that bind to cocaine molecules, rendering them
ineffective.
Amphetamines
● Is a synthetic drug and, with its derivatives and similar
stimulants, is strictly regulated today.
● Because amphetamines may be used therapeutically as
CNS stimulants, abuse may rise out of slow escalation of
a prescribed dose.
● However, they are more often initially used as a cheaper
alternative to cocaine.
● Methamphetamine (crank) and methamphetamine
crystals (crystal meth) are very potent stimulants and can
be easily made in clandestine settings with relatively
inexpensive over-the-counter (OTC) ingredients.
● Methamphetamine abuse is a growing problem in all
segments of the population and geographic regions.
Pharmacokinetics
- Amphetamines are prescribed for oral use , with peak
effects occurring within 60 to 90 minutes and lasting 2 to 4
hours.
- More rapid effects are obtained by smoking, snorting, or IV
injection.
- Amphetamines have a longer half-life than cocaine and a
longer, more intense effect.
Pharmacodynamics
- Amphetamines act similarly to cocaine, stimulating the
release of dopamine and norepinephrine in the brain and the
sympathetic nervous system.
- The dopamine release in the brain reward system produces
euphoria and an increase in self-confidence.
Side Effects and Adverse Reactions
● Initial use of amphetamines results in increased
alertness, improved performance, relief of fatigue, and
anorexia.
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 ● Stimulation of SNS leads to cardiovascular stimulation
with increased HR and BP.
● Amphetamine use over time can lead to irritability,
anxiety, paranoia, and hostile and violent behaviors.
● The physical effects of extended methamphetamine
abuse are notable in tooth decay and dermatologic
deterioration.
● Increased levels of stimulation, sometimes described as
“overamping” may result in amphetamine psychosis,
paranoia, seizures, and death.
● Without medical intervention, death may occur as a
result of dysrhythmias, myocardial infarction,
hyperthermia, and cerebral hemorrhage.
● Amphetamines usually cause only mild physical
dependence, but craving can be intense during
abstinence.
● IV use will cause the onset of withdrawal symptoms in
approximately 2 hours, whereas oral use results in
withdrawal symptoms in 8 to 10 hours.
● “Bath salts” is the name for a group of synthetic
stimulants that mimic many effects of amphetamines.
- these drugs contain synthetic versions of cathinone,
a compound found in khat plants that causes
amphetamine-like stimulant effects.
- these are not for use in bathing; the name “bath
salts” has been used to evade authorities and sell the
intoxicant in retail settings.
- negative effects of these drugs are tachycardia,
hypertension, psychiatric symptoms of hallucinations,
paranoia, and panic attacks; kidney failure, and
death.
Treatment
● Patients often seek treatment for complications of
amphetamine abuse such as panic reactions, psychosis,
or depression.
● Elevated BP and tachycardia can be controlled with
vasodilators and beta-adrenergic blockers.
● Drug elimination can be enhanced by administering
agents such as ammonium chloride that acidify the urine.
● Cessation and maintenance of abstinence are difficult in
amphetamine abuse. Like cocaine, withdrawal causes
more psychological symptoms than physical symptoms.
● Depression can last for months and is a common cause
of relapse.
Caffeine
● Caffeine is the most widely used psychoactive substance
in the world.
● Its use to promote alertness and to alleviate fatigue is
safe in most people.
● However, of concern to health professionals is the
marketing of caffeine laden “energy” drinks directed
specifically to teenagers and young adults.
● These products provide a “buzz” to fight fatigue, brighten
mood, and increase physical and mental performance.
● Caffeine is also added to some brands of alcoholic
drinks, and energy drinks may be used as mixers with
alcohol.
● Caffeine combined with alcohol appears to improve
response time but does not reduce the errors in
judgment caused by alcohol.
● Although weaker than other stimulant drugs, caffeine
shares characteristics of intoxication, tolerance, and
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withdrawal symptoms in some individuals, especially
when high doses are used.
Pharmacokinetics
- Caffeine is readily absorbed from the GI tract and reaches
peak plasma levels in about 1 hour.
Pharmacodynamics
- Caffeine is a methylxanthine that stimulates the CNS,
especially the medullary respiratory center.
- It also is a diuretic and myocardial stimulant. It can worsen
peripheral vasoconstriction in those with hypertension and
causes cerebral vasodilation, making it an effective
treatment for migraines and headaches.
Side Effects and Adverse Reactions
● Oral doses of 200 mg of caffeine (two cups of coffee) can
elevate mood and offset fatigue, but can also produce
insomnia, increase irritability, and cause anxiety.
● Intake of 500 mg or more per day is known to cause
intoxication with symptoms of nervousness, insomnia,
gastric hyperacidity, muscle twitching, confusion, chest
pain, tachycardia, and cardiac dysrhythmias.
● In toxic doses, caffeine influences behavior patterns and
may precipitate states of panic.
● Physical and psychological dependence on caffeine have
been found with chronic use of more than 500 mg/day.
● The most common reported withdrawal symptoms are
headache, irritability, drowsiness, and fatigue occurring
within 12 to 24 hours after abstinence.
Treatment
● Toxic reactions to caffeine and lethal doses of caffeine are
managed symptomatically.
● Attention is given to controlling hypertension,
dysrhythmias, and seizures, as with other CNS stimulants.
● Management of the patient with symptoms of caffeine
dependence includes assisting the patient to reduce or
stop caffeine intake gradually.
● Supplying a list of caffeinated products with their dosages
may help the patient avoid caffeine intake.
● Substituting decaffeinated beverages may also help
(decaffeinated coffee and tea contain 2 to 4 mg of caffeine
per cup).
DEPRESSANTS
Drugs classified as depressants have common physiologic
and psychological effects of sedation, decreased respiratory
and cardiac rates, and depressed CNS function. Drugs in
this category include alcohol, sedative-hypnotics,
anxiolytics, and opioid narcotics. With the exception of
alcohol and some federally regulated drugs, most CNS
depressants are medically useful. These drugs are also
widely recognized for their abuse potential, which leads to
rapid tolerance, dependence, and medical emergencies
involving overdose and withdrawal.
ALCOHOL
Alcohol is the most widely consumed substance of abuse in
the U.S.
Abuse of alcohol can lead to dependence and significant
health, social, legal, and interpersonal problems.
Alcoholism (alcohol dependency) is a chronic, progressive,
potentially fatal disease if left untreated.
Pharmacokinetics
- Alcohol is absorbed directly from the stomach and small
intestine.
- Absorption from the stomach is slower in the presence of
water or food, especially proteins and fats.
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- Faster absorption occurs when alcohol is mixed with
carbonated liquids.
- Alcohol is distributed to all body tissues and fluids, crosses
the placenta and can affect fetal development.
- Alcohol is primarily metabolized in the liver.
- In an occasional or moderate drinker, metabolic rate is
approximately one drink (7 g of alcohol)
Pharmacodynamics
Alcohol affects almost all cells of the body and has complex
effects on the neurons in the CNS.
- Alcohol is a general CNS depressant.
- Alcohol binds with receptors in the brain reward system,
resulting in the release of dopamine and promoting the
addictive process.
- The concentration of alcohol in the body can be
determined by assessing the blood alcohol concentration
(BAC).
- Alcohol interacts with many commonly prescribed OTC
medications.
- Potentiation and cross-tolerance with other CNS
depressants also may occur.
- Potentiation occurs when an additional CNS depressant is
taken with alcohol, increasing the effect.
- Cross-tolerance, the need for an increased dose of other
drugs, also develops to general anesthetics, barbiturates,
and other general CNS depressants.
Side Effects and Adverse Reactions
● Acute overdose produces vomiting, coma, and
respiratory depression.
● Alcohol-induced hypotension may lead to renal failure
and cardiogenic shock, common causes of
alcohol-related death.
● The effects of chronic alcohol use are numerous.
● One condition that can be prevented is Wernicke’s
encephalopathy, an inflammatory, hemorrhagic,
degenerative condition of the brain resulting from a
deficiency of thiamine owing to malnutrition associated
with chronic alcohol use.
- Untreated or progressive Wernicke’s
encephalopathy may lead to Korsakoff’s
psychosis, a form of amnesia characterized by loss
of short-term memory and an inability to learn.
● After excessive drinking, nondependent individuals
experience malaise, nausea, headache, thirst, and a
general feeling of fatigue.
● In those with alcohol addiction, sudden withdrawal from
alcohol may have life-threatening effects
- Withdrawal syndrome should be anticipated if the
patient reports consumption of more than 10 drinks
every day for a period of 2 weeks .
- characteristic signs of withdrawal are gross tremors,
seizures, hallucinations, and alcohol withdrawal
delirium (they develop because the brain has
adapted to the consistent presence of alcohol, a
depressant).
PIEDAD, CSO
● Symptoms of withdrawal may occur the first 4 to 6 hours
after the last drink, peak at 24 to 36 hours, and last up to
5 days.
● Seizures are most likely to occur 7 to 48 hours after the
last drink.
● Alcohol withdrawal delirium is a serious complication that
may occur from 30 to 120 hours after the last drink.
● Delirium components include disorientation,
visual/auditory hallucinations, and increased
hyperactivity without seizures.
● Death may be caused by hyperthermia, peripheral
vascular collapse, or cardiac failure.
Treatment
● Initial treatment of acute alcohol intoxication or overdose
requires implementation of the basic principles of airway,
breathing, and circulation (ABCs).
● No antidote for alcohol is available, and stimulants
should not be given.
● Alcohol-induced hypotension cannot be corrected with
vasoconstrictors.
● Alcohol may be removed from the body by gastric lavage
and dialysis.
● IV thiamine at a dose of 100 mg/day is often
administered to intoxicated patients.
● Patients with alcohol intoxication may also be
hypoglycemic because of lack of food intake
– treatment with IV glucose solutions may precipitate
Wernicke’s encephalopathy in a previously
unaffected patient.
- Thiamine should be started before treatment with IV
glucose in all patients with alcoholism and continued
until the patient resumes regular eating.
● Alcohol withdrawal delirium can usually be prevented by
administration of benzodiazepines such as
chlordiazepoxide (Librium) or lorazepam (Ativan) if the
patient has liver dysfunction.
● Benzodiazepines with long half-lives are the most
effective drugs in alcohol withdrawal to stabilize vital
signs, reduce symptoms, and decrease the risk of
seizures and delirium.
● Drugs approved to maintain abstinence may be used in
addition to cognitive-behavioral therapy for long-term
treatment.
Disulfiram(Antabuse) prevents drinking by causing an
unpleasant reaction if alcohol is consumed.
- Disulfiram disrupts alcohol metabolism, causing
accumulation of acetaldehyde when alcohol is ingested.
- Adverse reaction to the accumulated acetaldehyde
begins with flushing in the face and develops into intense
vasodilation of the face, neck, and upper part of the
body.
- Hyperventilation and palpitations may occur.
- Nausea occurs in 30 to 60 minutes with copious
vomiting.
- Headache, sweating, thirst, chest pain, weakness,
blurred vision, and hypotension follow.
- BP may decline to shock levels.
- The reaction lasts from 30 mins. to several hours and
can be brought on by ingesting as little as 7 mL of
alcohol.
● Disulfiram is metabolized by the liver, and excretion of
metabolites occurs through the kidneys and lungs.
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 ● Patients must be made aware that consumption of any
alcohol, even use of alcohol-based mouthwash, while
taking disulfiram can cause a severe, potentially fatal
reaction.
● All food and liquid medication must be checked for the
presence of alcohol, and alcohol must be used on the
skin.
● Using a family or other strong support system improves
adherence to daily dosing of disulfiram.
● Naltrexone is a pure opioid antagonist that decreases
craving for alcohol and blocks the “high” of alcohol use.
● Naltrexone (ReVia, Depade) 50 mg once a day by mouth
is the usual dose for alcohol dependency.
● Naltrexone is also available in an injectable
extended-release form (Vivitrol) that is given IM once a
month.
● Acamprosate (Campral) is used to decrease unpleasant
feelings such as tension, anxiety, and cravings brought
about by abstinence from alcohol.
● Combining acamprosate with naltrexone is more
effective than acamprosate alone but no better than
naltrexone alone.
● The most common adverse effects reported include
headache, diarrhea, flatulence, and nausea.
Sedative-Hypnotics
● Commonly abused sedative-hypnotic agents include
barbiturates, benzodiazepines, and barbiturate-like
drugs.
● Benzodiazepines have largely replaced barbiturates as
therapeutic agents for anxiety and insomnia, because
they have less risk of toxicity, tolerance, and
dependence.
● The short-acting barbiturates are preferred as
recreational drugs because they more frequently
produce euphoric effects.
Pharmacokinetics and Pharmacodynamics
● Sedative-hypnotics drugs act primarily on the CNS .
● Benzodiazepines enhance the effects of
gammaaminobutyric acid (GABA), an inhibitory
neurotransmitter in the brain.
● Barbiturates not only enhance the inhibitory effect of
GABA, but they can directly mimic the actions of GABA.
● Barbiturates are powerful respiratory depressants and
can readily cause death by overdose.
Side Effects and Adverse Reactions
● The abuse potential is much greater for barbiturates than
benzodiazepines.
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● The drugs are usually taken orally, but both may be
injected IV
● Excessive doses produce an initial euphoria and
intoxication similar to that of alcohol.
● Tolerance develops rapidly to the sedative effects of
barbiturates, requiring higher doses to achieve euphoria.
● Little tolerance develops to respiratory depression,
however, increasing doses may trigger hypotension, and
respiratory depression, resulting in death.
● An overdose of a sedative-hypnotic produces respiratory
depression and coma.
● Withdrawal from sedative-hypnotics can be very serious.
- In the first 12 to 16 hours after the last dose, the
patient may develop anxiety, tremors, weakness,
nausea, vomiting, muscle cramps, and increased
reflexes.
- After 24 hours, the patient craves the drug and
may experience delirium, grand mal seizures, and
respiratory and cardiac arrest.
Treatment
● Overdoses of benzodiazepines are treated with
flumazenil (Romazicon), a specific benzodiazepine
antagonist.
● Emergency life support measures must be taken in
cases of overdose.
● Gastric lavage may be used in extremely toxic cases if
the drug was taken orally within the last hour.
● Dialysis may be required to decrease the drug level.
● Gradual withdrawal of the drug is required during
withdrawal syndrome.
● Phenobarbital, a long-acting barbiturate, may be used to
control withdrawal symptoms in a patient dependent on
barbiturates.
- Phenobarbital is gradually withdrawn when the
patient is stable.
● To manage symptoms safely, hospitalization is
recommended during drug withdrawal for patients who
have been abusing large amounts of barbiturates.
Opioids
● Opioids include the naturally occurring opiates derived
from opium and the many semisynthetic narcotic agents
used as analgesics.
● Individuals who abuse opioids include those who use
illegal drugs sold on the street and individuals who
misuse prescription opioids.
● Street use is usually of heroin. In the medical setting,
some people misuse prescribed analgesics, including
health care professionals, who may have the highest rate
of opioid abuse and dependence of any middle-class
population.
● Ready access to drugs, stresses of the workplace
environment, and long hours that interfere with family life
are considered contributing factors in HCPs.
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 Pharmacokinetics and Pharmacodynamics
- Important to the abuse potential of opioids is their ability to
activate the brain reward system, reinforcing an addictive
effect.
- As drugs of abuse, opioids are taken orally, sniffed,
smoked, or injected subcutaneously (skin-popping) or
intravenously (mainlining).
- IV use will produce effects in seconds. - Smoking or sniffing
produces a longer onset and effect.
Side Effects and Adverse Reactions
● The primary effects of opioids include analgesia,
drowsiness, slurred speech, and detachment from the
environment.
● IV use casually causes a “rush” of feelings in the lower
abdomen, along with warm skin flushing and a strong
sense of euphoria.
● Signs of overdose of opioids include pinpoint pupils,
clammy skin, depressed respiration, coma, and death, if
not treated.
● Withdrawal symptoms occur with decreased amounts or
cessation of the drug after prolonged moderate to heavy
use.
● The administration of a narcotic antagonist such as
naloxone (Narcan) will cause withdrawal symptoms in
dependent individuals.
- Symptoms may include craving, abdominal cramps,
diarrhea, nausea, and vomiting.
- Symptoms appear about 8 to 10 hours after the last
dose, peak within 36 to 48 hours, and usually subside
in 96 hours.
- Although opioid withdrawal is acutely uncomfortable,
it is not usually life threatening.
Treatment
● Overdose of opioids can precipitate a medical emergency.
● A narcotic antagonist such as naloxone should be given
as soon as life support is instituted.
● Methadone (Dolophine) in decreasing doses over 10 to
14 days is most often used to decrease symptoms during
opioid detoxification.
● Some patients obtain relief from withdrawal symptoms
with the use of clonidine (Catapres), a centrally acting
alpha2-adrenergic agonist that may also be used for
nicotine addiction.
- It is most effective against GI hyperactivity but does
not decrease craving.
● Long term management of opioid addiction involves the
use of opioid agonists, opioid antagonists, and mixed
opioid agonist-antagonists.
● Methadone is the most commonly used opioid agonist.
- By substituting oral methadone for the abused
opioid, withdrawal syndrome can be avoided, and the
euphoria that leads to craving can be prevented.
- Methadone is an addictive drug, but its use in
maintenance programs alters the drug-using lifestyle,
reduces exposure to infectious disease, and controls
drug use.
- To prevent methadone abuse, it is available for
addiction treatment only through agencies approved
by the FDA and state authorities.
● Buprenorphine (Buprenex) is an agonist-antagonist opioid
that may be used for detoxification and maintenance
therapy.
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- It can decrease the symptoms of withdrawal and
suppress drug craving, yet it has low potential for
abuse.
- It is available in a sublingual tablet marketed as
Subutex.
- For long term maintenance, it is combined with
naloxone in a sublingual tablet marketed as Suboxone.
● Naltrexone (oral ReVia, injectable Vivitrol) is an opioid
antagonist that blocks euphoria and all other opioid
effects.
- When naltrexone is used, administration of an
opioid produces no effect, eliminating the reinforcing
properties of drug use.
- Naltrexone is used rather than naloxone for
maintenance treatment, because it is longer acting
and can be taken orally.
OTHER DRUGS OF ABUSE
Cannabis
● Usually sold as marijuana or hashish.
● Tetrahydrocannabinol (THC) is the active ingredient in
cannabis responsible for most of the psychoactive effects.
● Although a number of potential benefits of THC have been
reported, the only approved THC preparation is
dronabinol (Marinol), which is used to control nausea
and vomiting resulting from cancer chemotherapy.
● Dronabinol is also used to stimulate appetite in patients
with acquired immunodeficiency syndrome (AIDS).
Pharmacokinetics
- When marijuana is smoked, effects usually occur in 20 to
30 minutes and may last up to 7 hours.
- Because THC is stored in body fat, it is eliminated slowly,
resulting in a half-life of 2 to 7 days.
- When taken orally, it is almost completely absorbed but
undergoes extensive first-pass metabolism.
Pharmacodynamics
- At low to moderate doses, THC produces fewer physiologic
and psychological alterations than do other classes of
psychoactive drugs, including alcohol.
- Although its mechanism of action is uncertain, THC affects
cannabinoid receptors in the brain and may act in part
through the same reward system as opioids and cocaine.
Side Effects and Adverse Reactions
● Marijuana and hashish are usually smoked with the usual
effects of euphoria, sedation, and hallucinations.
● Low to moderate doses result in euphoria and relaxation,
enhanced sensory perception, and distortion of time
perception.
● Undesirable responses include short-term memory loss,
decreased ability to perform multi-step tasks, and
temporal disintegration.
● High doses may cause serious psychological effects;
intense anxiety, delusions, paranoia, and a state of toxic
psychosis can occur.
● Physiologic effects are seen most commonly in the
cardiovascular and respiratory systems. Decreased
sperm production, and decreased reproductive hormones
in both men and women may occur.
● A condition known as amotivational syndrome,
characterized by apathy, dullness, and disinterest, may
also occur.
Acute reactions, including intoxication and withdrawal, are
usually mild and time-limited.
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● Marijuana has low toxicity and no known level of lethal
dose.
● Complications may result when marijuana is used with
other drugs, such as heroin and cocaine.
● When taken in extremely high doses, marijuana can
produce tolerance and physical dependence.
● Abrupt cessation of high-dose marijuana may cause
irritability, restlessness, nervousness, insomnia, and
tremor. In rare instances, withdrawal can be prolonged
and difficult.
Treatment
● Individuals using marijuana may seek treatment for
anxiety or mood symptoms or may be treated for toxic
reactions to a combination of drugs that includes
marijuana.
● Treatment is directed toward relief of symptoms, and
administration of drugs is avoided if possible.
● There is no antidote or substitution therapy for cannabis.
Psychedelic Agents
● Psychedelic drugs are often referred to as hallucinogens.
● These drugs produce a change in level of consciousness
and induce hallucinations and mental states that resemble
psychosis.
● Primarily, they bring about alterations in thoughts,
perceptions, and feelings that normally only occur in
dreams.
● Currently, Ecstacy (methylenedioxymethamphetamine or
MDMA) is the most commonly used psychedelic.
- It is popular among adolescents and young
adults and may also be abused as a “rape drug.”
● The effects of psychedelic drug use are primarily
psychological, but cardiovascular and neurologic toxicity
may occur.
● Little or no physical dependence develops, but acute
panic reactions are common with toxicity.
● Panic attacks may be treated with antianxiety agent such
as diazepam (Valium) and by providing a nonthreatening
environment.
● Although a toxic reaction may mimic psychosis, the use of
antipsychotic agents such as phenothiazines
(haloperidol, chlorpromazine) can intensify rather than
ameliorate the experience.
Inhalants
● Inhalation is the major route of ingestion for a number of
common household and industrial volatile substances.
● Forms of use include sniffing, huffing, bagging, or
spraying.
● Because inhalants are readily accessible, inexpensive,
and produce a rapid high, they are more often used by
preadolescents and adolescents.
● The four main classes of inhalants are: (1) volatile
solvents (2)aerosols (3) anesthetic agents (4) nitrites
- They act as CNS depressants but are also
extremely damaging to the cardiovascular and
respiratory systems.
● Users may develop peripheral neuropathies and exhibit
tremors and weakness.
● Sudden death may occur from direct toxic effects,
aspiration of gastric contents, trauma, and suffocation.
● No antidotes are available and treatment of toxicity is
symptomatic.
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Prescription Drugs
● The types of prescription medications most frequently
misused are pain medications and sedative-hypnotics.
● Individuals may obtain these medications as valid
prescriptions for legitimate health issues but use the drug
in a non prescribed manner; others may use someone
else’s prescription with or without their knowledge or
permission.
SPECIAL NEEDS OF DRUG-ABUSING PATIENTS
Surgical Patients
● An individual who abuses drugs is at high risk for drug
interactions, complications, and death when surgery is
required.
● Preoperative assessment of all patients must include an
assessment of drug use.
● Respiratory changes in smokers make introduction of
endotracheal and suction tubes more difficult and increase
the risk for postoperative respiratory problems.
Postoperative headaches may be caused by caffeine
withdrawal in heavy users.
● The patient who is alcohol dependent but is not currently
drinking usually requires an increased level of anesthesia
because of cross-tolerance.
● The intoxicated individual needs a decreased level of
anesthesia because of the synergistic effect of alcohol.
Alcohol withdrawal delirium may be triggered by surgery
and the cessation of alcohol consumption.
Pain Management
● When addicted patients experience any type of acute
pain, the goal is to treat the pain.
● Addiction treatment is not the priority while the patient is in
pain. Withdrawal symptoms can exacerbate pain and
lead to drug-seeking behavior or illicit use.
● Severe pain should be treated with opioids, but at much
higher doses than those used with drug-naïve patients.
● The use of PCA may improve pain control and reduce
drug seeking behavior.
CHEMICAL IMPAIRMENT IN HEALTH PROFESSIONALS
Chemical impairment is a term used by health professionals
to indicate impaired performance as a result of drug use.
- It is estimated that 10% to 20% of nurses have
substance-abuse problems and that 3% to 6%
demonstrate impaired practice resulting from the
use of drugs.
Contributing Factors
● Factors contributing to drug abuse among nurses have
been identified as chronic fatigue, illness, responsibility for
patients’ responses to illness and dying, professional
dissatisfaction, access to drugs, marital and child care
problems, and downsizing.
● Other factors include nurses’ false belief that knowledge
of drugs provides immunity to drug problems.
- the issue has become less of a priority within the
nursing community , partly because the nursing
shortage and workplace hazards have received more
attention.
Characteristics
● Evidence of chemical dependence may be seen by
changes in personality and behavior, job performance,
and attendance.
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● Poor judgment, errors, inappropriate behavior, and
illogical documentation are common in the chemically
impaired nurse.
● Discrepancies in controlled-drug handling and records
may indicate drug diversion, the deliberate redirecting of a
drug from a patient or facility to the employee for personal
use.
Management
● Sometimes employment is simply terminated, allowing the
nurse to work elsewhere with no resolution of the problem.
● Management reports the nurse to regulatory agencies that
may revoke licensure to practice or refer the case to the
criminal justice system.
● In an effort to help impaired nurses, the American Nurses
Association, the National Student Nurse Organization, and
other nursing organizations and nurse substance-abuse
experts strongly advocate rehabilitation for nurses who
are chemically dependent.
● The goals of these programs are to protect the safety of
the public, to maintain the integrity of the profession, and
to ensure that the nurse is offered the possibility of
treatment and rehabilitation before the license to practice
is revoked or the job is terminated.
● Knowledge of the commonly abused drugs and treatment
during intoxication, overdose, withdrawal, and cessation
are critical to maintaining life and promoting healthy
lifestyles.

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