Substance Abuse and

Addictive Disorders
Group 1-B
 6
Opioid
Related Disorders
NEUROPHARMACOLOGY:
μ-opioid receptors – regulation and mediation of
analgesia, respiratory depression, constipation, and drug
dependence

ĸ-opioid receptors – analgesia, diuresis and sedation

Δ-opioid receptors – analgesia

NEUROPHARMACOLOGY:
3 classes of endogenous receptors within the brain:
● Endorphins
○ Generic name for all molecules with morphine-like
activity
○ Involved in neural transmission and pain
suppression
● Dynorphins
● Enkephalins
HEROIN
● most commonly abused opioid
● more lipid soluble than morphine
● cross the blood-brain barrier faster, more rapid and
pleasurable onset than morphine;
● first introduced as treatment for morphine addiction
● more dependence producing than morphine
CODEINE
● absorbed easily thru GIT and subsequently
transformed into morphine in the body
● decreased cerebral blood flow in selected brain
regions of opioid dependent
● evidence indicating that the endorphins are involved
in other addictions, such as alcoholism, cocaine and
cannabinoid
● Naltrexone has shown value in alcoholism
ETIOLOGY
PSYCHOSOCIAL FACTORS
● Higher incidence in low socioeconomic status.
● Children on single or divorced parents
● With at least one family member with substance-related
disorder
● Behavioral problems/conduct disorder
HEROIN BEHAVIOR SYNDROME
● Underlying depression, agitated type, with anxiety
● Impulsiveness expressed by passive-aggressive
orientation
● Fear of failure
● Use of heroin as antianxiety agent to mask feelings of
low self esteem, hopelessness and aggression
● Limited coping strategies and low frustration tolerance
accompanied by need for immediate gratification
HEROIN BEHAVIOR SYNDROME
● Sensitivity to drug contingencies, with a keen awareness
of the relation between good feelings and the act of drug
taking.
● Feelings of behavioral impotence counteracted by
momentary control over the life situation by means of
substance
● Disturbances in social and interpersonal relationships
with peers maintained by mutual substance experiences.
ETIOLOGY
BIOLOGICAL AND GENETIC FACTORS
● Evidence for common and drug-specific, genetically
transmitted vulnerability factors
● Substance abuse from another category
● Monozygotic twins more likely to be concordant
● Multivariate modeling techniques a higher proportion
of the variance – specific for opioids
ETIOLOGY
BIOLOGICAL AND GENETIC FACTORS
● Genetically determined hypoactivity of the opiate
system.
● Abnormal functioning in either dopaminergic or the
noradrenergic neurotransmitter system.
ETIOLOGY
PSYCHODYNAMIC THEORY
● Libidinal fixation
● Regression to pregenital, oral or even archaic levels of
psychosexual development
● Serious ego pathology
● Problems of the relation between the ego and the affect
is the key area of difficulty.
OPIOID INTOXICATION
● Altered mood
● Psychomotor retardation
● Drowsiness
● Slurred speech
● Impaired memory and attention
● Altered mood
● Psychomotor retardation
● Drowsiness
● Slurred speech
● Impaired memory and attention
● hypersomnia
● Opioid intoxication delirium
OPIOID WITHDRAWAL
MORPHINE and
HEROIN:
● 6-8 hours after last dose
usually after a 1-2 week
period of continued use;
● peaks during day 2 or 3
● and subsides during the
next 7 to 10 days.
● some may persist for 6
months or longer
MEPERIDINE
● begins quickly
● peaks in 8 to 12 hours
● and ends in 4-5 days.
METHADONE
● begins 1 to 3 days after
last dose
● ends in 10 to 14 days
OPIOID WITHDRAWAL
● Severe muscle cramps and bone aches, profuse
diarrhea, abdominal cramps, rhinorrhea, lacrimation,
piloerection or gooseflesh (cold turkey), yawning,
fever, pupillary dilation, hypertension, tachycardia,
temperature dysregulation
OPIOID WITHDRAWAL
Residual symptoms: Associated features:
● Insomnia ● Restlessness
● Bradycardia ● Irritability
● Temperature dysregulation ● Depression
● cravings ● Tremor
● Weakness
● Nausea
● vomiting
OPIOID WITHDRAWAL
CLINICAL FEATURES :
● Can be taken orally, snorted intranasally, IV or SC (Skin popper)
● Euphoric high – “rush”, especially when IV
● Feeling of warmth, heaviness of extremities, dry mouth, itchy face
especially the nose, facial flushing
● Initial euphoria is followed by period of sedation – “nodding off”
● Respiratory depression, pupillary constriction, smooth muscle
contraction (increase ureters and bile ducts), constipation, changes
in BP, HR and Temp.
OPIOID WITHDRAWAL
ADVERSE EFFECTS:
● Potential transmission of hepatitis and HIV thru use of
contaminated needles
● Idiosyncratic allergic reactions
● Anaphylactic shock
● Pulmonary edema
● Death
● Idiosyncratic drug reaction b/w meperidine and MAOI - gross
autonomic instability, severe behavioral agitation, coma, seizures
and death
OPIOID OVERDOSE
● Marked unresponsiveness, coma, slow respiration,
hypothermia, hypotension and bradycardia
● Clinical triad: coma, pinpoint pupils, respiratory depression
Treatment:
● Ensure adequate airway
● NALOXONE
○ slow IV initially at 0.8 mg per 70 kg of body weight;
○ repeated after interval of few minutes until signs of
improvement
■ increase RR
■ pupillary dilatation
MEDICALLY SUPERVISED WITHDRAWAL AND
DETOXIFICATION
METHADONE
● A synthetic narcotic that substitute for heroin; taken orally
● Daily dose of 20-80 mg;
● duration of action 24 hours
● Withdrawal from methadone produces abstinence syndrome
but can be toxified more easily than heroin
● Clonidine 0.1-0.3 mg tid to qid for methadone detoxification
MEDICALLY SUPERVISED WITHDRAWAL AND
DETOXIFICATION

ADVANTAGES OF METHADONE MAINTENANCE:

● Frees person from using injectable heroin reducing the chance
of HIV spread thru contaminated needles.
● Methadone produces minimal euphoria and rarely causes
drowsiness or depression
● Allows patient to engage in gainful employment instead of
criminal activity.
MEDICALLY SUPERVISED WITHDRAWAL AND
DETOXIFICATION
LEVOMETHADYL (LAAM)
● Opioid agonist that suppresses withdrawal
● Prolonged QT intervals asocial with potentially fatal arrythmias
(torsades des pointes)

BUPRENORPHINE
● 8-10 mg daily or thrice weekly
● Slow dissociation from opioid receptors
● Blocks subjective effects of parenterally administered opioids
● Mild opioid withdrawal syndrome occurs after abrupt withdrawal
MEDICALLY SUPERVISED WITHDRAWAL AND
DETOXIFICATION

OPIOID ANTAGONIST
● No narcotic effects; do not produce dependence
● Blocking the euphoric effects discourages person for
substance seeking behavior; deconditions the behavior
● Lack of mechanism to compel person to continue the drug
NEONATAL WITHDRAWAL
● Can lead to miscarriage or fetal death
● Maintaining the pregnant woman on methadone 10-40
mg daily
● If pregnancy begins while on high doses of methadone,
the dosage should be reduced slowly (1mg every 3 days)
and fetal movements monitored;
● Withdrawal is least hazardous during the 2nd trimester
FETAL AIDS TRANSMISSION
● Can pass HIV to infant through placental circulation and
Breastfeeding
● Zidovudine (Retrovir) alone or in combination with other
anti- HIV medication in infected women can decrease
the incidence of HIV in newborns.
 7
● Sleep inducer
● Antiepileptics, muscle
relaxants, anesthetics,
and anesthetic

●
adjuvants
Alcohol & Drugs: Sedative-,
Hypnotic- or
cross-tolerant
● Effects are additive
● Most important
clinically is
BENZODIAZEPINES Anxiolytic -
Related Disorders
 Three Major Groups
BENZODIAZEPINES BARBITURATES BARBITURATE-LIKE
SUBSTANCES

● Most prescribed ● Frequently prescribed before ● Methaqualone

drugs benzodiazepines were ("mandrakes", "soapers,
● Anxiolytics, introduced "Luding out", "mickey
hypnotics, ● Secobarbital ( "reds," "red finn")
antiepileptics, and devils," "seggies," and ● Heightens the pleasure
anesthetics, as well "downers") of sexual activity
as for alcohol ● Pentobarbital (Nembutal)
withdrawal ("yellow jackets," "yellows,"
● Schedule IV and "nembies")
controlled ● Secobarbital-amobarbital
substances combination ("reds and blues "
"rainbows " "double-trouble "
and "tooies")
 Three Major Groups
BENZODIAZEPINES BARBITURATES BARBITURATE-LIKE
SUBSTANCES

● Most prescribed ● Frequently prescribed before ● Methaqualone

drugs benzodiazepines were ("mandrakes", "soapers,
● Anxiolytics, introduced "Luding out", "mickey
hypnotics, ● Secobarbital ( "reds," "red finn")
antiepileptics, and devils," "seggies," and ● Heightens the pleasure
anesthetics, as well "downers") of sexual activity
as for alcohol ● Pentobarbital (Nembutal)
withdrawal ("yellow jackets," "yellows,"
● Schedule IV and "nembies")
controlled ● Secobarbital-amobarbital
substances combination ("reds and blues "
"rainbows " "double-trouble "
and "tooies")
 Three Major Groups
BENZODIAZEPINES BARBITURATES BARBITURATE-LIKE
SUBSTANCES

● Most prescribed ● Frequently prescribed before ● Methaqualone

drugs benzodiazepines were ("mandrakes", "soapers,
● Anxiolytics, introduced "Luding out", "mickey
hypnotics, ● Secobarbital ( "reds," "red finn")
antiepileptics, and devils," "seggies," and ● Heightens the pleasure
anesthetics, as well "downers") of sexual activity
as for alcohol ● Pentobarbital (Nembutal)
withdrawal ("yellow jackets," "yellows,"
● Schedule IV and "nembies")
controlled ● Secobarbital-amobarbital
substances combination ("reds and blues "
"rainbows " "double-trouble "
and "tooies")
Epidemiology
● The highest lifetime prevalence of
sedative (3 %) or tranquilizer (6%) use
was 26 to 34 years of age and those aged
18 to 25 were most likely to have used
sedatives or tranquilizers in the prior
year.
● ER visits: ¼ to ⅓ of all substance
● F: M ratio 3: 1
● W: B ratio 2: 1
● Barbiturate abuse: common among
mature adults (long histories of abuse of
these substances)
● Benzodiazepines abuse: common among
younger age group(< 40 years of age)
 Neuropharmacology
- Primary effects are
on the GABA-A
receptors ->
inhibitory effect
- Increase in affinity
of the GABA-A
receptor to GABA
- Increase chloride
conductance ->
hyperpolarization
of neuron
 Diagnosis
S.H.A. S.H.A S.H.A. Other S.H.A
Use Disorder Intoxication Withdrawal induced Disorder

Results from the Intoxication syndromes: Benzodiazepines: Delirium

prolonged use of incoordination, dysarthria, - Onset : 2 - 3 days / 5 - 6 days Persisting Dementia
the substance nystagmus, impaired - Symptoms: anxiety, dysphoria, Persisting Amnestic Disorder
memory, gait disturbance, intolerance for bright lights and loud Psychotic Disorders
DSM-5: and in severe cases stupor, noises, nausea, sweating, muscle Other Disorders
- Manifests 2 coma, or death. twitching, and sometimes seizures Unspecified Sedative-,
or more of Diagnosis: blood sample Barbiturates & Barbiturate-like Substances: Hypnotic-, or Anxiolytic
the criteria (substance screening) - Mild symptoms: anxiety, weakness, Related Disorder
- Within 12 sweating, and insomnia
months - Severe symptoms: seizures, delirium,
CV collapse, & death
 Diagnosis
S.H.A. S.H.A S.H.A. Other S.H.A
Use Disorder Intoxication Withdrawal induced Disorder

Results from the Intoxication syndromes: Benzodiazepines: Delirium

prolonged use of incoordination, dysarthria, - Onset : 2 - 3 days / 5 - 6 days Persisting Dementia
the substance nystagmus, impaired - Symptoms: anxiety, dysphoria, Persisting Amnestic Disorder
memory, gait disturbance, intolerance for bright lights and loud Psychotic Disorders
DSM-5: and in severe cases stupor, noises, nausea, sweating, muscle Other Disorders
- Manifests 2 coma, or death. twitching, and sometimes seizures Unspecified Sedative-,
or more of Diagnosis: blood sample Barbiturates & Barbiturate-like Substances: Hypnotic-, or Anxiolytic
the criteria (substance screening) - Mild symptoms: anxiety, weakness, Related Disorder
- Within 12 sweating, and insomnia
months - Severe symptoms: seizures, delirium,
CV collapse, & death
 Diagnosis
S.H.A. S.H.A S.H.A. Other S.H.A
Use Disorder Intoxication Withdrawal induced Disorder

Results from the Intoxication syndromes: Benzodiazepines: Delirium

prolonged use of incoordination, dysarthria, - Onset : 2 - 3 days / 5 - 6 days Persisting Dementia
the substance nystagmus, impaired - Symptoms: anxiety, dysphoria, Persisting Amnestic Disorder
memory, gait disturbance, intolerance for bright lights and loud Psychotic Disorders
DSM-5: and in severe cases stupor, noises, nausea, sweating, muscle Other Disorders
- Manifests 2 coma, or death. twitching, and sometimes seizures Unspecified Sedative-,
or more of Diagnosis: blood sample Barbiturates & Barbiturate-like Substances: Hypnotic-, or Anxiolytic
the criteria (substance screening) - Mild symptoms: anxiety, weakness, Related Disorder
- Within 12 sweating, and insomnia
months - Severe symptoms: seizures, delirium,
CV collapse, & death
 Other S.H.A
induced Disorder

Diagnosis
 Diagnosis
S.H.A. S.H.A S.H.A. Other S.H.A
Use Disorder Intoxication Withdrawal induced Disorder

Results from the Intoxication syndromes: Benzodiazepines: Delirium

prolonged use of incoordination, dysarthria, - Onset : 2 - 3 days / 5 - 6 days Persisting Dementia
the substance nystagmus, impaired - Symptoms: anxiety, dysphoria, Persisting Amnestic Disorder
memory, gait disturbance, intolerance for bright lights and loud Psychotic Disorders
DSM-5: and in severe cases stupor, noises, nausea, sweating, muscle Other Disorders
- Manifests 2 coma, or death. twitching, and sometimes seizures Unspecified Sedative-,
or more of Diagnosis: blood sample Barbiturates & Barbiturate-like Substances: Hypnotic-, or Anxiolytic
the criteria (substance screening) - Mild symptoms: anxiety, weakness, Related Disorder
- Within 12 sweating, and insomnia
months - Severe symptoms: seizures, delirium,
CV collapse, & death
 Patterns of Abuse
Oral
- Time-limited specific effect or
- Constant, mild, intoxication state
- Young age group: evening relaxation,
sexual act intensity, or short-lived mild
euphoria
- Factors of Substance-Induced
Experience: personality & expectations
- Middle aged & class group: regular
users (physician prescribed for
insomnia or anxiety)
IV
- Severe form of abuse
- Young age group: intimately involved
with illegal substances
- IV Barbiturates: pleasurant, warm,
drowsy feeling, cheaper than opioids
- Disadvantages: HIV, cellulitis, vascular
complications, infections, & allergic
reactions from contaminants
- Rapid & profound tolerance &
dependence
- Severe withdrawal syndrome
 Overdose
BENZODIAZEPINES BARBITURATES BARBITURATE-LIKE
SUBSTANCES

Lethality: large margin of Lethality: fatal Lethality: varies

safety
Overdose: minimal degree of
respiratory depression
Lethal dose:
- Dose ranges 200:1 or
higher
Symptoms: drowsiness,
lethargy, ataxia, some
confusion, & mild depression
of vitals
Serious conditions: overdose
Benzo + sedatives (alcohol)
Overdose: induced coma, respiratory
arrest, CV failure & death
Children: common due to home
medicine cabinets
Lethal dose:
- route of administration & degree
of tolerance
- Dose ranges between 3:1 & 30:1
- Same for both a long-term abuser
and a neophyte
Tolerance: rapid, withdrawal
ASAP prevents death
Overdose: restlessness, delirium,
hypertonia, muscle spasms,
convulsions & death (very high
dose)
Methaqualone: rare casualty of
severe CV disorders or respiratory
depression
Most fatalities:
- Methaqualone + Alcohol
 Overdose
BENZODIAZEPINES BARBITURATES BARBITURATE-LIKE
SUBSTANCES

Lethality: large margin of Lethality: fatal Lethality: varies

safety
Overdose: minimal degree of
respiratory depression
Lethal dose:
- Dose ranges 200:1 or
higher
Symptoms: drowsiness,
lethargy, ataxia, some
confusion, & mild depression
of vitals
Serious conditions: overdose
Benzo + sedatives (alcohol)
Overdose: induced coma, respiratory
arrest, CV failure & death
Children: common due to home
medicine cabinets
Lethal dose:
- route of administration & degree
of tolerance
- Dose ranges between 3:1 & 30:1
- Same for both a long-term abuser
and a neophyte
Tolerance: rapid, withdrawal
ASAP prevents death
Overdose: restlessness, delirium,
hypertonia, muscle spasms,
convulsions & death (very high
dose)
Methaqualone: rare casualty of
severe CV disorders or respiratory
depression
Most fatalities:
- Methaqualone + Alcohol
 Overdose
BENZODIAZEPINES BARBITURATES BARBITURATE-LIKE
SUBSTANCES

Lethality: large margin of Lethality: fatal Lethality: varies

safety
Overdose: minimal degree of
respiratory depression
Lethal dose:
- Dose ranges 200:1 or
higher
Symptoms: drowsiness,
lethargy, ataxia, some
confusion, & mild depression
of vitals
Serious conditions: overdose
Benzo + sedatives (alcohol)
Overdose: induced coma, respiratory
arrest, CV failure & death
Children: common due to home
medicine cabinets
Lethal dose:
- route of administration & degree
of tolerance
- Dose ranges between 3:1 & 30:1
- Same for both a long-term abuser
and a neophyte
Tolerance: rapid, withdrawal
ASAP prevents death
Overdose: restlessness, delirium,
hypertonia, muscle spasms,
convulsions & death (very high
dose)
Methaqualone: rare casualty of
severe CV disorders or respiratory
depression
Most fatalities:
- Methaqualone + Alcohol
 Treatment
Withdrawal
Withdrawal Overdose
●
● Eliminated from
Eliminated from the
the body
body ● Gastric lavage, activated
Benzodiazepines
Benzodiazepines slowly, symptoms
slowly, symptoms charcoal, and careful
continue to
continue to develop
develop for
for monitoring of vital signs
several weeks
several weeks and central nervous
system (CNS) activity
TX:
TX: Carbamazepine
Carbamazepine (Tegretol)
(Tegretol) ● Vomiting should be
induced
●
● Should
Should not
not be
be given
given toto a
a ● Activated charcoal - delay
comatose or grossly
comatose or grossly gastric absorption
intoxicated patient
intoxicated patient ● Comatose px in the ICU:
Barbiturates
Barbiturates ●
● Continue Phenobarbital
Continue Phenobarbital - IV fluid line, monitor vitals,
until daily
until daily dosage
dosage isis Insert an endotracheal
attained
attained tube to maintain a patent
●
● Shift
Shift to
to short-acting
short-acting airway, mech vent (only
barbiturates
barbiturates when necessary)
●
● Gradual
Gradual reduction
reduction ofof
dose
dose
 8
Stimulant
Related Disorders
 AMPHETAMINES
-most widely used illicit substances, second only to cannabis in the US, Asia,
Great Britain, Australia and several other western European Countries.

-1937 - amphetamine sulfate tablets were introduced for the

treatment of narcolepsy, postencephalitic parkinsonism,
depression, and lethargy.

-attention-deficit / hyperactivity disorder (ADHD) and

narcolepsy are current US Food and Drug Administration
(FDA) – approved indications for amphetamine
 PREPARATIONS
A. MAJOR AMPHETAMINES

1. Dextroamphetamine (Dexedrine)

2. Methamphetamine (Desoxyn)
a. potent form
b. inhale, smoke or IV
3. Mixed Dextroamphetamine - amphetamine salt (Adderall)

4. Amphetamine-like compound methylphenidate (Ritalin)

B. AMPHETAMINE-LIKE SUBSTANCES

1. Ephedrine

2. Pseudoephedrine – use illegally to make

methamphetamine

3. Phenylpropanolamine – safety margin is narrow

– Exacerbate hypertension,
– toxic psychosis,
– intestinal infarction,
– death
C. AMPHETAMINE-TYPE DRUGS WITH ABUSE POTENTIAL

1. Phendimetrazine (Preludin)

2. Diethylpropion (Tenuate)
o appetite suppressants;
o obesity
3. Benzphetamine (Didrex)

4. Phentermine (Ionamine)

5. Modafinil (Provigil)
o narcolepsy
o shift work sleep disorder
o obstructive sleep apnea
 COCAINE
-an alkaloid derived from the shrub Erythroxylum coca

-1880 first used as a local anesthetic

-active ingredient in Coca Cola in 1903

-development of mood disorders and alcohol-related

disorders follow onset of cocaine-related disorders

-anxiety disorders, antisocial personality disorders and

ADHD precedes dev’t of cocaine-related disorder
ETIOLOGY
I. GENETIC FACTORS:
● monozygotic twins have higher concordance rates for
stimulant dependence than dizygotic twins
● genetic factors and unique (unshared) environmental
factors contribute equally to the development of stimulant dependence

I. SOCIOCULTURAL FACTORS:
● these are powerful determinants of initial use, continuing use and relapse.
● excessive use is far more likely in countries where cocaine is readily
available
III. PHARMACOLOGICAL FACTORS:

● alertness, euphoria, sense of wellbeing

● decreased hunger
● less need for sleep
● improved performance
● enhanced sexual performance
 NEUROPHARMACOLOGY
-competitive blockade of dopamine reuptake by the
dopamine transporter

-increased concentration of dopamine in the synaptic cleft

-increased activation of D1 and D2 receptors

-cocaine also blocks the reuptake of norepinephrine

and serotonin

-cocaine is associated with decreased cerebral blood flow

and possibly with the development of patchy areas
of decreased glucose use.
-craving – high activation of mesolimbic dopamine system
(D2 receptors) in PET Scans

-effects are immediate but short-lived, (30 -60min) , require

repeated doses; metabolites present in blood and urine for
up to 10 days.

-psychological dependence can develop after a single use

-cocaine withdrawal mild compared to opioids.

 METHODS OF USE
-most common method of using cocaine is inhaling the finely
chopped powder into the nose – snorting or tooting

-SC or IV

-freebasing

-smoking
 Stimulant Use Disorder
AMPHETAMINE COCAINE

Rapid downward spiral of abilities to cope with Changes in personality that is unexplained
work and family-related obligations and stresses Irritability
Impaired concentration
Tolerance Compulsive behavior
Severe insomnia
Decreased weight Loss of weight
Frequently excuse themselves from work or social
Paranoid ideas situations every 30 min to an hour to find a secluded
place to snort
Nasal congestion
Self-medicate with nasal sprays
 Stimulant Intoxication
● MYDRIASIS ● Respiratory depression
● TACHYCARDIA or bradycardia ● Confusion, seizures or coma
● HYPERTENSION ● Agitation
● Perspiration or chills ● Irritability
● Cardiac arrhythmias ● Impaired judgment
● Elevated or lowered blood pressure ● Impulsive
● Dyskinesias ● Potentially dangerous sexual
● Dystonias behavior
● Loss of weight ● Aggression
● Nausea or vomiting ● Mania
● Muscular weakness ● Increased psychomotor activity
 Stimulant Withdrawal
● Crash
- anxiety, tremulousness, dysphoric mood,
lethargy, fatigue, nightmares (accompanied
by rebound rapid eye movement [REM]
sleep), headache, profuse sweating, muscle
cramps, stomach cramps, and insatiable
hunger.

- Peak in 2 to 4 days and are resolved in 1

week
- Most serious withdrawal symptom is
depression
 Stimulant Intoxication Delirium
● High doses
● Sleep deprivation from sustained
use
● Combination of stimulants
● Pre-existing brain damage
 Stimulant-Related Psychotic Disorder
● Paranoid ideations and delusions
- hallmark
● Formication - sensation of bugs
crawling beneath the skin
- Seen in cocaine use
● Most common with IV user and
crack users
● Treatment: short-term
antipsychotic medication
 Stimulants Adverse Effects
Amphetamines
NON-LIFE LIFE-THREATENING
THREATENING:
For pregnant women: ● myocardial infarction
● Low birth weight ● Severe hypertension
● Fushing
● Small head circumference ● Cerebrovascular disease
● Pallor
● Premature birth ● Ischemic colitis
● Cyanosis
● Growth retardation ● HIV and hepatitis
● Fever
● Headache ● Lung abscesses
● Tachycardia ● Endocarditis
● Palpitations ● Necrotizing angiitis
● Nausea and Vomiting ● Twitching to tetany to
● Bruxism (teeth grinding) seizure to coma and death
● Shortness of breath
● Tremor
● Ataxia
 Stimulants Adverse Effects
Amphetamines
PSYCHOLOGICAL:
● Restlessness
● Dysphoria
● Insomnia
● Irritability
● Hostility
● Confusion
● Generalized anxiety disorder
● Ideas of reference
● Paranoid delusions
● Hallucinations
 Stimulants Adverse Effects
Cocaine
Common:
● Nasal congestion; serious inflammation,
swelling, bleeding and ulceration of nasal
mucosa also common; long term use can
lead to perforation of the nasal mucosa
● IV use:
- Infection
- Embolism
- HIV transmission
● Acute dystonia, tics, migraine-like
headaches
 Stimulants Adverse Effects
Cocaine
Major Complication:
● Cerebrovascular Effects:
- Non-hemorrhagic cerebral infarctions - most common
- Transient ischemic attacks
- Cocaine is the substance of abuse most commonly
associated with seizures; second is amphetamine
● Cardiac Effects:
- Myocardial infarctions and arrhythmias are perhaps the
most common cocaine-induced abnormalities
- Cardiomyopathies
- Cardioembolic cerebral infarctions
● Seizures
● Death
 9
Tobacco
Related
Disorders
 Tobacco-Related Disorders
- Among the most prevalent, deadly, and costly of substance
dependencies
- It is also one of the most ignored

Role of psychiatrists in treating tobacco dependence:

● Growing recognition that most psychiatric patients smoke and
many die from tobacco dependence
● More likely to have psychiatric problems
● Development of multiple pharmacological agents
to aid smokers in quitting
 Nicotine
- It is the psychoactive component of tobacco which
affects the central nervous system
- Acts as an agonist at the nicotinic subtype of
acetylcholine receptors
- 25% of inhaled nicotine during smoking reaches the
bloodstream through which it reaches the brain within
15 seconds
- Half-life: 2 hours
 Tobacco Use Disorder
- Characterized by craving, persistent and
recurrent use, tolerance, and withdrawal if
tobacco is stopped

- The development of dependence is enhanced

by strong social factors
 Tobacco Withdrawal
- Withdrawal symptoms can develop within 2
hours of smoking the last cigarette
- Generally peak in the first 24-48 hours and can
last for weeks or months
- Mild syndrome of tobacco withdrawal can appear
when a smoker switches from regular to low-
nicotine cigarettes
 Tobacco Withdrawal
Symptoms:
● Intense craving for tobacco
● Tension
● Irritability
● Difficulty concentrating
● Drowsiness
● Paradoxical trouble sleeping
● Decreased heart rate and blood pressure
● Increased appetite and weight gain
● Decreased motor performance
● Increased muscle tension
 Clinical Features
Stimulatory effects of nicotine produces:
● Improved attention, learning, reaction time and problem
solving
● Lifts mood, decreases tension and lessens depressive feelings

Short-term nicotine exposure:

● Increases cerebral blood flow without changing cerebral
oxygen metabolism

Long-term nicotine exposure:

● Decreases cerebral blood flow
 Adverse Effects
- Highly toxic alkaloid
- Doses of 60 mg in an adult are fatal secondary to
respiratory paralysis
- Doses of 0.5 mg are delivered by smoking an average
cigarette
- Low doses of nicotine toxicity includes nausea,
vomiting, salivation, pallor, weakness, abdominal pain,
diarrhea, dizziness, headache, increased blood pressure,
tachycardia, tremor and cold sweats
 Adverse Effects
- Toxicity is also associated with: inability to concentrate,
confusion and sensory disturbances
- Nicotine is further associated with decrease in the user’s
amount of rapid eye movement (REM) sleep.

- During pregnancy, tobacco use is associated with an

increased incidence of low birth weight babies and increased
incidence of newborns with persistent pulmonary
hypertension
 Health benefits of
Smoking Cessation:
- Longer Life Span

- Decreases the risk of:

1. Myocardial Infarction
2. Cerebrovascular Accident
3. Lung Cancer
3. Low birth weight infants
 Nicotine Replacement Therapy:
1. Nicotine POLACRILEX GUMS (Nicorette)
- 2mg for <25 cigarette/day
- 4mg for >25 cigarette/day

1. Nicotine LOZENGES
- Useful for patient who smoke immediately on awakenings
- Highest level of nicotine

1. Nicotine PATCHES

2. Nicotine NASAL SPRAY (For heavily dependent smokers)

3. Nicotine INHALER (absorbed in upper throat)

 Non-Nicotine Medications:
1. BUPROPRION
- 150mg/day x 3 days then 2x a day for 6-12 weeks

1. NORTRIPTYLINE
- Second-line drug

1. CLONIDINE
- 0.2 to 0.4mg/day
Thank you
for
listening!
Stay safe always.
Upam, Kasan
Urrutia, Exequiel
Uy, James
Uy, Justine
Uy, Marc
Valderrama, Bea Aira
Valdes, Angelica
Pilapil, Jannela
Santiago, Arvee
Sotto, Karel
Yusoph, Isnihaya