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ABUSE Dependence

Substance U
intoxication

Joselito C. Pascual, MD, MSc, FPSCOT,


• 3.4 million Filipino illicit drug users (UPPIS, 2002)
• 8,189 admissions (DDB, 2003)

• Discrepancy in the incidence and


admissions underscores the
possibility of addressing the
magnitude of the problem at the
tip of the iceberg.
OBJECTIVES
• To discuss

• The available drugs of abuse


• The philosophy associated with biopsychosocial
approach in terms of:
effects, consequences and treatment
• The target population: Drug Users

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• Drugs presently available for use
and abuse:
alcohol;
amphetamine type stimulants ;
cannabis;
inhalants;
cough/cold preparations;
datura, mushrooms, areca;
sedative-hypnotics;
narcotics/analgesics and;
nicotine
(Pascual, 2000;Pascual, 2002; DDB, 2003)
nga-nga
Pinang,

Areca Nut

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ARECA NUT: Context of use
• Cultural meaning:
– Used in important ritual in restoring
harmony and peace between individuals or
within a community
• Stimulatory and euphoriant
effect *
* Herbal PDA, 2000; Weiss and Fintelmann, 2000

JCPASCUAL 2009 jcpascual 2011


• Causes the teeth to turn black-brown and
stains the tongue and oral mucosa
• Use has been associated with oral cancer *
* Mangla betel nut warning. Lancet 1993;341:810-819

BETEL NUT
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BETEL NUT
• Arecoline: a cholinomimetic alkaloid
– A potent diaphoretic
– Stimulates the salivary, lacrimal, gastric, pancreatic,
intestinal and the mucosal cells of the respiratory tract
– Increases 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
Shanon M., Herbal, tradittional and alternative medicine in Clinical Management of Poisoning an Overdose. Haddad,
Shanon and Manchester (eds) 2006

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Datura metel
(angel’s trumpet, talampunay)

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Datura metel
(angel’s trumpet, talampunay)

• Common uses and properties:


– Asthma
• Adverse effects:
– Hallucinogenic, anticholinergic effects*

*Herbal PDA, 2000

Shanon M., Herbal, tradittional and alternative medicine in Clinical Management of Poisoning an Overdose. Haddad,
Shanon and Manchester (eds) 2006

jcpascual 2011
Datura metel
(angel’s trumpet, talampunay)
• 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)
Shanon M., Herbal, tradittional and alternative medicine in Clinical Management of Poisoning an Overdose. Haddad,
Shanon and Manchester (eds) 2006

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2009
MUSHROOMS

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MUSHROOMS: Context of use

• Food
• Religious ceremonies
• Medication by herbal healers
• Substance of abuse
Shanon M., Herbal, tradittional and alternative medicine in Clinical Management of Poisoning an Overdose. Haddad,
Shanon and Manchester (eds) 2006
Aga, Shrooms
Amanita Muscaria

• Adverse effects:
– Dizziness, vomiting, abdominal pain, movement disorders, muscle cramps,
psychic stimulation, followed by deep sleep, confusion, mania,
unconsciousness, coma and, death*

*Herbal PDA, 2000


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Amanita muscaria
• 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).

JCPASCUAL 2009
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)
5000 years ago….
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• Effects mediated through nAChRs in the brain (VTA, NA)

• Exposure results to activation then desensitization of nAChR >


tolerance

Nicotine
• Chronic exposure:
increased nAChR (slower turnover of
desensitized receptors) > recovery
(desensitization) > hyperexcitable nicotinic system

• 1st cigarette: most pleasurable


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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

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Alcohol and the Filipino
Culture
• Many Filipinos hang out together
in the streets, in front of their
houses and stores especially
among urban poor and rural
communities.

• Filipinos from the middle and


higher-income bracket drink at
bars.
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• Beer: still a favorite among Filipinos

• Accounts for 15% of the Philippine’s 4


billion-bottles-a-year market.

Drinking among Filipinos


Source: Health Action Information Network, 2006

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• 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)

Native Drinks
Source: Health Action Information Network, 2006

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2005 World’s Top 10 Spirits Companies. Impact (2005) Vol. 35, No.22.

Jinro

Stolichnaya

Moskovskaya • The Impact Databank, a US alcoholic


Ginebra San Miguel beverage research firm, cited the
Filipinos as world’s top gin drinkers
Pirassununga 51

Bacardi • Ginebra San Miguel is the top gin brand


Smirnoff in the world in terms of sales at 27.4
million cases or P12 billion.
Russkaya

Tanduay

Kyoungwoul

0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50

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ALCOHOL
• Action on µ receptor sites in
the VTA
• Action on GABA receptors
resembles that of
benzodiazepines (increase in
GABA neurotransmission)
• Antagonist effect of some
receptors for the excitatory
neurotransmitter glutamate
(NMDA)
• Increase release of dopamine
in nucleus accumbens
• Stimulation of 5-HT receptors
(serotonin)

Koob G, Le Moal. Drug Addiction, dysregulation of reward, and allostasis. Neuropsychophramacology 2001; 24:97-129
Nutt D. Alcohol and the brain. Pharmacological insights for psychiatrists. Br J Psych 1999; 175:114-19

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Sedative-hypnotics
Rx
Opiates
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CL-
Cl- Binding Cl -
to GABA A receptor

GABA coupling to Transducer


(G protein)

Opening of
Chloride ion channels

GABA
BENZODIAZEPINE

Neuron hyperpolarization
RMP stabilization

Dampening of
Neuronal Excitability

Koob G, Le Moal. Drug Addiction, dysregulation of reward, and allostasis. Neuropsychophramacology 2001; 24:97-129 Nutt D. Alcohol and the
brain. Pharmacological insights for psychiatrists. Br J Psych 1999; 175:114-19
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CLUB DRUGS

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Cocaine
Methamphetamine
The Current Drug Scene
Designer drugs

Alcohol
Nicotine jcpascual 2011
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)

1. Lit E. et al. The Epidemiology of Substance Use. In:Sourcebook of Substance and Addiction. Friedman L
and Fleming N. 2003
2. Kaufamn & Friedman,1996; Haut & Rovere, 1984) jcpascual 2011
Mechanism of Action

CH2 CH NH2

CH3
Amphetamine

• Indirect monoamine agonists with both central and


peripheral actions

• Release of norepinephrine, serotonin, dopamine


from presynaptic terminals

CH2 CH NH

CH3 CH3
Methamphetamine
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club drugs

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
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club drugs
Ecstasy
(3,4- methylenedioxy-n- methylamphetamine)
– XTC, X, E, Adam, Clarity, Lover’s
Speed
– Euphoria, comfort, empathy
  HR and BP,cognitive impairment

Cocaine (benzoylmethylecgonine)
– Mood elevating
– High doses: irritability, psychosis,
seizure, unconsciousness, coma
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WHY DRUGS?

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Effects of Drugs

“Intoxication”

USE Rush “Normal”

“Withdrawal”

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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
Gail C et al. The Epidemiology of Substance Use. In:Sourcebook of Substance and Addiction. Friedman L and Fleming N. 2003

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Epidemiology of Use
Initiation of Use

• 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).

Gail C et al. The Epidemiology of Substance Use. In:Sourcebook of Substance and Addiction. Friedman L and Fleming N. 2003

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Popular Culture

• creation of several images of drug


use driven by advertisements,
television, movies and music
videos.

Wyszynski A, Yu V.: Patient using steroids, Manual of Psychiatric care for the
Medically Ill. Am Psych Press 2005

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DRUGS OF ABUSE:
Sought After Effects

– weight reduction
– anti-fatigue, activity – sustaining effect
– performance enhancing effects

Lit E. et al. The Epidemiology of Substance Use. In: Sourcebook of Substance and Addiction. Friedman L
and Fleming N. 2003
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DRUGS OF ABUSE:
Sought After 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”
Lit E. et al. The Epidemiology of Substance Use. In: Sourcebook of Substance and Addiction. Friedman L
and Fleming N. 2003
jcpascual 2009
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

Gail C et al. The Epidemiology of Substance Use. In:Sourcebook of Substance and Addiction. Friedman L and Fleming N. 2003
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Drug, drugs and drugs:
Polysubstance use

• Self-detoxification
• Stimulants: Benzodiazepines and alcohol taken to
alleviate stimulant withdrawal
• Alcohol: to modulate and enhance effects

Bearn J. Sedative hypnotics , 2004; Wolff K, Barbiturates and sedative-hypnotics, 2004;


Gossop et al. ,1991; Preston et al., 1984.

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Deliberate Self-harm
The Medical paradigm in Substance
Use, Misuse and Dependence
• Anxiety
• Depression
• Psychosis
Stahl S., Essential Psychopharmacology of Antipsychotics and Mood Stabilizes,
Cambridge University Press, 2002.

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Basal ganglia
Nigrostriatal
Dopamine pathway

Mesolimbic
dopamine pathway

Mesocortical
Substantia Dopamine pathway
nigra
Hypothalamus

Tuberoinfundibular
Dopamine pathway
m
ntu

The dopaminergicNA
pathways of
meg
Te

Increased levels of dopamine in the critical in


the brain
mediating rewarding effects or positive reinforcement for
drugs of misuse (Koob and Le Moal, 2004)

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AMPHETAMINE

• Reduced dopaminergic functioning in the

↓D2
mesolimbic system,

receptor levels
(withdrawal, early abstinence up to
4 months) (Volkow et al., 2003)

• Dysphoria, anhedonia, irritability, craving,


drug-seeking behaviour.

1. Lingford-Hughes A, Nutt D. Neurobiology of addiction and implications to treatent. B J Psychiatry 1999; 175: 114-119.
2. Schultz W. Reward signaling by dopamine neurons. Neuroscientist 2001;7:293-302.

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Use
Continued drug use
Recreational use to ward off pscyhological and
and Reward physical symptoms
(Dependence)

Tolerance
(adaptive processes in the brain
The Downside of Withdrawal

Drug use
that diminishes the effects of (Unpleasant symptoms)
drug)

Unopposed
Abstinence Compensation Process
Adaptations
(sensitization, craving,
cues)
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• Associated trauma
• Overdose (accidental, suicidal)
• Panic reaction ( “bad trip” ) or significant intoxication
• Inappropriate behavior
• Drug-seeking behavior (withdrawal)
• “Coerced” by the legal system

Reasons for nt y er
into Health System
emergency
Gail C et al. The Epidemiology of Substance Use. In:Sourcebook of Substance and Addiction. Friedman L and Fleming N. 2003
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Specific symptoms encountered with
Recreational Substance Use

Disorientation
Confusion
Destructive and assaultive behavior
Depression
Hallucinations
Delusions
Trauma

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Recognition of Problem

• History
• Questionnaires
• Biological markers
• Toxidrome

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General Approach
TOXICOLOGY
• Emergency emer
stabilization gency
e• m e revaluation
Clinical g e n c y
• Elimination of the drug/drugs
e m e r
• Excretion of the absorbed drug/drugs
• Administration of antidotes and/or pharmacotherapy
• Supportive therapy and observation
e m e r g e n c y
• Disposition er
e m e r g e n c y
TOXICOLOGY
e m e r g e n c y jcpascual 2009
Intoxication and Overdose

• proceed with basic ABCs of life support

• management of medical emergency

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Intoxication and Overdose

• 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

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Intoxication and Overdose

DETOXIFICATION

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Intoxication and Overdose


psychic agitation: – Diazepam 5 mg oral/parenteral
–1st generation antipsychotic: Haloperidol 2 mg deep im
–2nd generation antipsychotic: Olanzepine 5 mg deep im
Risperidone quicklet SL
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Intoxication and Overdose

Depression and Suicide

• Basic
suicide precautions (physical restraints)

• Drug induced or autonomous?


• Careful evaluation by an experienced health worker

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CLINICAL ISSUES
with drug use
• Single drug or a mixture?

• Illicit amphetamine or prescriptions or both?

• Drug-drug interaction or cocktail of death?

TOXICOLOGY
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LONG-TERM ISSUES
with drug use

• Psychological deterioration

• Psychosocial deterioration

TOXICOLOGY
PSYCHIATRY
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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;

• It is nearly impossible to “detoxify” long-term


memories of the context of use.
Gail C et al. The Epidemiology of Substance Use. In:Sourcebook of Substance and Addiction. Friedman L and Fleming N. 2003

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CONCLUSION
The DOWNSIDE
of recreational drug use

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The DOWNSIDE
of substance Use, Misuse and Dependence

• 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.

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The DOWNSIDE
of drug use
• 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.

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The DOWNSIDE
of recreational drug use
• 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.

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THANK YOU

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